Friday, September 25, 2009

Honorable Mentions: Reflections from a Monday at Grady

"Define in/out."

That's what I asked Richard, the Grady parking security guard, about one of these newly designated parking spaces the first day I saw the sign. MD IN/OUT PARKING--Right next to the "Board of Trustees" parking spaces on the ground level. Nice.

He shrugged his shoulders and then answered, "I guess it's like, 'Oh, let me run in and sign this chart' or 'Whoops, I forgot to get something from my office.'"
"But no firm rule?" I countered eyebrows raised.
"Naaaah, Dr. Manning," he said with a chuckle, "It's on an honor system. You doctors know all about honor, right?"

Call me silly but I am not sure this alleged honor system includes a clause about scoring an excellent ground level parking space in a ten story parking structure. At least Hippocrates didn't mention it anywhere in his oath.

The Monday IN/OUT dilemma

It all started with a doorknob rattle at 4 am. Zachary can't seem to get our bedroom door open, so he just rattles it until one of us leaps to his doorknob defense. My mommy senses kick in and my eyes almost always fling open the second he places the first foot on the floor. Still, I passively-aggressively lie there waiting to see if Harry will get up first. Rattle-rattle-rattle. Pause. Rattle-rattle-rattle. Each pause is punctuated with a baby-baritone "Mom-may. Mom-may. Mom-may." (The kid has the voice of a thirty-five year old man.)

I looked at Harry who took a deep breath snuggled even deeper under his covers. I rolled out of the bed, opened the door, and found my half-alseep two-year-old standing there with his blanket on his head. "Mom-may, I gotta go pee pee," he bellowed way louder than anyone should at 4 in the morning. I whisk him to the potty and then back into his own bed.

Alarm went off at 5:30-ish. That time was intended for me to make it to the gym on certain days, but not this day-- forgot to switch it to a less heinous time. Annoying. I hit snooze 1.5 times. The first hit was real; I snuck in five minutes worth of intended zzzz's. The second hit only counted for half since at that point I was lying there drowsy yet awake, but too scared to push the "sleep" button. This approach is crappy, because all it leads to is this period of waiting for the alarm to go off again. I dozed off for a second, literally, and was jolted awake by the alarm again. Accidentally hit "sleep" this time which turned off the alarm altogether. Arrrrggghh! Too early to get up, but resetting the alarm for later is too much of a production and the thinking involved would wake me all the way up. Before I could think further, fell back asleep.

7:10 a.m. Eyes flung open, house was eerily quiet. Way too light in the room for it to be the time I was supposed to wake up. Crap! I have overslept. Clinic at 8:30 a.m. so barring some miracle, was officially late at that point. Woke up Harry and, in true Manning splendor, we scrambled all over the house to get ourselves and our little guys ready to go. We also had our usual morning bicker over where backpacks were, is this shirt for Isaiah or Zachary because it's too small/too big, what is that all over Zachary's hands/shirt/pants, and why there is no system for knowing where the socks are. Yet despite this, somehow we made it out of the door by a respectable 8:10. In the driveway, I leaned into Harry's driver's side window for a quick kiss, and blew additional ones to the boys who were strapped into their carseats behind him.

Harry: "Love you, babe."
Me: "Love you more."
Isaiah: "Mommy, I love you all the way to Pluto."
Zachary: "I want some soy yogurt."

Jumped into my car, turned on NPR, and was finally on my way to work. Okay, girlfriend. If you hit zero red lights, you are good to go. I hit one red on Ponce de Leon, but the rest of the commute was pretty open. Definitely met qualifications for good traffic light karma. 8:33 a.m. on my dashboard, which is really 8:23 a.m. Wondered for 5 seconds why I bother with the "fast by 10 minutes" clock thing when all along I know the real time. Whatever.

Reached the homestretch--I turned onto Jesse Hill Jr. Drive a.k.a. Grady Street. Woo-hoo! You just might make it, girl! I threw on my blinker and busted a left into the employee parking garage. I already had my badge out and ready--quick "What's up" head nod to the security person, and headed through the access gate. Yes-sirrrr! Manning, you're a punctual rock star!

The NPR guy shakes me into reality with another time stamp.

"This is WABE National Public Radio. Your home for the classics and NPR news. The time is 8:26 a.m."

That's when I saw it. One of those "IN/OUT" spaces was wide open and calling my name. Kimberly! Kimberly! 4 minutes to clinic! I hit the brakes and my blinker. Suddenly, I felt guilty so just sat there for a moment. Thought about Richard-the-security-dude's definition of IN/OUT:

"I guess it's like, 'Oh, let me run in and sign this chart' or 'Whoops, I forgot to get something from my office.'"

Technically, I did have to sign something--the five trillion charts of the five trillion patients I would be seeing with the residents until 5:30 that evening. And hey, I'm sure I could think of something I could use from my office. Then thought about the whole 'honor' business. In a mocking, na-nanny-boo-boo voice I wagged my head and said aloud, "It's on an honor system!"

A horn blew behind me, and nearly gave me a heart attack. When I flung around, this young doctor behind me in a Toyota Prius had his hands up in a "What the hell are you doing" gesture. Pretty sure when I read his lips there was an 'F' bomb in there. Another honk, this one harder. Environmentally clean car, but environmentally foul mouth--go figure. I officially wimped out and drove past the ultra-awesome-but-on-your-honor parking space. In my rearview, I caught a glimpse of Dr. hybrid-car whipping into the spot sans a single stitch of internal conflict. He'd better be running in to sign a chart. Or to get something from an office.

