Lucky For Me Edson Liked Chinese Food

by Robert Lanz LCSW

 

I realize that my last post was pretty intense and in retrospect I hope no one started reading my blog with that story, pretty brutal.

In any case I wanted to lighten things up a little and after more than a hundred ER stories I decided to present something that I did outside the ER. A social worker is a social worker wherever he or she goes, taking their skills and values with them.

This youtube video is about 16 minutes long. It remains one of my favorite interventions…

. https://youtu.be/ika2Nr_Wh7Y

 

 

 

 

 

 

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Shift Change

by Robert Lanz LCSW

 

 

 

I thought the story about my bad experience in the pathology lab was the worst story I would ever tell. I should have known that even a good social worker is capable of repression under the right, or I guess, wrong circumstances- a normal response to the worst of anything. With effective repression, even your dreams are altered. Those nagging headaches and backaches and fatigue are there to remind you that you are in pain, temporary diversions to fool you into not paying close attention to what really is the source of the pain-like another dead infant. Another nightmare trip upstairs. Another charge nurse I’m friends with and have to make nice with no matter what the circumstances. A cumulative emotional thrashing in some far corner of the hospital, burning time I could have used to recover from the morass of bad patients, angry families, unnecessary death and the general cacophony of the ER. Upstairs is seldom, if ever, a relief. Even the cafeteria isn’t a good place to hide.

My trip up to neonatal ICU fills that category of no relief. NICU is a bad news zone on a good day and this was already shaping up to be a bad night because there’s only one reason to call the social worker up there after dark. The day shift worker gets to have a few in the win column on her shift, a baby finally turns back to normal baby color after a few days under the sun lamp, a baby is extubated and breathes on his own, that kind of stuff. No one calls down to the ER with that news and asks me up to celebrate life. Only bad news gets called down and the SW has to go up to take care of it.

The dead baby’s family was tearful as you would expect it to be after a lingering death following a difficult birth and an even more problematic pregnancy. After a night of passion with high hopes and big dreams, virtually everything that could go wrong did. Pre-eclamptic bleeding, a questionable ultrasound, premature birth.

Expectations may have some temperance with some families but hope is a powerful force and people will hold on to it until the end, or longer, and seem to be in a state of disbelief. This all leads up to great sadness with no one to blame but “circumstance”. It was catching. After hearing the endless dashing of hope since conception they certainly deserved some relief but other than an ability to listen and absorb the heartbreaking story I didn’t have much to offer.

When the family was finished and left I did my charting and the charge nurse did the same. I had unfinished patients waiting for me in the ER and they had been, what, cheated out of a timely intervention by the social worker when he had to go upstairs for another dead baby.

“Sorry I’m slow getting back to you. Had to go upstairs and I’m working alone tonight.”

Not much else to do or say.

A couple of hours later I got another call from upstairs. Another fetal demise mother, who was just a teenager, almost a child herself, wanting to hold her baby one more time and was now unwilling to let the nurse take it back to the morgue. The charge nurse didn’t know what else to do but call the social worker and invite him up for another torturous intervention where the only reward would be to have completed the gruesome task.

Another bullet I couldn’t dodge-babies having babies like they were cuddly stuffed pandas or something. Girls barely old enough to have sex having babies and now the mom holding the baby in a death grip you might say, oblivious to how much work and sacrifice it would have been to mother that baby. I remember thinking at the time, “Who signed me up for this anyway?”

The situation started going south the day her boyfriend convinced her they were in love and then convinced her that most people in love don’t use condoms or some such variant of that same old testosterone story. And in the end, just call the social worker to make it better.

Somehow I did. Active listening I guess. The mom reminded me of some of the girls I worked with in juvenile hall when I was younger and frequently asked, after a lengthy listening session, “What do you think is the best thing to do now?”

It worked well enough for her to voluntarily hand the baby to me, still wrapped in the baby blankets, I cradled the baby like it was still alive and went to the nurses station and wrote a brief note for the daytime social worker to follow up. I looked down at the silent package and it looked just like a sleeping infant to me, then I pulled the blanket over its face.

“Bob” the charge nurse said. “We’re short up here tonight. Can you put the baby in the morgue on your way back to the ER? I’ll have security meet you there and let you in. I already did the toe tag.”

Why not? Yeah. Why the hell not? Just another dead baby that looks alive going into the icebox. Why would that bother me? Ouch!

Dead babies in the morgue have their own special drawer and you never know how many of them will be in there, wrapped in towels or blankets or even heavy butcher paper sometimes. I never asked why. They just looked like pork chops or tri tip at the corner store and it hurts to even think about it.

