The Nicest Guy I Never Met

by Robert Lanz LCSW

When the overhead pager announces a trauma code everyone gets immediately focused, responding to some internal list of mental preparations and physical tasks to perform in anticipation of the arrival of the patient. That includes the social worker too, of course.

The social worker, like the rest of the trauma team, has to prep for anything that comes through the door. Will this be a frantic mom in the ambulance with the soon to be dead child? Will the paramedics be carrying a healthy baby with the soon to be dead mom on a stretcher? Under such circumstance, the healthy baby and/or the living mom will be taken aside by the social worker so the trauma team can work on the patient. What a place to start an intervention- so far behind the curve it will seem like there is no catching up. Catching up to what? Finding someone with some good news? Finding a functional family member who can take over some of the social work tasks? And on top of all that, having a trauma family doesn’t mean I get to forget all the other cases I’m attached to in the ER- it just means I get spread a little thinner.

More cops with questions. More phone calls to answer. More requests from the charge nurse about family coming. More lab values to be aware of. More interventions to discuss with the families. More radiological information to assimilate for when more family members and friends show up.

And when the family and friends and co-workers show up there is a reversal in the information flow. Is the patient on any medications or have any ongoing medical problems we should know about? Is the patient addicted to drugs or alcohol? More information to break down into its simplest elements and feed into the trauma team.

“The patient’s on Coumadin” or “The patient is a diabetic” or “The patient is undergoing chemotherapy this month.”

Everything out of the trauma bay is filtered to the family by the social worker. Everything relevant from the family to the trauma team is filtered back the other way too.

The night the nicest guy I never met showed up started out as a mystery as they often do. A young white man, could have been a garage band grunge rocker or a community college kid, had been struck on his bike while riding on a busy street. The car that hit him didn’t stop and the nice guy was knocked out immediately. Upon arrival he looked like he had been more functional than many of our trauma patients. No smell of alcohol. No marks to imply injections. Well groomed, clean clothes. But no identification.

Part of the social worker’s task list is to help identify the patient, notify the family and secure the patient’s valuables. Unless ruled out, it is assumed he may be the victim of a violent crime so the clothes and other personal property may become evidence and need to be treated as such. Gloved up I routinely plunge into pockets, shoes, pant cuffs, back packs and cell phones. Car keys and wallets or virtually anything can give me a clue as to what happened and who this person is attached to.

Over the years in my pursuit of identification I’ve found lots of drugs, lots of money, some fake ID’s, bullets, some porn, some sex toys, a few coke spoons and crack pipes and once a small live lizard in a homeless guys sock. I really didn’t expect to find anything strange in this young guys stuff. Wrong again. He had seventeen crisp one hundred bills in the front pocket of his levis.

Jeez, according to the police he was on a funky old three speed bike and no one around seemed to recognize him. No wallet but maybe that had been blown out of his pants onto the street and no one had found it yet, not an uncommon experience. Sometimes patients that come from board and care facilities have their names inked on the collar of their shirt or on their underwear. Not this guy. No cubic zirconium in his ear. No gold chains around his neck. No tattoos or obvious scars. Just all that cash. I’ve had several drug dealers brought to the ER with more money than he had but it was never in the form of crisp new bills like you get from the bank. More often it is crumpled small bills, and beside that, there is ink and jewelry as if to advertise, “Step right up. I sell dope.” Not this guy.

Somewhere, someone knew this guy and would be looking for him. I was right about that and soon my secretary called from the front.

“There’s a group of people out here. The police told them their loved one might be here. I think it’s the trauma guy’s family.”

I greeted them and we walked to the “quiet room” and got seated, the anxiety so obvious it could be cut with a knife. I asked for a physical description and it sure did fit the trauma patient and I already wished it didn’t. These nice people had no clue how bad he was, how bad the night would most likely turn out, so I started my slow slog into the bad news zone and watched as my practiced words sucked the color from their faces and the hope from their hearts. Mine wasn’t doing so well either.

“I’m going back to radiology, John (the patient finally had a name) is getting a CT scan. I’ll try to get the latest information from the trauma team.”

The news wasn’t good. When I spoke to the neurosurgeon he wasn’t hopeful as he explained that massive intra-cranial bleeding was not going to be fixed surgically. Too much blood. Too much swelling. John would go to the ICU, hooked up to all those machines and IV’s would be pumping all those medications. Desperation moves. Hope for the best.