8:40-- scurried into the Green Pod clinic panting after snagging a not-so-great space on the ninth floor--negating all of my traffic light karma, but not my honor.

5:35 p.m.

Running out of the hospital toward the elevator. Now rushing to pick up the kids and wishing I was parked on the ground level. Blue Toyota Prius still "IN" the rockstar parking space, which means the potty-mouthed resident doctor driving it definitely had more than one chart to sign, and more than a forgotten item in his office. IN/OUT my foot. Oh well. He got the space, and saved at least 3.5 minutes on his arrival, BUT you better believe there will be no honor-related honorable mentions for him.

9:10 a.m the following day- Sufferin' succotash! That's despicable!

Do you know the next morning, that Prius was STILL THERE!
(picture me with eyes narrowed, lips curled, hands on hips like "No he di'in't!")
Yes he DID! Dr. Foulmouth broke every part of the quasi-honor code and had parked his green machine in the IN/OUT spot while on OVERNIGHT CALL. For some reason, I thought anybody who would drive a Prius would automatically be a rule-follower. I have since changed my position. (Yes, I know, I'm being a hater.)

Next time you see Hippocrates, do me a favor and ask him what HE thinks about all of this.

Sunday, September 20, 2009

Reflections from a Friday at Grady: This bitter earth

"This bitter earth
What fruit it bears
What good is love

That no one shares?

And if my life is like the dust

That hides the glow of a rose

What good am I
Heaven only knows

This bitter earth

Can be so cold

Today you're young

Too soon you're old

But while a voice

Within me cries

I'm sure someone

May answer my call

And this
bitter earth
May not be so bitter after all."

Jazz legend Dinah Washington singing "This Bitter Earth"


Okay, so I guess I would be remiss if I didn't comment on something that happened to me at Grady. . .and sort of beyond Grady. . .last Friday. I was giving the lecture for Primary Care Grand Rounds (at Grady) and I. . .well. . .I started crying during my presentation. Yeah, you read that right. I started crying during my Grand Rounds lecture. Snot and all, and not a tissue within 50 feet of the podium. "Boo hoo crying" as my best friend Lisa D. calls it, and nope, no typo-- I was the speaker. Wow. Doesn't sound too grand, does it?

Listen--if you have read any part of this blog, you probably know that I have a lot of emotions when it comes to crack cocaine and the patients we care for at Grady who are affected by it. So it should come as no surprise to you that I decided to take a detour from our regular super-scientific talks and try something different, but related to crack cocaine. I guess my goal was to "humanize" our patients who use crack, and to paint them not as "crackheads" or these erratically-walking-down-the-street/washing-your-windshield/asking-you-for-money/weak-minded/fill-in-the-blank addicts. . .but as real people.

Of course, I did the regular background stuff of reading papers and doing literature searches. But the coolest part was the three weeks I spent walking around the hospital interviewing patients who used crack cocaine. Oh man. . . . .it was amazing the things people told me. And every person I talked to was so gracious. . .so open. I always thought I knew a bunch about street drugs and the dismal factors that lead to their use- but I did not know as much as I thought. I was excited about telling their stories.

Last Sunday, I was working on my slides and even though it was going well, I found myself hitting a wall. I decided to take a break and head to my vice of choice - Target. (Some have a drink to unwind, I go to Target.) While en route, my dad called me on my cell. (Not unusual, since I pretty much talk to my parents daily and subject them to a blow by blow of everything I do professionally.) Dad and I were chatting about my presentation, and I was doing my best to give him my vision of the whole thing. I hoped he'd give me something to help me with the roadblock I was hitting.

"You should talk to your Uncle Woody, " he suggested. "He will probably tell you a lot of useful stuff for your talk."

Uncle Woody is my dad's younger brother. One of the eleven children born to my grandmother and grandfather, one of seven sons, and one of the two children who graduated from a four year university.
Hmmmmm. I suppose I'd sort of known that my Uncle Woody was "on something", and I'd heard that he'd been incarcerated and hard on his luck over the years. I even knew that he'd stolen money from Dad at some point, too, yet even that I hadn't thought about much since Dad had forgiven him for it.

"Uncle Woody used crack?" I asked. The more I thought about it, the more I knew the answer. While he wasn't the only Uncle that had substance abuse issues, he was the only one who was always accused of having "sticky fingers" which is, as comedian Jamie Foxx says, "crack-ish."

"Oh, yeah, he definitely used crack," Dad said. I liked the gentle and understanding tone to his voice. It certainly did not sound the voice of a man who'd had his identity stolen, his credit annihilated, and even a criminal record created in his name all at the hands of the younger brother of whom he spoke.
"He's really open about it. I will call him and see if he'll talk to you about it. I'm sure he will."

