It Was A Cold And Rainy Night

by Robert lanz LCSW

I hate a cold and rainy night. I’m a sunshine and daytime guy who thinks people should stay home on cold and rainy nights just to give us folks in the ER a break from the downhill spiral that can occur on cold and rainy nights. But some people can’t stay home or don’t want to stay home or don’t care that we will be busy enough even if most people do stay home.

Junkies are like that. They live in dumpsters and will take a shot at the ER waiting room because they know it will be busy and it may be hours before they are called for treatment for their made up complaint. Meanwhile, being warm and dry in front of a TV keeps them happy. Unsettled people who are home alone might get fearful because it’s a cold and rainy night and it’s dark as well so they come to the ER for some relief from that combination of elements to hang out in the waiting room watching TV with the homeless dumpster guys. And one man on his way to a car crash, a heart attack, hypothermia and drowning apparently couldn’t resist going out on a cold and rainy night, either.

Luckily for him, maybe, there were no other cars involved in the crash by the arroyo, now filled with rapidly moving, cold rain water. Perhaps another guy would have kept his car on the roadway instead of flipping over the edge into that rushing cold rain water. That’s what the cops and paramedics thought. Because his car was upside down in the water, the paramedics had to tie themselves together, tethered to their ambulance in order to safely go into the water and “save” him. They got hypothermia too.

They all got into the back of the ambulance and tried to warm up together. It worked OK for the young paramedics with healthy hearts and lungs but not so well for the old guy who didn’t have much of a heart beat and whose lips and fingertips had already turned blue. The paramedics warmed themselves with their vigorous CPR actions and other resuscitation efforts so their lips and fingertips never got blue.

“Probably had a heart attack and crashed,” they said as they looked at the feeble EKG on the monitor. “Doesn’t seem to have any injuries.”

The ER physicians agreed with that assessment as they continued with the CPR and warming measures.

“Got a lot of water in his lungs so he was still breathing when he went into the water,” one of them observed. “The cold rain water might have saved him from a fatal heart attack, all that hypothermia. Too bad he drowned.”

A string of bad luck, a heart attack and maybe some seat belt injuries we couldn’t see because his blood wasn’t profusing well yet. Then hypothermia and drowning. This guy was heading for the exit, all right. But not on our shift. A few shocks, some warming blankets and he was good to go. Well, good to go upstairs to ICU at least. That’s where he died the next day after the rain had stopped and the sun came out. By then the junkies and easily traumatized had all gone home…

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Demographics

by Robert Lanz LCSW

When I go to see a patient with my demographic background and a serious medical condition, like any normal guy I become acutely aware of my own angst about these things. Having survived motorcycles, backcountry skiing, off-road racing, extensive third world travel adventures and being a roadie in a sixties rock band, I thought that with age I would just go gently into the night and die as an old man in my own bed.

The good part about aging, at least medically, is that many devastating illnesses tend to cluster in the under-fifty age group, especially those out-of-nowhere neurological disorders that sneak in and cripple you through no fault of your own. With these issues behind you along with the wayward testerone based decisions of youth, it is a relief almost to have finally arrived at a place with some degree of safety.

However, always lurking are the degenerative diseases of aging: heart problems, lung disorders, kidney disease, cancer, Parkinson’s, more cancer, dementia and all those other things that take quality away from the quantity of life there is left to otherwise enjoy. So even with some of the dangers behind us, oldsters have an equally apprehensive view of the future, which promises, at the very least, death.
When such issues present themselves in the form of a patient who, most likely, is or should be dealing with them, the ER social worker sees a natural intervention opportunity. Perhaps the intervention will be a simple walk through where all is normal, or it might be a major intervention because the patient is in denial. Luckily, my ER culture was such that the social worker could do “independent case finding”, which essentially meant we could see any patient we wanted to for any reason we thought was clinically appropriate. The ER docs were more curious than upset about us coming into their own clinical space. Good social work often has that effect.

The night was slow enough that I could actually cruise the charts for possible interventions or even some simple public relations work, giving the staff another opportunity to see what a clinical social worker does and how we do it. In the future, this knowledge might enable the staff to know when to refer patients to us.
That night I noticed a guy about my age-fifty four, a little young to end up on a monitor in the cardiac room, so I read his chart.