I went back to the quiet room, now the desperation room, and did my best to ready them for the worst. This morning everything was great. Tonight, everything went wrong. In a few moments the neurosurgeon came in-one of my favorite trauma team members I’d add.

“John’s been hit hard and has bad fractures on both his legs.”

The family gasped as if that was the worst of the news. I cringed but kept my game face on.

“Orthopedics is tending to those injuries. He also has a collapsed lung and a badly lacerated liver and they were talking about removing his spleen. The trauma surgeons are tending to those injuries.”

The family gasped again and swooned but leaned forward towards the neurosurgeon, seemingly in anticipation of the real issues at hand.

“I’m the neurosurgeon. Unfortunately he’s had a major head injury too. We were just looking at his head scan. Doesn’t look good I’m afraid.”

Desperate for something, anything positive the family pressed on.

“But he’s going to live, isn’t he?”

“Well I’ve never seen anyone in my practice with this severity of injuries survive, but we’re not giving up. If you’ll excuse me I have to get back to your son.”

When the neurosurgeon left, the group finally started to understand how grave the situation was. It probably didn’t help much when I handed all that money to his father who immediately got tears in his eyes. The whole room looked at those hundreds. Dad turned to one of the female friends who I was about to find out was more than just a friend. Dad held the stack of bills in his hands, a future no one would ever see.

“Denny” he said to the pretty young woman, “John went to the bank today to get this money so he could buy an engagement ring. He was going to propose to you tonight.”

Tears of joy merged with tears of sorrow, a best and worst moment of life at the same instant.

The young man went upstairs and died. When the story got out to the staff we all died a little too….

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Ride-Along

ridealong

by Robert Lanz, LCSW

       This one for my cop friends. (You know who you are.)

I carried a badge for six years and was considered a “peace officer” in the state of California after undergoing POST-Peace Officer Standards Training. I could legally carry a gun but generally didn’t. Too much responsibility. As an ER social worker who saw the worst of the worst outcomes of violence, there were times when I missed the badge and gun, even though it probably wouldn’t have saved me. I’ve got too much empathy to be the one to draw down first and I’ve got too much confidence in my own social work skills to have to resort to drawing down at all. At least so far. It might be that empathetic quality saved lives. Women peace officers, I’m told, tend to use verbal skills more often than men cops – and guns less often.

There were times when I believed if I had been in situations where a legal police shooting occurred which resulted in death, I would have handled them differently. Pride, ego and guns don’t go well together — on either side of the law.

Our local police force now has social workers in some patrol cars, working a shift with officers. They wear bullet-proof vests (just in case their verbal skills don’t work.) I’m proud that men and women in my profession have enough confidence in their social work skills that despite knowing any failure could be deadly, yet they still show up for work when they are supposed to. That’s confidence. I could do it and so could most of the other ER social workers I work with. In fact, I was once asked if I wanted to ride-along before the program even officially started, and in some ways I did want to. But I was older when approached (about fifty-five.) While I can hold my own in a fight against most guys in my age, most guys my age aren’t a problem on the streets. (When I was studying Krav Maga (the efficient and brutal martial art of the Israeli army, I was about fifty-two.

kravmaga

Most of the guys my size (five-eleven, two-hundred pounds) were usually twenty-five years younger. Whatever sparring skills I had acquired diminished considerably thirty seconds into the round, and I got my butt handed to me on a platter on a regular basis.)

The thing about going on a police ride-along would be that all the cops would have firearms to protect them, and I wouldn’t: a disadvantage I wasn’t sure I could tolerate.

However, when the cops asked me to go for a ride-along for half of a shift, I went for it.  I had a lot of cop friends from my ER contacts and they all thought it was a cool idea. They knew I was a social worker but they also knew that I used to carry the badge and that I was up to the experience. Most likely, it was a guy-thing: a test of some sort and it wouldn’t look good for social work if I failed. My supervisor in the hospital thought it would be a great idea knowing that I would be in a position to teach as well as learn, so my ride-along got the green light.

We handled basic calls in the early part of the shift: kids in the park smoking pot, homeless guys aggressively panhandling in downtown, a ticket for running a stop sign – typical for the night, from what I was told. Then the radio blared: we got a hot call and rolled-up to a shooting situation. And there I was: no gun, no vest, looking for that platter my butt would soon wind-up on. Just as my ‘partner’ was telling me to stay in the car and stay low, I heard a round whiz over the top of the black and white. My partner raced into action, his gun drawn.