After we hung up, I pulled into a parking space and just sat there for a moment thinking. I reflected upon my childhood memories of my Uncle Woody and smiled. He was so charming . . .and cool--I'm talking cool as a fan. . . . .and super good looking. One summer we were visiting Birmingham, Alabama when I was around ten years old. We stayed at his lovely home with his even lovelier wife, and I recall not wanting to leave. I remember the wall to wall carpet in his new home, the late model Cadillac he was driving, and even the way he smelled. He smelled like fancy cologne and success. His wife smelled even better, and in their bathroom they had a double vanity (which at age ten, I had never seen before.) Woody's wife had perfume with an atomizer sitting on the bathroom counter, and sprayed two sprays each behind my ten year old ears. I was elated. My Uncle Woody was the number one salesman at one of the largest Ford dealerships in Alabama, and it showed--his life was fabulous, and so was he.

Then, at some point, something went terribly wrong. We lived all the way in California, so my perception was distorted by the miles. I recall these vague reports of him. . . . "Woody lost his job" or "Woody's not with his wife anymore" or later on, "Woody will steal from you 'cause he's 'on something'." That went on for years. . .through my high school years, through college and beyond. The uber-successful uncle who had graduated from my college alma mater and who always smelled so good had become this blurry figure that I couldn't get my mind around. I began to wonder if my early memories of him were just a figment of my prepubescent imagination.

My cell phone vibrated in my pocket and startled me.
"Take this number down," Dad said firmly, "Woody is waiting for your call."
Robotically, I wrote the number down on a loose sheet of paper lying on the seat in my car. A few moments after I entered Target, I took a deep breath and called my uncle.

As soon as I heard his voice, there was something different about it. Always the life of the party, I was accustomed to his quick wit and tendency to entertain any person with whom he spoke. Today, it was appropriately serious. No lighthearted one-liners, no silent laugh track in the back ground or even the slightest hint of "shucking" or "jiving." It was a side of him that was as nebulous and foreign to me as the descriptions I'd heard of him over the years.

Two sentences into him telling me his story, I felt a pang in my heart that told me, Go sit down. Take this all in. This is real talk right here. He doesn't have to do this for you. Give him that respect. (Fortunately, most Target stores are now equipped with their very own Starbucks bistros.) I asked him to hold his thoughts for just a moment as I ordered a latte, sat down with a pen in hand and that same loose sheet of paper. I didn't want to miss a thing.

We launched into what turned out to be a pivotal discussion. Uncle Woody took me on his twenty plus year personal journey through the hell of crack cocaine (and alcohol) addiction. He told me how he was introduced to crack, how it made him feel, and when he knew he was "hooked." He described the deplorable living conditions he experienced at his worst, his deceitful means of acquiring money for drugs, and the self hatred that was perpetuated as a result. Eloquently, he shared of his meteoric rise to success as a young man followed by his plummet to rock bottom--all at the hands of drugs.

We talked about his life now, and his ongoing struggle with substance abuse. There was a childlike quality to it all. . . . almost like an attestation of some horrible abuse at the hands of a caregiver; filled with internal angst about whether or not it was all their own fault. He graciously (and courageously) agreed to let me tell his story, use his name, and even his picture.
"Anything I can do to help you teach people, Kimberly," my Uncle Woody said earnestly.

The entire time, I was somewhere between intrigue and tears. Like my dad and all of his side of the family, Uncle Woody is such a good story teller that the pendulum swung more towards the "intrigue" side. I hung onto his every word, inserting my gasps and "oh my goodness"es along the way. In the end, I guess I never really processed my feelings about it all. . . . . .

That is, until a little over three quarters into my lecture last Friday. I had incorporated all that Uncle Woody had shared with me into my slides, including a few of his notable quotes that I'd scribbled down feverishly in the Target Starbucks that day. The whole thing seemed to be going well. I told my patients' stories, and saved one of the very best for last-- Uncle Woody.

(Granddaddy, Grandmommy, Auntie Bunny, Mommy, Daddy, Uncle Woody, and Mudear
Mommy and Daddy's wedding day, July 23, 1966)

There I was, in my element. Talking and teaching. . . .totally my thing. Then I advanced the slide and there it was. It was a picture that included my Uncle Woody from July of 1966 (above). An image I'd seen a thousand times before, and a thousand more since I'd been preparing for this talk. It was from Mom and Dad's wedding day, and there stood 18 year old Woody in the wedding party. Mom with her angelic 19 year old face, Dad standing at military attention--with Uncle Woody to his immediate left. Next to Woody was my paternal grandmother, affectionately know to us as "Mudear." She looked so regal--standing beside her two college boys. Dad, the first to go to college, and then, Woody, who had graduated high school second in his class and who'd scored a full scholarship to play baseball at Tuskegee. I saw my maternal grandparents, Mom's older sister, Bunny. . . but at that moment, when it was projected on that screen, I saw that picture completely differently.

That was the Uncle Woody of my ten year old memories. If I closed my eyes, I could even smell his fancy cologne and hear his confident laugh. That laugh sounded so watered down and defeated in our recent conversation. I thought about how much courage it took for him to tell me his story especially since I know he knew how much my siblings and I once looked up to him.

The magnitude of it all smacked me across the face and punched me in the chest. What a parent wishes and prays for their child! Oh, how proud Mudear must have been during that time. . . .and how devastated she must have been to see her manchild's demise! Completely unexpectedly, I was immediately moved to tears at the very sight of the image--in front of the entire auditorium of attendees. I tried to speak but nothing came out. I cannot believe I am doing this during my Grand Rounds lecture. I cannot believe this. Get it together, Manning.

