Street Clinic

img_0048by Robert lanz LCSW

 

 

 

 

Sometimes a cigar is just a cigar-  Sigmund Freud

 

And sometimes a vacations is just a vacation unless you are a social worker far from home on the Indian sub-continent traveling alone. Then it is an adventure.

As per my plan, I entered India in stealth mode, late in the evening on a flight from Bangkok, Thailand directly to Calcutta- that would be the place referred to as the “black hole of Calcutta” for as long as I could remember  The most grinding poverty. The most grinding homelessness. The worst slums.  Maybe it’s better now but this was the middle 80’s and poverty was pervasive all over India-  it was just so much more obvious in Calcutta. I’d done some serious slumming in Mexico and Guatemala and Belize and Ecuador and all over Brazil so it’s pretty hard to shock me, but still it was a major transition, leaving the outrageous night life of Bangkok straight into the outrageous night death in Calcutta.

Part of adventure travel is, well, adventure. It is my preference to enjoy serendipity rather than security and I rarely make hotel reservations on my adventures but the whole black hole thing sort of had me on guard and I actually did make a reservation at one of the last of the Raj hotel.  Raj, being the somewhat pejorative term referring to the British dominance of the  area- Raj in Hindi, the local language, meant rule.  Although the Raj officially ended in the forties thanks to guys like Ghandi, the hangover of the social caste system remained, with the bottom dwellers referred to and often treated as untouchables by the remaining Brits and locals alike.  Hardly an acceptable solution to any self respecting social worker.

But there I was in the Raj hotel with an aging British marm who owned the place and served as the social director for wayward westerners like me. It seemed like a different century to her and her family and obviously they wanted it to be that way.  I was more accustomed to budget travel, low dollar and low key. To me it was better to spend a month on the cheap than a week of predictability with umbrellas in my mixed drinks and foofi linen from Egypt.

Coming into the city from the airport, bonfires burned in trashcans everywhere but it was still very dark and the street life was muted.  My taxi had driven through the giant gates of the hotel and I was transported back in time, servants and maids fussing over me, causing a vague sense of discomfort I wasn’t used to.

When I got up at sunrise, inside the safety of the hotel walls, all was peaceful and I paused a moment to take in the sounds coming from beyond the gigantic gates.  That might have been a good time to go back to bed, but I didn’t, moving to open the small wooden door that would transport me into the maelstrom that was the street life of Calcutta. Teeming hardly describes the activities I witnessed. Imagine if everyone in your neighborhood lived in glass houses and acted like it wasn’t glass and you could see them in the kitchen and the bedroom and the bathroom.  On these mean streets, the morning bathroom was the gutter. The morning shower was a fire hydrant and a bucket. The kitchen was a hibachi fueled by dry cow dung. Yet somehow there a sense of modesty- a lot of practice I guess…

This was a city where the people lived on the sidewalk. Everything in daily life took place on the sidewalk, except walking, of course.  People slept on the sidewalk, ate on the sidewalk, were born on the sidewalk, died on the sidewalk and in a scene I didn’t even want to imagine, were conceived on the sidewalk.  All under the watchful eyes of the ever present cows who were regarded as holy and got to do whatever they wanted to do whenever they wanted to, including blazing a trail through hearth and home on the sidewalk.  I hadn’t had that kind of sensory overload since the band I worked for in the sixties played a gig at the famous psychedelic Fillmore Auditorium in San Francisco. Wow man. What a trip.  I had to go back to the Raj hotel and take a nap.

That night, at the communal dinner table Hindu men in white gloves cut and served roast beef to all the westerners gathered, where I’d like to say, almost ceremoniously, we enjoyed a multi-course and lavish meal. We were all in good spirits while just outside the gates people were dying of starvation, having babies on the curb who might also starve or die from lack of medical care. I was starting to feel like my karma might be suffering.

“Well Bob, what do you do in America?” a clean cut young guy about my age asked.

“I work in a busy emergency room. I’m a social worker.”

“So you know a lot about medical care?”

“Well, I’m a social worker. I rarely touch patients, except them to give a hug or a reassuring arm on their shoulder.”

“You should come with us” he signaled that the ‘us’ included several attractive women at the table who turned out to be a wandering group of European nurses who apparently moved from desperate medical situation to desperate medical situation in third world countries kind of like what I did when I was younger except I was looking for some warm water and decent waves to ride.

“We’re going to be working at Dr. Jack’s street clinic. I usually run a big hotel in Bangkok but I do my vacations here every year. Working on my karma.”

What’s a guy to do? Say no? All those karmic opportunities. All that social working. All those pretty nurses. Sometimes spontaneity and serendipity lead to great adventure. Sometimes they don’t.

The sun was barely peeking over the Himalayas and it was already ninety degrees, sort of like leaving a Las Vegas casino at dawn, the outdoors is so different than indoors it is almost confusing-but there was nothing confusing about this crowd.  These were the untouchables, lined up as far as I could see, unable to afford the six cents it would cost to go to the government clinic.  How lame is that? If it wasn’t for all those wandering European volunteers, the black hole denizens  wouldn’t have any medical care at all. And there I was, lined up with those nurses all ready to do some serious touching of the untouchables.