I took cover, crawling under the car, trying to become as small a target as possible. It seemed like forever, but in a minute or so, it was over. Calling to me as I lay under the car, the cops called out to me, giving me the all-clear. When I came out, I looked about as dirty as a crackhead in a roadside cantina. Of course the cops had a good laugh. But I passed the test: no anxiety attack, no crying, no soiling my pants.

When I got back to the ER, I was so filthy that I had to dive into the clothing bin reserved for the homeless again to find something else to wear. Luckily, I do most of the  clothes-shopping for the homeless bin, and I keep a set of acceptable clothes set-aside for an  occasion such as today’s.

My advice to law enforcement: take young social workers on a ride-along – let them experience all the adrenaline-filled ‘fun.’ Let them learn to hope for the best, plan for the worst, and not to pee in their pants.

These days, no more ride-alongs. But I’m always happy to consultant — from my office.

Dividing line

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Little Miss Marfan’s

Marfan

by Robert Lanz, LCSW

Marfan’s syndrome is rare and many hospital social workers will go years without coming into contact with one of the unfortunate patients who have this illness. It is more likely that the ER social worker will be acquainted with a Marfan‘s patient than the social workers ‘upstairs.’ At least, that’s how it seems to me.

Unlike the more enigmatic neurological disorders like multiple sclerosis, Parkinson‘s disease, amylatropic lateral sclerosis, myasthenia gravis and all the rest of those diagnoses that are difficult to pin down at first, Marfan’s, if it serious enough, can be diagnosed fairly early in life. But because it is a spectrum disorder with different levels of symptomatology, it may also be discovered late in life. Either way, it’s a difficult diagnosis for the patient if they are at the high end of that spectrum where it causes weakening in the connective tissues- joints and heart valves and even eyes and intestines may be affected. With luck, in a mild case, patients may not even know they have it. Without luck, as one grows through adolescence, the most obvious visual symptom is noticeable gangliness. These patients are taller than other family members and have spindly fingers, flat feet and their extended arm span is greater than their height.

Other obvious signs are spine curvature and a protruding breastbone, but the most dangerous complication is leaking heart valves.  Leaking valves can cause blood to pool in the heart chambers which can lead to clots, a potentially fatal condition.  Some of these patients need to have those valves replaced surgically and they also have to take blood-thinning medication-the dreaded Coumadin CurseCoumadin is like warfarin, what you get at the drug store when you buy rat poison. When ingested by rats, it thins their blood to the point where it all leaks out of the rat’s blood vessels and they die quietly in the garage or down in your basement where you later find them mummified. Warfarin can do the same to humans too if the human isn’t careful. If that isn’t enough to terrify you so far, there is some older literature that refers to a few Marfan’s patients with developmental delays and thought disorders, also.

Of course, if there were a frequent flyer patient with Marfan’s and schizophrenia, she would be on my list, especially if she had lower than normal intelligence and some symptoms of a histrionic personality disorder, what some ER nurses refer to as a “train wreck”. A lot to work with but not impossible for a skilled clinician.  Over time, our Little Miss Marfan’s became one of the regulars and had thrown a few tantrums in the ER, so she was often referred to the social worker for intervention. Despite the constraints of time and the difficulties of her diagnosis, over an extended period she and I were able to grow close enough to engage in a behavioral truce she wasn’t willing to share with other staff. The triage nurse would call me as soon as she showed up at the check in desk.

“Bonnie’s here, Bob.”

I’d go out front and start schmoozing, because if I was successful, her ER visit would probably go OK. For the most part, everyone respected our relationship and I did too. It was a great deal easier to have her as a friend than as the kind of enemy she could turn into, with her history of extensive treacherous ranting and raining hell down on the staff during busy shifts. It took time, finding a commonality we could use as a bond, finding a neutral zone we agreed would be anger-free and require tolerable behavior toward all of the staff. I think her flirting with me and me letting her do it was what finally worked, although I could be wrong about that. Whatever the reason, the ER time we spent was generally serene and I considered it to be good social work intervention. Not exactly a dream date, but workable.