You could hear a pin drop. I waited a moment and did my best to continue. Okay, Kimberly. Please don't go into the "ugly cry" like when Halle won that Oscar. That's when it crosses from touching to weird. Don't go there. Come on, girlfriend, pull it together. For a few seconds I felt embarrassed, but something about the audience comforted me; their understanding eyes, their patient silence.

On Friday, the pendulum swiftly swung the other way with nearly one hundred onlookers. I processed my feelings about my uncle, my Grady patients, and my feelings about crack right then and there--whether I was ready or not. And in a strange way, it felt good to release those emotions (even if it was in front of five trillion people that I have to see on Monday.)

Dear Uncle Woody,

Thank you for not being too proud or afraid to tell me your story. Thanks to your honesty, a lot of people learned a lot that day, and I learned something about myself. I learned that I love you--and you know what? Not as much has changed in thirty years as I once believed.

Now, I respect you for completely different reasons.

With love from your niece,


Now that I think about it. . . . .thanks to my patients at Grady--and my Uncle Woody--my Grand Rounds talk was kind of therapeutic. . . .and pretty grand after all.

Thursday, September 10, 2009

"I just wanted to say thank you. . . ." *

*written/posted with permission from patient's family

This is the text message I received yesterday at 9:27 p.m.

"I just wanted to say thank you. . . ."

I looked at it for a few moments before it registered who it was from- the 22 year old daughter of one of my patients from the inpatient service last month. She'd gotten my number after we'd had a really difficult discussion about her ill father--my patient. Her dad . . . . a prince of a man who'd suffered a severe anoxic (lack of oxygen) brain injury after a complicated procedure three years ago. Repeated infections caused him to come in and out of the hospital. Nonverbal and nonresponsive, the quality of his life was questionable at best. I spoke to his wife at length that Sunday morning and still remember her face; a solid mask of pain. In the family waiting room, she sat meekly in a wicker chair; hands wringing a tattered piece of tissue. The soft fabric of her hijab camouflaged the tears that rolled down her cheeks. "Please call my daughter," she said in a soft and heavily Amharic-accented voice. "Please call and talk to her about all of this. She is in college and studying to be a doctor. Please talk to her."

*67 (or "star six seven")
That's what you dial before you return a page or call a patient from your personal phone. It blocks your number on caller ID and ensures that you won't be getting any random calls from random people later. *67. That's what I dialed before I called my patient's daughter. I'd promised her mother I would call her, and that is exactly what I did.

To be honest, my recollection of the conversation is that it wasn't too great. Who wants to tell a twenty-two year old college student that her formerly healthy patriarch has little to no chance of meaningful recovery? Who wants to bring up ominous words like "hospice" or the dreaded "do not resuscitate" order between study breaks? I would have much rather asked her what she thought of Beyonce's latest video or, if she is the worldly type, a chat about the Obama administration's health care proposal or North Korea shooting missles. Anything but this discussion. Let me tell a sixty seven year old woman this about her octagenarian parent. Not a twenty-two year old girl about her daddy.

"I want to honor my father. Letting him die is not honoring him."

"We want the same thing. We do. I want to honor my patient. Your father is my patient."

Usually these heavy conversations don't happen through an iPhone earjack on Ponce de Leon Avenue. We teach our students to pull up a chair, sit at eye level, and to show empathy. She wasn't even in the state of Georgia, so I didn't have that option. There was no quiet room I could lead her to, away from the beeping machines and overhead speakers. I couldn't touch her hand or furrow my brow to indicate that I was indeed listening to her every word. No small box of too- rough facial tissue to hand her should she cry. No home court advantage at all. It was weird.

There were these periods of silence where I was sure the call had dropped. By the end of the chat, I couldn't tell if I had horribly offended my patient's daughter, confused her, or completely turned her off to the medical field altogether.

"Hospice is a death bed," she'd said boldly.

"Let me teach you more about hospice," I countered.

That was all I could think to say. I was careful with my words--and my tone. Even over the phone it was obvious that she wasn't afraid of doctors, especially me and my iPhone earjack several hundred miles away.

But she did let me teach her a little more about hospice. In fact, she asked me great questions and let me teach her a little more about a lot of things. And even though the conversation did not end with a firm decision to pursue hospice care, it did seem to be a healthy dialogue. She asked to have a number to contact me should she need to ask more questions.

"What is the best way to reach you, Dr. Manning? Your number was blocked."

"My cell phone."

I decided to tell her the truth, the whole truth, and nothing but the truth-- since this had been the theme of our entire phone call. Against everything I constantly preach to the residents and students, I gave my personal cell phone number to a patient. (Well, technically not a patient, but you get the idea.)

Fortunately, there were no random phone calls. No inappropriate crossing of lines or entering of personal space. Just an occasional question here or there leading to more opportunities to explain things better. Mostly in the form of very respectful text messages.

On August 31, my month on the wards ended. That meant I was no longer caring for her dad--but I still thought about him--and her. None of her text messages ever told me what they'd ultimately decided to do, and that was okay. I wondered how he was, and how they were all coping with it. How was my patient's daughter doing in her pre-med coursework? Was she able to concentrate on Organic Chemistry? Was she able to laugh out loud and do the things college kids do? How was his wife? Was she weeping in the bathroom during her lunchbreaks? Was she really okay? Did those conversations I'd had with them make a difference at all. . .or did they just make matters worse. . . .

