Tipping Point

Robert Lanz LCSW

 

Some people’s lives seem to be hanging in the balance, a delicate balance in which the slightest upset in the equilibrium can lead to difficult outcomes. If you have been living in your old fashioned apartment for twenty years and the hydraulic sling that lifts you out of bed and into a chair is about as old as the building, the tipping point can come with that final ounce of gained weight.

The hydraulic handle worked fine. The man was in the sling, perched precariously somewhere between the bed and the chair when the eye bolt connection to the ceiling beam gave way and he dropped about four feet onto his leg. That would be the leg that for lack of exercise had no muscle tone and when the three hundred and fifty pound body crumpled onto it, the knee was torqued way out of the normal range of movement.

It was easy for the paramedics to understand the mechanism of injury and the appropriate first responder intervention- splint the leg and transport to the ER. It was there that easy ended, slipping quickly into difficult and then impossible- more on that later.

A splinted leg is way too long to fit into the confines of the old time elevator in the aging building so two paramedics and two husky firemen somehow managed to carry the heavy bundle down three flights of stairs and into the ambulance. Turns out that was the easiest part…

In the ER all of the patient’s radiological results and labs looked good- we test everything in old people who fall, no matter what the reason. Everyone was amazed that no bones were broken and no terrible structural damage was done to the knee. If it had, it would have been easier for us- well not us- for me- to keep the patient in the hospital for some orthopedic repair. Then it would have been someone else’s nightmare to get him home. But it wasn’t someone else’s nightmare- it was mine…

It is almost impossible to get any insurance carrier to pay an ambulance bill to take a patient home. They figure that anyone that injured should just stay in the hospital- then they would deny payment if we didn’t do any further treatment of the patient when he was admitted upstairs. That night there wasn’t even a private insurance company to call- the patient had MediCal, state provided health care. They won’t take anybody home without an appointment. Try that on at midnight. Oh, I made a few calls but got hung up on pretty quick. It was getting close to my bedtime and I was getting desperate. I could spring for the ride with my own dough but I couldn’t even get any takers with that. I could try to admit the patient just so I could go home. That’s unacceptable, although tempting. I was getting really desperate, then I remembered that one of my musicians friends had just had a piano, a full on honky tonk, heavy piano, delivered to his house and he spoke eloquently about the team that delivered it, musicians also. Hmm. Is that legal? Piano movers do move big things and have all the equipment to make it seem easy. Just as I was giving it serious thought and was about to call my musician friend, a medical transportation company who had dropped off a patient upstairs was taking a shortcut through the ER back to their van.

“Whoa there my friend. I don’t recognize the company you work for. Is it new?”

“Yeah. First time at this facility We’re expanding.”

“How’d you like to get frequent referrals from the ER?”

Bargain made. Bargain kept. About six months later the company sent us over a bunch of pizzas and sodas. No piano movers necessary. Just good social work.

 

 

 

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Slip Sliding Away

by Robert Lanz LCSW

 

It was as if the nurse let the life slip out of the child’s arm when she pierced his skin
preparing to start an IV line. A more religious guy than me might have seen the little soul exit like an angel and float away, hope itself, leaving the room.

No one ever told the parents but they probably figured it out at some point. They should have paid more attention but they didn’t know what we knew about the frailty of a little boy’s life. They thought nothing bad could happen but we didn’t have that luxury.  Sick in the morning with vomiting and diarrhea are difficult symptoms and the parents called the pediatrician. They were instructed to go right to the ER.  By the time they showed up, well after dark, it was obvious the little boy was in serious distress. In the ER it is never a good sign when you get to the front of the line quickly. He bypassed the rest of the waiting patients and went straight to a treatment room displacing a teenager who thought she was pregnant. That’s when the life started to slip away.

