Monday, October 26, 2009

Reflections from an October at Grady: Flowers for the Living

(* Entry written with permission of patient and family, names changed.)

Mrs. L's actual window sill, taken with my phone with her permission

I walked into the room of my patient, Mrs. Lloyd* (names changed) one morning and immediately noticed the same two things that always leap out at me upon entering her room: First, her daughter, Nicole, who had become a permanent fixture at her bedside throughout the hospitalization, and second, the constantly growing shrine of cards, flowers and balloons sitting on the window sill.

"We love you, Mama"
"Get well soon"
"We miss you, Big Mama"
and my favorite one, which read

"Too blessed to be stressed"

Every day there was something new. This particular morning there was a clear plastic container with a little black fish swimming around inside. "That's from her grandson," Nicole said with a hearty chuckle. "He said it would keep her company."

Mrs. L's fish, also photographed with her permission

Although her overall prognosis was poor, the energy in her room was always so rich. The cards, flowers, gifts, balloons, and now fish represented a person whose life was meaningful. This was a woman who was loved and cherished--and that's a blessing.

There are so many people I've cared for during extended hospitalizations whose window sills were a stark contrast to Mrs. Lloyd's. Rooms void of any visitors, cards, or sentimental items despite weeks and weeks in the hospital. There was this one gentleman I cared for a few months ago who was born and raised in Atlanta. He was even a self-proclaimed "Grady Baby," yet in the nearly thirty one days I cared for him, I never saw any signs of doting loved ones on his side of the room. Not a card, not a flower. . . . .not even remnants of half-eaten McDonald's from a hungry visitor. Then one day near the end of the month, I was elated to find a giant bouquet of balloons on his window sill. Eureka!

"These are beautiful, Mr. James!" I recall exclaiming, "I'm so bummed that I didn't get to meet your visitor! Who brought these for you?"

He didn't even make eye contact with me. He just kept staring out of the window with his skeletal back to me when he murmured flatly, "Oh, them was the man's that was in the bed next to me. He had so much flowers and stuff that they couldn't carry it all, so the nurse just left 'em with me. You can have 'em if you like 'em so much." This was his fourth week in the hospital under treatment for complications of AIDS. Sometimes that made me even sadder than his disease. But this wasn't the case with my patient, Mrs. Lloyd--her room was oozing with love.

Aaaah, Mrs. Lloyd. Mrs. Lloyd was a woman in her late sixties who had spent the last several months fighting a cancer that had rapidly spread throughout her body. She was admitted to our team early in the month after she had stopped eating and had become too weak to walk. She was evaluated in the Grady Primary Care Center where she was found to be dehydrated and with signs of an infection. With such advanced cancer, this wasn't unexpected.

Although her daughter, Nicole, had excellent insight on her mother's disease, she preferred to focus on the short-term, concrete details. "The medicine y'all gave her for her bowels really helped. She moved 'em real good, doctor," spoke Nicole while smoothing the cover over her mom. I glanced at Nicole quickly and took a mental picture of her. I'd decided early on in her mother's hospital stay that she was someone that I wanted to remember. At that moment, I promised myself that I would. Remember her. Remember this.

That wouldn't be hard because Nicole was memorable. Her round face was covered with a smattering of freckles, and her wide smile was the first thing to greet anyone who entered the room. Forty something year-old Nicole was what folks in my neighborhood would have called "big-boned-ed" but --like many such women I know--it didn't seem to dampen her confidence one bit. Her head was always held high, and there was always a twinkle in her eye. She smiled and laughed a lot. Each of her front two teeth was rimmed in gold, which perfectly matched her heart and her intentions for her beloved mother. Even during the hard conversations about things like the "Do not resuscitate" order or even hospice discussions. . . .she managed to exude positivity and to eek out a happy facial expression. Remarkable.

Every morning, Nicole was meticulously groomed from head to toe, and this day was no different. Her mane of sandy colored, shoulder-length dreadlocks was neat and purposeful, and perfectly spilling out of one of the many signature, brightly colored fedora hats that she wore daily.

"Wow, you really look so nice every day I see you." I was so impressed by her ability to fix herself up every morning with all that was happening to her mom. Finding her in a tattered t-shirt and wrinkled sweatpants would have been both understandable and acceptable under the circumstances.

"You know, doc, I kinda thank it makes my mom feel a little better when I clean myself up. You know what I'm sayin'? Like, I tell myself, if I look a mess, I think it would scare her. . . I don't want her to be able to look at me and tell how sick she is, you know?" She glanced down at Mrs. Lloyd who remained sound asleep. Yes, I think I do know. Nicole always seemed to know what to say.

"I think that's a great way to make your mom feel better, you know, putting so much time into your appearance," I spoke quietly. Then I added, "I like the way you dress her up, too. I bet that makes her feel good." We both rested our eyes on Mrs. Lloyd, and stood in silence for a few moments. Mrs. Lloyd had lost her wiry mane from a combination of aging, chemo, and chronic illness, but Nicole always decorated her mother with a different turban each morning, and even put a little lip gloss on her lips. And the best part of it? Whatever color fedora that Nicole wore, her mother donned a headcover of the identical shade. It was probably one of the sweetest gestures I have ever seen. Today was fuschia day.
Mrs. L's colorful turbans

I gently peeled back the cover and prepared to examine Mrs. Lloyd. I hated to even awaken her, and did my best not to. Suddenly I saw her lashes batting and her eyes slowly opening.

"Hey, Mrs. Lloyd, it's me Dr. Manning," I greeted in a hushed voice, "I came to see about you and Nicole this morning. Are you in any pain?" She offered me a slightly bewildered look. I knew there was a reason I didn't want to wake her up.

"Momma, are you in pain? Tell Dr. Manning if you in pain," interpreted Nicole to her mother. It worked. Mrs. Lloyd shook her head no. I studied her face carefully, looking for a grimace or any other sign of discomfort. Her face was quiet and peaceful; consistent with her response to Nicole.

I gently touched her cheek with the back of my hand. Her smooth, milk chocolate complexion was free of even so much as a laugh line. "Mrs. Lloyd, Nicole and them must not've worried you too much as kids. You don't have a single wrinkle on your face! Not a one!" I curled my lips playfully, put my one hand on my hip, and gave a "come on" gesture with the other hand. "Give it up, Mrs. Lloyd. You need to come on and tell me your beauty secrets."

"Chile, you know Black don't crack!" Nicole said and rolled her neck in jest. We both immediately laughed out loud, united in our African-American culture, and thus in our knowledge of that age-old saying. Mrs. Lloyd gave a knowing glance in our direction and offered a tired smile. It was her version of a "fist bump."

I then proceeded to quietly examine Mrs. Lloyd. The veins on her neck, her heart and lungs, and her protuberant abdomen. I ran my fingers along her extremities, pausing to check for pulses, and then applying gentle pressure to assess for fluid retention. My eyes traveled back to her face and waited for a moment. She had finally closed her eyes and drifted back into a peaceful slumber. I noticed her eyelashes--someone had applied mascara to them--and even her eyebrows had been shaped. This was what Oprah meant when she said 'The love is in the details.'

After gingerly replacing the covers over Mrs. Lloyd's bony shoulder I returned my attention to Nicole. She stood patiently in her fuschia hat, and as soon as she saw me look in her direction, she gave her same wide smile. What a remarkable woman. I scanned her face once more and vowed to retrieve it from my memory some day. Every freckle, every gesture. Remember her. Remember this.

"Nicole. . ." I cleared my throat and finished, "Nicole?" She raised her eyebrows and tilted her head sideways. I decided that I would tell her exactly what was on my mind. "Thank you for teaching me so much about how to be a better daughter. You are truly a remarkable human being, and . . . .I will never forget you. I mean that." I knew I was at risk of sounding corny, but I didn't care. With all of the flowers that she'd brought to Mrs. Lloyd, I thought she deserved a few flowers of her own. Flowers for the living.