Multiply these swirling thoughts and burning questions by all the patients who touch you, and now you know how dizzying this job can be. At some point, I guess you just get used to it. . . .learning to accept that sometimes you never get that closure you want. . . . . .

9/9/2009 9:27 p.m.
"I just wanted to say thank you. . . . ."

. . . . but. . . .sometimes you do.

Wednesday, September 9, 2009

Reflections from a Thursday at Grady - What's in a name?

"What's in a name?

That which we call a rose
By any other name would smell as sweet."

~ Willam Shakespeare's Romeo and Juliet

"Say my name, say my name
You acting kinda shady
Ain't callin' me baby
Betta say my name."

~ Destiny's Child "Say My Name"


"That'll be $44.52," the cashier told my mother at Publix one afternoon.
"Thank you-- Justin," she said cheerily with her eyes focused on his name badge. Sure enough, it read "Justin." After taking her debit card information, he decided to return the favor.
"Come back and see us, Mrs. Draper, and have a great day."
It was a veritable name-calling lovefest.

My mom always calls a person by their name whenever possible. She asks. She remembers. And if for some reason it slips her mind (which things often do with my mom), she asks again. It's one of the things I love the most about her. No one is ever a "hey you" or even an "excuse me, ma'am", especially if they have a name tag on. She gets the origin, the pronunciation, the whole kit and kaboodle. And not once have I ever seen a person mind.

A few weeks ago, I was rounding on one of my favorite floors at Grady, 7A. After seeing my patient, I realized that the chart was out of paper. I headed over to the unit clerk to ask for some assistance.
"Pardon me, Ms. Natalie, but do you have any extra progress notes up here?" I then remembered that I hadn't greeted her. "Oh, I'm sorry! Good afternoon!"
Ms. Natalie smiled wide revealing the trademark gap between her two front teeth and handed me a two sheets of Grady progress note paper. "You know I got you, Dr. Manning!"
"Thank you, ma'am!" I announced and prepared to write a note at the nurses' station.
"No problem, Dr. Manning!" she answered. Again came the bright smile.

I stood quietly at the counter writing for a few moments until my concentration was broken by the boisterous banter of a few of the nurses finishing their afternoon report. I lay my pen down in anticipation for what was sure to be their characteristically warm greeting. The ward wasn't particularly busy this day, and by the relaxed pace of the staff, it showed.
"Where you been, Dr. Manning? We thought you had put us down!" laughed Mrs. Nix, one of the senior nurses.
"Yeah, Dr. Manning!" Mr. Stanley chimed in, "You too cool for 7A?"
We all chuckled as we exchanged hugs. "Come on, Mr. Stanley and Mrs. Nix! You know I love me some 7A," I responded lightly.
"How is Master Isaiah?" Mrs. Nix asked with a twinkle in her eye. "Oh, and the baby--what's his name again? How his that little pumpkin?"
"Thank you for asking,"I said. I was flattered that she'd remembered my sons. "That little pumpkin, Zachary, is almost 3 now, and he and 'Master Isaiah' are both doing great."

I smiled and then returned to writing my note. I finished the last few lines and signed my name and license number. I paused for a moment and thought about the game plan for this patient. Darn, I wonder what time that MRI is going to happen?
"Hmmm," I said aloud while scanning the board to see which nurse was caring for my patient. At the top of the board was a familiar sight: "Nix, RN - Charge Nurse." No surprise there. Next were the names of the other nurses, followed by the rooms to which they were assigned-- "Shepherd, RN", "Stanley, RN", "Nwoke, RN", "Salami, RN", "Sunday,RN" and "Chiwiteloju, RN." Aaaaah, Ms. Salami, cool.

I headed down the hall toward the regal African woman clad in white who stood at the pull-down chart preparing medications. She had already begun to grin before I even reached her. "Hey, Dr. Manning!" she spoke with her musical Nigerian accent. I returned her greeting with a hug.
"Mrs. Salami, do you know when my patient in bed 2 is going for his MRI?"
I was glad she was his nurse. I knew she would know this kind of helpful information.
"They told me two o'clock, but I am going to call them right at 1:30. I know he is wondering what's going on," she answered while separating pills into a little plastic cup. "I can page you if I hear differently, or if he doesn't go at 2pm." I loved the staccato sound of her Yoruba-twinged English.
"Thanks, Mrs. Salami, I'd appreciate that."
Sliding the note into the three ring binder of the chart, I gave the entire ward an exaggerated wave before scurrying to the stairwell.
"Bye, Dr. Manning!" they replied in unison; a chorus of multitonal voices, melodic accents, and positive energy--hands down one of my favorite things about Grady.

It probably has more to do with Mrs. Draper than anyone else that I always try to learn the names of the people I work with-- no matter where they are on the totem pole. My rule is simple: if you have taken the time to learn my name, I will make every effort to learn yours. It still amazes me how much such a small gesture means to people.