Chest pain and anxiety. Blood pressure medications and anti-rejection medications. Heart transplant about four months prior. Divorced, teenaged kids living somewhere else, no visitors, suffering alone. Scared me just to think about it and I surmised he felt the same way, so I went into his room and struck up a conversation.

“That whole heart transplant thing seems so scary,” I offered.

“It was. I was on the transplant list but running out of time. My cardiologist was getting concerned about my spot on the list and thought I was coming perilously close to passing on. I didn’t realize how close it was until he noted that there was a three-day weekend coming up and maybe someone else’s bad luck would be my salvation. Sure enough, Sunday night my beeper went off and it was the hospital telling me to come right down; they would be ready to do surgery in two hours. My broken heart almost stopped. Six hours later I was waking up in the recovery room with a new one. A seventeen year old girl in a car crash and a bad head injury saved my life but she lost her own.”

“Somebody watching over you.”

“I guess. I’m just glad it happened. Not that way of course.”

“Does it feel different having a young female heart?”

“Man, I don’t know. I was so close, so desperate I would have taken any heart. I’m just happy to have it but I’m not happy about how I got it.”

The nurse came in and started disconnecting his IV, his pulse oximeter and EKG leads and told him we had called his cardiologist and that the cardiologist was OK with him going home. She added that our doc would be in to speak with him before he left and that he’d probably want have a follow up with the cardiologist in a couple of days.
More than a drive-by, less than an intervention. Just a good story, some relief for the patient and some for the aging social worker. All bad things don’t end too soon. Maybe I will die an old guy sleeping in my own bed at home…

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Last Night

Farwell

by Robert Lanz, LCSW

On my last night of work—my last shift ever—there was a small party for me in the nurses lounge. The usual fare was served: chocolate everything with copious amounts of coffee. These going away parties never got too emotional and were usually unfocused and brief as there was always, always, always, a cardiac arrest or other trauma to disrupt things. Any tender emotions that staff members might have been feeling regarding my leaving would have quickly shifted to anger or disgust following an overhead page about some incoming disaster. Sad goodbyes, even after thirty years, took second place to code traumas or code blues, which was always a real possibility and everybody knew it.

With that in mind, no one ever got so caught up emotionally that it would have been hard to shift to an entirely different mental state, thereby bringing an abrupt end to the party. Besides, everybody knew that I would be throwing a huge all-out bash at a local pub within the month, at which no one, except for the cops and paramedics, would have to leave from abruptly. I would then have the appropriate and lengthy sendoff that I had earned.

I’m not sure what I expected for my last night. Not that my expectations mattered. As they say, “it is what it is”. The rest of the world wasn’t going to be different just because I was ending my career in the hospital where I had spent half my life since kindergarten. To the rest of the world it would be just another night. Maybe something wild would happen. Maybe not. Maybe I’d be bored or maybe someone will throw up on me- more than likely, I wouldn’t be called upon to give any good news.

To be honest I was probably a little more affected by it all than I let on and probably everyone knew it. I walked the halls and looked around, seeing things that brought so many memories, good and bad. All those strangers’ deaths and all those friends’ deaths. It was really hard not to wonder when it would be my turn.

About one in the morning the shifts had changed and the overnight nurses were settling in with the overnight docs. I wanted to hold them all and squeeze them all of course, but that would have been a little overboard, so I just bid them goodbye and told them all I’d see them at the Adios Party. I thought I’d finished when I heard the phone ring.

“Hey Bob, can you come down to room fourteen? Got a kid with a weird head injury. No one speaks English.”

A kid with a weird head injury could mean anything. The overnight social worker was already with another patient and she didn’t speak Spanish so I figured I’d go ahead and get things started. If it turned into a Children’s Services and police nightmare like it could have, I’d get things started and find someone to translate and let the overnighter finish it herself.

The doc headed me off in the hall and took me to the X-ray box- never a good sign. He started giving me the history while he searched for the digital image of the kid’s skull.

