by Robert J Lanz, LCSW
“The creative and imaginative efforts of every one of us counts, and nothing less than the health of the world hangs in the balance.” – John Kabat-Zine
Sometimes the social worker’s role is so easy and direct that it almost makes me feel self-congratulatory knowing that doing something concrete can be of so much help. If I get to start my work day by helping someone in any way at all, then at least I can carry that with me through the rest of the night. That can be really important in this place, where getting hammered in one way or another is commonplace. It often it seems that I can go through a whole shift without actually being of much help to anyone. It’s not because I’m not good at what I do, or don’t care about what I do, and certainly not due to a shortage of patients needing help. It’s more that there is a shortage of patients who want anything at all to do with change—and that includes getting better from whatever distress has lead them to the ER. In many cases, if they do want change, they would rather not have to participate in effecting it themselves. They will do terrible things to their bodies, things that anyone ought to know better than to do. Then, the will show up with some illness or injury or chronic condition and flop onto a gurney with that withered and wasted “Help Me” look. The most help for those guys is to remind them that it is their body and the best help they will get is from themselves. That’s a pretty advanced concept for most of them and getting them to embrace it is just a dream we have. Personal responsibility as a concept. Probably won’t see a whole lot of that again this year either.
When a patient shows up in the ER and he can’t even tell you what medications he is taking, it’s not a good sign. When he responds to queries about why he is taking those unknown medications his answer is inevitably, “Because my doctor told me to.”
These are the folks I’m supposed to be able to fix—the ones who can’t seem to remember their own diagnoses.
Many people define themselves by their illness, their diagnosis, the trials and tribulations of their treatments and medications. Their life is centered around doctor’s offices, pharmacies, hospitals and rehabs, along with the occasional ER visit when they wake up in the middle of the night, catch a $700 ambulance down to the hospital and tell us that their hemorrhoids are really itching tonight, and could we give them something to help them relax. They get one of those $500 Valiums and they are ready to leave. They don’t end up defining themselves by their limitations but they seem to think they do and besides, they get away with it, make money from it and many of them even get reduced rent because of it. A lot of folks don’t seek improvement from that situation. It isn’t because the system made them that way, nor because their parents made them that way and it’s not because circumstance made them that way—unless you consider genetics a circumstance. The results are not fully in on that issue. Anyway, there are lots of chair-bound folks around who are doing just fine. We even have an ER doc who has one leg. I saw a well-dressed one-legged patient in the waiting room the other day and he was smiling and reading the Wall Street Journal.
Anyway, before I get off on a total rant, let me get back to that night. One of the nurses came to my office to tell me that there was a young woman in one of the group rooms who needed a taxi voucher home. I generally guard my vouchers so that I have some left for after dark when it isn’t safe for women and kids and feeble old folks to head home. I always check the patients’ charts to see where they live before committing to a voucher because, like all things in health care, there are never enough resources and too many takers demanding what resources there are. I made a couple of stupid moves that cost the hospital about 60 bucks when I hadn’t checked before committing to a voucher, and the patient lived several cities away. This can especially problematic, since generally speaking, the further the patient comes to get here, the lower the chances are the patient will have insurance or pay the bill. But at one AM, they always seem to come up with the universal lame excuse, as in “Well, how am I supposed to get home?” This is usually spoken with an attitude of entitlement that generally would be a little forward even if the patient was a movie star or had been on some reality TV show.
I also like to see what medical problem the patient has before I send them home in a cab, to make sure they can actually safely get home in a car and get into the house on their own. Sometimes there is a big gap between the patient being “medically clear” and “able to go”. Medically clear means that they need no more treatment on this visit, and as always, we need the bed for another patient who is fuming in the waiting room after a three hour wait in line behind a bunch of guys with minor discomforts who can’t remember what medicines they are supposed to be taking. “Able to go” means that we won’t get sued for having them leave too soon. That was frequently left to my discretion. The doc’s job is to fix the patient’s current problem the best they can and get them out of the ER. That’s when they tell me the patient is “medically clear”. What happens next is up to me and I sometimes become the de facto guardian against ethical screw-ups, impractical plans and the resulting law suits that might occur when a “medically cleared” patient went home and fell or died or somehow got worse because he left too soon. That is probably a stretch of my job description that the hospital doesn’t want to know about. I’m a social worker; what would I know about medicine? Somebody tells me a patient is okay and I send him home, right? Not always. With twenty years of observation in the ER, I did have a lot of experience with medical care. To buff out this experience, I took the time to go to Emergency Medical Technician school, so I did know the very basics of patient care and assessment. Six years of college didn’t prepare me for the patient I was about to see, but a hundred and ten hours of EMT training at UCLA did. Everyone was glad I took the time for the EMT course that day.