Her face grew serious and determined. She reached down and rubbed her mother's leg slowly. "You know, Dr. Manning. . . .I ain't remarkable. Now my mom? She's remarkable. When you have a mom as good as my Momma been to me, it's easy." She shook her head and then locked eyes with me. "The bible says, 'Honor thy father and thy mother,'" she said with her raspy voice. "I'm just being obedient, Dr. Manning."

I vaguely remembered hearing someone preach a sermon on that at some point. Then I thought about the last time I'd heard someone say that. It was nearly a year ago when my good friend, Crystal C., was caring for her mother during her battle with metastatic lung cancer. Her mom couldn't drive any more, and my friend cheerfully taxi-ed her mom to every appointment, every pharmacy, every errand, and every place she so desired. Like Nicole, she told me that she was honoring her mother and being obedient. What a testament to a parent's life to have a child with such an attitude! Remember them. Remember this.

I do remember. I remembered the many times that I'd seen Nicole carefully doting on her mother over those weeks. Getting her coffee just right and inching it up to her lips to take a sip. "Too hot, Momma?" she would ask, and then put an ice cube in it. Pillows underneath her head with pillowcases from home, paint on her fingernails, and color coordinated head coverings. I also remembered Nicole's two teenage daughters who accompanied her on many of the hospital visits; equally smitten by their grandmother. Plucking her greying eyebrows, fluffing her pillows, rubbing her feet with vaseline. The love is in the details.

"They will remember this," I uttered aloud in context with my thoughts. "Your daughters. They will remember how you honored her." I cleared my throat again and added, "I will remember this." We were both silent again, this time as if someone had pushed a pause button. I glanced out the window into the bustling downtown Atlanta traffic. Nicole released a sigh to break the quiet tension.

"Look, Dr. Manning . . .I know my Momma sick. I know she might be in her last days, too. But taking care of her to me is a joy. I ain't doing nothing she didn't do for me. Nothing. Like I said, Dr. Manning, I'm just being obedient." My eyes moved from the window just in time to see Nicole plant a kiss on her mother's dewy brow. Obedient was an understatement.

"That you are."

I bid her adieu and headed toward the door. I stopped short of the handle and looked over my shoulder toward Nicole and Mrs. Lloyd once more. She had settled down into the bedside reclining chair next to her mother and closed her eyes. Honor thy father and thy mother. Words to live by. Remember her. Remember this.

I looked skyward and thought for a moment. "Exodus?" I asked with my eyes squinted.

She kept her eyes closed and smiled wider than ever. "Exodus 20:12," Nicole corrected me. I snapped my finger and nodded my head slowly as I left the room. I guess I had paid attention to more of that sermon than I thought. I could hear her throaty hum as I exited. . . .humming the old spiritual, "Going up yonder." How fitting.

***
That was the last time I saw Mrs. Lloyd and Nicole. We talked about hospice care, but they weren't quite ready to make that decision when they left that following day. Last Sunday, just two days after she was discharged from the hospital, Mrs. Lloyd passed away. . . . .or, as the church folks say, she "went home." I think I like the idea of Mrs. Lloyd going "home" better than the idea of her dying. . . . . .

"Too blessed to be stressed."

I'm not sure of too many of the details of her death, but there is one thing I know for sure about the moment that she made her transition. . . . Mrs. Lloyd was indeed blessed, and was so surrounded in love that she probably wasn't the least bit stressed. :)

***

"Honor thy father and thy mother:
that thy days may be lo
ng upon the land
which the Lord thy God give
th thee."
-Exodus 20:12 KJV

~For Crystal C., a sister and friend who also epitomizes"honoring thy parent"~


Friday, October 23, 2009

Reflections from a Friday: The Heart Makes Room

More to love. . . . .

Zachary at 5 days old

Zachary as the man of the hour on his third birthday, today.
_________________________________________________________
***

"I think I'm kind of nervous about having another baby," my friend Natalie L. said to me during her pregnancy with her second child, Sam. She sighed and added,"I can't imagine loving anyone as much as I love Eli."

Zachary had just been born, and as soon as Natalie said that, I remembered something my paternal Grandmother, Mudear, had told me long ago. Mudear had eleven children, and more than thirty grand and greatgrandchildren combined. During a quick visit to Birmingham while in college, I was with her in her TV room which held shelves and shelves of pictures of all of her descendants. I recall asking her how she could manage to divide her heart between so many children and grandchildren. My Mudear was so wise. She smiled in her gentle way before saying,

"No matter how many you have, something funny happens to you as a mother. Your heart just makes room. Don't even matter how many you blessed with. Each one has their own space made just for them. Each child, each grand, each great grand. Your heart just makes room."

Your heart just makes room. So that's what I told Natalie that day. . . . .and not because I was just trying to sound deep either. It was because I now knew it to be true. It was also because I, too, felt a little trepidation about trying to share my love with Zachary when he was on the way. Then on October 23, 2006 he arrived. . . .and just like Mudear promised, my heart made room. In fact, it made lots and lots of room.

All that room made for him caused me to fall in love. Madly and deeply. I am in love with his silly laughter, the way he tucks his feet under himself when he sleeps, the way he pronounces "Spiderman" as "Podderman," and the way he turns into the world's most fearless superhero with just a zip of a costume (especially The Incredibles!) My heart swells just at the thought of feeling his sticky hands pressed against my face, and at the mental image of him dancing (and moonwalking) to his favorite song. ("All Star" by Smashmouth). I look forward to seeing him in the morning, can't help but sneak into his room to kiss his face during the night and can laugh out loud at the very idea of some of the hilarious one-liners he has offered up over the last three years. What a delight.

Yeah. . . .so today's reflection isn't really about Grady per se. . .but it does have a lot to do with how I care for my patients. Motherhood has changed me as a person, and so very much as a physician. Knowing what I know now makes me take pause for a moment with just about every patient. Even the most difficult, manipulative, and yes, annoying patient, was once somebody's baby. Before the damage done by cigarette smoking, and before the heart disease, or the alcohol and drug dependency, or the HIV, or the mental illness, or the morbid obesity . . . .somebody at some point held them in their arms wishing the world for them. Just like my Mudear did with her eleven children, just like my parents did with the four of us, just like I did when Zachary and Isaiah were born, and just like I still do every single day.

***

A few months after Natalie L. had her second son, Sam, she sent me a short email that read:

"You were right. My heart made room. :)"

Natalie L. with Sam, for whom her heart made room (with the independent swimmer, Eli, in back with floaties)
____________________________________Zachy and Sammy discussing the pros and cons of being a little brother (and how to give a good overhand pitch.)

Happy 3rd Birthday, Zachary a.k.a. "Zachy," "Pooda", "Zack-Attack", "Zachy-Poo!", "Toogie," "Woobie," and (when he is fed up with all the nick names)"ZACH-A-REE!!!" I am SO thankful for the chance to be your mom, and even more thankful today that Mudear was right --the heart indeed makes room.

How can you NOT be in love with this face?
video

The "All-Star" in action!

Sunday, October 18, 2009

The Cumulative Effect: Reflections from a Sunday at Grady and Beyond

"There's only now
There's only here
Give in to love
Or live in fear
No other path
No other way
No day but today."


"No Day but Today" from the Broadway show RENT



Today I woke up at what my mom calls the "crickety-crack of dawn." I tip-toed around our room bumping into things while trying to get myself ready in the dark. Ah hah! Grabbed my iPhone and used the "Flashlight" app to see my hand in front of my face. Oww! Stubbed my toe. Why didn't you just set everything out last night? Knew the answer to that one--Too much like right.


My mom had the children at her house (and let them sleep over!) the night before, so this particular morning, Thing 1 and Thing 2 didn't have to be factored into the a.m. chaos. Took pause for a moment. . . .thought about how fortunate I am to have my mom a.) in my life, b.)in my childrens' lives, and c.) in Atlanta AND willing/able to spend extensive time with my two rambunctious pre-school boys. Love her.