Case in point: I once worked with a resident who'd had quite a few awkward interactions with the nursing staff. They complained about her, and the resident complained about them. She would insist that the nurses were disrespectful, and surprise, surprise- the nurses had the same to say about her. One day we sat down to talk about these issues, and my first question was, "Which nurse or nurses are you having trouble with?" As it turns out, she could not name a single RN on the floor. Even after I described them one by one, she had nothing. Unfortunately, she had not committed one staff member's name to memory--even after 16 days on service. They all knew her name, but she didn't know theirs. Not a one. My single piece of advice to her? Learn the nurses' names and make every effort to address them by name. Start there, and see what happens. You know what? She didn't have any other problems for the rest of the month. In fact, at the end of the month, they were sorry to see her go. Kind of interesting, don't you think?

So what's in a name? That's easy, Mr. Shakespeare. Regardless of smell, I know this much is true-- a lot is in a name. Affirmation is in a name. Acknowledgment is in a name. And as I am learning more and more. . . . . . .respect is in a name. Folks just like it when you think enough about them to not only ask their name, but remember it and use it.

So thank you, Justin at Publix, for being so pleasant to my mom in the grocery store. And thank YOU, Cheryl Draper, for teaching me early a simple truth that helps me every single day at Grady--exactly what's in a name.

Monday, September 7, 2009

Thirty nine is the new forty. . . . .

"Thirty is the new twenty."

- Jay Z

Grady Seinfeld Moment -Birthday Edition:

One of the nursing assistants in the clinic heard that my birthday was on Labor Day, and asked, "How old are you gon' be, Dr. Manning?"
I poked my chest out and told her proudly, "Thirty-nine and feeling fine!" (Lame, I know.) Guess what she said?
"Oh, hell, you might as well be forty. Don't even bother with 39, just tell people you forty. Any time somebody says 39, everybody just thinks, 'Yeah, yeah- you forty.'"

(Sorry, Jay Z, but it looks like thirty is the new. . .well, thirty. . .and even worse, forty is the new . . .well, thirty nine. Wait - or is it thirty-nine is the new forty? Either way, the ten year allowance is hot for a rap tune, but not so in real life. I'm not bitter, either. I'm just sayin'.)

Feelin' thankful. . . .

Unless you have a heart of stone, working at Grady has a profound effect on you. It brings you up close and personal with extremes of life, death, and everything in between. But what it really does is make you appreciate those little things that you otherwise might be tempted to take for granted. And so, in the spirit of what I have learned from my dear old Grady, I am feeling truly thankful on today.

Why all the warm fuzzies? As you may have already gathered , today happens to be my birthday. I'm not ashamed to say it- it's my thirty-ninth birthday. And you know what? It's been a wonderfully blessed thirty-nine years. (By the way, I'm 3 months older than Harry, who takes great pride in calling me a "cougar" who robbed the cradle. . . . .)

Anyways. . .so how did I ring in the birthday? Well, for starters, I was off work for the long weekend. (Woo hooo!!) Harry and I took the kids to Lake Lanier Islands for the weekend, which was a complete hit. (Super close, super economical, and super fun!)
We dropped the kids off with my mother on our way back into Atlanta, and the rest of the afternoon was spent simply holding my husband's hand and feeling like a girl. *Sigh* I have to say. . .for a working momma with two kids under 5, my husband does an exceptional job of making me feel "like a girl" every single day. (Even if he thinks I'm a "cougar.")

So. . . .here are ten things that make being 39 and me pretty darn great:

10. My two superhero sons are convinced that I am a beautiful fairy princess that must be protected. . .whether I am up 5 or down 5 pounds.

9. Really, really rich friendships- and now witnessing my kids being friends with my friends' kids. . .awesome.

8. My mother and my father are still my heroes. (They call and text me daily! How gnarly is that?)

7. My siblings are totally awesome, and I genuinely adore all of my in-laws- especially my mother-in-law. (Crazy, right??)

6. I absolutely love my job- and would still show up if I won the lottery. (No kidding.)

5. Not to toot my own horn, but all I'm saying is two pregnancies, size 6 and no stretch marks. (That's right, I said it.)

4. Listening to Isaiah praying for me at night. (OMG. . .what could be better?)

3. Zachy smooching me. . . .oh, and being 100% potty trained!! (Nights, too! Yeah baby!!)

2. Every time I look at my husband, I think, "if you weren't my baby-daddy, I'd sure wish you were."

1. I'm comfortable in my skin, and I like being me!
(Offspring of the Class of '96 - Meharry Medical College)

By the way, if I seem infinitely wiser in my next posts, it's only because I'm even growner than I was before. . . . .yes, you thought it was not possible, but it is possible to be even growner. Yes, I meant to say "growner." So yes, I am knocking on 40, and it's officially a grown woman.*

*(But not as grown as my husband, Harry- he's the original grown man.)

Harry a.k.a. The original Grown A-- Man, yes, with his sons getting a SHOE SHINE at Lenox.
A SHOE SHINE? Now tell me- what is growner than THAT?

Friday, September 4, 2009

Seinfeld Moment: The Advanced Social History

True story, I ain't lyin':

"Sir, do you ever drink beer, wine or any alcohol?"

"Yeah, ma'am. . . . I ain't gon' even lie-- I do, but just beer, though."

"Got it. . .so, when you do, what kind of beer do you drink and about how much?"

"Usually, I just drink that Billy Dee. I'll get me a deuce deuce after work. Sometimes two."