The security staff opened the door and left. The baby already had the toe tag so all I had to do was slip it into the drawer and leave. I pulled on the handle, expecting to see the little packages that were always there. What I got was the fetal demise from neo-natal ICU, unwrapped, pleading eyes wide open staring right at me.

The emotional energy flung me back into the wall, tears streaming down my face as my knees buckled and I went down hard, defenseless. I almost dropped the baby as I hit the floor, a dead baby staring me in the face and another one clutched to my chest.

I don’t know who put that baby in the drawer that way and I was ready to hurt someone but for a moment I couldn’t even get up off that ugly cement floor, just the sobbing alone withered me. Finally I put the baby I was carrying in the drawer, removing one of the blankets and wrapping the other staring baby head to toe. I held its eyes closed until they stayed that way on their own. It was a little late for me but I didn’t want anyone else, ever, to feel what I just had.

I went back to the ER and found no patients waiting for me, the shift had changed and I left for home. I don’t remember much after that. That wasn’t repression. That was on purpose. This is a terrible story and I’ve never told it before. You’ve got it. Please never ask again what the worst thing that ever happened to me in the ER is.

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Mr. Puffy

 

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by Robert Lanz LCSW

 

I live in a pretty cool neighborhood called Silver Lake and I worked about fifteen miles away in a hip LA suburb called Pasadena, famous for the Rose Parade and Rose Bowl on New Years Day. It’s an easy trip back and forth between work and home except for one little stretch of funk between the freeway and my house by the lake. Of course it’s never scary when I am on the way in to work in the afternoon but on my way home after midnight, transiting the funk zone puts me on high alert.

First I have to cross the LA river. On one side of the bridge is the Toonerville Gang, so named because the old Red Car trolley used to pass by there sixty years ago when the tracks lead from Burbank to downtown LA. On the other side of the bridge is Frogtown turf- when the I-5 freeway cut through and eliminated the Red Car tracks it created the prefect neighborhood for thug life with minimal in and out points and easy to defend. It was right next to the LA river, thus, Frogtown. I knew about these gangs because I went to high-school with a lot of members of both of them. I also knew about the gangs because I was a LA County probation officer for almost ten years. Besides that we sometimes got trauma patients from the area when the county hospital was too busy to take any more and they were diverted to our emergency room.

Just past that danger zone, was the out of place in our neighborhood topless joint, the only place to get a beer and some company at one in the morning when I was driving home. Some nights were so bad in the ER that the bar actually looked welcoming and that’s all I’m saying about that out of place place….

After I went under the I-5 bridge and crossed Riverside Drive I was back in Silver Lake and felt safe and sound-well, safe anyway. And the story could end right there but under that bridge, living unmolested on the sidewalk was Mr. Puffy, the homeless guy.

Mr. Puffy didn’t start out with that name but over time it came to fit him, kind of like the clothes he wore. And as far as I could tell and as far as I could smell, he never took them off for any reason and over a several month period he started to look like the guy in the Michelin Tire commercial or maybe the Pillsbury Doughboy- he just kept layering up. I stopped once when he was keeled over at an odd angle and I thought he might have died or been murdered. I put on my ever present rubber gloves and mask and approached him and gave him a good shake like I was taught to do in EMT school. He woke up quite abruptly so obviously he wasn’t dead. With that smell he could have been.

“My name is Bob and I’m a social worker. I thought maybe you could use some help.”

“Fuck you” he yelled. “I hate social workers.”

Hey, I thought. He’s not my patient and not my responsibility. He wasn’t acting suicidal or homicidal- although my assessment of that was pretty brief. I left Mr. Puffy there and that was the end of my intervention-almost. Between Mr. Puffy and the topless place it was always interesting to go home and while it wasn’t too hard to resist the topless temptation it was always difficult to zip by the schizophrenic with a load in his pants and a bad attitude about social workers. A “Fuck you” response has never dissuaded me from trying to help someone in need.

In the mid-eighties or so, psychotropic medications began to improve and the days of Thorazine cocktails were waning. New anti-psychotic medications with a more benign side effect profile became a staple in the ER. It was a good sign and we all hoped that better medications would lead to better compliance with chronic thought disorder patients like Mr. Puffy. The feeling was, if we could get psychiatric patients started on the new medications they would clear their thinking and that clarity would result in a desire to continues with the medications. Made sense to us, but we weren’t the ones that needed the medications and that was just a group fantasy we all had. Chronic thought disorder patients remained, well, chronic, but I still had a dream for the sidewalk schizophrenic.

Along with the new meds was a new way of administrating the meds, my all time favorite being the time release, injectable Haldol that worked for a month-so before it wore off, the patient, while still thinking clearly, comes to the clinic at the three week point and gets another shot. Not perfect by any means but a lot closer than we ever got before.