“The kid says he fell and hit the wall at school and wouldn’t stop crying so the school called his father to come and get him.”

After so many years, you learn that nothing is that simple. But this case didn’t present a very suspicious mechanism of injury, so why was I there?

“And with that history you sent the kid over for a CT scan? What’s up with that?”

“He wouldn’t stop crying. He seemed a little dizzy. I thought he might have had a concussion but with that lightweight fall it wasn’t likely. Oh. Here’s his scan.”

The box lit up his skull in almost three-dimensional clarity and I was reminded of something I always joked about. You know how to tell a bad break on a CT scan or X-ray? Even the social worker can see it.

And there it was, a tumor the size of a walnut. The tumor that would have caused symptoms sooner or later and the little head whack at school just made it sooner.

“Big tumor. What do you want me to do?”

“I don’t speak Spanish and this will probably be emotional so I need you to be there.”

“And what about that tumor?”

“Probably kill him in a month or so.”

“And I have to tell him that?”

“No. It’s your last night. We’ll send him down to Children’s Hospital with a copy of the scan. Let the neuro guy down there tell them.”

I didn’t tell him but the neuro guy down at Children’s wasn’t a guy, she was a woman. She lived across the street from me and was a long-time friend. I’ve seen her many times since then, but I never asked her about that little boy. I don’t do that kind of work anymore.

Dividing line

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Spoiled

Anthony Bourdain

by Robert Lanz, LCSW

I won’t say my secretary Miss B makes fun of me to hurt my feelings, and it never does because I know we are friends. She’s a recovering addict and once told me, “Bob, you’re always the same. To me, that consistency is comforting. I see how you are with all he patients and I know that’s how you will be with me.”

That’s flattering. She’s seen me under the worst of circumstances with the most difficult people and all the emotional difficulties that come with major loss of some sort, aimed squarely at the guys in the front row: the SWs and the doctors. On several occasion when I was being threatened or berated by some broken person,  Miss B came out from behind her desk and got into their face the same way I did when I was a probation officer. I can do that as a probation officer in juvenile hall but it would be frowned upon my doing so as a social worker in an hospital. Still, I liked that she did it because it showed she was protective of me. Besides, I felt the same way she did, but under the circumstances, couldn’t unleash my fury.

But it wasn’t those occasions that she made fun of. Rather, it would be phone calls from what she referred to as “my patients.” She called them that because they called to see if I was on duty that night before getting themselves in situations where they’d wind up in the ER.

By definition “my patients” had perceptual difficulties, but they weren’t like the one-timers who lost loved ones or received a debilitating diagnosis or had near-death experiences. The regulars were the stoners, the homeless, the psychiatrically-impaired: the goofballs without structure, the brain-damaged or some combination of the above. Ask anyone who works in an ER: these are “social work” people. These are my people, and to many of them I’m “their” social worker: they have a perceptual reality like the one I have with my secretary. I find it equally flattering and I’m touched by it.

It reminds me of when I worked in the Family Treatment Program in juvenile hall. To many of those kids I was the dad they never had, the older brother they didn’t get: the adult that made the clear rules and enforced them fairly. Some of them continued to call me after their release from detention or took a bus down to see me, or asked if I could take them surfing or just have a talk. A couple of them even figured out where I was when I had Flaco’s Cantina in Utah and came up to help me out, chopping firewood and shoveling snow. That was very touching, too.

I came to understand those kinds of relationships over time out of necessity: if patients were coming to the ER to see me or one of the other social workers specifically, I wanted to know why. After a lot of thought and a little reading I figured out that in some strange way I was both an anchor and a flotation device to them: something they could hold on to when their emotional storms blew in. In their eyes, I was ensconced in the safety of a 500-bed hospital with a forty-bed emergency department and a social-work unit where they could become enveloped safely in. Once again, I was flattered.

My supervisor upstairs found out about “my patients” and called me up for a talk. I wasn’t concerned, because I was getting results with these “patients,” even if I was often unconventional in my methods. My supervisor mentioned the CEO of the hospital was aware of the positive happenings on the evening shift, and he was pleased. The CEO was a good guy and always seemed on top of his game, so I was pleased too. Nonetheless, I’m sure the financial bottom line was always a consideration — after all, he was the CEO.