(Here's the part where being a black woman who grew up in the '70's comes in handy.)

"Huh? Billy Dee. . Billy Dee. . . Billy Dee. . ..wait. . .Billy Dee as in
BILLY DEE WILLIAMS on the Colt 45 commercial?"

(Non-black people: refer to picture above. Black people born in the 70's: Don't get all bourgeois on me--you know exactly what I'm talking about.)
"So wait--you drink twenty-two ounce cans of Colt 45?"
Wo-ow. How funny is that?

"Yeah ma'am, that Billy Dee." 

(He is dead serious and not even picking up on my amusement.)

Yes, boys and girls. It's not a job, it's an adventure.
Wow. . . all this talk about Billy Dee Williams is inspiring me to pop me some popcorn and order Mahogany or Lady Sings the Blues on pay per view. But don't worry y'all--I won't be cracking open "that Billy Dee."

Billy Dee Williams as Lando Calrissian - the original playa from The Empire Strikes Back.
(Don't hate the playa. Hate the force.)

Thursday, September 3, 2009

It's not about me: Reflections from a Monday at Grady

"Nobody understands my pain," my patient said solemnly, "I wish I could get somebody to know how I feel. People think they know me, but they just don't." He gazed back at me with ocean blue eyes, and then, in a split second, they were hidden behind a clenched grimace. I rubbed the side of my neck and prepared myself to be patient. My residents stood in respectful silence in a semi-circle at the foot of the bed.

The thing is. . . . I knew this patient. In fact, I knew this forty-something year old gentleman quite well from the last two or three times I had admitted him to the hospital. He'd remotely had a few blood clots -- what we refer to as a DVT or deep venous thrombosis, that in his case traveled through the veins to his lungs, where it then became what we call a pulmonary embolism. To protect him from further clots, he was supposed to be on lifelong anticoagulation (blood thinners) which he often neglected to take. When we'd see him, he usually complained of pain in his legs that rarely matched clinical findings, and the complaint was almost always accompanied by a request for narcotic pain medications.

The first time I cared for him, he left the hospital with a cross-my-heart promise that he would indeed take his medication as prescribed. Unfortunately, he didn't take the medicine as prescribed, and like clockwork, he'd subsequently show up in the Grady ER. After a complaint of pain or shortness of breath, he'd get admitted to the hospital to thin out his blood again and exclude a new clot again.

(Background for non-doctors: There are a few types of blood thinners. Heparin can be given IV, and thins the blood immediately. This is often started right away when someone is hospitalized for a clot or suspected clot. Warfarin comes in a pill form, and has to build up in the system. This process can take as much as five to seven days, depending on the patient. We often "bridge" our patients in the hospital by giving them heparin while the warfarin levels reach therapeutic level. Unfortunately, this means a hospitalization. While there is a type of heparin that can be given outside of the hospital for bridging, it is quite expensive making it sometimes difficult for uninsured patients to obtain. It is also a self administered shot, so takes a very compliant and motivated patient--which this patient was not.)

"Have you tried Motrin?" I asked even though I knew the answer.
"I'm allergic to Motrin. I'm also allergic to Tylenol and Ultram, too," he reported. Again the clench-eyed wince, again my neck rub. I could feel myself getting annoyed, which isn't really a good way for a doctor to feel about her patient. I shifted my feet from side to side in an effort to redistribute my emotions.

"Do you know when my nurse is going to be back to give me some more pain medicine? I'm in agony, doctor." He pulled the covers up to his chin and peered over them like a child who had just been tucked in. The residents cast fleeting glances to one another. They are watching what you do. Treat this guy badly, and you give them license to do the same. I cleared my throat and proceeded to look over his medication administration record.

"You actually received quite a bit of pain medicine about an hour ago, so you aren't quite due yet." I swallowed hard and willed myself to be patient with him.

"Doctor," his muffled voice spoke through the blankets, "that Morphine don't do nothing at that dose. One time when I was here they gave me some Dilaudid, and that helped a lot." Of course it worked, man. Okay, Manning . . . .Stay calm. Be professional. Stay calm. Be professional.

"I'm sorry you feel that way. I'm looking closely at what you've been given, and this is a pretty good dose of morphine, sir." More throat clearing, more foot shifting. Stay calm. Be professional. Stay calm. Be professional. "I'm not sure if you were told or not, but your tests confirm that you did not have a new clot."

He lifted his chin to get a better view beyond his blankets. Next came another grimace; this one exceptionally melodramatic. I reached for my neck, but decided against it. This is not about you. This is about him. Stay calm. Be professional. Stay calm. Be professional.

"I'm so glad I don't have a new clot, doctor," he continued in his best earnest voice. "I am very worried about what could happen with my blood so thick. How long do you think it will take to get my levels up? Last time it took 6 days, but I will just be patient with whatever y'all think."

I pressed my lips together, trying to think of an empathic response. The problem is, I wasn't feeling so empathic even though I knew I should. The pregnant pause continued as he periodically writhed in his alleged pain. I found myself looking for gestures other than the signature neck rub to blow off steam. Even though you are annoyed, don't look annoyed. Stay calm. Be professional. Stay calm. Be professional. Your residents are watching you. They will follow your lead.