About the third time we used the injection type Haldol in the ER I noticed there was enough left over in the little bottle for another shot. And that’s when the Mr. Puffy moral quandary came over me. Not some simple moral quandary like, should I stop at the topless bar and get a couple of margaritas and a naked lap dance after a hard night of death and destruction in the ER, but a true existential moral dilemma of epic proportions.

The dilemma would involve multiple felonies. First I would have to boost the drugs and syringe from the ER where I was a trusted employee. Second I’d have transport the medications with the intent to misuse them and then third, I’d have to sneak up on the social work hating Mr. Puffy and needle hug him and hope to hell he wasn’t allergic to phenothiazines. And I’d be doing it on a busy street not far from the North East Division headquarters of the Los Angeles Police Department where I knew a few cops. And I would be almost directly across the street from that topless bar. Pretty risky. But I was growing tired of the total inability of anybody to do anything to alter the course of Mr. Puffy’s life. I hated my helplessness as much as he probably hated his own.

Of course, I never did steal the Haldol, that was just a dream too. But I did drop food once in a while and sometimes a blanket or more clothes to layer into. Then one night, he was gone and I never saw him again. The out of place topless bar disappeared a few months later although I doubt if there was a connection. No more temptations on the ride home. No more moral quandaries in the early morning hours of my own desperation.

Now there is a medical marijuana dispensary and a musicians rehearsal studio in the building where the topless joint was but they’re locked up by the time I come home. Sometimes I swing by the Burrito King at Sunset and Alvarado and get a beer and some tacos. I don’t pay any attention to the homeless guys nearby or the junkies that Linda Ronstadt sang about in of one her songs called Carmalita so many years ago.

Just saving myself now…

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Man Down

by Robert Lanz LCSW

It was another one of those patients who can lead to nothing but problems- of course we didn’t know it when he came in, unconscious and possibly on his way to death. All the docs knew was that he was flat lining and they couldn’t figure out why. You’re never too young to have a heart attack but there is a curve and this guy was on the wrong end of it for that diagnosis. His pupils were round and barely reactive so it probably wasn’t a brain swelling event. His lungs were clear but he was barely breathing so it probably wasn’t a pulmonary embolism. But nothing we did seemed to be working and that meant I would need to contact the family. Normal stuff.

Normal stuff except for the business card I found in his wallet announcing he was a high ranking officer at a local corporation not too far from our own business district in downtown Los Angeles-and I won’t say any more than that because about twenty seconds after I found that out, hospital security called to tell me there was a woman in the waiting room asking about him. Must have been his wife I thought, noting his wedding ring. I was going to have to get her into the family room and get her ready for some bad news.

I peeked out into the waiting room and didn’t see anyone that looked like she might be his wife. There was the usual number of patients and families, a couple of heavy drinkers, a couple of other regulars, a hooker and a couple of guys from a bicycle crash with their lycra and funny shoes setting them apart from the rest of the crowd. But no one looked like the wife. I caught the receptionist’s eye and she gave me a nod towards the hooker, or the one that looked like a hooker. Don’t want to be judgmental, yet.

Oh no. Not the hooker. Not the one with the skin tight dress and overflowing breasts, looking a little disheveled. Disheveled in the sense that it looked like maybe she threw on her clothes while someone had a heart attack and called 911 while she was doing it. Not a street hooker. A street hooker might have called 911 but she would have disappeared, not come to the ER to see how her client was doing. If this was a hooker, she was a high end one. This wasn’t getting any better.

I went back to see how the patient was doing before I talked to her. He was already dead. Young, married, dead for reasons unclear, a beautiful woman who everyone assumed was a hooker and she has no right to any medical information. And there I was, right in the middle.

So I called the cops. I was trying to keep the ER docs out of the upcoming drama. We were too busy and we didn’t need to grieve and we hate having to lie to anyone, even hookers. We needed to uncouple ourselves and the hospital from all the bad energy. We’re a community hospital from a good community and the businesses were very supportive of our mission. Very supportive.

Luckily one of my friends was the watch commander and all I had to say was, Joe, I need a cop down here with bars right now. Not a street cop. Not a cop with stripes. I need bars or stars. Joe understood. Every call to the police is on a recorded line and as problematic as an upstanding corporate guy dying in the arms of someone not his wife. No use complicating things by adding unnecessary evidence or circumstances that could be blabbed around. This dead guy had enough problems. he didn’t need all the bad things coming his way to be spread around the community. I guess in the Everything Else list, this too was going to take some creative social work. I wanted to separate us from the circumstances as best I could. The patient was young and dead and that would entail police and the coroner. He was also prominent in downtown LA and the less the hospital was involved the less the circumstances would be somehow attached to us.

