Unintended Consequences


by Robert Lanz, LCSW

I should have known better. I’d been in the Amazon jungle, the Peten jungle and Nepal’s Chitwan forest and I’d worked in jail. Bad guys are bad guys where ever they are, whether they are locked in a cage the size of a cubicle or live an apparently unfettered life in the remote rain forest of the Amazon Basin. A case in point:

When the old-world missionaries arrived in the Amazon basin in the nineteenth century and wanted to attempt to “save” the heathen Yanomami tribes by getting them current with the modern tools of Europe. But the deal soured quickly. The introduction of steel axes to a select tribe proved to be a game changer for the recipients of the updated technology. Suddenly, it allowed them to fell large trees in hours versus the months it used to take them using their ancient stone-age tools. ‘Modernity’ allowed them to create larger slash-and-burn areas for farming, exponentially expanding the  reproductive abilities of the previously “primitive” tribe. This idea wasn’t lost on the other other nearby tribes. Lest the balance of power in the area go out of kilter, the other tribes often preemptively slaughtered the “modernized” tribe while they still could.

That intervention, much like many interventions in later centuries, had unforeseen consequences. Hearts were in the right place, but heads…well…you know the saying.

A book from my school days, “That’s Not What We Meant To Do” by Steven M. Gillon, pretty much sums up the dilemma:

Not meant to do book

That’s Not What We Meant to Do: Reform and Its Unintended Consequences in Twentieth-Century America, by Steven M. Gillon

Mr. Gillon’s book is a macro-view. Most critical problems of the ER are micro-view, though they usually reflect larger social trends. We can’t fix larger social trends in the ER, just tend to the results of them. In and out: that’s it.

In my first months in the ER, I realized that homeless people, thirty years later there are still lots of them, would always be a time and resource problem: difficult people with the obvious and well known difficult problems. Poor self care. Poor judgment. Overuse of drugs and alcohol. Poor follow-up with medical care. Manipulating the system to their advantage, and overtaxing it at the same time. All that stuff. They are difficult to care for and difficult to follow-up and difficult to get rid of.

The social worker’s job, in part, is dealing with difficult patients, but  especially helping them get discharged from the ER after their medical issues have been addressed. Considering the alternative (a cold night, hard ground with no drugs or alcohol or decent company) most homeless people would prefer to sleep in a warm bed, get some decent food, maybe flirt with a cute nurse, and even prescribed some mind-alternating drugs. Those, too, are macro problems.

While the ER social worker may be empathetic to large and complicated social issues, the ER is not a social-work agency: it is a medical facility with social workers in it. Those social workers are no where near the top of the food chain. Rather, they are often guests in someone else’s house, perhaps pushing their social work agenda when able to, and trying to massage the policies of the hospital. In the big picture, that should always be the social worker’s goal.

But the main goal of the ever crowded emergency room is medical: get the patients in, get them stabilized and get them out. Fortunately in my hospital, the doctors had respect for social work philosophy and tasks, and frequently referred patients to the social worker when they were “medically clear” but not quite ready to leave the ER.  Without social work presence the patients would be discharged by whatever means necessary and newspaper headlines would scream out horror stories of patient dumping and patients dying right after discharge. For social workers, that is an intolerable situation, and in my facility our influence allowed for the occasional sleep-over, some opiates to avoid withdrawal, a decent meal to the regulars who were not abusive, rain ponchos, warm blankets on a cold night and fresh clothes for a new start.

In that sense I was like the lame missionary that selectively gave steel axes to the Yanomami and neglected the neighboring tribes. But on this occasion, I didn’t see it coming the same as those missionaries of old didn’t see it coming when they placed the other tribes at a disadvantage. And like prisoners in jail who perceive being disrespected, the reaction of those disadvantaged tribes was quick and brutal. Like I said: good intentions, bad outcome.

Like many stories this one starts with, “It was a cold and rainy night,” And on that night I had to get rid of a relatively healthy, medically-cleared homeless guy. I let him shower and get some fresh clothes from our abundant stash – most which I provided myself. (It just saved me a lot of valuable time.) ER beds are valuable, and sick people or people with sick kids don’t want to hear about there being no bed space because a homeless guy brought in by paramedics with urine soaked pants and vomit on his chest now won’t leave.

A good social worker is ready for such an issue, even if it costs him or her a few bucks from their own pocket. Cheap, compared to not being able to clear a bed when a sick patient was waiting to be admitted. That’s a micro issue.

Perhaps had I studied anthropology more vigorously or reflected on my jail supervision experiences, I could have seen the unintended consequences of my act of missionary zeal. Besides the clothes I kept on hand, someone recently donated several warm coats. The one that fit my soon-to-be-discharged and now well-dressed and fed patient, was a nice leather jacket, well over a hundred bucks when new. The guy looked sharp when he departed. Several nurses didn’t even recognize him all cleaned-up.

They did recognize him however, when he returned a couple of hours later, again with  paramedics, his face bloodied and bruised, his clothes covered in dirt and mud.

The ER doc barked, “Let’s call a trauma code on this one, he’s got a lot of facial injuries and he can’t remember what happened! Hey, wasn’t he just here?”

Charge nurse answered “Yeah, we signed him out a couple of hours ago. Ask Bob. He was the last guy to see him.”

Right: ask Bob what he was thinking when he sent a homeless guy back to the street dressed in an expensive leather jacket! And, of course, that jacket was nowhere in sight.

The overhead speakers went off:  “Code Trauma! — Code Trauma!” I put my hands over my ears and closed my eyes. What was I thinking?!… Unintended consequences. Should have seen that one coming. No excuses and now none for you either.

Pay attention: it looks very bad when the social worker is the cause of a Code ‘Lame.’

Dividing line


About robertjlanz

Author and health care professional.
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