And so we went on with our doctor-patient interaction. The residents stood quietly and listened carefully. I could feel my patience waning and hanging on by a thread. If something didn't change quickly, I'd be sure to erupt into neck-rolling and finger wagging--gestures I am certain he'd pushed doctors to before. He was also probably used to doctors becoming so frustrated that they'd a.) give in and become indifferent or b.) make passive-aggressive medication changes that would force the patient to leave AMA (against medical advice.) I am pretty sure the last time I'd cared for him, I'd done some hybrid of the last two.

Feeling like I was reaching boiling point, I made a decision to talk this over with myself before uttering another word.

Real me: What is this guy's deal? Why do we keep having to admit him when we know he just wants pain medicines? This is so ridiculous!

Empathic me: Do you think he wants to be forty-three and getting admitted to Grady five times per year?

Real me: No, but the dude is like, not even taking responsibility for any of his own actions. He is not taking his medicines. He knows that if he shows up in the ER he will get admitted.

Empathic me: Yeah, but why do you think that is? Do you think when he was in kindergarten, he said, "Hey, when I grow up I want to be addicted to Percocet and manipulating doctors at Grady!"

Real me: Probably not.

Empathic me: What IS his deal?

Real me: His deal is that he is annoying.

Empathic me: No, his deal is that he has a problem. He probably does have some pain, but the pain medicine is a problem. He does not have stable housing, he doesn't have family support, and every doctor he sees treats him like he is annoying.

Real me: But he IS annoying.

Empathic me: But that should not affect you being his doctor. Get off your high horse.

Real me: High horse? Give me a break.

Empathic me: You can start with some honesty.

Real me: I am being honest. I am trying to help but he is insulting my intelligence and it really is annoying. We have way too many patients to see to be dealing with this again.

Empathic me: But this is not about you. This is about your patient--and you signed up for this. Focus on that, and not yourself.

My direction became a little more clear right then. I would be honest. Even if he did not like it, I would be honest. And I would focus on him, not me.

"Sir, here's the thing," I chose my words carefully; ever-cognizant of my residents' eyes and ears. "I am really concerned about a few things. My first concern is that you absolutely have pain, but in talking to you, it is a long-standing or chronic type of pain. The pain you describe today is identical to what you told me before. And while I know that it is uncomfortable for you, I am not sure giving you habit-forming narcotic medicines for this is the right thing to do." I waited for him to speak, and when he didn't, I continued. "This time you didn't have a new clot, and from all of our work-up, you seem to be clinically stable. I am concerned that having you come in and out of the hospital is also not good. You seem to have trouble taking the warfarin. Why do you think that is?"

"Doctor, I stay in a rooming house and I am on foot everywhere I go. It is hard for me to make it to the clinic and when you go to the pharmacy, the wait is really long. My legs hurt, and all that walking makes it worse. I tried other stuff, but it doesn't help." His blue eyes were like pools, and for the first time, he looked truly sincere.

"That does sound rough,"I replied softly. "I didn't think about that." That sucks, yes. But still, this isn't working either. "What do you think about us looking into you taking the Heparin injections while your warfarin levels increase? We could see if we could get it covered and possibly try again."

"I hate them shots, and I just can't do it. Plus they said I am not a good candidate since I had so many clots in the past." Empathic me gave me a shoulder rub, reminding me to keep the proper focus. Be honest.

"Sir. . . again, my concern is that this has become a cycle. The easy thing to do is to give you pain medicine and keep you here while your warfarin reaches therapeutic levels. But I can't say that this won't happen again, and this is really not good what we're doing now," I spoke calmly. This time I did feel empathic.

"So what does that mean? You just kick me out?" he asked.

"No, sir. I am going to first contact our social worker to see if she can assist you with your medicines and where you live. Then, I am going to consult our Ethics Team. They help us with tricky and confusing situations or what we call 'ethical dilemmas', and, sir, I really think this is an ethical dilemma. You have clots and you need your blood thinned. You have pain, too. But it is your responsibility to take your medicine and keep appointments, and you haven't been doing that. Having you admitted over and over is bad for you, it really is. And we can't help you make more responsible decisions unless we hold you accountable to some degree. You understand what I'm saying?"

He didn't exactly care for what I was saying, but he did seem to respect my honesty. "Do you think it would hurt if I took those shots? I mean the Heparin shots."

"It's probably a bit uncomfortable, but I'm told it's bearable," I answered with my first smile of the encounter. "Would you like me to have the pharmacist come look over your chart and talk to you about it?"

"That would be good," he said with a half-smile.

When I left his room, I didn't feel annoyed any more. In fact, I thought about him a lot for the rest of the day. I wondered what he did when he wasn't in the hospital-- was he lonely or bored or scared? How did he even end up like this? And did he wish that he could be somewhere else. . . .without a history of clots, or unstable housing, or inevitable hospital admissions? It was true--this wasn't about me.

His care was later transferred to one of my colleagues a few days ago, and I am still not sure what ultimately happened. I do know that, on that day, his doctor was honest and tried to get over herself long enough to treat him with some dignity. Hopefully, the doctors-in-training who stood in the wings watching will take pause the next time, welcoming a little internal dialogue before reducing themselves to an unprofessional or passive-aggressive default . . .

Afterall. . . it's not about us, and we signed up for this.