Pretty soon I had a cop with bars, a captain,  another friend who I could explain our position to openly. He got it. He also got his own room and his own phone number and his own liaison (me) and was far enough from the ER treatment area that we would not be part of the ensuing flow of cops and family.

Pretty soon I had the real wife show up and I have no idea how she found out. Pretty soon I had a corporate officer from the patient’s business who also wanted information. How the cops kept the woman the patient was with separated from the patient he was married to is still a mystery. The less I knew, the better I liked it. The corporate officer was in the loop as he apparently was friends with the wife. I didn’t see the woman I assumed was the hooker, or a close friend who dressed like one anyway, so I assumed the cops took her back to the station as a material witness to whatever had happened and that’s the cop’s job to figure out. We’re medical people and all we need to know for our legal documentation is what happened after he got to the ER.
Luckily my intervention worked just like I hoped it would.

An hour later the doc who had been trying to revive the patient asked me if the cops had ever showed up on his patient.

“Yeah, they did.” I said. “You guys were really busy and I didn’t want to bother you. Remember, this is a coroner’s case so keep it legal.”

“OK Bob. Thanks. What was the story anyway?”

“Not sure. I was really busy too and left it to the cops. They’ll leave it to the coroner.”

And for the most part, the ER was left out. Just like I planned.

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Harold and Mildred

by Robert Lanz LCSW

She was one of those older women like my mom or my aunt- women who were small children during the first world war. Women, who, when reaching what should have been the security of adulthood were thrashed again by the ravages of the great depression, wondering for years what could be worse, what next- And then she, like all the women in her generation found out what next was the second world war, the war that brought an end to the depression but rained down a whole new hell on already battered Americans.

Americans who watched their friends and brothers and husbands and fathers marched off to a distant war, a war that killed hundreds of thousands of men and even some women.

When all that was finally over and those that were coming home, did come home, there seemed to be a rhythm that satisfied a daily life. Not a hot danceable rhythm, just the rhythm of routine and people liked that. After two long wars and a great depression, people just wanted to feel safe, to hunker down behind a white picket fence with a loved one and not have anymore changes or adventures in life. Changes and adventures were too scary with bad consequences. What they longed for was sameness, security and predictability. They wanted to wake up to the same stuff every day, safe stuff. And they wanted to have a solid mate to hunker down with. In a life of frightening changes the forever of marriage offered a great comfort.

Of course, changes happen anyway in even the seemingly perfect marriages when couples grow old together. That’s what happened to Mildred, the last few years of her life turning into a nightmare. A nightmare some people would have thought of as punishment for some evil deed, although it is hard to imagine a deed so bad and pathological as to cause such profound torture.

Mildred never brought it up when she came to the ER with her husband, a once successful attorney who slipped into dementia and probably Alzheimer’s at the end of the contract they had married into about sixty years before. Alzheimer’s sufferers fall and get sick and have chronic medical problems like any other person in their age group but their ability to cope with those things and respond appropriately and accept help from a loved one are all compromised. A guy who used to be smart and powerful in the court room was now getting lost on the way to the bathroom, his power and sense of self ebbing away, replaced by depression and angry outbursts.

On their second visit to the ER I noticed some bruising on Mildred’s upper arm, the kind that show up on kids and old people when they have been vigorously grabbed and held tight. I tried to edge into the private space of their lives to assess the danger level Mildred may have been in. She probably knew I knew she wasn’t being totally truthful about the injuries. A little late in the party to change partners, she had picked the one she wanted and they planned on having the last dance together.

“Oh, I was in the garden with Harold and lost my footing. He grabbed my arm so I wouldn’t fall.”

A possible explanation but in my experience, not the most probable one.

“Mildred, you know I’m the social worker. My job is to look out for people, young people, old people, frail people, people who might not be totally able to look out for themselves. Sometimes I wonder about you. Your husband’s a big guy and I’ve seem how confused he is. I’ve also seen a couple of his outbursts down here on other visits. I just want to be sure you’re safe.”

“I’m safe. My husband would never hurt me.”

“If he lost control of himself who would you call for help?”

Mildred sort of stared off for a moment. Enough time to consider a couple of wars and a depression followed by forty years of safety and security. She had weathered the storm and seen the sun shine again. Going back to the storm wasn’t an option.

“We’ll be fine young man. Thank you for your concern.”

Maybe a younger social worker would have called the police or Adult Protective Services. Maybe a social worker who hadn’t been a long time observer of that generation himself would have just considered the mandated reporter rules. Those are the rules that say you should err on the side of caution and report any suspicions. But I know what happens when the cops or protective services get involved in these cases. Nothing good would come of it, nothing good for the contract they had signed with their wedding vows. So I just let it go.