Although social workers seldom learn any business skills in college and most of them remain satisfied spending other people’s money, I’m not that way myself.  Like any good businessman I want to know that my money is being spent effectively. As Dennis Miller once said, “I don’t mind spending my dough on the helpless but I do mind spending it on the clueless.” Regardless of what they taught us in graduate school, there is not an endless supply of money to fix everything all the time. If you think there is, you might have gone to grad school in the sixties when President Lyndon Johnson actually thought social welfare programs would end poverty in seven years and taxpayers could go back to spending their money on homes and vacations for themselves. But nearly fifty-years and trillions of dollars later,  we have more poor and dependent people then ever. But that is a rant for another time.

The emergency room provides, by law, the most expensive medical care money can buy. Yet a high percentage of ER patients do not even have a medical emergency or even an urgency. What they do have most of the time is some personal difficulty: medical, emotional, financial, chemical, or the like, and they are looking for relief. Absent a physical malady, they look to the social worker to provide relief.

The form of that relief depends on the individual style of the social worker. Everybody is different. Not everyone brings the same experiences to the table. Each brings their “self” to the party, with that “self” wrapped securely in the ethics, values and skills of a social worker. Maybe at your job you can’t always be “you,” but you can always be the “social work you.” That’s the anchor social worker; the flotation-device social worker, too.

For most of you, the first thing you do when you get in a car is buckle up And if the car doesn’t have a seat belt there will be some anxiety involved. I’ve been in plenty of seatbeltless third world taxis, and I assure you, it is disconcerting. When something can go wrong you feel a lot better knowing there is an anchor or flotation device to go to. So that is what I strove to become for those patients who felt unanchored and adrift or about to crash some time.

I’ve heard this story so many times I accept it as almost universal. Patients say they were at home, often alone, and started to feel dread or anxiety or suicidal or even hungry. The feelings remained unabated and over time overwhelmed the coping skills of the patient and they call for help. They call the ER and speak to the secretary to see if their favorite social worker was there. Sometimes they even ask the secretary to tell us they are coming in for a visit. She always told me, of course, at the top of her lungs: “Bonnie’s coming,” or “Joe” or “Mike” or “Lucille” or “that stinky homeless guy who plays the guitar.” Whomever.

The patients had the same tale: “As soon as I thought about going to the ER I started to feel better. When I got in my [car-bus-taxi-bike] and headed for the hospital I felt even better. When I saw the big red lights that said ER I knew I would be OK.”

The anchor was set and they felt better.

I often met those patients in the waiting room. If they had no medical complaints I could sometimes solve their problem right then and there: no expensive medical tests, no CYA EKG‘s — no taking-up an expensive bed when there was a cheap and easy fix. Maybe some talk therapy or some active listening or some fresh clothes, or, if it wasn’t too busy, a meal together in the cafeteria. If the patient wasn’t harmful to themselves or others and wasn’t gravely disabled, the patient could choose not to see a doctor. I’m an EMT and know the basic medical stuff, but I always ran my waiting room interventions past the doctors and triage nurse. No one complained about these chair side evaluations. Who would when the expensive and crowded ER is usually, well, expensive and crowded. I’m sure that is part of what the CEO liked.

Many times the patient’s presenting problem was suicidal feelings or hearing voices, too serious for a drive by in the waiting room, but everyone knew it was my patient and once the medical staff was finished with whatever medical workup they thought was appropriate it would be my call to admit or discharge the patient.

By having that anchor relationship I could often just ask the patient if they felt safe going home. If they didn’t I would arrange for the admission. If they felt safe, I’d hang out with them for a while longer to be sure and then have them promise to come back by ambulance if they changed their minds.

Sometimes I just needed to offer some direct provision of services like food or clothes or bus tokens. Remember my guy Richard in the Big Dick story? He’d come down for some fresh clothes every few weeks and maybe have dinner with me. Before he figured out that anchor thing he would fake some illness and use a valuable bed and other valuable resources just to get some clothes and a meal. When I confronted him about his ruse he apologized and promised not to do it again and he didn’t. He remained his goofy self and I have no delusions about his ongoing drug use and camping in the arroyo but as to his misuse of the ER, he kept the bargain and on some level we were almost friends.

