Mr. Puffy



by Robert Lanz LCSW


I live in a pretty cool neighborhood called Silver Lake and I worked about fifteen miles away in a hip LA suburb called Pasadena, famous for the Rose Parade and Rose Bowl on New Years Day. It’s an easy trip back and forth between work and home except for one little stretch of funk between the freeway exit and my house by the lake. Of course it’s never scary when I am on the way in to work in the afternoon but on my way home after midnight, transiting the funk zone puts me on high alert.

First I have to cross the LA river. On one side of the bridge is the Toonerville Gang, so named because the old Red Car trolley used to pass by there sixty years ago when the tracks lead from Burbank to downtown LA. On the other side of the bridge is Frogtown turf- when the I-5 freeway cut through and eliminated the Red Car tracks it created the prefect neighborhood for thug life with minimal in and out points and easy to defend. It was right next to the LA river, thus, Frogtown. I knew about these gangs because I went to high-school with a lot of members of both of them. I also knew about the gangs because I was a LA County probation officer for almost ten years. Besides that we sometimes got trauma patients from the area when the county hospital was too busy to take any more and they were diverted to our emergency room.

Just past that danger zone, was the out of place in our neighborhood dive topless joint, the only place to get a beer and some company at one in the morning when I was driving home. Some nights were so bad in the ER that the bar actually looked welcoming and that’s all I’m saying about that out of place place….

After I went under the I-5 bridge and crossed Riverside Drive I was back in Silver Lake and felt safe and sound-well, safe anyway. And the story could end right there but under that bridge, living unmolested on the sidewalk was Mr. Puffy, the homeless guy.

Mr. Puffy didn’t start out with that name but over time it came to fit him, kind of like the clothes he wore. And as far as I could tell and as far as I could smell, he never took them off for any reason and over a several month period he started to look like the guy in the Michelin Tire commercial or maybe the Pillsbury Doughboy- he just kept layering up. I stopped once when he was keeled over at an odd angle and I thought he might have died or been murdered. I put on my ever present rubber gloves and mask and approached him and gave him a good shake like I was taught to do in EMT school. He woke up quite abruptly so obviously he wasn’t dead. With that smell he could have been.

“My name is Bob and I’m a social worker. I thought maybe you could use some help.”

“Fuck you” he yelled. “I hate social workers.”

Hey, I thought. He’s not my patient and not my responsibility. He wasn’t acting suicidal or homicidal- although my assessment of that was pretty brief. I left Mr. Puffy there and that was the end of my intervention-almost. Between Mr. Puffy and the topless place it was always interesting to go home and while it wasn’t too hard to resist the topless temptation it was always difficult to zip by the schizophrenic with a load in his pants and a bad attitude about social workers. A “Fuck you” response has never dissuaded me from trying to help someone in need.

In the mid-eighties or so, psychotropic medications began to improve and the days of Thorazine cocktails were waning. New anti-psychotic medications with a more benign side effect profile became a staple in the ER. It was a good sign and we all hoped that better medications would lead to better compliance with chronic thought disorder patients like Mr. Puffy. The feeling was, if we could get psychiatric patients started on the new medications they would clear their thinking and that clarity would result in a desire to continue with the medications. Made sense to us, but we weren’t the ones that needed the medications and that was just a group fantasy we all had. Chronic thought disorder patients remained, uh, chronic, but I still had a dream for the sidewalk schizophrenic.

Along with the new meds was a new way of administrating the meds, my all time favorite being the time release, inject-able Haldol that worked for a month-so before it wore off, the patient, while still thinking clearly, comes to the clinic at the three week point and gets another shot. Not perfect by any means but a lot closer than we ever got before.

About the third time we used the injection type Haldol in the ER I noticed there was enough left over in the little bottle for another shot. And that’s when the Mr. Puffy moral quandary came over me. Not some simple moral quandary like, should I stop at the topless bar and get a couple of margaritas and a naked lap dance after a hard night of death and destruction in the ER, but a true existential moral dilemma of epic proportions.

The dilemma would involve multiple felonies. First I would have to boost the drugs and syringe from the ER where I was a trusted employee. Second I’d have transport the medications with the intent to misuse them and then third, I’d have to sneak up on the social work hating Mr. Puffy and needle hug him and hope to hell he wasn’t allergic to phenothiazines. And I’d be doing it on a busy street not far from the North East Division headquarters of the Los Angeles Police Department where I knew a few cops. And I would be almost directly across the street from that topless bar with a lot of foot traffic. Pretty risky. But I was growing tired of the total inability of anybody to do anything to alter the course of Mr. Puffy’s life. I hated my helplessness as much as he probably hated his own.