Mildred and Harold made a few more visits to the ER in the next year and I always made it a point to check in with them. Harold followed a fairly predictable path of deterioration but I never saw any more marks on Mildred and I assumed things were stable or at least tolerable per their contract and I was relieved I hadn’t disrupted the flow they had chosen to live their lives with.

But when they didn’t show up for almost a year I began to get anxious and the downside of my failure to report began to chip away at me. On a couple of occasions I thought about calling their house but I didn’t, trying to balance my fear of knowing against my fear of not knowing. Maybe a younger social worker would have handled that differently too.

Time passed and the life and death craziness of the ER night shift covered my fears and I had all but forgotten the aging couple until the paramedics brought Mildred in. She had taken a fall and couldn’t get up. Harold wasn’t there to help her anymore.

Mildred told me that Harold’s doctor finally insisted he go to a facility that specialized in Alzheimer’s care. The separation had been hard on Mildred, being alone after all those years together. But she was a dutiful wife, visiting Harold every day, watching the man she knew slip away until one afternoon he no longer recognized her and all the emotional connection between them was severed. At least for Harold anyway. Mildred , however, of sound mind, was still up for that last dance, her own emotional ties intact and her daily visits continued.

One day, as if talking to a stranger, Harold told her, with the glee of an infatuated adolescent, he had fallen in love- fallen in love with another patient who was equally demented.

Mildred told me she tried to endure but eventually she saw how happy he was with his new love and hers alone was no longer enough to sustain her. She said she still loved him and liked to see him happy but that the heartbreak couldn’t be endured forever. She accepted he would have the last dance with someone else and she would be going home without her partner. She thanked me for all the concern I had shown over the years.

Her life was ending the way it had begun, cold, insecure and frightening and she chose to endure it alone.

I never saw her again but thought of her often like I do of the older generation in my own aging family. My generation had its own wars and financial crashes and job insecurities. We won’t know about the last dance either until the time comes. I just hope we can live up to the fine example set by Harold and Mildred….

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Freefalling

by Robert Lanz LCSW

If you are one of those families that has more kids than space at some point you will move the sofa too close to the window, not realizing the sofa is just another playground ride to a three year old. This is especially important if you live on the second floor like the kid who fell out the window and landed in the bushes that night I was working. His parents didn’t realize he had fallen until he crawled out of the bushes and banged on the front door.

“Who is it?” was the wrong question at that point.

Calling 911 when the kid wasn’t even crying may have been a wrong decision too. Showing up in the ER with an uninjured child announcing he fell over ten feet out the window will bring on multiple interventions including x-rays and a nosy social worker who will give you a safety lecture. If you have more bad luck the social worker will call the police and they will call the department of Children’s Services if the paramedics haven’t already done so. The police will make a home safety check on the spot and then add another layer of admonishment and safety lectures.

The Children’s Services worker will repeat the admonishments and safety lecture when she visits within the requisite seventy two hours. By now you will believe the entire medical/social/legal system thinks you are incapable of learning from experience but somehow several repetitive admonishments and lectures will get you up to speed in your child protection duties.

I used to teach getting home safely to the fifth graders at the local school adopted by the hospital as part of our community services outreach. I was never sure why they picked me for the job but I enjoyed it and the kids seemed to like my presentations. Fifth graders are usually ten years old and able to function independently if they get the right instruction and learn to use the right tools, that’s me, and follow the right rules  until a parent gets there.

The rules were pretty simple. Don’t answer the door if you don’t know who it is. Don’t have friends over unless your parents know and approve of them. Have a neighbor your parents trust as a standby just in case. If I was teaching the class now I’d have to add in a safety lecture about cell phones and porn sites.

In those days the kitchen was the most dangerous room in the house- gas, flames, boiling water, sharp objects, wet floors and all that. Now I’d guess the most dangerous room in the house is the one with the internet connection and no parents around. And while I’m still in the safety lecture mode, here’s an aside for you grown ups. You will age out of the kitchen dangers and move into the truly most dangerous room in the house for oldsters, the bathroom.

For that nightmare, turn your water heater down so you can’t possibly scald yourself even if it seems like really hot water is a good idea at the time. Replace the glass shower door with a plastic curtain. Put no skid surfaces on the floor and grab bars next to the shower, the bathtub and the toilet. And speaking of toilets, they are a common place for faints and even heart attacks so in the future when you are sitting on one, look around and notice there is no place in the whole room for a soft landing. Be careful.

And next time grandkids come over to visit, make sure the sofa isn’t next to a window on the second floor.

End of lecture. No safety checks needed….

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The Bell Curve

by Robert Lanz LCSW

A few months back, one of my professional colleagues, Patrick Scott, on his Facebok page presented an article in which the subject was about when, if ever, a patient with a major thought or mood disorder was amenable to psychotherapy.  I hope this vignette will shed some light on that question.