When adults experience dehydration they slowly fade into that condition losing their fluids through fever or vomiting or diarrhea or some combination of those symptoms over hours. Kids have little reserve in their bodies so when they get close to their danger point in the dehydration spectrum they don’t fade. They collapse. The nurse quickly recognized the gravity of the situation of the child who had walked into the treatment room and then had no pulse.

“Call a Code Blue. Call peds.” she yelled out.

The parents weren’t sure what was happening any more than when they didn’t follow the pediatrician’s instructions to take the child to the ER hours earlier. Several rounds of vomiting later, here he was, dying.

As his lifeless body quickly became the focus of too much attention in a room full of adults in scrubs, the only person not assisting in patient care was me. It would be me who would be serving as the conduit between the code team and the parents. Everybody in the room would rather have been somewhere else. Me too.

Of course, the parents wanted to be with their child understandably thinking it would have some positive effect on him. Sometimes it does if the patient is conscious and frightened. But when the team is working on an unconscious child who is dying and prayers don’t seem to be getting any traction, all of us are frightened.

Frightened we got started too late. Frightened we might miss some critical symptoms like the parents did when they delayed coming to the ER. Frightened we might miss some critical clinical lab values. Frightened that nothing we did would matter even if we did our interventions with perfection. Perfect sometimes isn’t enough when someone is this close to the edge and could die right in front of the family.

In a code situation, parents in the room can become a minor distraction and we didn’t have any space for that at the time. I managed to get them out of our way briefly but they couldn’t stand the separation and begged to be with their child. Maybe they finally realized the gravity of the increasingly desperate interventions and started thinking about him dying but probably not being dead. That was too much of an emotional leap for them but one the code team had already accepted.

No one wants to have an audience when all those code interventions aren’t working but sometimes I can’t do anything about it except to stand there and watch too, that room full of pain and heartbreak and hopelessness.

I’d like to say it all ends there, we could just sign some papers and go back to the other patients. That never happens and everyone knows it but the parents. For them, there is no life to go back to. Our pain lasts for days, past a few more deaths and after those deaths the youngest one will finally leave our hearts like all the others.

I never knows what to say to make it better….

 

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And Then

by Robert Lanz LCSW

 

 

 

In the ER where busyness is one of the constants to overcome, the change of shift can provide some difficulties when patient information is passed from the leaving staff to the arriving staff. The night doc gets information from the day doc. Same with the nurses. Same with the social workers. Misinformation. Incomplete information. Or even flat out wrong information often leads to confusion and sometimes mistakes. Of course, when the daytime social worker hands off patients to me the same thing can happen. If it is a really busy change of shift mostly I just have to trust another person’s clinical assessment like I would my own. Here’s some advice. Don’t do that.

Apparently a father with an aging mother with dementia passed out from an overdose of Valium in the park while babysitting her. Someone called the cops and they called the paramedics. Dad and the mother were brought to the ER to get checked out. By the time I arrived for my shift at 3:30 she had already been admitted to be followed up by Adult Protective Services and the errant father was sleeping it off and was thought to be medically stable. He was waiting to be awake enough to talk to the police, sort of in a benzodiazipine holding pattern.

He was snoring in a room with three other patients and a nurse. No one thought he needed to be in restraints- possibly right but also possibly due to the extra charting requirements it would place on an already too busy nursing staff.

When there is a airplane crash or a boat sinking or a train running off the tracks the follow-up investigation always shows the same thing well summarized in the survival book aptly entitled “Deep Survival” by Laurence Gonzales. ” …unexpected interactions arise naturally out of complexities of the system. Such accidents are made up of conditions, judgements and acts or events that would be inconsequential by themselves. Unless they are coupled in just the right way and with just the right timing, they pass unnoticed.” Or, as my friend Paul, a commercial airline pilot for over thirty years says, “sequential fuck-ups ” are the problem. Small oversights and small mistakes add up until disaster hits and in retrospect everyone asks the same questions- Why didn’t we see that coming? And that? And that? The mistakes have increasing consequences and turn into into “And thens.”