Of course, I never did steal the Haldol, that was just a dream too. But I did drop food once in a while and sometimes a blanket or more clothes to layer into. Then one night, he was gone and I never saw him again. The out of place topless bar disappeared a few months later although I doubt if there was a connection. No more temptations on the ride home. No more moral quandaries in the early morning hours of my own desperation.

There is a medical marijuana dispensary and a musicians rehearsal studio in the building where the topless joint was but they’re locked up by the time I come home. Sometimes I swing by the Burrito King at Sunset and Alvarado and get a beer and some tacos. I don’t pay any attention to the homeless guys nearby or the junkies that Linda Ronstadt sang about in of one her songs called Carmalita so many years ago.

Just saving myself now…

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Man Down

by Robert Lanz LCSW

It was another one of those patients who can lead to nothing but problems- of course we didn’t know it when he came in, unconscious and possibly on his way to death. All the docs knew was that he was flat lining and they couldn’t figure out why. You’re never too young to have a heart attack but there is a curve and this guy was on the wrong end of it for that diagnosis. His pupils were round, equal and barely reactive so it probably wasn’t a brain swelling event. His lungs were clear but he was barely breathing so it probably wasn’t a pulmonary embolism. Narcan had no effect.  Nothing we did seemed to be working and that meant I would need to contact the family. Normal stuff.

Normal stuff except for the business card I found in his wallet announcing he was a high ranking officer at a local corporation not too far from our own business district in downtown Los Angeles-and I won’t say any more than that because about twenty seconds after I found that out, hospital security called to tell me there was a woman in the waiting room asking about him. Must have been his wife I thought, noting his wedding ring. I was going to have to get her into the family room and get her ready for some bad news.

I peeked out into the ever crowded waiting area and didn’t see anyone that looked like she might be his wife. There was the usual number of patients and families, a couple of heavy drinkers, a couple of other regulars, a hooker and a couple of guys from a bicycle crash with their lycra and funny shoes setting them apart from the rest of the crowd. But no one looked like the wife. I caught the receptionist’s eye and she gave me a nod towards the hooker, or the one that looked like a hooker. Don’t want to be judgmental, yet.

Oh no. Not the hooker. Not the one with the skin tight dress and overflowing breasts, looking a little disheveled. Disheveled in the sense that it looked like maybe she threw on her clothes while someone had a heart attack and called 911 while she was doing it. Not a street hooker. A street hooker might have called 911 but she would have disappeared, not come to the ER to see how her client was doing. If this was a hooker, she was a high end one. This wasn’t getting any better.

I went back to see how the patient was doing before I talked to her. He was already dead. Young, married, dead for reasons unclear, a beautiful woman who everyone assumed was a hooker and she has no right to any medical information. And there I was, right in the middle.

So I called the cops. I was trying to keep the ER docs out of the upcoming drama. We were too busy and we didn’t need to grieve and we hate having to lie to anyone, even hookers. We needed to uncouple ourselves and the hospital from all the bad energy. We’re a community hospital from a good community and the businesses were very supportive of our mission. Very supportive.

Luckily one of my friends was the watch commander and all I had to say was, Joe, I need a cop down here with bars right now. Not a street cop. Not a cop with stripes. I need bars or stars. Joe understood. Every call to the police is on a recorded line and as problematic as an upstanding corporate guy dying in the arms of someone not his wife. No use complicating things by adding unnecessary evidence or circumstances that could be blabbed around. This dead guy had enough problems. he didn’t need all the bad things coming his way to be spread around the community. I guess in the Everything Else list, this too was going to take some creative social work because I wanted to separate us from the circumstances as best I could. The patient was young and dead and that would entail police and the coroner. He was also prominent in downtown LA and the less the hospital was involved the less the circumstances would be somehow attached to us.

Pretty soon I had a cop with bars, a captain,  another friend who I could explain our position to openly. He got it. He also got his own room and his own phone number and his own liaison (me) and was far enough from the ER treatment area that we would not be part of the ensuing flow of cops and family.

Pretty soon I had the real wife show up and I have no idea how she found out. Pretty soon I had a corporate officer from the patient’s business show up who also wanted information. How the cops kept the woman the patient was with separated from the patient he was married to is still a mystery but the less I knew, the better I liked it. The corporate officer was in the loop as he apparently was friends with the wife. I didn’t see the woman I assumed was the hooker, or a close friend who dressed like one anyway, so I assumed the cops took her back to the station as a material witness to whatever had happened and that’s the cop’s job to figure out. We’re medical people and all we need to know for our legal documentation is what happened after he got to the ER.
Luckily my intervention worked just like I hoped it would.

