Friday, July 30, 2010

Reflections of a Clinician-educator: Kimberly and the Giant Calipers

Grasshopper: This is an outrage! You are a disgrace to your Phylum, Order, Class, Genus and Species!

Centipede: Say it in English!

Grasshopper: YOU, sir, are an ASS!

from Roald Dahl's childrens' classic "James and the Giant Peach"

I used to love the book "James and the Giant Peach." If you've never read it, it's this wonderfully trippy journey of the imagination written by British author, Roald Dahl (the same guy who came up with the Willy Wonka books and also the recent book-turned-movie "The Fantastic Mr. Fox".) Poor little James had a few traumatic and convoluted experiences, including getting lost inside of a giant cavernous peach. Despite this, he learned some great lessons there and met some great friends along the way (even if they were insects). Although I loved that book, I'm still not sure about Roald Dahl and what could have been going on with him when he came up with this tale but that's another story. . . .

Anyways, I like to think of medical school and residency training that way. Some parts of it can be downright terrifying, and despite this, you encounter a few people and experiences along the way that ultimately help mold you into an even better version of yourself. Sometimes it's intentional, other times it happens by accident. Either way, it's necessary.

Kimberly and the Giant Calipers

When I was in my internship, I was rotating on inpatient Cardiology with this really hard-core Socratic teaching cardiologist. Every morning we started the day at like 6:30 a.m. for a half-hour of teaching. Here's how it went down:

  1. Dr. Socrates marches in and carrying a tray of slides holding pictures of what are quite possibly the world's most heinous EKG tracings.
  2. Dr. Socrates sets up projector at very back of the room and then switches off lights. Ginormous image of world's most obscure EKG tracing now in wallpaper proportions over the entire wall. (No, not on a screen, but the size of the ENTIRE WALL.)
  3. Us terrified interns sit at front of the room vacillating between feelings of nausea and near-fainting. At least one will actually vomit or lose some other bodily fluid.
  4. Dr. Socrates perches glasses on his nose and walks toward our seats. Although he is only 5'4" max, his shadow is projected on the wall which makes him look like a big, scary monster that has just jumped out of a closet.
  5. In his hands are these gigantic wooden calipers for EKG tracings that are, literally, the length of my arms.
  6. Interns begin praying to whatever God they pray to that somehow, someway they don't faint, become incontinent, or make a complete fool out of themselves in some other way, or that if they do, that all of the others also do the same.
  7. Some unlucky intern gets handed the giant calipers and told to go to the front of the wall.

the calipers: like these, but wooden and scarier

the projected image: like this, but an EKG and scarier

Early one morning, circa 1996

I'd been standing in front of the ginormous projected EKG, and had just measured every interval, and answered the initial basic line of questioning. It always started with basic questions, followed by a series of harder questions that felt like water torture. I swallowed hard and prayed for sphincter control.

Me: "This appears to be some kind of incomplete bundle branch block, sir. Left, that is." I wanted to be noncommital, yet smarter-sounding. I could feel myself getting woozy and diaphoretic. "Some kind of interventricular conduction defect, sir." Uh oh. Want to take it back immediately.

Dr. Socrates: (Big sigh) "Okay, so Dr. Draper. . . . .tell me, what are YOUR criteria for left anterior fascicular block?"

Okay, let me give you more on Dr. Socrates. He was from somewhere overseas and spoke with an unapologetically thick accent that seemed to emphasize all the things that you were doing wrong. He constantly looked exasperated with us, and still wasn't happy even when there was a budding cardiologist on the team (which there was that month.) He was so intimidating that during the first few sessions, even when you knew the answer, it fell out of your brain into a crack in the ground, never to be seen or heard from again.

Me: "My criteria?" I had no criteria.

Dr. Socrates: "THE criteria." Even worse.

Me: "Umm. . . a left axis deviation and. . . .ummmm"

Dr. Socrates: "and WHAT?" I could feel myself beginning to sweat. The giant calipers slipping out of my hands.

Me: "Is the QRS interval a little bit prolonged but not too prolonged, right?"

Dr. Socrates: "Is it?"