The patient had burned the inside of her thigh and her calf pretty badly—first and second degree with small patches of loose flesh showing. As I watched the ER tech carefully apply the cream and wrap the wounds I noticed the burn pattern was unusual. Burn patterns are something I know about from being on the Suspected Child Abuse and Neglect Team for more than ten years, where trying to figure out the difference between an accidental spill as opposed to a purposeful act gave me far too many opportunities to put together a mental picture of what had happened. This pudgy young lady, still in the shorts and halter top she was wearing when the burn occurred, did have a very obvious hot water burn, but not one with a typical splash formation.
Most hot water burns, especially accidental ones, are in a fan-like pattern from the splash, and from the body’s recoil reaction to hit with a hot liquid. This lady’s burns looked like they had been pool burns, sitting in the same place for a long time despite the obvious pain they would have caused. Sometimes you see those kinds of burns on kid’s feet when they are held in scalding water, and it is usually pretty obvious from the sock-like pattern that the kid didn’t do this to himself. This woman’s leg burn was more like that. But who would hold a full-grown woman down just to burn her on the top and side of her leg?
The patient was resting quietly with her eyes closed while getting her legs wrapped and as I watched, I tried to imagine how she got burned that way. I asked her nurse if the patient had said anything about it, but she hadn’t. Her doctor didn’t have any ideas either, preferring to treat the burn, not the patient, concerning himself with treatment over causation, a constant difficulty in the ER where time is tight. It was one of those busy days when you treat and release as soon as possible. If she is a competent adult and doesn’t claim someone else did it to her, then it doesn’t matter how it happened. But I was too curious to let that be.
I gave the patient a little shake and she woke up, looking dreamily around the room with the warm glow of narcotics cursing through her veins.
“Wow, what happened?” I asked. We aren’t real subtle in the ER and don’t have time for extensive warm-ups most of the time.
“I don’t remember.”
“You’ve got second degree burns covering half your left leg and you don’t remember what happened?” She didn’t appear to be lying. “What’s the last thing you remember?”
“I think I was stoned.”
Well, that was a start. I knew it was a spill, but why hadn’t she woken up? I looked a little harder at the leg. It was burned so badly that it didn’t seem possible for her not to have known when it was happening. I considered the possibilities and thought I had a good idea that would explain the burn in such an unlikely position.
“You shot or smoked heroin. You made some tea or coffee in the microwave. You wanted to meditate so it was probably tea. Just before you nodded out you got into a Lotus position and when you nodded, you poured that scalding liquid right onto your leg. You were too stoned to know it so it had time to really burn you.”
“Chamomile tea. It was tea. I was trying to relax.”
Pretty damn relaxed, I thought.
“Well, I can get you home in a cab. The hospital will pay for it. Can you walk OK?”
“I can’t feel my foot. I don’t think I can walk.”
As I learned to do in EMT school, I asked if she could wiggle her toes. She couldn’t. I asked if she felt it when I touched the tips of her toes with my finger. She couldn’t. I couldn’t find a pulse where one should have been on her ankle, and she was only able to feel pain when I pulled on her foot a little, a classic symptom of Compartment Syndrome, a medical condition that occurs when you cut off circulation to a body part for too long. Sort of like when you take too much heroin and can’t fell pain and pass out with your legs crossed in the lotus position.
We called the surgical resident and he came down to the ER and did the same tests I did with the same poor results. Two hours later she was in surgery. She lost the whole leg. An above the knee amputation. Brutal change of life for most folks.
No one said thanks to me after the patient left the ER. No one said anything about the patient being medically clear when, in fact, she was two hours from amputation. No one even thanked me for not sending her home in a cab. No one said, “Hey, good catch.” They just called the surgeon and he cut off her leg.
A few months later she was back in the ER for some unrelated medical problem. I almost didn’t recognize her when I walked by her room and probably wouldn’t have if she hadn’t yelled out.
“Hey, Bob. What’s happening man?”
There was a lot of air where her leg used to be, a very obvious mismatch with the other leg that now was quite toned. She must have been in rehab since that day she lost the leg, getting her good one strong in anticipation of the coming prosthesis. I hoped she didn’t have any bad feelings towards me for what happened to her, even though it wasn’t my fault.
“They’re fitting me for my new leg next week. All titanium. High tech. Seventy thousand bucks. But I’m disabled now and I have MediCal so they are paying for everything.”
She didn’t even seem that upset. At twenty-four I think I would have had a much stronger reaction to losing about 20 percent of my body mass, half my mobility, a disruption in my sense of sexuality and on and on. That would be the normal reaction, but of course, she wasn’t normal. She just wanted to have some tea and relax. Too bad she’d thrown heroin into the mix, or she would still have had both legs and the great State of California would have saved about a hundred and fifty grand. But now she is defined by her medical condition, and has free medical care and Social Security income for life. What could be better? I was there working my ass off every night to keep my medical insurance current and she was home drinking tea and meditating on my dime.
Maybe I over-react to these things that seem so expensive and senseless. After all, what could I have done? Send them all far away in a cab? Maybe I should have taken a little time to meditate, too. Brewed some hot tea too, mellowed out a little, relax. Pass on the heroin though.