The first “And that” in this disaster scenario was not restraining the patient. The second “And that” was me not bringing it up. The next “And that” was the cardiac arrest patient who needed the bed space occupied by the sleeping dad along with the nurses full attention. The next “And that” was when the OD dad was rolled into the hallway to make the necessary space for the cardiac arrest with no mention to anyone that he now had free range and was essentially off tether- no restraints. The “And then” list started about there

When I returned to the ER from a consult in pediatrics all I saw was an empty bed in the hallway where sleeping dad had previously been. Sleeping dad had obviously converted to waking dad while the staff continued trying to resuscitate the full arrest. And that’s how I discovered my patient had disappeared. No one had seen him leave. Too busy.

I called security and we fanned out over the campus to try and locate the escapee in the hospital gown and bare feet. A five hundred bed hospital has a lot of places to hide out in or fall down in or go back to sleep in. After a few moments I saw the patient crumpled on the ground with his eyes closed. Back to sleep? Maybe. I gave him a shake and he opened his eyes but I wanted to do a quick physical survey before moving him. I knelt down and gently moved his joints and checked his pupillary reflexes. I looked for bleeding or deformities. I noticed him wince slightly when I gently grasped his elbow.

Pulling his gown up a bit I could see a badly deformed ankle fracture. I looked up over his shoulder and saw the top floor of the three story building that housed the psychiatric unit on the first floor. If he went up there to the top and somehow got onto the roof and then jumped he would land just about exactly where he was now curled up. About that time one of the security officers helping in the search showed up with a wheelchair.

“That’s not going to be enough Hal. Go call a trauma code. We’ve got a jumper.”

Pretty embarrassing to have my patient escape, jump off the roof of the psych ward and then having to call the paramedics onto the hospital grounds and then transport the patient less than a hundred yards to the trauma center. I would have to tell the chief trauma surgeon all the “And thens”, starting with my own. And then I would have to make an embarrassing list of the “And thens” the first being the assumption he was a simple overdose and missing that he was just an over medicated psychotic and then it went down hill from there.

The next time someone passed me a patient they said they had evaluated I listened politely. And then did my own work up. And then it never happened to me again…

 

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Occam’s Razor

by Robert Lanz LCSW

 

Occam’s Razor is a principle stating that among competing hypotheses, the one with the fewest assumptions should be selected or when you have two competing theories that make exactly the same predictions, the simpler one is the better.

Turns out that Mr. Occam’s razor cuts both ways. In most cases if you hear hoof beats you expect to see horses about the same time. But there are times when the circus is in town and an errant zebra breaks loose from its moorings and runs up on you. But since you are in horse response mode the zebra can sneak up and bite you on the butt. That is a clue you are on the wrong trail and need to adjust your intervention appropriately.

I love living in southern California. We get to do things all year long that many people never get to do. We love our surfboards and skis and off road vehicles and all that sunny weather. We often joke that if we want a change of season we just get into our vehicle and drive to it. Want winter? Go up to Big Bear. Want summer? Drive out to Palm Springs. If the weather is really good you might have a problem finding a parking place at the beach on Christmas day. And, of course, we love our motor cycles because we can ride them all year long.

Springtime however will always bring about a spate of accidents associated with those pesky two wheelers. The first really warm day gets everyone out, dusting off their bikes and riding gear and heading out to one of the local canyons that end not too far from my hospital. Motorcycles and springtime are a difficult combination if you get stuck working the weekend shift in the ER where the trauma guys in helicopters will be working overtime-and so will you- bringing in the results of too much fun at high speed.

All the trauma doctors and nurses and the phlebotomists and x-ray techs are too busy to tend to the non-medical needs of the trauma victims. The social worker thus becomes the last member of the team to actually speak to the patient but will be responsible for the “Everything Else” list that doesn’t pertain to the patient’s actual medical care.