The Coumadin Curse can strike anywhere, any time, to anybody. When it was finally my turn, it was the treatment, or torture, of choice for a deep vein thrombosis that caught me off guard when I was battling a painful case of diverticulitis. The diverticulitis was over after a couple of weeks “upstairs” but the thrombosis lingered for almost eight months. So did the Coumadin regimen, a curse especially brutal for an active guy. Thin blood precludes fighting, surfing, skiing, mountain biking and a few other of my normal activities. I was stuck in adrenaline limbo, left only with walking my dog for excitement, as I had done when I had a significant back injury when she was just a pup. Boring except for the dog bonding part.

The Coumadin diet you get forced into is broad enough to satisfy most folks, especially vegetarians, but once you settle in on your diet choices and have them synched up with your meds you can’t change it much. A dietary screw up could change this thing called your INA levels and make your blood thinning medicine less effective or even dangerous if you are a glutton like I sometimes am. That’s why Coumadin patients have to go to the clinic every week to have their blood tested. Too bad there isn’t a clinic for the rats and mice.

One of the secretaries in the Coumadin clinic, right across the street from the emergency entrance, also worked part time with us in the ER. On my second week check up, she dropped a bomb on me as I was signing in.

“Look Bob. There’s Bonnie just ahead of you. She’s in the waiting area.”

And just when I thought life couldn’t get any more cruel.

She was in the waiting area and I couldn’t avoid her. She started flirting immediately, just as if we were in the emergency room and I was the social worker. Now we had two things in common. Coumadin and flirting. Hard to tell which was the more difficult for me and I wondered when things would stop piling up, but then realized what a wimp I was, because some day I would be back to normal and she never would. Some day we’d be over the clinic flirting and get back to ER flirting. Some day there would, for me at least, just be the ER face time together again and I hoped to get back to our previously agreed upon truce.

That went on with Little Miss Marfan’s until I got over the DVT and the Coumadin Curse became just a bad memory. We did our truce dance in the ER until I retired some ten years later. What changed with Bonnie and me in those years was my appreciation for how difficult it was to live with that Coumadin inconvenience even when I knew it would eventually be gone, a relief she was never going to know. To have the Coumadin Curse for life along with all her other mental and physical challenges was a burden I didn’t even want to contemplate. Now we were bonded with the curse and if that made our relationship better, and it always seemed to, so be it, and I was willing to let her flirt with me any time she wanted…

Dividing line

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Domestic Violence – Still Another Reason Not to Drink

Broken bottle

by Robert Lanz, LCSW

When it comes to domestic violence, men are weak, recalcitrant, and hopeless for the most part, and the disinhibitory effects of alcohol are frequently a contributing factor.  Joe the wine-imbiber found that out the hard way.

I’m sure there was a prior history connected to the events that brought Joe down to the ER with the paramedics that night. After all, it would be rare for an aggrieved wife (or whatever she was) to pick up an empty wine bottle, most likely something with a screw-top, given the consciousness level of this couple, and break it over a guy’s head without good reason. I’m also sure it may not have been an entirely spontaneous event when after breaking the bottle over Joe’s forehead while he was either passed out or sleeping soundly, Mrs. Joe looked in her hand and noticed she was still holding the bottle’s jagged neck. Maybe a light went off over her head: Why waste a good weapon when there’s still work to be done? Or maybe she flashed back to an old gangster or cowboy movie and realized a person could do a lot of damage with a few deft moves and some broken glass, especially if Joe wasn’t wearing a shirt.

The woman proceeded to carve Joe like a Thanksgiving turkey, taking care not to damage the parts she may want to relate to later, like his penis. The rest of Joe’s fleshy, drinker’s body was fair game: nothing too deep, but deep enough to require sewing to fix.

The paramedics called the cops. They arrived at Joe’s, did a brief interview with him and he was loaded into the ambulance. He apparently told police ‘it’ was his fault again: he didn’t want to press charges.  (In those days, you could actually get away with that.) It took one-hundred and eighty-six stitches to close Joe up: a truly Frankensteinian task. Any DV patient is a social-work patient, and Joe being a guy didn’t exclude him from our reporting requirements, even if the assailant was a female.

Later, the cops came to the ER to finish their report and walked into the treatment room just as the doctor was doing some Downward Dog stretches trying to get his back into a more relaxed state after being hunched over Joe the first hundred stitches. My immediate thought when I walked in with the cops was that Joe himself wasn’t going to be in any stretching situations for an extended period of time. Yeah, yeah honey I really wanted to go to that yoga class with you but you cut me pretty bad. Maybe next time. Naw.

