by Robert J. Lanz, LCSW
The ER: Frantic doctors and nurses working heroically against the clock to save life and limb. EMTs defying the laws of physics to give accident victims a last chance at survival. Blood, sweat, tears, pain and panic. Agonizing dilemmas and one mind-numbing crisis after another. Most of us have our own ideas about a what a hospital emergency room is like, either from personal experience or from depictions in books or in movies and television shows. Almost every large hospital has an emergency department, better known as the ER, just like on TV. Well, almost like on TV. On television, they only have to deal with their agonizing dilemmas and mind-numbing crises for an hour, while in a real ER, the agonizing dilemmas and mind-numbing crises go on all week long. I know all about these dilemmas and crises because, for more than thirty years, I worked the night shift as a social worker in a busy urban ER.
Wait a minute. Doctors, nurses, medical techs and paramedics, yes—but socials workers in the ER? What do they do?
When most people think of social workers, they think of child safety and custody issues, welfare recipients and the mentally ill, but our training encompasses much more. Because the people who end up in the ER are a microcosm of society at large, we have to be prepared for almost anything. We perform psychiatric and suicide evaluations to decide if it is safe for a patient to be discharged. We do stress evaluations and death notifications. We counsel victims of violent crimes, substance abusers and the families of dead or dying patients. In addition to these responsibilities, the ER social worker performs countless tasks, small and large, which aren’t in any job description and often involve last minute improvisation. Over time, we become friends with the police and the coroners and the paramedics, relationships I don’t recall learning about in graduate school. Once, an astonished family member of an ER patient said to me, “You do everything here.” More accurately, everything that isn’t medical and that needs to get done is left for the social workers to do. Not everything—everything else.
There was a time when most large hospitals in California had a fully-staffed department of 40 or more social workers. Then, in the 90’s, everything changed with the economy. The hospital I worked in made severe cuts and disbanded the department, ending up with a 60% reduction in the social work staff. The various department heads, faced with drastically slashed budgets, had to decide whether or not to include a social worker on their payrolls. Wisely, the Emergency Department at my hospital decided not to cut the social work staff, sacrificing one nurse position per shift to make the numbers work. I viewed this vote of confidence as an opportunity to define what good ER social work was.
The model for hospital emergency rooms across the country is for one daytime shift to be staffed by a social worker, or for an SW to be on call, taking time out from his or her regular hospital duties to address ER needs. That social worker could be called to the ER when a doctor decided that a “social work situation” had arisen. Over the years, I’ve come to believe that the doctors should never be the ones to decide when social work was needed, and as the de facto team leader in my ER, I was in a position to teach the doctors—and the rest of the hospital staff—what good social work could accomplish. It didn’t hurt my cause that I was a middle-aged white guy like most of the doctors and administrators.
Our hospital had full-time social work coverage in the emergency department sixteen hours a day, seven days a week, with on-call coverage for the time when none of us was physically present in the hospital. I made the decision to work the night shift, which as anyone with ER experience will tell you, is when all of the action takes place. It’s when the majority of violent crimes are committed, and when, due to alcohol and drug consumption or just plain craziness, most of the truly bizarre behavior is on display. Often, on really bad nights, the night shift goes on until morning. Because of my time in the ER, I know things that most people will never know. I know things that most people would never want to know, things that I don’t even want to know.
Social work students and even beginning social workers often ask what sort of background best prepares one for the emergency room. I begin by telling them about the obvious attributes that bring people to the field: empathy, optimism, a belief in the innate power of people to do better than they thought they could, a sense of fairness, desire to be a caretaker and the idea that social work can make the world a better place. These are altruistic qualities of the heart, which some people have in abundance, others less so. The basic social work education acquired in graduate school seeks to build on these attributes and to add the communications skills needed to put them into effective practice. Altogether, this is enough to get a candidate started in the field of social work, and may even get you into the game in the ER, but will hardly make you a winner. You need a lot more than the basic training and a good heart to survive and succeed in the hostile, fast moving environment of a big city emergency department. The real lessons come fast and furious, and if they aren’t learned quickly, the social worker won’t last long.
There’s the education and the big heart and the ability to learn fast and think on your feet—and then there’s the dark side. Because so much of what you might encounter in the ER is related to the patients’ darker aspects, a social worker who is not in touch with his or her own grim and dangerous feelings may not be willing or able to recognize them in patients. Consequently, some small but important things are likely to be missed—things, which if caught, might be the difference between life and death. A social worker who knows his own feelings—especially the dark and scary ones—will have a better chance of using his training effectively, the same way an ER doctor uses his skills and instruments to save a life.