That includes securing the patient’s stuff, often in a hazmat bag- clothes, boots helmet,  gloves, money and cell phones and anything else that might help with friends, family, police, trauma doctors or maybe even the coroner. The patient may be unconscious or near death or so confused as to not serve as a decent witness to his own accident.

On the Sunday it was my turn, I gathered all the stuff and secured it in my office, separating the wallet and cell phone from the rest of the property. For the first fifteen years of my career there were no cell phones so I was in detective mode. Fortunately the last fifteen years were easier. A cell phone in your pants is like carrying a laptop with you and has just about all the information we will ever need. Pretty simple to speed dial the last number on the phone or go to the “Mom” button. Too bad that when it was my turn for the “Mom” button, the phone was crushed. The interchangeable SIM card hadn’t been perfected yet so there I was back to the pre-digital age again. Anyway I was sort of on top of things or thought I was when the far off hoof beats still sounded like horses.

I spoke to the highway patrol officer who was investigating the accident. He told me the patient was apparently riding alone and hit some gravel on the outside of a curve and went down pretty hard. His helmet had significant damage and the young rider was confused with no recollection of falling. An obvious head injury with unreliable memory and no one to help us out as to what really happened.

By the time it was my turn to see the patient I still didn’t have enough information to contact anyone who knew about him. Back from the CT scan he was sitting up on the gurney and seemed in OK spirits despite the gravity, or near gravity, of the situation. He didn’t remember the accident but he did remember the start of the day, having breakfast then heading out for the canyons with one of his riding buddies.

Wait a minute. One of his friends? There were no friends with him. He was laying there on the side of the road for half an hour before the helicopter got to him and none of the other motorcyclists enjoying the day seemed to know anything about him either. Doubtful that one of his friends would just blow by him and keep going. When I discussed this with the trauma surgeon she just thought he was showing post concussion confusion. She thought my information was solid since it came from the paramedics and the highway patrolman. They didn’t see any zebras either.

It was about that time the patient’s wife called the hospital and was patched through to me and I quickly explained his medical condition and the circumstances of the crash.

“Where’s Harold? Was he hurt too?” she asked.

“Who’s Harold?” I asked tentatively.

“His best friend. They went to breakfast together then up to the canyons.”

“On the same bike?”

I was immediately and momentarily terrified thinking that maybe Harold got tossed over the edge of the cliff and down into a thicket of chaparral. It’s happened to me before up in the canyons when one of those people who doesn’t believe in seat belts gets thrown from the car as it goes over the edge and is found laying in the bushes.

“No. Harold has his own motorcycle.”

I heard a click on the phone and the wife said,

“Hold on a minute. I have another call. It’s Harold’s wife.”

It seemed forever and it seemed to me that maybe the circus was in town.

“That was Harold’s wife.”

Turns out the Harold was just a couple of minutes behind our patient who had a better memory than we thought.

“Harold was up in the canyon laying beside the highway with a broken leg. He’s stable enough to go by ambulance. I guess they used the helicopter for another guy.”

“Uh, Dr. Veronica. I finally contacted the trauma’s family. Those hoof beats I told you about that came from the highway patrol.”

“Yeah, sure Bob.”

“Zebra. Sorry.”

 

 

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Senora Demasiado

by Robert Lanz LCSW

 

I quickly grew accustomed to biker junkies, crack heads, homeless speed freaks and alcoholics of all walks of life and the occasional novice pot smoker who got some super bud and had an anxiety attack landing them in the emergency room and needing some Xanax or other benzodiazepines to calm down.

Pot, even the killer weed you can now buy legally is never a true medical emergency, although in the midst of a panic attack I’m sure it feels like one. Opiates are generally medically benign when taken appropriately. Taken in excess, of course, they are a central nervous system depressant and an overdose will ruin an otherwise blissful high. I always thought the most dangerous part of the most commonly abused opiate, Vicodin, was all of the Tylenol that came with it. By the time you develop a bad Vicodin habit, 20-30 pills a day, you end up taking the equivalent of about 25 Tylenol Extra Strength capsules and it’s kind of hard on the liver. Not as bad as alcohol but close overtime.