Joe told the cops he was okay. With the outcome of the night’s events, and he didn’t want Mrs. Joe to go to jail, so together they left. Pretty forgiving guy, I thought.  And so there I was, all ready to do my social work pitch on a guy with a record number of sutures and he was resistant to catch. To him, the slasher evening was just another part of the intricate interweave of his less-than-perfect, marital-like relationship. Given the very less-than-perfect participant, my pitch was minimal: half-hearted, barely meeting the requirements of the hospital policies and procedures manual. Just when I was about to experience a twinge of social-work guilt, it I got a call from the waiting room.

“Bob. Mrs. Joe is out here and wants to see her husband.”

“Tell her it will be a couple of more hours back here. We’re still sewing.”

I bit my tongue, almost saying, “But if her name is Betsy Ross, send her back.” Instead, I just hung up. More tongue calluses – it never ends for us.

A couple of minutes later I got another call from the front: “That guy’s wife says she’s going home to sleep, but wants his keys. She followed the ambulance in a cab, and now she’s locked out of the house.”

Talk about adding insult to injury. Joe’s going to be in acute pain when the wine wears off, if he ever lets it, and a laugh or a sneeze will be excruciating. Then again, there was the possibility, and I’m not making this up: he most likely had more of the painkilling grape beverage hidden in the garage or the garden somewhere and Joe would use the medication he thought would work best as soon as he got home. I’m sure he would now have the good sense to pour it into a plastic cup and toss the empty bottle really far away.

Joe handed me the keys and I took them up front and gave them to his lovely. ahem, wife. She looked like she might need a referral to a dentist, but that was a chronic rather than an acute situation. Besides, she wasn’t actually my patient and all I needed to know was that she was steady on her feet and we wouldn’t incur liability by giving her a key chain that included car keys. She passed my visual test and I got a confirmatory nod from our triage nurse in the waiting area. I suppose she got home okay. At least she didn’t come back on my shift.

I went back to see how Joe was doing and brought the requisite domestic violence handouts in the very, very unlikely event he volunteered to go to a safe-shelter, a place thirty miles away, where alcohol was not allowed and all residents attended twelve-step meetings twice a day.

The doc was just finished his hundred and eighty-sixth stitch:”Can we get this guy home with a cab voucher, Bob?”

Joe didn’t come back on my shift, either.

Dividing line

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The Swamp

by Robert Lanz, LCSW

I’ve been to the jungles of Mexico, Central America and South East Asia, but those were mostly walking trips with a little boating thrown in. My first trip to the Amazon was different-very different.

Bob driving boat

We had flown up to Manaus, in Brazil, an incredible city in the middle of the rain forest sitting at the confluence of the Rio Solimois and the Rio Negro where the “Amazon” officially becomes the Amazon. A thousand miles east, where it dumps its fresh water into the sea it is about a hundred miles wide. Where we were, by comparison, the grand river was essentially a creek, only five miles wide.

At first, I wasn’t scared. Manaus is a big city cut from the jungle, with most of the amenities found in big cities anywhere, movies, supermarkets, drug stores etc. However, unlike most first world cities, the safety factor diminishes when you step off the sidewalk. Alligators, snakes, piranhas, giant leaping iguanas, fresh water sharks and other fish big enough to swallow us like minnows were everywhere. Lots of reasons to not stray from the sidewalk.

So we chartered a boat, hardly more sophisticated than Humphrey Bogart’s famed African Queen, and we chugged up river, soon parting the jungle and totally losing sight of the Manaus skyline along with any sense of the safety of a sidewalk.

This journey would involve a new set of survival skills, most of which we had only imagined but had yet to put into practice. Luckily, we had the foresight to hire a native guide and a dugout canoe in tow behind us just in case. I’ve surfed most of my life and I’m comfortable in the water most of the time but being a good swimmer here might not be much help. Carrying a weapon of some sort might not either. It was the rainy season and normally exposed islands were now underwater. Large trees poking out of the depths were the only evidence of land, somewhere down there. A lot could go wrong.

Freeboard is the distance between the water and the highpoint of the sides of the boat-or canoe. On the boat we chartered it was about three feet, sort of a sidewalk separation from the unknown creatures we were undoubtedly floating over. The canoe had only about three inches of freeboard which meant fingers were dangerously exposed to those creatures when we held on to the sides to steady the delicate balance of the hand carved craft.

native fisherman

While fishing for piranhas, each catch of the steel-toothed carnivores had the canoe rocking. Without land to swim to if we got swamped, we’d have to try to get to one of the nearby trees and try to climb safely into the branches. So far, whenever we got close to those trees, the twenty pound iguanas living in them would panic and leap from their perch, hitting the water like guys cannon-balling in a backyard pool party, causing waves that could have easily swamped the low freeboard canoe. The fear I felt that day still lingers in my memory bank. Amygdala time again.