Finally made it out of the house with matching socks and shoes, jumped into the car and headed to "The Gradys." Even managed to pack a change of clothes since I was planning on doing the Atlanta AIDS Walk after seeing my patients. Whew!

Smiled when I thought about the big kiss I planted on Harry before running out. Knew that he had a fun day ahead--The Falcons playing Chicago at the dome and major tailgating beforehand. One of his best friends, Derrick, had flown in from Chicago, which would guarantee some serious trashtalking. I love the idea of him doing something he really, really enjoys. And he really, really enjoys football. Especially when he gets to hoop, holler, shout, and point at the game in person. "It's an experience, babe," he has said. Eehhhhh. I'm not too big on watching football (other than the Superbowl with the cool commercials and all) --but watching Harry watch football? Now that's an experience.

Grabbed an excellent parking space on the ground level of the parking garage without even having to sneak into the MD/IN OUT spots. (By the way, I think somebody in Grady security read my blog because they now have an orange cone in front of the MD/IN OUT spaces now, but I digress. . . .) The point is, I reached the ward with time to spare . . . . .which meant more time for connecting with my patients and my team.

One patient told me he liked the way I shook his hand and always looked him in his eye. He said that most of the time, people didn't make eye contact with him and shook his hand wearing gloves. He asked me if having AIDS meant that we were supposed to shake his hand with gloves. I told him no. Promised to try hard to look everyone in the eye and to be careful to only greet people in gloves if it was 100% necessary.

Another patient said that I was the third person to come in his room and wake him up that morning. "Your student doctor was here first, then your intern or whatever she is, and now you," he said. But he didn't look mad.

"I'm sorry, sir," I said quietly, "but you know I have to see you for myself. Maybe it would be better if we all came at once?"

He smiled at me warmly. I liked the way the morning sun bathed his gaunt face in light. "To be honest with you, I don't mind so much. The student is real nice, and treats me good. He even gave me this so I wouldn't be bored." The patient held up a "WordFind" paperback book that apparently had been bought for him in the gift shop. "The intern, she's always sweet to me, and look like she really care about me. When you sick all the time, it helps when somebody is just nice for no reason, you know?" Nice for no reason. That's what I'm talking about.

I nodded while being sure to look him in the eye. I was forced to wear gloves in this room, because due to his current infection, he was on something we call "enhanced contact isolation," which requires gloves and special gowns. Thought about the fact that he, too, was living with AIDS, and really hoped he didn't think the gloves were because I didn't want to touch his hand. I softened my eyes to try to make up for the latex that stood between the human contact. "I'm glad you can feel how much people on our team care," I said. "That's really important to us."

"Yeah, everybody is nice," he continued,"and you always nice to me, too. So by the time I add it all up together, I guess it's good that y'all all come in here one at a time. It's like a whole bunch of nice visitors coming to see about you." By the time you add it all together his glass is half full. Hmmm. Made a note of that, too.

Met up with my team and rounded with them on our new admissions. Remembered the eye contact and skin-to-skin handshakes, had some great teachable moments, and kept the glass half full as much as I could. Realized that the medical students on my ward team were growing up before my eyes this month, and took a few seconds to take that in. Cool. Finished up just after noon, and sprinted out of the hospital to our office building across the street.

Jumped into my office like Clark Kent, peeling off my white coat and quickly changing into sneakers and a sweatshirt. 12:35 p.m. 25 minutes to get over to Piedmont Park to join my medical student advisees for the 2009 AIDS Walk. Felt glad that I had that ground floor parking space when I headed out. Sweet.

Took in the sights along the way. . . .a young woman exaggeratedly strutting down the Piedmont Avenue. . .damn. She broke my heart a little bit. . . .she was a little too scantily clad, a little too interested in grabbing the attention of the cars passing by, and had such a desperation about her. Saw a family pushing a baby in a stroller on this unusually cold October day. . . wondered if they had no choice but to have that infant out in 48 degree weather. . . .then I reached a stop light and glanced over to my left.. . . .a preteen girl was sitting in the passenger seat of her Mom's car beside mine. She offered me the most genuine smile. Nice for no reason. Decided I would focus on that for now instead of my street-walking little sister or the little baby out on a too cold day. Those good vibes must've worked--managed to get an unbelievable street parking space less than a block from Piedmont Park on 12th avenue. Yay.

Once I walked inside of the park, a quick wave of exhaustion came over me, reminding me that I'd already been up for several hours. Got a second wind when I saw all of the people. Hope was in the air, and lives were being celebrated. So inspiring. Saw five of my 15 student advisees walking down the grassy knoll, and we all charged into the AIDS Walk crowd together. The park was blanketed with people. . . .some laughing, some crying and hugging. The energy was rich and really good.

At one point, I heard a woman singing on the podium. . . . . .decided to stop and take it all in. The people affected by HIV and AIDS. The sons, the daughters, the brothers, the sisters, the husbands, the wives, the partners, the friends. And my patients. The thousands of cherished loved ones lovingly remembered on the AIDS Memorial Quilt. The reason we were there. Her voice rose over the crowd slowly and sweetly. . . . .

"There's only us
There's only this
Forget regret--
Or life is yours to miss.

No other road
No other way
No day but today."

Looked at one of my students, who, before I could, said, "Wow. I love that song." Sigh. Me, too.

Several Emory medical students were out there, many of whom were not my advisees. It was great to see them all there along with a few of my other friends and colleagues. But, like the mom I am, I was hoping that all of my "kids" would show up. Kept doing head counts until eventually the result was: Ant, Tony, Marla, Mara, Doug, Mark, Adam, Dapo, Doris, Jin, Hreem, Dan, Vishes, Jenna, Alanna. Recounted just to be sure. Wow. All fifteen of my student advisees were physically there for the walk. All of them. On a Sunday no less. (Okay, you may not realize it, but getting fifteen designated medical students to be in the same place at the same time for anything other than an exam or a party is near impossible.) But they were there. Some of them even had their significant others visiting for the weekend. . . .but they came anyway, sweethearts in tow.

"I'll be really disappointed if you don't come."

That's what I told them the first year when there were only seven of them. The stakes were higher with more students this year, but I stuck to a similar appeal. For some reason, it was really, really important to me to have all of them there. And they came through. All of them. With bells on. They prioritized this over something else. I can't explain to you how proud I felt at that moment.


video
(Student Doctor Chin-Quee shows a little team spirit . . . we even raised enough

money to get a fancy sign!.)

***


So today, I am reflecting on the cumulative effect of things . . . . .a decided effort to focus on what is collectively good. . . . . .

Like the cumulative effect of Harry being so great to me all the time is me wanting him to be happy. I've stockpiled all the small gestures and thoughtful deeds that he does every single day to make my life great. And at this very moment, he is in the Georgia Dome--likely ridiculously happy-- and probably without any trace of a voice.

Like my mom always being so gracious and involved in our lives as well as our kids' lives. It affords us the opportunity to do things that a lot of other couples can't. Those date nights, long weekends, and adult only vacations-- that she makes possible for us. Yeah. It really adds up . . . . to more satisfaction in my marriage, which means a better life for Isaiah and Zachary. Thanks, Mom.

Like gloveless handshakes, eye contact, smiles from young passengers in cars . . . it all builds into overall positivity. And yes, having all fifteen of my student advisees amongst the throngs of AIDS Walk participants on a cloudless Sunday was different than having even fourteen of them there. Something about the cumulative effect of each individual making the decision to be there was indescribable.

A day that literally started in the dark emerged into something so bright. Excellent parking space karma, students buying "WordFind" books for isolated patients, and thoughts about wonderful family. Pivotal discussions with two patients who just happened to be living with AIDS, and both of whom my students and I ultimately honored today. Kind of like a giant handshake with no gloves.

The take home point? Small things put together become big things. . . . .even if it doesn't always seem like it. Being a little unkind or a little inconsiderate snowballs. . .just as kissing your children and telling them they're wonderful makes them eventually believe it.