I’m not sure why opiates are so rampant these days because my working experience was mostly prior to a bunch of Millennials on Oxycontin who somehow got strung out enough to actually stick needles in their arms and steal their parents jewelry to support a heroin habit when they couldn’t get any more pills. My colleague Dr. Drew has some ideas on all those things and he’s way smarter than I am about the neurochemistry and the neuroanatomy that seem to make it almost impossible not to rob fast food joints.

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In the nineties I took a class in why internet porn became so quickly popular and they had an interesting thesis that may explain why Oxycontin did too. Basically the premise was that the porn, through a pesky pop up, got the attention of the person on the internet and the curiosity turned into a greater pursuit and soon an otherwise “normal” person was getting very excited about it. Then it sort of got away from him and the next thing he knew he was downloading weird stuff from the net. These were the same guys who wouldn’t think of stopping at an X-rated bookstore somewhere. They didn’t know they had the weakness until it had them.

Same thing could happen with opiates too I’d say. If you have some pain that needs tending to and you aren’t on your game, the next thing you know you’re in the ER making up stories or even throwing yourself down the stairs just get some Vicodin. The good part about pain medications is they work really well. The bad part is that people with minimal insight let that get away from them when they discover opiates kill all the pain. Marital pan. Financial pain. Family pain. Unemployment pain. Not enough Likes on Facebook pain. An otherwise non-pathological person is strung out and then he is a pathological person and he’s turning into a junkie. Like the porn guy, something most people would be able to handle, this guy can’t. Genetic? Lame? Not paying enough attention to the downstream possibilities? Not looking at the WTF moment that we in the ER see every night? What did you think would happen when you (fill in the blank here)?

I don’t know, I’m more of a 60’s guy myself. The junkies from that time started out pathological in the first place and got addicted from there. Most of us hipsters never experimented with opiates or any downers for that matter, preferring to go the other direction and squeak out all the pleasures of the decade choosing psychedelics and good smoke. We could never understand why junkies chose to sleep through those most interesting times ever and the thought of a needle or cooking with a bent spoon was anathema to our crowd. Weed and acid were a lot more fun, in moderation of course.

I had friends, gangsters mostly, that I grew up around, who became addicted to heroin-  Vicodin hadn’t been invented yet- but it was no big deal to most of them. When their habit got too expensive, they didn’t escalate from robbing the local 7-Eleven to the local Bank of America. That was too dangerous when all they really wanted to do was get their habit back under control and affordable. No programs out at the beach featuring yoga, massage and 12 Steps with an ocean view. No alteration of neurochemistry or neuroanatomy for them. They had a much simpler solution. They had Desert Hot Springs, a small town, dying without dignity ninety miles east of Los Angeles in the cactus shadow of its more upscale neighbor, Palm Springs, across the I-10 Freeway and a few golf courses away. It was the perfect place to dry out, kick the heroin habit or at least get it back to affordable, holing up in a dilapidated motel with a friend or lover along with whatever was available to ease the week-long discomfort associated with cessation of opiates. Jonesing is what they call it -Jones being the emotional and physical pain of the body crying out for a better refill of opiates than the drugs available to make it more bearable.

They would use the Mother’s Little Helpers of the time, the infamous barbiturates in sleeping pills- Reds, Blues Rainbows (seconal, amytal and tuinal). Alcohol and weed would work too in a pinch along with the ever-present Valium.  Cramping, vomiting, diarrhea, the shakes, a runny nose like a bad case of flu and acute emotional anxiety for a week really sucked but in and of itself it is not medically dangerous. Psychologically dangerous for sure. Really hard for sure. But thousands of folks go through opiate withdrawal cold turkey in jail all the time. You’d think that such a journey might serve to develop a little insight in these guys or in fact even terror. Nope, that’s not part of the junkie experience. Not when they can get barbiturates and alcohol and benzodiazepines out there in the faded glory of that funky motel. Those drugs could cause addiction themselves but not in the short amount of time it took to kick opiates. So there you are, using dangerous drugs to get off less dangerous drugs and in ten days or so, all better and ready for the next round. Faster and cheaper than the thousand bucks a day for a program out in Malibu with stunning ocean sunsets. Not near as much fun though. That’s my story and I’m sticking to it.