It’s surprising I had any room for these fears, given the night experience we had in the same low freeboard canoe when our guide suggested we abandon the relative safety of the bigger boat and look for crocs with a giant flash light. With their glowing red eyes, the crocs looked liked surprised kids at a birthday party getting their pictures taken with a powerful flash bulb. With such eyes, I imagined they would be able to back-track to the source of the light-us. Us in a low freeboard canoe. We even-well-not we, the native guide-grabbed a baby croc that was swimming by and pulled it into the canoe. Trepidation would describe my feelings and I just wanted to get back to the safety of the big boat with all of that freeboard.

We tied the big boat to a house on stilts, apparently the home of a family member of our guide, and hung our hammocks, then rocked gently to sleep. Not so gently actually, thanks to a few bad dreams about the denizens of the deep separated from us by only by a few inches of wood called our boat. Normal fears.

In the morning we were awakened by the sound of children laughing loudly and splashing vigorously. I looked overboard to see a dozen little native kids swimming around the boat, some even using it as a diving platform, straight into the darkened river we had been plying for piranhas and crocodiles.

kids in boat

Of course, they weren’t scared, they knew the swamp. They were familiar with the dangers and just acknowledged them as a minor inconveniences they had learned to accommodate in their lives, as we might if we stayed there long enough. When you live by the river, you soon learn there is no way around it, only through it. The swamp, of course, initially seems scary and there is a sense that it would be safer to go around it. But the swamp is endless. You can’t ever go around it-only through it. Attempts to circumvent those fears just postpone the inevitable, waste time and may get you lost. Nevertheless, my first inclination was always to stay in the boat. Thankfully I overcame those fears and soon found myself swimming with the kids, laughing and splashing like I never thought I would.

By now I’m sure you recognize that this story, while true, is a great metaphor for the grieving process. No way around it, only through it, scary as it initially seems.
I have related this Amazon adventure tale to many patients who seemed to be stuck in the grieving process, fears often turning to somatic complaints that brought them to the ER with problems relating more to emotional pain than some disease process.

It’s a good story. It’s also a good metaphor and seemed to get a strong response most of the time. Maybe you could tell it yourself some time. Just say, “I heard a social worker tell this interesting story…”

Dividing line

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Pathology

 

by Robert Lanz, LCSW

People have often asked me, “What was the worst thing that ever happened to you in the ER?” (I take that to mean, ” — thus far.”) My answer: “There is no worst thing; the worser thing is always coming.”

But one of the worst things that did so far happened, happened the night I had a fight with our hospital’s pathologist (aka, the autopsy doc.) The pathologist works in a icebox-like laboratory next to the morgue. Day or night doesn’t matter to him: no windows, nor sunlight. He never sees a living patient. He never deals with loved ones of dead patients. He never speaks to the social worker. This social worker had no experience or friends or any resources available to him to smooth-out a bad connection with a pathologist, when such smoothing needed to be done.  Not good.

If the pathologist doctor was adept at or slightly more desirous of interacting with the living, he likely would have gone into another specialty. I could even understand urology or proctology. At least those guys make visits to the ER.)

It’s important for medical specialists who only occasionally consult in the ER to see how social workers interact with patients, their families and the ER physicians. Social workers then become ‘people’ to them. If the social worker has to have an interaction on another of their visits at least they know they can utilize these social worker ‘people’ if they need them.

Every ER social worker has tales of working alone on the night shift, having to be dragged upstairs to deal with deaths in the ICU, angry parents in pediatrics and mentally-ill alcoholics demanding to be signed-out against medical advice — all at the same time, of course.  I was unique in that I knew of no other ER social worker, who had pissed-off the hospital autopsy doc — at least to the extent I did.

There are twenty social workers “upstairs” (the part of the hospital where patients who are admitted reside — the ‘nemesis zone,’ which I have talked about in previous stories.) With so many social workers up there during the day, it’s rare for the social worker down in the ER to be called upstairs to help. But the ER social worker at night is the only social worker in the hospital and it is common when there is a crisis to get a request  from upstairs: ‘Bob, can you come up?’