Be nice for no reason. Take a moment to reflect on the little things. . . . . .sometimes that's the very best way to realize just how big your life can be. :)
_________________________________________________________

"The Rain Choir" -- one of the coolest examples of how dramatic the cumulative effect of several small, everyday things can be. Try watching it with your eyes closed. . . .amazing!

Wednesday, October 14, 2009

Rock Steady: Reflections from a Wednesday at Grady

Aretha Franklin a.k.a. "Re-Re" singing Rock Steady, 1971
(check it out to get what I'm saying)


"Her stress test was negative, and she is still doing well without an oxygen requirement or any chest pain. If it's okay with you, Dr. M, I think we can let her go home," one of my interns said to me on rounds. "And I'll be sure to schedule her an appointment to follow up in the Primary Care Center in at least a week. I talked to her all about this, and she is comfortable with our plan." I was, too.

"Great!" I affirmed with a smile, "Do you know how she's going to get home?" I'm a pretty predictable attending. I like to know who a patient lives with, how they are getting home, but more importantly, even before we get to that point, I like to know for sure that the patient is not only aware of the plan but understands it, too.

"Her son is coming to get her. He lives with her and I talked to him this morning. I also spoke to her primary care doctor."

I gave my intern an exaggerated nod of approval as I marked the "discharge" box on my billing card. "Rock steady!" I stated for emphasis, still nodding.

Rock steady. It's one of my favorite sayings on rounds. It describes when all the parts are in place, and when we working as a well oiled machine. It's when we're all learning, showing empathy, and making folks feel better. It's what I think of when my team is doing a great job taking care of our patients, which they were. It's when folks are being cared for and treated with the respect they deserve. Rock steady.

"That was a song by 'The Whispers,' right Dr. Manning?" asked Adam, the fourth year student rotating me this month. "'Rock Steady' was."

I chuckled out loud and responded, "As a matter of fact, it was." I was impressed that a.) this twenty-something year old med student had any idea who "The Whispers" were, and b.) that he was clever enough to catch on to the fact that my use of the term "Rock Steady" was extracted from an R & B hit. He was almost spot on.

Almost. "Adam, you're right about that--and how you even knew about The Whispers is beyond me. Your knowledge of soul music will be reflected in your evaluation." Our team collectively laughed. "But you know what, y'all? Whenever I say, 'Rock Steady', I am thinking not of The Whispers, but actually of The Queen herself, Aretha Frankilin." The group was a little too quiet for me. What? Y'all aren't hip to Aretha singing 'Rock Steady?' Unacceptable. So, yep, you guessed it. I gave them my best "Re-Re" impression and broke out in song. Right there on the ward. (Hey, I saw it as a "teachable moment.")


"Rock Steady, Baby!
That's what I feel now!

Let's call this song exactly what it is!
(What it is! What it is! What it is!)
Step n' move your hips
With a feelin' from side to side
Sit yourself down in your car and take a ride!"
(You have to lean back and do your one-handed steering wheel move on that part.)


They were cracking up laughing. (Probably as much at me as with me.) Something about that song makes a person feel so bold and alive that they could really care less who is laughing at or with them. Which was true--I didn't. The funny thing is. . . . .that song is on the "playlist" of my mental soundtrack-- especially when I'm on the Grady wards. Aretha Franklin's shrill, soulful voice on the track revs me up and boosts my confidence. Something about the beat, the horns, the whole laid back feel of the rhythm adds a little pep to my step and makes me want to throw my shoulders back and tackle anything that comes my way. Anything.

A patient cursing me out? Rock Steady, baby. Ten admissions? Rock Steady, baby. Twelve thousand things to do in only a limited number of hours? Rock Steady, baby. I'm with Aretha when she sings this one. Let's call this job exactly what it is.

It starts when I first pull into the Grady Piedmont Parking Garage. As soon as I step out of my car, the percussion instruments start shaking. By the time I begin walking through the lot, the bass guitar has kicked in and I'm right on step with the beat. I start swaying my hips ever so slightly from side to side while waiting for the elevator to carry me down from the deck towards the hospital. If no one joins me on the elevator, maybe I'll even bop my head and hum. . . . and sometimes, sing a line or two. What's amazing is that I can hear the entire song as if it were playing in Dolby Stereo on the most pristine system ever.

By the time I walk into Grady, Aretha has already belted out the first few bars and is doing her thang. Yep. Me and Re Re, jamming to the beat with a full set of brass backing us up--and me feeling amped for the day ahead. Horns! I want to do my best James Brown slide across the floor of the hallway but usually decide against it as not to frighten the onlookers. (I have done it at least two or three times, I admit.) Heeeeeeeeeeeyyy!!! (That's the good part.) That war cry always makes me want to shadow box in the corner for a minute or two before taking on the residents, students and patients. The backup singers are in my ear snapping their fingers and harmonizing, "What it is, What it is, What it is!" I shimmy my shoulders when no one is looking, tap my toes while writing notes, and thump my fingers on the chart box just a little bit. Rock Steady, baby.

****

I know it sounds kind of "Ally McBeal", but I think we all have our mental soundtracks at some time or another. (Well, at least I do.) But I especially do when caring for patients on the Grady wards. The music drives me forward, makes me think, and reminds me to be present. . . . . . really present.

I remember feeling particularly somber during my ward month in August 2005. Hurricane Katrina had annihilated New Orleans and her people, and I recall being glued to CNN between seeing my patients. I never forgot the desperate, crying, pleading victims. . .no, patients. . . . crowded outside of the New Orleans Convention Center waiting for assistance. Waiting and waiting. Hot and dehydrated. Lost. Scared. In shock. The women with babies--oh, those little babies--the elderly matriarchs and patriarchs, and their faces. The dazed children in frayed clothes. I prayed so hard for them back then. Especially at night. I knew they were afraid of the dark. . . . .my kids sure are.

Then, at some point during that month, the Red Cross began flying in patient after patient to be admitted to Grady. Suddenly, those nameless faces became real people as they joined the other patients on my census, and I recall being mesmerized and humbled by their stories. One lady who'd lost everything said to me, "The Lord is still in control, and I'm just gonna trust Him and keep on thankin' Him for all He's done for me." She had no idea where her family was, and was hundreds of miles away from all that she'd known for all of her seven decades of life. I couldn't believe that she still had this attitude in the face of such adversity.

Victims of Hurricane Katrina outside of the N.O. Convention Center, 2005

At that point, I started hearing this song "I Will Find a Way" by Fred Hammond, a gospel singer, in my head over and over. My patient's words became a mantra, and that song. . . that song became a solemn soundtrack in my mind to remind me of my patients' struggles. Every time I heard it inside of me, I could feel my eyes stinging with tears-- I could see those faces waving on rooftops and wading through water. And what moved me about that track wasn't even so much about my faith. . . . it was more about hope. I interpreted that song as so hopeful for something better, and so thankful for the good that preceded the hard times. To this day, I am immediately transplanted to August 2005 whenever I hear that first few bars of the guitar strumming in that song . . . .

"Searching here and over there,
for the things I've lost,
I don't have them anymore. . .

But I will find a way to lift up my hands,
and I will find a way to worship You, Lord,
though my heart is low, I'll find a way,
to give You praise. . .

I will find a way to love You more. . . ."

from Fred Hammond, I Will Find A Way


***

Back then, it was Fred Hammond . . . .reminding me to always remember my patients' hardships and personal hells-- and to be careful to not complain too much. This month, it's me and good ol' Re Re, or if you don't know her like I do, Aretha Franklin. . . . Rockin' Steady.

My "playlist" changes often. . . .who knows what it will be on my next ward month?
Either way, know this. . .if you see me around Grady with an extra skip in my step or even a reflective look in my eye, it's probably got as much to do with how I'm feeling that day as it does with what's playing on my mental iPod. And in an era of high tech everything, I like having my very own internal musical library linking me to emotions, experiences, and quite often, my Grady patients.