This is pretty long compared to most of my stories, have a coffee, relax, give it some thought.

If you think it’s easy to tell a crazy person from a not so crazy one
you’d be right most of the time but most is not good enough when
you’re doing an evaluation on a patient in the emergency room.
Before I get into a rant about psych evaluations I ought to tell you a
quick story about a dying woman that forever changed the way I look
at brain function and memory and how that put me solidly in the corner with Carl Jung and Joseph Campbell. If you don’t know who those guys are go directly to Google or Wikipedia and read up on them, then you’ll know what I’m talking about.

Before the dead woman, I knew less about brains and neuroscience than about how people are who they are. My undergraduate degree was in sociology and the group focused orientation created a separation between behavior learned by culture and what individual organisms started out with. We were lead to believe there was a marked line between what was physiology and what was culture.

Of course that was a long time ago-before PET scans and CT scans and brain mapping and all those techy things. The soon-to-be dead woman from South America had been involved in a serious car crash and sustained a massive head injury and everyone knew she was going to die soon. Sometimes there is nothing to do but wait and this is especially true with bad head injuries. When the brain swells and eventually becomes too big for the space it lives in, it has to go somewhere and that somewhere is a hole in the bottom of the skull where the spinal cord sort of becomes the brainstem. The brainstem is what you have in common with an alligator, a very primitive place channeling the basic functions of your brain to the other areas where thinking and feeling reside. There is no sociology or culture in the brain stem. At least I thought so until I was part of the crowd standing there watching the woman die as the higher functions of her brain tried to push through that little opening occupied by the brainstem.

The last thing we saw in her time of death was the woman crying out Aye. Aye. Aye. I never previously heard anyone say anything at the time of death and yet here was a woman not only saying something but something consistent with her culture. And that was when I took a look at that cosmic question- where is the “person” located in the brain?

Of course 20 years and several thousand interventions later we know that “memory” isn’t just located in the memory center but tends to be more pervasive over your brain. If that is true then maybe other things we thought were in certain places may also be pervasive, like psychiatric disorders. So let’s get back to evaluating psychiatric patients and how to be a good evaluator way more than most of the time.

If you know the history of thought and major mood disorders you know that generally there is a range of time in which the symptoms show up. At one end of the bell shaped curve there are a few kids whose parents or family members were aware that their child was always a little different, even beforethe sturm und drang of adolescence. In the middle of the bell shaped curve is the adolescent and young adult. The majority of those who will eventually have a full mood or thought disorder diagnosis will be in that age range and their symptoms will start to be obvious during these times. Whatever normal lives they had begun to have are now less normal than their peers with social and school and employment progress more impaired. Functionally that is were they tend to be stuck.

Those who show their symptoms at the other end of the bell shaped curve are lucky in the sense that they have had the time to develop a greater sense of who they are and because of that with the right medications and therapy they have a more developed “person” in their brains. Social skills, education, work experience etc. may have developed more like a person without a major mental disorder if it shows up later in life.

This is really important for more than one reason. The late bloomers actually have a somewhat functional personality to return to between psychotic episodes. They also are more likely to respond to the newer anti-psychotic medications because those medications have less of a sedating effect. When I started in this business, in the seventies, the major anti-psychotic medications were phenothiazines. They were quite heavily sedating and patients who were having hallucinations stopped having serious symptoms when they took their meds and patients who were having acute delusions stopped having acute delusions. These were wet blanket medications. They were a wet blanket over the patient’s personality so not only did the symptoms go away, so did the patient’s personality and his ability to function. The meds stopped all the bad things but did the wet blanket effect over the good things too. So how do you tell the late bloomers from the early bloomers when they are both acting equally psychotic?

The real problem will be the late bloomers- the ones who had plenty of practice being successful acting normal before they became psychotic. Now is the time to reflect on the South American woman dying and crying out “Aye. Aye. Aye.” Her dying cries seemed to indicate that some behavior is all the way down to a cellular level. This will be the person who can go to their non-psychotic place during a psychiatric evaluation in the ER for the same reason the South American screams Aye Aye Aye at the moment of death.

There were surely several patients who fooled me during my career, but in my defense they most likely fooled everyone else too and most likely didn’t get referred to me in the first place. If they did get referred to me I would do an evaluation to see if the person would be likely to hurt themselves or someone else.

Here’s two stories that will demonstrate how far a good social worker should go to ensure patient safety.