If the prospective ER social worker has ever had door-to-door sales experience, it is likely to be useful. Most hospital patients don’t want to hear what the social worker has to tell them, yet it’s important that they not only hear and understand the information, but that they also accept it. Making a pitch to patients who will use any number of defense mechanisms to reject it requires a certain expertise. I believe that if you have tried to sell vacuum cleaners or magazine subscriptions to people who had no idea how much richer their lives could be if they bought them, you are positioned to do good social work. What you have to say—the reality and brutality of a death diagnosis, loss of a limb or some other terrible event will not be heard and accepted if it isn’t presented in such a way that there is no choice but to accept it. Here’s a fitting baseball analogy: You’re the pitcher and the patient is the catcher, and if the pitcher is not able to quickly discern the skill level of the catcher, there will be a lot of balls rolling to the backstop. One of the most important concepts of social work is START WHERE THE CLIENT IS. Having a strong sense of just where you are will make this a lot easier.
It is helpful if the ER social worker has a broad range of life experiences, because problem-solving is rooted in real life rather than graduate school lessons. It is these life experiences that humanize our interactions and help give the social worker’s pitch the spin needed for an easy catch. The lack of life experience can often be offset by reading and studying, and not just texts and articles. An ER social worker should be able talk to patients of any race, age or class about almost anything they might be interested in. Start where the client is. If the worker acquires enough knowledge about life through travel, reading, studying or simply paying attention, he or she should be able to make a good connection, and then be ready to help the client. First, there has to be a connection.
I have this fantasy in which I’ve been scheduled to give the keynote speech at a social work convention. The traffic on the way to the convention center is awful and I find myself making a last minute entrance. I arrive at the auditorium, which is buzzing with attendees; I race in and take a seat on the dais just in time to hear the master of ceremonies introduce me to the crowd.
“Ladies and gentlemen, our featured speaker needs no introduction,” and there is a huge round of applause. I step to the podium, clear my throat and look toward the rear of the auditorium, where there is a large banner that reads: WELCOME, NUCLEAR SCIENTISTS OF AMERICA. I hesitate, but only for a moment. I look out at the audience and say, “Before me are gathered the greatest minds in the field of nuclear science in America, and perhaps the world. There is probably nothing I can tell you about nuclear science that you don’t already know, except how it can influence people and how that influence will reflect back on you and guide you in your endeavors in the field.”
I keep up the pitch for my allotted time without ever mentioning nuclear science again and at the end of my speech I receive a standing ovation. People in the crowd are nodding their heads and saying things like, “There’s a guy who really knows nuclear science.”
This fantasy is not so far-fetched, because nuclear science, like anything else, is relevant to people and their feelings. And although we all have different interests in our lives that send us in different directions, when it comes to peoples’ feelings, their hopes and dreams, fears and insecurities, we are all the same. It is that sameness, that common ground that the social worker has to address. A good social worker finds a way to make us all feel connected.
Finally, and maybe most importantly, there is the social worker’s sense of humor. Humor can bring people closer and it can help with the death and loss that are natural occurrences in the emergency department. It can humanize a spiteful patient, make the most difficult doctors more bearable and the unchangeable things acceptable. Humor is the greatest stress buster available, especially when aimed at oneself. When a person is able to laugh at his own comic foibles, he will be better equipped to face the challenge of social work in an emergency department.
Sometimes in the day to day performance of my job, it’s hard to keep everything in perspective, and like any human being faced with horrible choices on a regular basis, it’s normal to try to find simple solutions to complex problems. When we in the ER joke about forced sterilization, murder and tossing people back into the street, the jokes are really just thinly disguised ways of covering our feelings with grim humor and venting our frustration over not being able to fix everyone who comes to us for help.
Because of the hours I kept, my work day usually ended at a time when few others were getting off. There was no one to go have a beer or a cup of coffee with. I’d go home and my wife would be fast asleep, so I would just sit there alone, full of energy and stories to tell. Since there was no one to tell them to, I decided to write them down. Some of these stories are funny, some are heartbreakingly sad. Some are bitter and others reflect the fear that is always just beneath the surface. Some are all of these at once—just like a night in the ER.
I hope these stories will show how hard I tried as well as how badly I failed, either because I didn’t try hard enough, didn’t care enough, or just wasn’t good enough. Whatever the case, it makes me a lot like everyone else who works in the ER—hopeful, yet frail, and determined to do better.