I got partnered with a cute Dutch nurse who spoke decent English and had a dry sense of humor. Our first patient had a huge festering wound on his leg-cancerous the Dutch nurse observed.

“We’ll be doing some debridement and a dressing change. Try to ignore the smell.”

I’m pretty tough. Been a lot of places, done a lot of things but I like to do them right. Good hygiene. Universal precautions. Infection control.

“Where’s the gloves?” I asked sincerely.

The dry sense of humor dryly slid away -replaced by what looked like a dour expression.

“No gloves.”

“No gloves? How do you practice infection control?”

“See that tub of Matar over there?”

I knew what Matar was. In the very modern ER where I worked it was used to disinfect the trauma room after patients were admitted or died.  Dangerously caustic stuff. Our protocol was to double glove and use protective eye wear when cleaning with Matar.

“Just dip your hands in it before your touch the patient. Then dip them again when you’re done. Wipe off with that towel.”

When I was in the army that was called “field expediency”. Do what you have to do with the resources you have. Good training. Learn to think clearly.  For me it provided the clarity of a vacation moment.

“How much would it cost to buy a case of gloves around here?”

Rolling here eye’s slightly she said, “About forty dollars American.”

“Here’s two twenties. Thanks. It’s been real.”

I went over and took a walk through the Queen Ann Park where wealthy Indians were busy playing cricket and drinking gin and tonic over by the polo club. The park was still Raj. No homeless untouchables in sight. An old trolley passed through on rusting narrow gauge track, an advertisement painted on the side promoting a new brand of laundry soap.  The image showed a perfect message, It Pays to Buy Surf.  Or gloves I thought.

I went back to the hotel and packed my bags and went to the train station where hundreds of people and several cows had taken up residence.  I got a first class semi private cabin (air conditioned) ticket on the 187 Up train to Varanasi, where I’d get my camera stolen by one of the infamous Durga Mandir temple monkeys and then watched as cremated remains were pushed off a wall into the sacred Ganges river while I suffered vigorously at both ends from some train food I had mistakenly eaten..

That was a welcome relief compared to Calcutta.

 

But that’s not the end of the story. Home safe a year later I got wind that a co-worker was headed to Thailand. I packed a nice bag of medical supplies, including three boxes of gloves and sent them to the hotel guy so we could both get a karmic upgrade.

 

 

 

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Death On The Highway

It’s been over five years since I did my last shift in the ER so I’m fresh out of fresh ER stories. This, however, is sort of  an ER sotry from the eighties.  The patient needed a level one trauma center and a social worker and all he got was me. Shortly after this incident I went to UCLA and attended Emergency Medical Technician school.  When you are the only medical professional in your little village, people come to depend on your judgement. I had a friend about half an hour away with a clinic and he would see anyone I brought to him free of charge so I guess I was a triage person.  If I was going to have that responsibility, and it didn’t look like there was any way out of it, I’d need to buff out my skill set.

Bob Lanz LCSW EMT

 

 

 

DEATH ON THE HIGHWAY

 

I’m not the first guy to have trouble with his moral compass while traveling. Hell, that’s why a lot of guys do travel, to work out the kinks in their moral compass far from home.  But this isn’t a story about drugs or sex or smuggling or any of that other stuff that is so much fun while on the road. This has to do with my real moral compass. What was the right thing to do? And how much was I willing to pay to be morally right?

The evening started out nice enough. I was staying at a little fishing village catching a few waves and hanging out, chilling in the balmy tropical air. I had made arrangements to go to a friend’s house for dinner about 30 minutes away and this was long enough ago that no one had phones so meeting someone for some reason was always up for confusion and revisions.

I pulled off the dirt road onto the paved highway that headed through the mountains over to Banderas Bay. The night was warm and the air was thick with the smells of wet jungle and all the bugs you could ever want.  I had picked up an older couple at the crossroads, as any reasonable person would do, and in the direction I was headed I could get them pretty close to where they were probably headed too. I make it a practice to go pretty slow while jungle driving in the third world, especially in a vehicle like the Jeep-no top and no seat belts.  A lot of things can go wrong in the jungle, on the highway, in the dark-well, you can see where this is going.

We crested the highest part of the hill between the ocean and the bay and were dropping down nicely, with the wind in my hair and too much noise to have much of a conversation.  My linguistic skills constantly suffer from what I can only think must be brain damage of some sort and it causes me no end of embarrassment.  Sometimes, during rambling conversations I have lost control of, I realize it is better to not even get started with anything more complex than Buenas Noches.  So when we first saw the motorcycle lying on the side of the road, no one spoke.  When I noticed that there was a guy laying in the ditch about fifty feet from the bike no one spoke and my first thought was maybe they didn’t see what I saw. Pretty lame for me to think that and here’s where the needle on my moral compass was about to get a workout. Here’s where it would become painfully obvious that they had a different moral compass than I did. A south of the border compass or maybe they didn’t need a compass of any kind to know where they were going. They sure as hell didn’t need a compass to know what could go wrong here.