There are a plethora of men and women just like him and they can be expensive or they can be less expensive if good social work judgment is used. And I know it is an anathema to most social workers but any employee should save the system more money than it costs to employ them.

Even my secretary knows that….

Dividing line

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The Nicest Guy I Never Met

classic-engagement-ring

by Robert Lanz, LCSW

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

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

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

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

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

All information out of the trauma bay is filtered to family members by the social worker. Everything relevant from the family to the trauma team is filtered back the same way.

The night the ‘nicest guy I never met’ showed up presented as a mystery, as they often do. An unconscious young white male, who could have been any garage-band grunge-rocker or a community college kid, had been hit by a car while riding his bike on a busy street. The car that hit him didn’t stop and the nice guy was knocked unconscious immediately. Upon arrival he appeared to be a more highly-functional type than the majority of our trauma patients: no smell of alcohol; no marks to imply injections; well-groomed, clean clothes. But, no identification.

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

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

Jeez. According to the police, he was on a funky old three-speed bike. No one around recognized him as an ER regular. No wallet, but maybe it had been blown-out of his pants and onto the street, but nobody had found it yet. That’s not uncommon. Sometimes patients that come from board and care facilities have their name inked on their shirt collar or on their underwear band. Not this guy. No gaudy cubic zirconium in his earlobe. No gold chains around his neck. No tattoos or obvious scars. Just all that cash. I’ve had several drug dealers brought to the ER with more money than this guy had, but it was never in the form of crisp new bills straight from the bank. Drug money is more often a bunch of crumpled small bills, and the holder has ink and jewelry that advertises: “I sell dope. Step right up.” Not this guy.

Somewhere, someone knew this guy, and they would be looking for him. I was right about that, and found out when my secretary called from the front: “There’s a group of people out here. I think it’s the trauma guy’s family.”

I greeted them and walked them into the “quiet room” and got them seated. Their anxiety was so obvious I could be cut with a knife. I asked for a physical description and it fit the trauma patient.  I wished it didn’t. These seemingly nice people had no clue how bad-off their loved-one was nor how bad-off the night would most likely turn out. I started my slow slog into the bad news zone and watched as my practiced words sucked the color from their faces and the hope from their hearts. It sucked it from my heart, too.

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

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

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

“John’s been hit hard and has bad fractures on both his legs.” The family gasped as if that was the worst of the news. I cringed but kept my game-face on. “Orthopedics is tending to those injuries. He also has a collapsed lung and a badly lacerated liver and they were talking about removing his spleen. The trauma surgeons are tending to those injuries.”

The family gasped again and swooned, then leaned forward toward the neurosurgeon. “John’s also had a major head injury. From the scan of his brain, it does not look hopeful, I’m afraid.”

Desperate for something — anything positive — the family pressed on: “But he’s going to live, isn’t he?”

“I’ve never seen anyone in my practice with this severity of injuries survive. But we’re not giving up.”

After the neurosurgeon exited, the family started to understand how grave the situation was for John. It probably didn’t help much when I handed all John’s money to his father, who immediately start crying. Everyone in the whole room looked at those hundreds. Dad turned to one of the female friends, who I was about to find out had been more than just a friend. Dad held the stack of bills in his hands and stared at them.  He said to the pretty young woman: “John went to the bank today to get this money so he could buy an engagement ring. He was going to propose to you tonight.”

The best and worst moments of life at the same instant. Tears of joy merged with tears of sorrow.

Upstairs in the operating room, John died. When the story got back to the ER staff, we shared something with the family: we all died a little, too.

Dividing line

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Ride-Along

ridealong

by Robert Lanz, LCSW

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

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

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

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

kravmaga

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

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

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

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

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

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

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

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

Dividing line

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Little Miss Marfan’s

Marfan

by Robert Lanz, LCSW

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

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

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

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

“Bonnie’s here, Bob.”

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

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

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

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

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

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

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

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

Dividing line

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