An hour later the doc who had been trying to revive the patient asked me if the cops had ever showed up on his patient.

“Yeah, they did.” I said. “You guys were really busy and I didn’t want to bother you. Remember, this is a coroner’s case so keep it legal.”

“OK Bob. Thanks. What was the story anyway?”

“Not sure. I was really busy too and left it to the cops. They’ll leave it to the coroner.”

And for the most part, the ER was left out. Just like I planned.

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Harold and Mildred

by Robert Lanz LCSW

She was one of those older women like my mom or my aunt- women who were small children during the first world war. Women, who, when reaching what should have been the security of adulthood were thrashed again by the ravages of the great depression, wondering for years what could be worse, what next- And then she, like all the women in her generation found out what next was the second world war, the war that brought an end to the depression but rained down a whole new hell on already battered and insecure Americans.

Americans who watched as their friends and brothers and husbands and fathers marched off to a distant war, a war that killed hundreds of thousands of men and even some women.

When all that was finally over and those that were coming home, did come home, there seemed to be a rhythm that satisfied a daily life. Not a hot danceable rhythm, just the rhythm of routine and people liked that. After two long wars and the Great Depression, people just wanted to feel safe, to hunker down behind a white picket fence with a loved one and not have anymore changes or adventures in life. Changes and adventures were too scary with bad consequences. What they longed for was sameness, security and predictability. They wanted to wake up to the same stuff every day, safe stuff. And they wanted to have a solid mate to hunker down with. In a life of frightening changes the forever of marriage offered a great comfort.

Of course, changes happen anyway in even the seemingly perfect marriages when couples grow old together. That’s what happened to Mildred, the last few years of her life turning into a nightmare. A nightmare some people would have thought of as punishment for some evil deed, although it is hard to imagine a deed so bad and pathological as to cause such profound torture.

Mildred never brought it up when she came to the ER with her husband, a once successful attorney who slipped into dementia and probably Alzheimer’s at the end of the contract they had married into about sixty years before. Alzheimer’s sufferers fall and get sick and have chronic medical problems like any other person in their age group but their ability to cope with those things and respond appropriately and accept help from a loved one are all compromised. A guy who used to be smart and powerful in the court room was now getting lost on the way to the bathroom, his power and sense of self ebbing away, replaced by depression and angry outbursts.

On their second visit to the ER I noticed some bruising on Mildred’s upper arm, the kind that show up on kids and old people when they have been vigorously grabbed and held tight. I tried to edge into the private space of their lives to assess the danger level Mildred may have been in. She probably knew I knew she wasn’t being totally truthful about the injuries. A little late in the party to change partners, she had picked the one she wanted and they planned on having the last dance together.

“Oh, I was in the garden with Harold and lost my footing. He grabbed my arm so I wouldn’t fall.”

A possible explanation but in my experience, not the most probable one.

“Mildred, you know I’m the social worker. My job is to look out for people, young people, old people, frail people, people who might not be totally able to look out for themselves. Sometimes I wonder about you. Your husband’s a big guy and I’ve seem how confused he is. I’ve also seen a couple of his outbursts down here on other visits. I just want to be sure you’re safe.”

“I’m safe. My husband would never hurt me.”

“If he lost control of himself who would you call for help?”

Mildred sort of stared off for a moment. Enough time to consider a couple of wars and a depression followed by forty years of safety and security. She had weathered the storm and seen the sun shine again. Going back to the storm wasn’t an option.

“We’ll be fine young man. Thank you for your concern.”

Maybe a younger social worker would have called the police or Adult Protective Services. Maybe a social worker who hadn’t been a long time observer of that greatest generation himself would have just considered the mandated reporter rules. Those are the rules that say you should err on the side of caution and report any suspicions. But I know what happens when the cops or protective services get involved in these cases. Nothing good would come of it, nothing good for the contract they had signed with their wedding vows. So I just let it go.

Mildred and Harold made a few more visits to the ER in the next year and I always made it a point to check in with them. Harold followed a fairly predictable path of deterioration but I never saw any more marks on Mildred and I assumed things were stable or at least tolerable per their contract and I was relieved I hadn’t disrupted the flow they had chosen to live their lives with.

But when they didn’t show up for almost a year I began to get anxious and the downside of my failure to report began to chip away at me. On a couple of occasions I thought about calling their house but I didn’t, trying to balance my fear of knowing against my fear of not knowing. Maybe a younger social worker would have handled that differently too.