However there was a different story too. The story of Senora Demasiado (Mrs. Too Much) the name we gave to the elderly Cuban refugee woman who showed up in the ER one night in what appeared to be the middle of a gigantic anxiety attack. We’re not mean and generally preferred to treat those acute symptoms with some benzodiazepines like injectable Ativan because it works quickly and efficiently and then we can do a reasonable medical/social work-up to see what the right treatment plan would be. Senora Demasiado was in line for one of those. Mr. Too Much was with her and he eventually fessed up that she had made this sort of presentation for years at several emergency rooms and had burned through more than a few family physicians while she became very addicted to Valium.

Well, with Valium addiction there is no week long runs out to the desert with some heroin or Vicodin to help with that withdrawal. While the overuse of Valiums alone won’t kill you, even taken by the handful, once you’ve got to that handful stage, trying to stop without acute medical intervention is dangerous. You can have seizures the same way during withdrawal from alcohol or barbiturates if there is abrupt cessation after chronic overuse. You also get sleep disturbance, confusion, vomiting, headache and the one symptom that is usually the withdrawal deal breaker, acute anxiety.

Yeah I know. Confusing. After forty years in the business and growing up in Hollywood in the sixties I’m still a little befuddled about all this addiction stuff when it seems like a person with even a little insight, judgement and impulse control could stop self destructing before, say, prison, AIDS, hepatitis C, loss of money, friends and family or even death. Just saying, pretty lame. Time for a trip to the desert….

Anyway that’s how the staff saw Mrs. Too Much who came to the ER several times so acutely anxious it would have been malpractice to not give her some relief-and in fact, over time, it became obvious that would be the only way we could ever get any relief from her. Unrelenting crying, screaming and begging and over the top anxiety. We called her prescribing doctor and he felt the same way. What to do? Cut her off?  She consistently refused programs to go through a supervised withdrawal. She would doctor shop all the way down to the Mexican border and when that burned out she just started to go across the border into Tijuana and walked into the farmacia there and bought a couple of hundred pills, stuffed them in her bra and walked back to America.

For all I know she may have been caught by the customs guys who, just like us, soon discovered they were as clueless as we were as to what to do when the several Valium she had taken while still in Mexico wore off when she was in custody. I’m sure they didn’t want her in their space any more than we wanted her in ours. A couple of hours with her and in my fantasy when the border guards saw her coming after her next discount medical trip to TJ they just gave her a wink and a nod and a welcome back to America. Lucky guys.

We couldn’t do that wink and a nod thing in the ER, of course. Nevertheless, we remained clueless about what to do. Her family doctor was clueless too and her husband was so stressed out he was about to start an addiction of his own. If I remember right even the ethics committee got involved. They weren’t sure what to do either. Finally, in desperation they consulted the night shift social worker in the ER. Since we had tried everything else, well, everything but a trip out to Desert Hot Springs, it seemed to be resting on me. In my desperation to have a workable answer when no one else could it I  sort of suggested that since she seemed to have unfettered access to her drug of choice on both sides of the border and since the drug was rather benign other than the addiction part and given that she had never overdosed and since she had been addicted since she was in Cuba several presidents ago it was obviously pointless to try and get her to stop now.