Having worked in an emergency room for several years, I was a lot more confident of my medical skills than my conversational ones right then so I came to a stop and jumped out to assess the situation.  There was a young Mexican guy on his side curled up like he was sleeping. Now I had traveled in Mexico enough to think this was a possibility. Some intoxicated guy decided this is where he needed to sleep so he just laid the bike down and assumed a fetal position beside the road.  Once in New Mexico I saw the same thing and all the locals laughed and thought it was funny when I stopped to help the local drunk that apparently made a practice of passing out on or near the roadway. But not this time. I noticed that the guy had blood coming from a scalp wound and he was making gurgling sounds.  The blood had already coagulated which meant that no one else was willing to stop and help him. That was an important clue.

A couple of other cars stopped when they saw me stop first and I tried to get one of them to go to town and call an ambulance.  It would be a futile gesture as I could pretty much see that this guy had a major head injury and would probably die no matter what level of care he got. The nearest ambulance was at the state line about twenty minutes away-and they were on the other side of the line and might not even come to where we were. There was an increasing number of gawkers stopping but no one was doing anything to help the guy so it was pretty much my show.  There isn’t a lot to do first aid wise for a major head injury and the cut had already stopped bleeding. What this guy needed was a helicopter ride to a level one trauma center.  What he got was a helpless gringo who wanted to do something but couldn’t.

The couple riding with me were trying to get me to just jump in the Jeep and leave the guy there and have him be someone else’s problem. Another valuable clue.  Let’s see if I can get this right.  They were afraid of getting in trouble with someone and didn’t want to stick around.  I was driving and I was a gringo and I could easily be blamed for the accident and I could go to jail or have to pay a big bribe or both.  On the other hand, no one was going to help this guy but me and I was a medical professional and had certain beliefs and ideas about taking care of people who needed help.  I couldn’t just leave him there alone but if I stayed maybe no one else would send for help and if help did arrive I could be blamed. No easy way out of this one. And the couple kept telling me that we ought to leave.

This might not have turned into a real moral quandary for another person with a different compass.  That wouldn’t be me and I knew what I had to do but I would have to be in stealth mode. So when the couple was momentarily distracted by a passing bus I jumped in the Jeep and took off, yelling back to them that I was going for help. Like it or not, it was their problem now as they were stuck in the jungle in a low traffic zone.  I drove as fast as I could to my friend’s house and he took me over to the police station telling me on the way not to mention to the cops that I had stopped.  Everyone seemed to have a much better handle on this situation than I did, in terms of the danger factor.

The police in this little town were state police.  That meant they were cowboys. They wore cowboy boots and Levis and cowboy shirts and cowboy hats and had big cowboy belts.  They carried cowboy carbine rifles and half of them carried their pistols just stuck into their waistband and aimed at their dicks. Very macho cowboy cops. They jumped into their cowboy pickup and followed me back to the crash site where things hadn’t changed much since my departure. The couple I had temporarily abandoned did some significant scowling but I had a Mexican of my own with me and the cops with us too so there wasn’t much more than scowling they could do.  With all the clues indicating a discrete exit would be the prudent thing to do, and my friends dropping some serious hints too, my compass was still overriding my judgement.  I know what needed to be done. That dying guy could easily have a broken neck and he should have his spinal column stabilized before being transported.  I figured the cops would call an ambulance and the ambulance guys would know something as basic as spinal stabilization.  I guess I was still in some sort of lame denial zone.

The cops picked the guy up and laid him down in the bed of the pickup with no attempt to stabilize his neck so if it was broken he would now be facing paralysis, if he lived.  Just when I thought it couldn’t get any worse, they threw the guys motorcycle in the back of the truck with him.  When they turned on their lights and sirens and took off, the motorcycle fell over and landed on the guy’s head. The couple was no where to be seen when we left, watching the flashing lights and truck disappear into the night.  I never saw them again and that was all right with me.  Later I figured out that they were a lot smarter than I was.

A few days later I found out the guy was taken to the little hospital in the next village up from where I started the evening.  I’m sure there was no trauma team waiting and I’m sure there was no neurosurgeon to read his CT scan and I’m sure there wasn’t a CT scan machine anyway.  While he was waiting to die the school buses from the neighboring villages brought all the kids by the hospital on their way to class, marching them all past the soon to be dead guy’s bed until one of them took a closer look and said “Hey. That’s my uncle Jose.”

A least when Jose died, they knew who he was and he didn’t have to die alone.

That was best I could hope for I guess…

 

 

 

 

 

 

 

 

 

 

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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 actually 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

 

DSC_0004

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 continue 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, equal 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 because 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 but 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 and insecure Americans.

Americans who watched as 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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