And to that I say, "Rock Steady, Baby." That's what I'm feelin' now. :)

Monday, October 12, 2009

Grady Doctor in training? You decide.

__________________________________________________________

The morning light crept through the window on a Saturday morning and tickled my eyelids. I cracked them open and looked around--still lying on my back (which happens to be my preferred sleeping position.)  

Aaaaahhhh.

The house is quiet, which is pretty unusual for us with two boys under the age of 5. Nobody screaming, nobody crying. I blink slowly and enjoy the moment.

Zen.

I hear a soothing noise in the background. . . . .a glance towards the window tells me it's origin--an early morning thunderstorm. This definitely has all the makings for a perfect morning snuggle-fest. I scoot closer to Harry and lean my head against his back. Now I hear the soft rain. . . .sychronous with his breaths. I feel so happy. . . .

The moment was short-lived . . . . .Isaiah and Zachary must have sensed this peace from their room, and were determined to break it up. Like gangbusters they threw open our bedroom door and then pounced on our bed. Fortunately, their entry was much rowdier than they were once they found their places under our down comforter. Somehow, the kids let Harry continue with the visions of sugar plums that must have been dancing in his head, and both snuggled under each of my arms. I pulled them in close to my chest, and decided that, no, this was zen.

After a few seconds of breaths and raindrops, Isaiah reached over my torso to touch Zachary. Here comes the fighting. I braced myself for Zachary's retaliation which would be sure to break us out of our tranquility. But nothing from Zach. Not a punch, not a kick, not a yelp. Guess he's still sleepy.

"Mommy," Isaiah declared quietly, "Zachy feels hot." I was impressed that he remembered to use his "inside voice" with sleeping Daddy in his presence. Then I processed his statement.

"Hot?" I asked while placing my flattened palm on Zachary's forehead.

"Yes, Mommy, he's hot," Isaiah said matter-of-factly. Wait--is this a four year old or a forty year old I'm talking to? I registered his temperature with my hand. Eeeehhh. Warm maybe, but I wasn't going to follow a lead from someone who just started Pre-K. (I'm just saying.)

"Son, I think he just feels toasty since we are all cuddling together. That's called body heat, and it makes you feel warm."

Isaiah yawned, stretched and then sat up on the bed. The look he gave me said, "Body heat? Yeah, right." He wasn't buying it.

"Tell you what, Isaiah," I spoke while wrapping my arms around him, "I will keep my eye on him to make sure he isn't getting a fever, okay?"

"Yeah, keep an eye on him, 'cause he's hot," he said while climbing out of our bed. Funny.


As the morning progressed, Zachary ate two bowls of oatmeal, karate chopped his brother, and wreaked havoc on the house, all while dressed in his muscle Hulk costume. Definitely no signs of being under the weather. I left the kids in their playroom and snuck away to shower, get dressed and run a few kidless errands. Twenty minutes later, I emerged from the room with car keys in hand, ready to head out of the house.

"Gentlemeeeen! Mommy's going bye-bye for a few minutes! See you in a little bit!" I yelled toward the playroom while walking to the door. (We yell through the house to get each other's attention waaaay to much, I admit.)

Predictably, Zachary's two year old feet scampered in my direction. He wrapped his chubby hands around my neck and pressed his soft cheek against mine. Felt my heart skip a beat. Also felt something warm against my skin--Zachary.  

Hmmm. He does feel a little warm.

I scooped him up into my arms and carried him to the kitchen. Propping him up on the kitchen counter, I grabbed a thermometer and slid it under his armpit. Before the "beep-beep-beep" could even signal a value, I'd already measured out the Children's Motrin. I knew he had a fever. Everyone knows that the mommy-cheek-thermometer is as good as gold. Case in point:  

Beep-Beep-Beep! 101.3.

"Yummy! Medicine," giggled Zachary as he slurped up the berry flavored syrup. His temperature was far more alarming than his behavior. Suddenly, I heard an abrupt voice that made me jump.

"What are you doing, Mommy?" Isaiah asked firmly. I placed Zachary on the floor and found Isaiah standing behind me with a puppy mask and rain boots on. He startled me."Why are you giving Zachy some medicine, Mommy?"

"Uhhhh, well. . .um, he, uhhh. . . ." I realized that I was stammering. No one likes "I told you so's"--especially from pre-schoolers. He stood there patiently, brows furrowed behind the puppy mask waiting for a reasonable reply.

"Well, Isaiah, I think you were right. Mommy took Zachary's temperature, and he has a little fever. I'm kind of surprised since he ate so well this morning and is playing like himself, you know?" I couldn't believe that I was explaining myself to a four year old kid dressed as a dog in red wellies.

Isaiah stood for a moment and just stared at me with eyelids at half mast. I shuffled a few steps over to hide the Motrin that sat behind me on the counter. Then he shook is head, and shrugged his shoulders.

"Told you he was hot!" he announced and spun on the rubber heel of his Lighting McQueen boots disappearing down the hall toward the playroom. He told me he was hot. That he did.

****

Future Grady Doctor with excellent clinical acumen in the making? Only time will tell. I have to admit. . . .the thought of one of my boys as a physician does bring a smile to my face. I can also admit that the thought of both of my Manning boys becoming multi-millionaire NFL quarterbacks like Peyton and Eli ain't a bad alternative either. (Just being honest!) Besides, it was Isaiah who told me that he had NO interest in being a doctor when he grows up because:

a.) he doesn't want to grow up since you have to work every day and never play with toys, and
b.) doctors are girls. (His point of reference is my circle of girlfriends. Go figure.)


Happy Zachy and my littlest intern, Isaiah, in his puppy mask.

Saturday, October 10, 2009

Reflections from a Saturday at Grady: Grady-isms

Kicking up my feet on Saturday post rounds in my office. (Yep, I wear jeans on weekends.)


I was rounding with my team post call on rounds today and one of my interns, Tyler, asked me a very reasonable question:

"What in the world is a 'risin'?"

Let me put this into context for you. We'd seen a patient with multiple soft tissue abscesses on her arms, legs and abdomen, likely pus collections from a germ we commonly see in the hospital called staphylococcus aureus (or "staph" for short.) While the whole team was at the bedside, I asked the patient, "When did you first start getting these risins on your body?" (What can I say? I'm one to cut to the chase.)

That launched us into a glorious discussion of "Grady-isms," or words and phrases that you probably should know if you want to navigate the waters of this fire-breathing dragon of a county hospital called Grady. Oh, I should mention that a lot of these "Grady-isms" do reach beyond the doors of my dear old Grady. It's probably fair to say that a lot of this language is indigenous to folks in the southern United States, and some of the terms tend to be more common amongst African-Americans. (FYI: As a sho' nuff African-American, I can authorize this statement.)

Terminology
one must know for survival and effective communication in Grady Hospital:*
*(NOTE: Use care with YOUR personal use of these words unless you are are culturally competent enough to do so-- otherwise, it comes out all WRONG. . and can border on offensive. Trust me on this, people.)

"Risin"' - an abscess or a boil or an alleged spider bite. "I'm here because I got a risin on my behind."

"Nature"- anything referring to a man's ability to gain an erection "I ain't taking that medicine 'cause it messes with my nature."

"Running off" - having diarrhea "I started running off last night."

"Fell out" - fainted "One minute I was standing there, then I just fell out."

"The Gouch"
- gout "My toe swoll up and somebody told me I had the gouch one time."


"Arthur"
- arthritis (as in Arthur-itis) "How you doing, sir?" "Well, ol' Arthur is messing with me today."


"Minute" -
a really, really long time. "Hey there, Miss Manning! I ain't seen you in a minute!"


"Hot minute"
- a really short time "My chest has only been hurting for a hot minute."


"Straight"
- fine, well, okay. "Sir, are you okay?" "Yeah, I'm straight."


