January 10, 2019

Ugly Betty

Never judge a book by its cover.

-old saying

‘Betty Luna’ was a frequent flier at all of our local ERs for years. Everyone was on a first name basis with her. To look at her, Betty was truly disgusting. Over 300 pounds, butt white, greasy white hair pulled back in a little pony tail. Her only clothes were a set of matching grey sweatshirt & sweatpants. She was schizophrenic which meant she smoked like crazy (appropriately enough). Over 90% of schizophrenics do. Someone found a mechanism by which schizophrenics specifically are calmed by nicotine more than your average smoker. Not to mention the poor impulse control and judgment that goes with being schizophrenic. And it is actually encouraged in psychiatric hospitals because the staff knows it makes their job easier.

Between the obesity and the smoking, she had emphysema and heart failure and her blood pressure was always dangerously high. Of course she never took her psych meds, much less those for her blood pressure, etc. Worse, because she was obese, the smoking, the heart failure and just plain not taking care of herself she had chronically swollen lower legs and feet. Both shins had chronic deep ulcers that always had at least some infection and were oozing pus or at least fluid from the open skin.

Because of her mental illness Betty could get very touchy and nasty if you pushed her or if it was just a Bad Betty Day. Once she was in the cafeteria and apparently thought it would be funny to pour hot water or coffee down the back of the neck of some other person using the cafeteria. This led to her being banned from coming into the hospital outside of the ER for months. Hospitals are forbidden to refuse anyone at least stabilizing care who shows up at the ER. Occasionally, with a long well documented record of the police being called for a patient’s behavior multiple times, it is possible to ban someone from an ER, but that is very rare. And her sleep in a patient bed or in a chair in the lobby after being seen privileges were revoked.

This of course was a big problem because as far as anybody could tell, she was homeless and slept in an ER every night if she could. She was cagey enough to know that if she said that she was homeless, then that would mean social workers would start trying to place her in some facility. And her schizophrenic paranoia sure didn’t want that. She would nearly always refuse any tests or care, much less admission to the hospital which was always needed for her various problems. And of course she wasn’t going to let us give her any psych meds. To truly get rid of the ulcers on her legs she would need to be admitted for weeks or months to a long term rehab hospital for IV antibiotics, special dressings and wound care, possible surgery, and of course to get her other problems treated enough to let the legs heal. There is a very good public rehab hospital in LA County that would have been perfect for her. That wasn’t gonna happen. A few times she agreed to let me do tests. Usually she reneged on the deal after agreeing. Once she even got nasty with the (too sweet for her own good) nurse who was trying to do an EKG on her. She threw the EKG cables at her and stormed out. I think I was able to talk her into staying in the hospital once. And we heard rumors after her periodic disappearances for a few weeks at a time that they were caused by her being admitted to some other hospital. Once, even the to next County Hospital from LA County, over an hour away. As I said Betty was surprisingly cagey and able to get around well despite her issues.  She knew all the ins and outs of getting by on the fringes of society. She told me once about how one particular church had an open store for the homeless where they gave whatever they had for free to people like her between such and such hours one day a week. She knew how to keep herself in the basics.

The only thing she ever really wanted from us was dressing material and bandages for her weeping legs. They needed to be changed several times a day. Sometimes she would try to get a Tylenol #3 for her leg pain, but I would tell her she needed to let us do tests and stay for something like that to happen. Since the reaction against the massive abuses of psychiatric patients that lasted up until the late 60s, it has been very difficult to force psych patients to stay in a psych hospital. They need to meet strict criteria of danger to self, danger to others or be gravely disabled to the point that they cannot provide for their basic food, clothing & shelter. While Betty was truly a danger to herself, it was of the slow kind that would not meet criteria for a psychiatric hold.

As I mentioned and have detailed at length Betty was repulsive in her behavior and appearance. But there was a softer side of Betty. She could be very sweet when it was a Good Betty Day. Once she got to know you she would tell her favorite staff members ‘I love you’. One of the nurse supervisors, who smoked as well, spent extra time with Betty as they were often both outside smoking regularly. She told me that Betty once asked her if she wanted to go out together. Betty volunteered to teach her how to rob graves. Dunno if this was intended to be a date or just friends hanging out and I hope Betty wasn’t really robbing graves, but you never know. And the hospital staff and probably a few people in the church store, etc. were the closest thing Betty had to friends or real relationships

 She was essentially retarded, for want of a more politically correct word. Eventually all schizophrenics develop something more or less like dementia. It is part of the disease and the brain physically atrophies and shrinks due to the lack of much real thought or life content during their entire adult life. The earlier you get schizophrenia, the worse it is. John Nash, the real guy from the movie A Beautiful Mind, didn’t come down with it until college or grad school. He went on to get a Ph. D. in math & win a Nobel Prize. And his life was still shattered. Betty told one of the nurses once that she started hearing voices when she was 7. For all intents and purposes, her mental development stopped there. She was child-like and able to navigate the system well after doing it for all of her 50 some years, but she was quite limited. Heartbreakingly tragic if you think about it.

As I like to keep my ER as drama free as possible, I developed a routine with Betty. As soon as I heard she was in the lobby, I would get her a sandwich, juice and a blanket and bring it to her. Then I would say hi and ask if she wanted to be seen or just get the dressing material, which she always put on herself. Nearly all the time she just took the dressing stuff. Gradually I became one of her ‘I love you’ recipients. Once she even gave me some childish Disney Valentine’s Day stickers she had gotten from someone. They were of various Disney characters in hearts, etc. with ‘I love you!’ on them. Not my style, but I couldn’t refuse them. About that time, I started replying to her ‘I love you’s with ‘I love you too Betty’. I brought them home and gave them to my wife after telling her about Betty. Pretty sure we still have one on our address book at home.

 On a Bad Betty Day it was almost impossible to talk to her. She would get very irritable and go onto rants about whatever was bothering her or someone (maybe imaginary) who wasn’t treating her well. I was able to talk her down a little sometimes on those days by asking her what was happening and telling her ‘I love you’, but those days she usually ended up just leaving early while grumbling on her way out the door.

The beginning of the end came one day when I heard that the last time Betty was in the ER, she had maggots coming out of the ulcer on one leg. Maggots are fortunately pretty rare in the ER. Usually it is someone with chronic leg wounds like Betty. And, of course, homeless with a side of alcoholism or mental illness that would let you ignore your health long enough and bad enough that flies lay eggs there that are allowed to turn into maggots. Maggots only eat dead flesh so they are actually not that bad for you, but the conditions that let them get there are obviously horrible for you. A cutting edge wound treatment is to use sterile maggots to clean out only the dead tissue.  At that I knew and told people that she would be dead within a year.

Betty kept coming in for a while and fortunately remained maggot free. But her blood pressure and breathing kept getting worse. Regardless, she refused tests, treatment and admission. Her blood pressure was in the low 200s all of the last times I saw her. Then she stopped coming for months at a time. When she did make her increasingly rare appearances, she looked haggard and bad.

Most of the last 6 months or so, we only heard rumors about her. That she was in the ICU at USC County Hospital, etc. The last verified Betty sighting was from a friend at his other ER job. She supposedly had a heart rate of 200 and was allowed/encouraged to sign out Against Medical Advice. In my book, this was malpractice, as in that case she could have easily been dead within hours. But it wasn’t my decision and I can sympathize. Betty was an unappealing handful to deal with. It has been a year or maybe even 2 since more than a flimsy rumor of a Betty sighting. I sure she is taking the dirt nap now. At least she is at peace. She rarely had anything like peace in her troubled life.

I LOVE YOU BETTY!!!

Jeffrey F. Wade, MD, FACEP