Jack Johnson, a surfing folk singer, has a famous song, “On and On” that sort of summed up our dilemma. And there we were. We give up Senora. You get to be a benzo addict for the rest of your life and if your doctor calls and wants you to get a shot of Ativan in the
ER then so be it. We wouldn’t give her a prescription. We would continue to offer a program if she wanted to get “well.” All we did was sort of get in the middle of a bad deal. The other part of the deal was up to her regular doctor, and the pharmacist in Tijuana I guess,

It’s rare for us in the ER to concede defeat. Rare but not unheard of…..

 

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Tin Man

by Robert Lanz LCSW

 

 

The Wizard of Oz was always one of my favorite movies when I was a kid. Maybe because all kids loved it. Maybe because Judy Garland built a castle with the proceeds of the Oscar winning movie on the street where I grew up. Maybe because the house has frequently been owned or rented by interesting show business people ubiquitous in my neighborhood. In fact a Grammy winning recording engineer lives there now. Or maybe I loved it because it was a really great movie.

But the Tin Man in the movie is nothing like the Tin Man in this story, except that, I guess, they were both on a quest to find a heart but in very different ways.  The ER Tin Man was on a solo quest, all down hill, no happy ending.  Our Tin Man was a huffer, a sniffer or whiffer with a penchant for what I had learned when I was a probation officer was the perfect inhalant, Five Star Silver spray paint in a can. It was guys like the Tin Man that finally moved the state of California to put all the huffables under lock and key, forever frustrating me if I have to go to Pep Boys or Home Depot on my project days and the store guy has to get a special key so I can get my own spray can.

Those who sniff fumes, usually the propellant not the paint, just spray it into a rag and whiff away. In a pinch, gasoline or most chemicals like that will work to some degree. In a pinch, if there is no rag handy a sock will do. I remember when I was a PO, mothers often complained that their sons came home with paint on their chin and a missing sock. Not a good sign.

The Tin Man was like that except he was so depressed and so incessant and so brain damaged and so sloppy that in his quest to stay high, or higher I guess, he frequently got off target, missing his nose and mouth by inches or more and eventually his hands and face were covered with that Five Star Silver paint. Thus The Tin Man.

The homeless huffer slept in the bushes not too far from the hospital and had been to the ER several times for being unable to care for himself.  The cops wouldn’t arrest him and the psychiatric unit wouldn’t admit him and he just remained in the ER until the social worker could get rid of him.

That was me on several occasions and like a mother hen I got my friend in housekeeping to give me some acetone and rags to clean him up.  Some people thought I spent too much time with him- sometimes I did too because besides cleaning him and feeding him and getting him some fresh clothes there wasn’t much we could do. You can’t jump off a high place or shoot yourself without being locked up in a psych unit if you survive but a chronic, slower path to the same death escapes the 5150 confinement rules. Apparently screaming and griping and tantrums by the social worker don’t get much traction either.

So the Tin Man cycled in and cycled out, all the social workers wondering what to do with a guy who accepted his impending death more graciously than we did.  Even on direct questioning he denied being acutely suicidal, stating “I don’t want to kill myself. I just want to stay high until I die.”

When the paramedics brought his charred remains in they described his “home” behind the overgrown weeds in a nearby vacant lot.  City camping with a discarded sofa and an overstuffed chair and even a coffee table with a big candle in the middle for light.   No one knew if he was out of socks or rags or if he had actually figured out a better way to inhale that mind numbing propellant.  Apparently, while pretty high already he sprayed half a can of paint into a large plastic trash bag then put his head in it. When he passed out and slumped off the couch the bag got too close to the candle flame and that was it for Tin Man.

Burns are the most painful way to die, seen it several times, patients begging for an opiate injection of painless death. No one thought the Tin Man suffered very long though, having not moved from where he fell, curled up like a burned wood match like we used to use for camp fires when I was a kid on a camping trip.

In The Wizard of Oz at the end, everyone got what they wanted.  I guess our Tin Man did too….

 

 

 

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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 Gandhi, 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 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 is 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 to give them a hug or a reassuring hand 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 her eye’s slightly she said, “About forty American dollars.”

“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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