"Straight" - really? seriously? "Obama won the Nobel Peace Prize today." "Straight?" (can also be "straight up")

"Straight "- really, really awesome. "How did you like Dr. Malebranche when I referred you to him?" "Aww man, Miss Manning! He was straight!"

"Black n' Milds"
- Pipe tobacco cigarillos


"Pack-a-last"
- how much a person smokes. "Sir, how much do you smoke?" "Awww, Miss Manning, a pack-a-last me 2 days." "Oh, so you smoke half a pack per day?" "Naww. A pack-a-last me 2 days." "Gotcha."


"Peoples
" - family "Wher're your peoples?" "They all over Atlanta, but I don't never talk to them."


"Church-home"
- your church "Ma'am, do you have a church-home?" "Yes, I go to Berean Christian Church on Panola."


"Stay
" - live
"Where do you stay?" "I stay off of Bankhead with my cousin and his son right now."

"See about" - check on, visit, take care of. "You said you live by yourself?" "Yeah, but my son lives around the corner and he sees about me 'bout once, twice a week."

"Toot" - snorting cocaine

"Shoot
" - injecting any kind of illicit substance. "Do you shoot?" "Aww, heck no. I'll toot sometimes, but I don't never shoot."


"Dip"
- putting smokeless tobacco in your cheek or lip "Do you smoke, ma'am?" "No. But I do dip."


"Billy Dee
" - Colt 45 beer
(disclaimer: only heard this one once, but think it's hilarious!See my post from 9/4/09)
"Deuce Deuce" - 22 oz beer, usually malt liquor

"The Shakes"
- Alcohol withdrawal tremors


"Crumbsnatchers"
- little kids
"Hey there, Miss Manning! How them crumbsnatchers doin'?" "Oh they're great, thanks so much for asking!"

"High blood" - hypertension

"Low blood" - anemia

"Testes"
- tests "I'm only here to get the results of my testes."


"Mash
" - push
"What floor, ma'am?" "Can you mash twelve please?"

"Miss
" - Doctor "Hi there, my name is Dr. Manning." "It's nice to meet you, Miss Manning."


Okay, for real. . .what is there NOT to love about this job? I'm sure that I am blanking on some really important ones, but this is definitely a start. (If I forgot a whopper, hit me in comments.) Like I said, a lot of these terms are not unique to Grady and Atlanta only, but understanding these words sure does help with caring for folks at Grady!

Gotta run. . . Harry and the crumbsnatchers have been gone for a minute and will be getting back soon! :)

Thursday, October 8, 2009

Reflections from a Wednesday at Grady: Makeup to Breakup and Walking on "Sunshine"



(Good Day Atlanta Segment from Wednesday, October 7, 2009)



__________________________________________________

"Weren't you on TV this morning, Dr. Manning?" asked one of the senior nurses on 9A as I entered the room of my patient, Mrs. Dinkins* (names are changed.) I glanced at the clock for a quick timestamp and made a mental note of the time. 9:21 a.m.

The nurse, Mrs. Perry, is one of my most favorite nurses on 9A. She has been nursing since long before I even finished high school, and it shows. Fortunately, she seems to have taken a liking to me as well, which often lightens my load when caring for sick patients on her floor.

"Yes, ma'am, I sure was," I answered while leaning toward the light switch in the room. I turned my attention to Mrs. Dinkins. "Good morning, pretty lady! It's me, Dr. Manning. You mind if I turn on your light?"

Mrs. Dinkins smoothed out her hospital gown and nodded. I flipped on the light and approached the right side of her bed as florescent light bathed her half of the room. Her edentulous smile warmed my heart. Nothing like a big smile to start the day-- with or without teeth. It's what my kids call "giving some sunshine."

Nurse Perry walked toward my patient and started chattering. "I saw you on Fox 5 this morning, Dr. Manning. I was putting in a catheter and looked up there you was! I said to my patient, 'There goes my girl!'" She opened the breakfast tray and moved it toward Mrs. Dinkins left. I pictured her drawing her patient's attention to the television while having a Foley catheter inserted. Eeewww.

"Did I do alright?" I playfully replied. It's kind of fun to hear the staff acknowledge that they've seen one of my segments. I appreciated the acknowledgment. I reached for Mrs. Dinkins' wrist to check her pulse.
"Oh yeaaaaah, Dr. Manning! You always do good--you and Dr. Winawer--and I when I see you I always say, 'That's my girl!'" She propped a pillow behind Mrs. Dinkins head. "You comfortable, sugar?"

"Yes ma'am, I'm 'bout as comfortable as you can be with them hard pillows." Mrs. Dinkins emptied a packet of nondairy creamer into her lukewarm coffee and sipped it. Being the coffee snob that I am, I felt a small wave of nausea come over me as she slurped loudly. Peering up from the mug she raised her eyebrows and asked,"You was on TV this morning, Miss Manning?"

"Yes ma'am, I sure was. But tell me. . .how are you feeling today?" I felt another ripple of nausea while watching her take in a mouthful of the very softly scrambled eggs on her plate. Double eewww.

"I'm starting to feel a whole lot better," she replied while chewing.

"Excellent!" I responded cheerfully. Mrs. Dinkins was serious about those eggs. "Do you want me to come back when you finish breakfast?"

"Nawww, you fine. What channel you was on this morning?" she querried as she looked all around her tray for salt. She frowned at the packets of "Mrs. Dash" that she found instead.

Nurse Perry chimed in from the neighboring bed. "She's always on Fox 5 every week. And I'm always like, 'That's my girl!'" I looked over my shoulder in her direction and smiled. I felt my chest poke out a little. Nurse Perry peeked around the pink curtain separating the two patients and added,"You know what I was thinking when I saw you today, Dr. Manning?"

I grinned in anticipation of her compliment. "What's that, Mrs. Perry?" I palpated Mrs. D's chest wall and abdomen, and made eye contact with her. "You move your bowels this morning?" She nodded while still gumming those slimy eggs.

Nurse Perry went on. "You know what I was thinking, Dr. Manning? I was thinking, 'Why they always got so much heavy makeup on my girl when she's on TV?' You need to tell them makeup people that you don't need all that make up. You so much prettier in person." She pulled her gloves off her hands and tossed them in the waste basket. "Tell them that you need a better color on your face, too. That base they use on you is way too dark."

I laughed and shook my head. "I have to confess to you, Mrs. Perry, that usually I'm running so late into the studio that I don't even get my make up done. It's just my regular makeup applied a little heavier."

"Really?" she asked while placing her hands on her full hips and raising one eyebrow. Here we go.

"Yep. Maybe it looks funny to you because it's in high definition." I was trying to come up with something, anything to get her off of me. Good ol' Grady.

"Mmmm. Well. . . . I'm sure you always have people say stuff about that makeup to you, Dr. Manning," said Nurse Perry. "I mean, do you tape it at home? I bet you are like, 'Dang!' I'm sure when you see it you probably always think about that make up." That makeup. Wow. 'Dang' is right.

I laughed nervously. Wow. I can't wait to blog about this one. "Uuhhh. . . . honestly? I am usually pretty okay with it."

Nurse Perry put her hands back on her hips and cocked her head sideways. Oh goodness. NOW what is she about to say? "Nooooo, Dr. Manning. I'm always like, 'Lawd have mercy. My girl needs to do something 'bout that makeup.'" Ooommph. Body blow. I inspected Nurse Perry and wondered how much time she had spent checking out her own face that morning. Decided that she, too, could use a couple of pointers for her overall look. Or might even be a good candidate for that show where they ambush you and make you over.

Suddenly, I heard my patient clearing her throat, and for a fleeting moment thought she might need me to Heimlech those scary eggs from her throat. "Well, I kinda thank you look pretty," she injected with her raspy-eggy voice. She flashed her gummy "sunshine" at me once more.

"And I think you look pretty, too. Thanks, Mrs. Dinkins. At least somebody's on my team." I winked at my patient and retied the back of her gown for her.