Patient number one was a late bloomer psychiatrically. He had graduated from college, gone on to get it a degree in one of those difficult science fields, STEM’s they call them now, at a respected university. He even worked for a while before some genetic element finally manifested itself and took over his life. He was a late bloomer with a graduate degree and moved away from his family to start his career. Maybe if he had been living closer to home his family may have seen his decompensation sooner and got him some help. Maybe. The patient also had diabetes so when he began his schizophrenic confusion his blood sugar suffered significantly. Very low blood sugar sometimes looks like schizophrenia and psychotic behavior. Highly elevated blood sugar can also cause confusion. Both of these blood sugar levels are medically dangerous so besides the dangers of a major thought disorder this patient had a dangerous medical condition as well. And also, to his own detriment, was his ability to have the social skills to fool people during psychiatric evaluations. Aye. Aye. Aye. This guy, luckily for me, had previously been to the ER and was known to have a psychiatric disorder. Of course he didn’t tell me that. His caseworker, who I’d known for many years told me he had gone to the patient’s single room occupancy living situation, housing for disabled people, and found the patient naked writing nonsense on his walls with his own feces. It was also noted that the patient’s monthly supplies of psychiatric medications and insulin appeared untouched so an ambulance brought the patient to the ER to be an evaluated medically and psychiatrically. Luckily for me the caseworker gave me the heads up about the patient and his bizarre behavior.

Of course the difficult patients always show up on busy days. When I needed the most time I had the least of it but because of the information provided by the caseworker I figured I should bump this patient to the front of my timeline. If he was as disturbed as his behavior indicated the first thing I needed to determine was if he needed to be in restraints to prevent himself from hurting himself. Considering his history I also want wanted a nurse to do a one touch finger stick to determine if he had an emergency blood sugar level.

When I went in to the patient’s room the patient looked a little disheveled but he made eye contact with me and was pleasant. When I told him his caseworker was a friend of mine and he had called ahead to have me look in on him he seemed to appreciate it. We talked for about five minutes and he showed no signs of psychiatric disorder. None. If I hadn’t been armed with the info from his caseworker I would’ve been fooled. In any case he appeared harmless, was in control of himself and wouldn’t need restraints. About five minutes later he got out of bed and walked out of his room into the zone where we all do paperwork, answer phones and interact with each other. At any one time there was about eight to ten staff in the area. That would be the eight to ten staff that looked at the naked patient and then at me asking in unison, “What’s up with your patient, Bob?”

“He needs restraints and he’s diabetic. Not sure what is worse right now.”

We put him in restraints and did a one touch. Blood sugar about 450. That was about five o’clock and by seven we knew for sure the patient would need a medical admission because he hadn’t been using insulin and if we let him go home he would just get worse. We called the medical resident to admit the patient and order a psych consult for later when he was stable. That would give me some breathing room, get him medically stable and then he could have a lengthy psychiatric consult upstairs.

The medical resident came down and saw the patient for a few minutes then came to talk to us about it. The patient refused to be admitted and to the resident appeared sane enough to do so and it was then back on us.

I wasn’t happy. The resident may have done at most, thirty psychiatric evaluations in his whole life and I had done thousands. Writing crazy stuff on the wall in his own excrement was a difficult symptom and not taking his psych meds and his insulin made it lethal as far as I was concerned.

I called upstairs to the psych ward and a psychiatric nurse came down to evaluate the patient. She knew about the blood sugar and saw how elevated he was and knew he would get worse. She knew he was off psych meds and then writing on his wall with his own feces. She knew he had been walking around naked. But since this patient was a late bloomer he could fall back on his acquired socialization skills and convince a psych nurse he was sane enough to take care of himself, she refused to admit him to the psych unit against as will.

Back to the medical resident for a medical admit. He came back down and refused to admit the patient against his will, again. Damn.

“I’m not admitting the patient. If you guys keep him down here against his will, that’s kidnapping.”

“Well” I said. “He’s not leaving on my shift.”

Our docs were lining up behind me.

“And if you think I’m kidnapping the patient, maybe you’d better call the cops.”

“I’m the resident and I’m not admitting him” he said. Then he left.

Our docs looked at me. I could call the cops and they would come down to put the patient on a 72 hour hold just because I asked them to. That would piss off everybody, well not everybody. Certainly not our docs or the cops. Everyone wanted a resolution and we were on sketchy legal grounds since the psychiatric nurse sort of had the last word on that part of the patient care. But legal grounds were not the only issue here. I thought we weren’t on decent ethical grounds because if he went home and continued as he was, there was good chance he would slip into a diabetic coma and die. If that happened everyone would be asking who in hell thought it was OK for this poop writing schizophrenic with a blood sugar of 450 go home. Being a late bloomer gave him the ability to “act” normal for short periods of time. But there was still the matter of medical non-compliance, shit graffiti and out of control blood sugar.

“Not on my shift” I yelled out in a crowd.

The docs agreed.

At midnight my relief signed in and I explained the situation to her. The evening docs signed out to the overnight docs. We all went home but everyone promised to keep the patient there.

