The Bell Curve

by Robert Lanz LCSW

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Our docs were lining up behind me.

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

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

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

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

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

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

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

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

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

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

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

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

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

“I didn’t.”

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

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

“She’s sober now Bob. She goes home.”

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

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

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

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

Aye. Aye. Aye.

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Cops

by Robert Lanz LCSW

I was standing causally in the doorway to the suturing room so the patient who was handcuffed to the bed by all of his extremities could only see the ceiling for the most part. He had been cooperative during the stitching and now was lying quietly, maybe counting the dots in the ceiling tiles like we did when we were kids in grammar school.

We had sewn up his big fat lip and he was medically cleared to be booked into jail. It was a busy night and I got to this party a little late, always wanting to check on any possible problems in the ER and even a handcuffed bad guy in custody with a well armed cop in the room had potential. He’d already showed some bad intentions before he got arrested and my experience told me most guys with bad intentions don’t give them up that easily, if at all.

The uniformed cop was pretty fresh on the job but appeared to have mastery over the situation-at least while the guy in custody was in four point restraints. But getting him out of the room, through the ER crowd and into the police car could be problematic.

That’s probably why the trainee cop called the training officer and Officer Villa showed up to help. No need to have a scene in the ER with a guy who already showed a willingness to fight. Officer Villa said “Hi” when he passed me by and walked over to the prisoner’s bed, leaning over him to check the damage and look him square in the eye. Best to get a read on the enemy I guess before taking off his leg cuffs so he could walk out to the black and white. Villa’s face interrupted the upward gaze of the prisoner but from where I was I couldn’t see much. The vibes were OK and the prisoner was calm.

“Officer Villa” he said in a easy going manner as if they knew each other. “How’s it going? Did you see your mom today?”

Relaxing his stance, apparently caught off guard he answered like he was talking to one of us.

“No, but I called her.”

“Did she tell you I fucked her last night?”

As fast as a rattlesnake strikes a mouse in the desert underbrush Villa drilled him with a power punch to the jaw, immediately undoing an hour of our fancy suture work.

The new cop was pretty shocked. He looked at Villa then looked at me. We were frozen in time. Well, not all of us. The guy with the gushing bloody lip was yelling and cursing like he was still getting hit. We may have been in a state of suspended animation but he sure as hell wasn’t.

Villa looked at the trainee cop and then at me.

“Bob, I’m calling the station right now and the watch commander will be down in a few minutes. No use having your name on all that paperwork, I’m taking the hit.”

The new guy just looked at me and shrugged. I disappeared.

I went and told the doc what happened. Sort of. I left out the part about me being in the room. No use being all over our paperwork either. After all, Villa did the crime and he would do the time. Didn’t need me involved in all that.

“Is that cop a friend of yours Bob?” the doc asked.

“He is.”

“Well I’ll just sew that guy up again. I live in this city. As long as you tell me it’s legal, no problem. Make sure your friend remembers who I am.”

“Don’t worry. Your name will be all over the paperwork. Ours and theirs. But they will do whatever they can to keep you out of court if it comes to that.”

“Thanks, I guess.”

The giant double doors to the outside parking area for paramedics and police hissed open.

“Hey, look at the bars on that collar. Must be the watch commander.”

“Hey Bob. Where’s Villa?”

The prisoner got sewn up again. And the doctor was sure he wouldn’t get any speeding tickets in our town. The watch commander asked him a couple of questions and that was it.

Villa got ten days off without pay. Nobody asked me anything.

A few days later I got a call about the time I would get off my shift.

“Hey Bob, I’m getting bored. Wanna get a brew?” It was Villa.

Neither one of us ever mentioned the events of that night again. Another silent test and I suppose I passed…

But wait. That’s not the end to the story.

Almost ten years later one of my regular long time psychiatric patients, a woman I had befriend during repeated admissions to the ER, called my office directly.

“Bob, I know about a murder but I’m afraid to call the police myself. You know how they can be with people like me.”

By that time, Villa was a sergeant and working in Robbery/Homicide.

“I’ll hook you up with a guy I trust. You’ll be safe.”

My name didn’t appear on any of that paperwork either but I heard the crime was solved.

That’s the end of the story. Except for at Villa’s retirement after he did his thirty years. A social worker well received in a room full of cops….

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Taxi

by Robert Lanz LCSW

A good story has a beginning, a middle and a memorable ending, a conclusion that wraps up the ways in which an obstacle is presented in the beginning and how the events in the middle reshape the main character in order to provide that meaningful ending. This is basic Joseph Campbell storytelling with the “hero’s journey” being the most basic structural format.

A good technical writer can use the story structure signposts to guide the story and a technical writer already knows the end of the story when he starts: he just needs to fill in the requisite blanks to complete the formula. A creative writer keeps a vague idea of structure in his mind but lets his characters and the hero find their own voices and they can tell the story themselves. This is more of an artful and unconscious process. With an ER story, sometimes you might think you know the end because you think you’ve heard the beginning from someone who seems reasonable at the time-a friend, a family member, the cops, a neighbor, a nurse or doctor or the paramedics. Of course, you never really know.

On the night this story takes place, a couple obviously in love or one of its variants probably had some end in of story in their minds when they left their board and care facility in San Bernardino, an edge of the desert city about sixty miles to the east of us and not near as glamorous as our town, so maybe there was a honeymoon element to this couples poorly planned departure. Totally dependent on government interventions for food and housing, health care and spending money, they turned their back on security and headed for the great wide open.