Nurse Perry opened her mouth and widened her eyes taking mock offense at my statement. "I am on your team, Dr. Manning. You know you my girl! But for real. Go look in the mirror and check that makeup out. It just doesn't become you." I am not kidding you--she put her hands on my shoulders and directed me into the mirror in the patient bathroom. "See what I'm saying?"

Okay, now she is really tripping. Isn't she the charge nurse? Doesn't she have something else to do right now? "What Not To Wear." That's the name of that show! "Honestly, Mrs. Perry? I'm cool with it. And nobody has really said anything about the makeup being bad, or heavy, or dark, or whatever. No, I take that back. Nobody but you--like every time I see you." Raaawwwrrrrr. (Claws out) Kind of snarky, I know.

We stood in that little bathroom facing that warped mirror for only 5 seconds, but it felt like 5 minutes. This is awkward. At some point we both made the unspoken decision to mask the uncomfortable silence with industrious patient care. I returned to focusing my efforts on Mrs. Dinkins and her needs. Nurse Perry went back to charting and passing meds.

After a few moments, I felt a little bit bad about cat scratching Nurse Perry for her candid statements. Certainly the rules of Grady Seinfeld moments dictate that outlandish comments that border on insulting are actually terms of endearment. She must have sensed my thoughts, because after gathering all of her medications and papers in her arms to leave, she looked back over her shoulder and smiled at me. "You do know you still my girl, don't you?"

I responded warmly and met her eyes briefly. "No doubt. And you do know you're still one of my favorite Grady nurses, right?"

I wrapped up the visit with Mrs. Dinkins and answered her questions. After covering her with a blanket, I headed towards the door. "You want me to turn this light off or leave it on for you, Mrs. D?"

"Oh. . baby, you can turn it off," she said. I clicked the switch down and quietly stepped out of the room to scribble a note on the chart. Just as I finished up and closed the chartbox, I heard Mrs. Dinkins' scratchy voice murmuring what sounded like my name. I stuck my head into the door before leaving to address her question.

"Ma'am?"

"I still thank you look kinda pretty, Miss Manning. Mek-up and all." She offered me her most genuine smile and it made me feel a little tingly inside. I walked back over to her hand grabbed her bony hand.
"And you know what, Mrs. D? I think you just might be my 'FP' today," I stated with a squeeze of her hand. She furrowed her brow and parted her lips to say, 'Huh?'--but before she could, I clarified it for her. "'FP' stands for 'favorite patient.'"

***

I stopped in the staff bathroom before leaving the floor to check myself out one more time. Maybe I internalized Nurse Perry's suggestions more than I'd care to admit. Without even thinking about it, I unrolled a few squares of toilet paper and gave my cheeks and forehead a quick swipe. I looked in the mirror and laughed. What am I doing? At that moment, I decided to make a mental recording of Mrs. Dinkins' scratchy voice in my head and a mental picture of her toothless "sunshine."

"I still thank you look kinda pretty."

I balled up the tissue, tossed it in the trash and thought to myself, 'You know what? Me, too. '

Throwing back my shoulders, I went on with the rest of my day--giving myself my own internal "sunshine" . . . . . and feeling, well, kinda pretty. :)

Happy Birthday, Poopdeck. . . . .



Today is my Dad's birthday. And why is that relevant to this blog? Well, that's an easy question to answer. He is one half of the dynamic duo that helped raise this crazy blogging Grady doctor. He is my hero to this day, and one of my very best friends. He is probably the greatest fan of anything I write, even a letter on a scrap of paper. And he is just an all around gnarly guy. A simply extraordinary human being.

Anyone who knows me, knows how I feel about my dad. And if you don't know me and you just read this blog for kicks. . . . now you know, too. :)

Monday, October 5, 2009

Random Reflections from Grady Wards: The Karate Kid


*names, details changed but story written with permission of the patient.

"Wax on. Wax off."

-Mr. Miyagi in "The Karate Kid"
_______________________________________________________________
Sometimes there are patients admitted to the hospital who don't have a clear clinical picture. Is this belly pain because of appendicitis? Or is it just a nonsurgical bowel issue such as diverticulitis? By no fault of the patient, these instances can be pretty frustrating. Most of these clinical situations involve my service (Internal Medicine) and another service (i.e. Surgery, Psychiatry, etc.) And it's not just those times when there is a medical conundrum that makes things tricky. If someone comes in specifically for say, a broken leg, but they also have a side of HIV and uncontrolled diabetes, they generally don't get admitted to the Ortho service. They instead go to the ultimate destination for patients with multiple issues: Medicine.

The truth is that I'm okay with this to a certain degree. I'm happy to care for a lady with complicated medical issues while my surgical colleagues do their part, and I'm glad to manage a critically ill gentleman with active psychiatric issues. But sometimes the problem is purely nonmedical. Okay, maybe it starts out kind of questionable, but eventually time and lab tests allow us to remove all doubt. That's when it becomes pret-ty darn annoying. And this isn't unique to Grady Hospital at all. It happens everywhere. Medical doctors responsible for the primary care of hospitalized patients with nonmedical problems--a national epidemic. Somebody needs to call Michael Moore, for real.

*(Non-doctors: When I say "nonmedical," I am referring to issues that do not warrant the involvement of internists like me. . .issues that are, say surgical or psychiatric in origin. Get my drift?)

Okay. . . .so today I am reflecting on this twenty-something year old fellow admitted to my Grady inpatient team for "altered mental status." Someone in his neighborhood had called 911 after finding him "acting weird" outside of his Midtown apartment. When he was assessed in the emergency department, he vacillated between being completely nonverbal with staring and blinking to being full-on aggressive and combative.

No one was around to give a history or background on him, and the only thing found on his person was his driver's license. His urine drug screen was negative. His blood alcohol level, tylenol and salicylate (aspirin) levels were undetectable. He even had the extended toxicology screen looking for all sorts of cool things that only come up on that TV show "House"-- and that was negative, too. A CT of his head showed no signs of trauma, and even a lumbar puncture yielded no clues of a cause related to his spinal fluid. No open pill bottles anywhere or evidence of self-mutilation. Just a blinking, staring, catatonic Latino gentleman. . . .with a negative workup.

ER admitting diagnosis: Young guy with no past medical history and negative tox screen who is acting real odd. Maybe schizophrenia?
ER ad
mitting plan: You can't go home, but you got to get the heck up outta this emergency department. (Translation: Admit to Medicine)

This is where I got involved. We were asked to "exclude medical causes" of his altered mentation. Like I said, I am all for assisting with the care of a patient. I am happy to explore and data mine for any potential medical etiology, too--especially when it is a real possibility. For the next 72 hours, we did just that. We examined him from head to toe. We asked him questions (most of which he never answered.) We asked each other questions and stood around pontificating about what this could be. We called the social worker to search for clues about him from his environment, but no real leads. Just the same blinking and staring, occasionally interrupted by thrashing limbs against wrist restraints and angry protests in what sounded like Spanish.

The nurses kept asking me why was he on the medical floor, and I had no answers for them. My service was busy--with over twenty patients at the time--and I was tired. Too tired to keep wrestling over a question that did not seem to be mine to ask. From the very start, it looked like a call for the "mind police"--and I really hoped Psychiatry could provide us with the insight (and care) we needed to better serve this patient.

Enter the Psychiatry Consult Team

"This looks like some kind of catatonic state. It could certainly be a catatonic form of schizophrenia," said the Psych attending physician with gentle authority. His soft voice was as soothing as a lullaby. "He says a few words in Spanish, but according to my resident who is fluent, it makes no sense." (The bilingual resident stood beside him firmly nodding her confirmation of this detail.) Dr. Smoothvoice rubbed is chin and added," You know. . .This could also be severe depression with psychotic features, but it just isn't clear. Catatonia is seen frequently with mood disorders, so that has to be considered. It's all very interesting. We'll continue to follow him with you."