Time passed and the life and death craziness of the ER night shift covered my fears and I had all but forgotten the aging couple until the paramedics brought Mildred in. She had taken a fall and couldn’t get up. Harold wasn’t there to help her anymore.

Mildred told me that Harold’s doctor finally insisted he go to a facility that specialized in Alzheimer’s care. The separation had been hard on Mildred, being alone after all those years together. But she was a dutiful wife, visiting Harold every day, watching the man she knew slip away until one afternoon he no longer recognized her and all the emotional connection between them was severed. At least for Harold anyway. Mildred , however, of sound mind, was still up for that last dance, her own emotional ties intact and her daily visits continued.

One day, as if talking to a stranger, Harold told her, with the glee of an infatuated adolescent, he had fallen in love- fallen in love with another patient who was equally demented.

Mildred told me she tried to endure but eventually she saw how happy he was with his new love and hers alone was no longer enough to sustain her. She said she still loved him and liked to see him happy but that the heartbreak couldn’t be endured forever. She accepted he would have the last dance with someone else and she would be going home without her partner. She thanked me for all the concern I had shown over the years.

Her life was ending the way it had begun, cold, insecure and frightening and she chose to endure it alone.

I never saw her again but thought of her often like I do of the older generation in my own aging family. My generation had its own wars and financial crashes and job insecurities. We won’t know about the last dance either until the time comes. I just hope we can live up to the fine example set by Harold and Mildred….

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by Robert Lanz LCSW

If you are one of those families that has more kids than space, at some point you will move the sofa too close to the window, not realizing the sofa is just another playground ride to a three year old. This is especially important if you live on the second floor like the kid who fell out the window and landed in the bushes that night I was working. His parents didn’t realize he had fallen until he crawled out of the bushes and banged on the front door.

“Who is it?” was the wrong question at that point.

Calling 911 when the kid wasn’t even crying may have been a wrong decision too. Showing up in the ER with an uninjured child announcing he fell over ten feet out the window will bring on multiple interventions including x-rays and a nosy social worker who will give you a safety lecture. If you have more bad luck the social worker will call the police and they will call the department of Children’s Services if the paramedics haven’t already done so. The police will make a home safety check on the spot and then add another layer of admonishment and safety lectures.

The Children’s Services worker will repeat the admonishments and safety lecture when she visits within the requisite seventy two hours. By now you will believe the entire medical/social/legal system thinks you are incapable of learning from experience but somehow several repetitive admonishments and lectures will get you up to speed in your child protection duties.

I used to teach getting home safely to the fifth graders at the local school adopted by the hospital as part of our community services outreach. I was never sure why they picked me for the job. Maybe someone found out I had worked my way through college as a after school and summer vacation playground director. I enjoyed it and the kids seemed to like my presentations. Fifth graders are usually ten years old and able to function independently if they get the right instruction and learn to use the right tools, that’s me, and follow the right rules, until a parent gets there.

The rules were pretty simple. Don’t answer the door if you don’t know who it is. Don’t have friends over unless your parents know and approve of them. Have a neighbor your parents trust as a standby just in case. If I was teaching the class now I’d have to add in a safety lecture about cell phones and internet porn sites.

In those days the kitchen was the most dangerous room in the house- gas, flames, boiling water, sharp objects, wet floors and all that. Now I’d guess the most dangerous room in the house is the one with the internet connection and no parents around. And while I’m still in the safety lecture mode, here’s an aside for you grown ups. You will age out of the kitchen dangers and move into the truly most dangerous room in the house for oldsters, the bathroom.

For that nightmare, turn your water heater down so you can’t possibly scald yourself even if it seems like really hot water is a good idea at the time. Replace the glass shower door with a plastic curtain. Put no skid surfaces on the floor and grab bars next to the shower, the bathtub and the toilet. And speaking of toilets, they are a common place for faints and even heart attacks so in the future when you are sitting on one, look around and notice there is no place in the whole room for a soft landing. Be careful.

And next time grandkids come over to visit, make sure the sofa isn’t next to a window on the second floor.

End of lecture. No safety checks needed….

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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 thought.

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 in 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, even before the sturm und drang of adolescence. 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  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 now 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 taking 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 a guest 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 in my own hospital. I stammered through a bogus 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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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, me being out of his view. He had been cooperative during the stitching and now was laying 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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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 essentail 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 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 in town 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. But 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. Even though these two were skating around the edge of being able to care for themselves, 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 six years of 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 family members all at the same time 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 the patient. Luckily, one of the secretaries recognized Amir among the concerned drivers as someone connected to me. 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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