Downstairs, where the patients I have already started to evaluate or began an intervention with, will now have to wait until I come back from an emotionally and time-consuming situation waiting for me in one of the wards upstairs. Being pulled upstairs when I am still needed downstairs in the ER is a challenging, time-consuming tug of war that always put a drag on my ability to service the ER.

Tonight, a new grandmother was upstairs visiting her daughter’s very premature baby. The baby was still-born, weighing under the requisite five-hundred grams to even meet the criteria for a child to be issued a birth certificate. The still-born was sent off downstairs to the pathologist. In this situation, a still-born is not wrapped in a towel and placed in a morgue drawer like a larger dead infant would. That would be an easy fix. Security would open the door to the morgue and I could show the body. Instead, what is referred to as pre-term tissue is placed in a specimen jar and sent to the pathologist for whatever analysis he’s going to perform down there in his lab. Whatever it is, I’m sure it has rarely ever included a visit to the ’tissue’ from a  grieving grandmother accompanied by a meddling social worker. I guess the pathologist didn’t read the current social work literature, so I imagine he didn’t quite get how important viewing the remains is to the grieving process (regardless of the condition of the remains.). And this grieving grandmother wanted to view those remains. Who am I to deny her closure?

The remains in this instance, were in a jar on a shelf in a lab — a lab neither the grandmother — nor I — had ever witnessed the inside of. A mother making such a request may have had more emotional or legal or policy energy behind it to pull it off. But such an unusual request by a grandmother: that was a stretch.  I worried the pathologist might hide behind hospital policies and procedures and keep us out of his private space. The insistent grandmother raised the issue to one of the nurses. The nurse punted to the charge-nurse. The charge-nurse punted to the night supervising-nurse who served as the hospital administrator on this particular night. Fortunately, the night supervising nurse and I had a lot of ER ‘mileage’ together with a lot of mutual respect. Grandma was insisting she had a ‘right’ to view the remains. But the remains weren’t in space I had access to. The space in question was the lab, access to which can only be had with permission of the pathologist. Being it was almost eleven at night, the pathologist had gone home hours ago and was probably in bed.

Yep, he was  asleep when the hospital operator called and got him on the phone. I told him of grandma’s request. In no uncertain terms, he told me that it might be a good idea if I went back to social work school if I thought that grandma seeing the macerated remains of her still-born grandchild was a good idea. Click. That from a guy who worked in a room with no windows.

Macerated. Hmmm.  More dilemma. Should I try to de-tune that word and explain to grandma why the pathologist is reluctant to have her view the remains? I tried my usual ‘soft version’ of the truth, deflecting her ire towards hospital protocol instead of me.  “You tell that pathologist I’m tough and I can take it. And tell him I insist on seeing my grandchild!”

I had the hospital operator dial him again.”Uh. Doc, the grandmother here says she insists. She says she wants me to view the remains first, and if I think her viewing them will be too gruesome, she will trust my judgment.”

“Jesus Christ! Tell security to open my lab and let you in! The jar is labeled. Anything goes wrong, it’s on you. Don’t wake me up again!” Click.

Whew. He didn’t did ask for my name.

I went in. It was the middle of the night. It was quiet. It was dark. I groped around for the light switch and finally, I found it –the room lit up brightly: everything was either medical-green or stainless steel. I saw saw lots and lots of jars on metal shelves lining the walls and I did the best I could to avoid looking too closely at the contents. When I found the appropriately-labeled jar containing the grandchild, the remains didn’t look too macerated at all. Just very small.

I brought grandma in. She had her closure.

As she was leaving the hospital, grandma thanked me and apologized for pitting me against the pathologist.

I never heard from or spoke to that pathologist again. For all I know, he’s still down there in that lab.   Maybe one of these days, I’ll take a look. Maybe try to friend up a little. Do a little social work.

Dividing line

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Dying With Dignity

5 wishes

by Robert Lanz, LCSW

In case you don’t have a TV or a newspaper or internet connection, a young woman with terminal cancer named Brittany Maynard has been in the news for the last few weeks. She was well aware of her impending death and the painful and debilitating “cure” available to her that perhaps might squeak out a few more days of of life. She decided against it.

Those of us who work in hospitals know there are physicians who will buck the system and bend things around in an attempt to help someone with Brittany’s particular end-of-life wishes. But Brittany’s wishes are not the routine. To die her way, Brittany had to move to Oregon, where the medical establishment is more open — and more caring, I might add — to people making Brittany’s choice.