Just as their town, know colloquially as Berdoo, was less glamorous than ours the couple’s lives were bound to be less glamorous than Tom Petty’s but what the hell, they were young and in love! Well, they weren’t exactly young in birth years, both in their forties and other than hormonally they most likely had a different idea of love than most of the rest of us. Such human flotsam and jettison soon ends up reuniting with some agency or another and in some manner are returned to the security of their board and care facility. Romeo and Juliet on SSI.

I don’t rightly recollect how they got to the ER but my best guess is that one of my cop friends realized the couple were just lost in space, not criminals but they still needed to get out of our town and back to theirs. The cops know there is a social worker in the ER- most likely me at night- and I’d be able to muster the creative resources to return the errant love-struck couple to their proper living situation, clearing them off the police blotter. It’s the Everything Else list again. In the big picture the ER social worker is on duty for all these difficult situations that roll down hill until they bottom out in our hospital basement, the last stop with a conscience.

I rarely call my boss at home for guidance. After all, it’s night and I’m a grown up and she has to get up in the morning and I don’t. Still, the only solution to this problem, at least the only financially and ethically responsible solution was to get the runaways back to the edge of the desert. The folks at the board and care facility were sympathetic with my situation but wouldn’t send anyone to get their wards. Even after I strongly suggested it they wouldn’t even front the dough for bus tickets. That’s when I called my boss-not about the dough, I could easily cover that with my credit card, but to pull it off I would have to get them to the bus stop myself and make sure they didn’t cash in the bus tickets and use the refund for a quickie at the Motel Six. Anything short of watching their bus disappear to the east was not OK with me. Neither the hospital, nor me, nor my profession had a legal mandate beyond making sure they didn’t represent an acute danger to themselves or others or were suffering a grave disability. These two were skating around the edge of being able to care for themselves, but legally I couldn’t lock them up and they didn’t need to be locked up. This was more of a shepherding maneuver- they were just a goofy couple needing structure and it was my turn to provide it.

“No problem, Bob-make sure the charge nurse and docs are OK with it. Have them call me if they need a social worker when you’re gone.”

This was, and I know you youngsters will find this hard to believe, before cell phones so once I left the hospital grounds I was off tether and it was uncharted territory. I spent thirty years at that fantastic hospital because virtually everyone from my secretary to the CEO was familiar with and entirely comfortable with the outcomes from my previous untethered interventions. Free rein is a great place if you do it right. A good social worker should have no problem with that.

I called a cab and it arrived and would get us to the Greyhound bus stop, actually an old converted gas station, with about ten minutes to spare. I probably could have predicted the bus would be late since I was untethered and pressed for time. It was- by more than an hour- and I had to treat the lovely couple to dinner, junk food from a machine, while we waited. They wanted to smoke so I had them sit outside and I chatted with the taxi driver and that’s where the real story began.

Taxis serve a different function in southern California than they do in most places because this is essentially a car culture unlike big cities on that other coast. I didn’t even realize it until I was in the army in 1967 and met guys from New York and they told me it was common for adults there to not have a car and many of them didn’t even know how to drive. Unbelievable! But they probably think it is equally unbelievable that there are adults in SoCal who hadn’t ever been in a cab. Well, maybe from the airport but not shopping or going to work and certainly not on a date.

And there I was, spending quality taxi time with a displaced Iranian who taught me more about the middle east and America then I ever learned in college.

The driver was about my age and loved America even though he gave up a professional career as a pharmacist in his birth country. He worked seven days a week, twelve hours a day, rarely saw his full family but loved them dearly and provided all the security they needed, kind of like the government was doing with our amorous passengers.

But the passengers had every day off and the Iranian cabbie told me he had only taken four days off in the last five years. It wasn’t a complaint, just a statement of fact that described his situation. He wasn’t sure what to make of the eloping lovebirds. I’m not sure my explanation of how they ended up in their situation made any more sense than how he ended up in his.

It was an interesting way to pass an hour. A history lesson, a warm communication between a guy who left everything behind to come to America and get everything he needed, something, on some level he had in common with the runaways from Berdoo. And here he was bonding with a fifth generation, middle class white American who, for the most part had an easy life if I wanted it.

The driver thought I was a good guy and I thought the same of him. The bus came, the lovebirds went home and I rode back to the hospital. Oh yeah. Amir the cabbie refused any payment for the experience.

For years I would see him, in his cab, taking wayward patients home, often with cab vouchers provided by the hospital. And, of curse, when I called for a cab I always asked if Amir was on duty. He probably knew that and sometimes asked if Mr. Bob was working when he got an ER call. And so it went….surely I couldn’t know the end of this story when it started.

One night, years later, there was a big car crash right in front of the fire station and right in front of the Iranian carpet store. A taxi driver had hung a U-turn and got broad sided. I heard the call on the paramedic radio and my heart stopped. I expected the worst.

Luckily, the victim was not Amir. Unluckily, the victim didn’t speak English. When all the local cabbies showed up at the hospital no one would give them any information because they weren’t actually related to him. Luckily, one of the secretaries recognized Amir among the concerned as someone connected to me and called back to the trauma room.

Amir was a Godsend. He came back to the trauma bay and translated for us and then waited until the victim was able to go home. Everything was all wrapped up and tidy.

“Hey Bob” the chief of trauma services and a family friend for over thirty years yelled out in the crowd, “How did you find a Farsi translator so fast at midnight anyway? That was amazing.”

“Just lucky I guess.”

But it wasn’t luck. It was that off tether thing a good social worker should always look for. Some day it will pay off, you just never know when. And the creative social worker, just like a creative writer, lets the characters find their voices and guide the story to its conclusion.

Horticultural social work. Plant the seed. Tend the soil. Some day the seed will grow into something helpful. Believe in that….

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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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