Interesting? FOLLOW him with me? Dude! This patient has not said more than 10 words to us in three days! Uggghh.

"I appreciate your insight," I replied carefully to hide what I was really thinking. I contemplated my next words for a moment before speaking. "So. . . .since catatonic schizophrenia is not really my expertise. . .did y'all consider assuming care of this gentleman on the Psychiatry service? I mean, since the differential diagnosis seems to be mostly psychiatric causes?"

Come on, buddy. Tell me something good. See how collegial and professional I am being here? (Insert rosy, pleasant smile here.)

"Well, I'm not sure that we've completely excluded all medical causes," he answered quicker than I would have liked. Officially killing me. Softly with his soft voice.

The all-star Spanish speaking resident chimed in. "We also have no male beds on psych right now, so we couldn't transfer him even if we wanted to. Please call us with any questions, okay?"
Arrrrggghhh!! Booo! Hisssss!

"I certainly will." I deliberately grinned to keep from scowling as I watched the psychiatry team head down the corridor and off the ward. I was two seconds away from raising up my arms and one leg in full "Karate Kid" stance to emphasize my feelings. Then I glanced over my shoulder, and remembered the two medical students that I'd taken on rounds with me that morning. (I figured I'd save my "Karate Kid" warrior pose for a more private setting.) They stood there quietly, as if waiting for me to say something deep. I had nothing.

Finally, I shrugged and said matter-of-factly, "Oh well. Let's go and see how he's doing today. You never know, we might have an epiphany while we are in there."

In we walked, frustrated me with two bright-eyed, bushy-tailed third year medical students in tow. We had already pored through his chart one more time, hoping to find the missing piece. Now, I just stood there scanning the patient, the room for anything that might provide a clue.

"I was reading about schizophrenia, and doesn't it usually present when patients are in their twenties?" one student asked earnestly.

"Yes, you are absolutely right. But twenty seven would be a little on the later side for a first time presentation," I answered while continuing to study the patient.

"Maybe this is a recurrence in someone who already has schizophrenia," suggested the other student.

"Good thinking. . . . definitely a possibility. . . . .hmmmm," I spoke while pulling back the sheet and inspecting my patient's toes. I shifted my attention back to his face and then back to his feet. "Hmm."

I grabbed the patient's hand and said to the students,"Look at his hands and feet. He is meticulously groomed. Perfectly manicured and pedicured. And look at his face--especially his eyebrows. My goodness, I have never seen brows so perfectly shaped." Turning my head sideways and squinting, I let out an audible sigh while still holding his restrained hand. "Sir, whatever is going on with you. . . .you were okay as as recently as a few days ago. Those brows are no more than three days old. Just a few days ago, you were well enough to sit in a salon somewhere. Unless you know something I don't."

The students shifted glances toward one another, not sure if I was joking or serious.
"I'm serious," I replied firmly, "Look at him. This is not a disheveled guy who hasn't been taking care of himself. This kind of grooming takes time and energy."

The other funny thing I noticed is how the patient looked at me as I spoke. He in no way gave me the puzzled stare of a person who is unfamiliar with the English language. It almost seemed like he fully understood me, and as if part of his nonverbal state was voluntary. I wondered how a non-English speaking, schizophrenic guy could manage to know exactly the best place for an impeccable mani-pedi and pristine eyebrow arching. It just didn't add up.

After a thorough exam (again), I was out of ideas.

"Sir, we are working closely with the Psychiatry doctors to help you feel better. They recommended some medications for you which we started on yesterday, and will see if it helps you. I will return with our Spanish interpreter to tell you this." I make a point of always talking to people as if they understand me, whether they are comatose, demented, or even catatonic. I guess a part of me never knows what the person is getting.

Before we left the room, I playfully leaned over the patient and added, "Mr. Jimenez. . .the minute you start talking to me--do you know the first thing I am going to ask you? Who does your brows, and are they waxed, plucked or threaded!"

Without any warning, he rolled his eyes, batted his lashes, and snapped his finger on the restrained right hand for "yes, girlfriend!" emphasis, and then--I KID YOU NOT--he stated in the most born-and-raised-in-the-United-States-and-not-even-nonEnglish-speaking voice,


"Oh, sweetheart, I only thread!"

I jumped back and nearly fell over the edge of the chair sitting at the bedside. It was like one of those moments on "America's Funniest Home Videos" when someone pretends to be sleeping on the couch and then leaps up, scaring the poor passerby to death. Funny and predictable on TV, but this time, not so much. I widened my eyes and shook my head in disbelief. He added a neck roll and glared into my incredulous eyes.

Now that I thought of it, he kind of favored Ralph Macchio from "The Karate Kid."
The students looked at me and then at each other. No one could believe what they had just heard. Wait, did he really just say what I think he said? I had to make sure I wasn't crazy.


"Where do you get your brows threaded?" (I really did want to know.)

"A girl can't tell all her secrets," he replied with a devilish grin. His voice was decidedly feminine and delicate.

I shook my head and laughed out loud nervously. "I can't believe you are talking to me, Mr. Jimenez. I can't believe it! Why haven't you said anything until now?"

He chuckled, curled his lips and answered,"No one asked me anything I felt like answering 'til now." Awesome.

And so, from then on, the seal was broken. He told me of his devastating breakup with a long term boyfriend the week prior to his admission. "He wasn't 'out' yet," he explained to me about his former love. "I helped him get the courage to be his true self, and do you know he came out and then got him somebody else? It was awful, Dr. Mannings. And someone I knew, that asshole!"

I still couldn't get over the fact that he a.) was talking, b.) in English, and c.) without as much as hint of a Latin accent. It had to be, hands down, one of my greatest Grady moments of all time. I listened to the rest of his story, and learned that my Psychiatry colleague was indeed correct. This seemed to be a case of severe depression with catatonia. And the medication appeared to be helping.

It took a while to convince my Psychiatry colleagues that he was actually talking to us in perfect English, but once I did, they immediately returned and were quite helpful with the rest of his management. He walked out of the hospital behaving in a completely appropriate manner, and promised to come see me as an overbook in the clinic one week later.

I was delighted to hear that he was at the front desk asking for me that following Monday in the Green Pod clinic. He was taking his antidepressants and had already been set up with a psychiatry appointment. The jovial, confident gentleman that sat across from me was light years away from the odd, blinking, staring mystery man I'd seen just 7 days before. Amazing.

We chatted about how things were going, and how much better he was feeling. "Dr. Mannings," he said with a bright smile (his pronunciation of the "Dr. Mannings" was the only time I detected his South American roots), "I have something for you." His words were warm and genuine. "Thank you for taking so much time with me. And for talking to me like a real person. This is for you. . . .It's not much, but I know you will appreciate it."

A wave of uneasiness came over me. I always feel a little funny when a patient gives me some kind of gift. I hate the thought of a person spending limited money to show appreciation. He reached into his pocket and handed a card to me. He saw the puzzled look on my face and clarified with a wink,"This is where I get my brows threaded, girl!" We both threw our heads back and laughed. I was glad to see him feeling better. Oh, and yes girl, he was still groomed to a 't' and you better believe those brows were fierce.


The actual card given to me by Mr. Jimenez. (still in my wallet!)
__________________________________________________________

So, the honest to goodness truth: I go to that very shop to the very person he suggested (who is AMAZING, by the way) to have my eyebrows shaped-- to this very day. Don't believe me? Look below (just saw her last Wednesday.) Of course, back then when she asked me who referred me, I just told her, "It's a looooong story."


The moral of the story: Paying attention to the little things really pays off. You get the right diagnosis, and if you're lucky, you get the right person to do your brows, which if you ask me is win-win. Thanks to my patient Mr. J., I no longer wax my brows. From now on, "sweetheart, I only thread!"




Someone getting their eyebrows "threaded"



Me and my brows thanks to my patient, Mr. Jimenez, and my amazing threader at Hair Images!
Wax off, baby!