Since then, letters to the editors of many large newspapers have been flooded with personal stories of terminally ill people who changed their minds about trying to control  their process of dying.  I have never read anything by anyone who thought a few weeks of torture before a sure death was a workable idea. If you have been following this blog for a while, you may know that in my first story, Dying Sooner (ninety-five stories ago,) I outlined my personal belief about the dying process and argued that it was incumbent on the social worker to help families formulate a plan for their terminally ill loved ones. That story was based on my own experiences fifteen years ago, and I’m ambivalent about the “progress” we have made with the end-of-life rules in our health care system.

The introduction of the Five Wishes seems to be a start, and I’d suggest everyone make themselves aware of the document and get one signed for yourself and everyone else you know. Click on the link:

5 wishes preview

To me, it is like the shingles vaccination was: I didn’t think about it until I got shingles. Fortunately, most people who had chicken pox are now aware of the vaccine.  (I will add that having personally suffered the torment of chemotherapy and radiation, accompanied by some serious surgical scraping, I vigorously spread the word about the HPV vaccine too.)  Like vaccinations, the Five Wishes are a good prevention for what might happen.

I’ve seen hundreds of people die, and dignity is rarely part of the equation, especially in the ER.  Trauma patients are naked in a room full of strangers, each stranger working on a different part of the patient’s body: IV’s in the arms, catheter in the urethra, a finger in the rectum, a tube down the throat, and if you have really bad luck a, tube painfully placed into your chest cavity.  With extremely bad luck, the surgical resident will crack open your ribs, spread them wide enough to put his hand into your chest so as to do the pumping movement necessary to squeeze the last remnants of blood fr0m your heart into circulation. I’ve never seen it work successfully, but we try. Dignity? Well, if you’re young, one of the nurses will put a towel over your genitals. Maybe.

When your monitor flat-lines the trauma surgeon declares: “That’s all. I’m calling it. Time out 19:47.”A sheet is placed over the body and everyone exits the room.  A police photographer enters, removes the sheet and snaps a few photos. Often, police will look for evidence of a crime on or around the patient. As a final act of ‘no dignity,’ the housekeeping staff enters to clean up your waste. A part of you — the detritus of our futility — is thrown into the hazardous materials bin. When we’re trying to save your life, dignity is not an issue. We at the ER, do hope you led a dignified life and we hope that is how people will remember you — instead of like this. But we did what we had to do. And we did it for you.

Non-trauma deaths (heart attacks, pulmonary embolism, sepsis and the like) are far less gruesome and usually less intrusive into your body. But even then, the necessary violence of CPR is brutal and sometimes breaks ribs. Of course, the patient is unconscious for the procedure. Eighty percent of the time, unconsciousness will be permanent. Time out 21:02. Not a lot of dignity there, either. It’s obviously why ER physicians don’t allow a patient’s family into the treatment room during resuscitation attempts. I have had more luck with patients’ families in that regard, but less with the docs, though I found the docs did soften over time. In one instance, a young man wanted to be with his father while his father died. I brought the young man into the treatment room. At first the docs gave me the stink eye, but in moments the docs forgot him, and furiously concentrated on their work to save the patient. The son held his father’s foot for almost half an hour while we desperately tried to save his father. He later told me that he was an airline pilot, and that his training had been helpful in keeping him calm and focused during this ordeal. For my intervention, he thanked me generously. As the social worker, I knew exactly what the son got out of being with his dad in those last moments of his dad’s life. I wanted be sure the docs knew, too. I suggested to the son he tell them so. He did.

On the other hand, there is “upstairs,” where some patients die after being admitted. There may be more dignity up there, but dying up there is a slow and expensive fade-out rather than the quicker death — and medical beating — they get in the ER. Upstairs still lacks the dignity of dying peacefully at home, the way most people died, until medical technology came along and extended certain lives for hours, days, weeks or even months. But upstairs still beats dying in the ER. Most of the people in my family died at home quietly in their own beds. Of course, they had a real advocate fighting for them for have the dignity (me.) That’s how I’d like to leave when I die. The dignity upstairs comes at a very high price. No doubt that price will be a big issue for medical ethics people in the very near future.

In reality, there is about as much dignity at the end of our existence as there is at the beginning. The beginning, of course, is filled with hope and promise. But, each is a bookend to the amazing thing we call life.

Smiling baby

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