When I came back the next day the patient was still there but finally gave up and agreed to be admitted for his elevated blood sugar. We won the battle, leaving the patient unrestrained, by just waiting him out and as far as we were concerned the rest of the system was wrong and we were right. If that patient had gone home and died from a diabetic coma whose fault would it be? As far as I was concerned mine. And I was able to convince our docs that I was right because I was right. But legally I guess we were okay because the psych nurse and the med resident said so. I’ll let the psych nurse and the medical resident tell the parents when they come to the ER and ask why a guy who walks around the ER naked and writes crazy stuff on his wall in his own poop was okay to go home and die.

Close call I’d say. Luckily I held firm. Luckily the docs trusted me. Neither one of us wanted to be the one to answer that question.

The next time I wasn’t so lucky. A young woman came in from a hip beach town down by the Mexican border. She and her sister and her friend decided to visit our town and party, staying at a high end hotel not far from the hospital. They were in their early 30’s, very attractive, had a lot of money and they liked to drink. I guess that would just be a great party to go to if one of the women didn’t have a bipolar disorder and recently stopped her meds. She also fired the manager of her small manufacturing business the previous week. That would be the manager who helped start that successful business 10 years before. Bipolar, manic phase behavior, drinking.

By the third day the party had fallen apart. The patient had been intoxicated and not sleeping for 48 hours. She locked the other two women out of the room without their keys and yelled in a drunken rage so the hotel staff called the cops and the cops called an ambulance. The patient was no longer just in the hotel, but now a loud obnoxious guest in the ER. She was intoxicated and impulsive enough to be put in restraints while I interviewed the friend and sister. They confirmed the obvious bipolar history and symptoms. They confirmed the impulsive, self-destructive behavior and heavy drinking. They were both terrified by the patient’s deterioration and both of them seemed reasonable.

“We get patients like this all the time” I said. “A lot of them get in a manic phase start drinking and head up to Las Vegas and party. No one notices in Vegas that they are manic because in Las Vegas they just look like they are having a good time. They almost always end up in some unsafe sexual situation with friends in hot pursuit and finally law enforcement gets involved.”

“How did you know that?” one of the friends asked.

“Well it’s happened several times on my shift.”

“No. Not before. Now. How did you know about Maria?”

“I didn’t.”

“That’s exactly what happened during a 24-hour binge. She kept running off with these strange guys and wouldn’t listen to us. We finally called the cops and they put us on the plane. We got back to the hotel and that’s when she locked us out.”

Drunk. Off her meds. Firing her manager. Impulsive and dangerous sexual activity. Educated, with money, she had a lot to lose if she continued to act out and everyone was begging me to lock her up and get her medicated. Everyone thought that was the best plan. Everyone but the psych nurse who came down to evaluate the late bloomer patient. She sobered up and psyched down returning to the “normal” that late bloomers have and early bloomers don’t. The nurse refused to write a 5150 hold on the patient. The doctor on duty was sort of a new guy and he wasn’t going to risk his license for me or that cycling bi-polar. And he had a psych nurse opinion to fall back on.

“She’s sober now Bob. She goes home.”

Big mistake. Normally I would fight. Well normally I wouldn’t have to fight and I could just have our doc call the psychiatrist on call and have a doc to doc talk. The psychiatrist has to depend on the ER for referrals and he wants to make nice with our docs and usually bends to our observations even if his own nurses thought different, a big advantage of the doctor to doctor consultation. This is a workable system most of the time but not tonight thanks to a lame psych nurse and a new ER doc and me not fully asserting myself like I should have. Most isn’t enough, of course, but I lamed out and didn’t put myself in a situation to fight a losing battle with an ER physician.

The patient did have two responsible adults with her I rationalized. But I knew I was wrong and I knew I was going to have to pay a price. It was just a matter of time before I would find out how much of one and my fear was I would have to pay really big. Oh, I can hide behind a psych nurse eval. I can hide behind my notes that said the patient could’ve benefited by hospitalization. I can hide behind the ER doc insisting that we discharge the patient. That might work most of the time. Not this time.

Of course that doc wasn’t around the next day when the patient’s family called to complain. She’d used her credit card to go the airport to fly back to Vegas. She was unable to stand up for the flight after consuming a lot more alcohol both in the airport and on the plane, apparently sobering up enough to get through what passes for security before boarding. She continued drinking on the plane and there was an ambulance waiting at the other end of the flight when she landed. At some point even the folks in Las Vegas realized she was a bipolar in a manic phase and needed to be locked up and medicated.

The family was all over me for not doing that myself in my own hospital. I stammered through a lame excuse for giving up my power but they were still angry at me and the system they thought I represented. I knew something bad was going to happen. Luckily it wasn’t something terrible.

Aye. Aye. Aye.

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