I look over at my other two co-interns like I'm on some kind of game show hoping they will start shouting out answers. Instead they are both quickly thumbing through their pocket notebooks hoping the spotlight wouldn't turn onto them. No help at all.

Me: "Um, yeah, it's . . . uh. . .short. I mean, yes sir, it is prolonged."

Dr. Socrates: "How prolonged?"

Me: "Umm. . .prolonged a little bit but still less than 0.12?"

Dr. Socrates: "And? I'm waiting." Wait, did he just roll his eyes at me?

AND that was the extent of what I knew about THE criteria. That is, that was all I would be able to recall under those circumstances. I mean, all I really knew is that it wasn't a left bundle branch block, which I'd determined after using the giant calipers. I knew that somewhere in there there was some rule about right bundle branch block, but I wouldn't dare utter it while standing in the big shadow box. I shifted from side to side on my feet, hoping this would end. Instead he sat at the back of the room like Michael Douglas on "A Chorus Line" bellowing scary questions out without the least bit of sympathy. I was sure I was going to be sick (or lose sphincter control.)

Like Michael Douglas at the back of that dark theater, but darker and scarier

Dr. Socrates: (sighs in the most exaggerated way ever) "You interns don't know NAAAH-THING. Don't they teach you NAAAAH-THING? How do you not KNOW the criteria for a left anterior hemiblock?"

Me: speechless but thinking, I might partially know, but the chances of me being able to tell a screaming, 5 foot madman with white spit flying from his mouth are slim to none.

Dr. Socrates: "Look at the inferior leads!" He grabs the calipers from me and heads to the front of the room. He stomps his foot. "LOOK! Don't you see those Q waves? You can't call this a left anterior fascicular block in the face of an old inferior myocardial infarction! Come ON! This is KEEEED STOFF!"

But it wasn't kid stuff. It was new stuff. To me and to the other two interns rotating with me that month. I wanted to become more proficient at EKG reading, but this was terrifying. And so, for an entire month, we withstood the giant calipers until eventually something happened. We kept getting challenged. We went home and studied. We tried harder. At some point, we started getting the answers right. And when we did, he just asked harder questions until we somehow got those, too.

By the end of the month, we realized that hearing him say, "Don't you interns know NAAAAH-THING???" was really a term of endearment, and that his other winner--"Help! Help! THAAAT is what this poor man will be saying while you interns try to ASSASSINATE him by not knowing NAAAAH-THING." --was his way of saying, you have to know this not just for tests but for patients. On the last day of the rotation, I gave him a big hug and even wrote him a thank you card. Crazy as it sounds, that rotation turned out to be one of my most favorite months of residency (despite the PTSD it cause me for complex EKG reading.)

13 years later, I can truly say that I remember that attending with warm nostalgia instead of nausea. While I can't say that I personally endorse his colorful method of teaching, what I can say is that now I do appreciate his dedication and passion to our medical education. Now that I'm a clinician-educator, I know what must have gone into gathering all of those EKG tracings and getting them onto kodakchrome slides. I recognize how committed he had to be to meet us every single morning at 6:30 a.m. before rounds, all while still being responsible for the entire service of patients and probably countless other things. I can now see how, deep down, he had high expectations of us and for us, and though he wasn't so touchy-feely about it, he really cared. And in the end, I'm thankful for it.

Kind of like James and the giant peach. He started out lost and surrounded by scary things. With time, those things became more familiar and less daunting, and even downright enjoyable. Though somewhat traumatic along the journey, he was better for it. The struggle was worth it, and yes, necessary. That attending may not have been warm and fuzzy like a peach, but at least he wasn't apathetic. When it's all said and done, I'll take spunk over apathy any day.

So now, I let my learners get lost in the giant peach just a little bit. . . .never at the expense of patient safety, of course--but enough for them to struggle and learn. I take the best of Dr. Socrates, and soften it with my own style. Like him, I expect them to do well, to learn with experience, and to try. And also like him, I do my best to back it up with instruction, time, and passion. Even if their journey into the core of the peach gets a little rough, I know it's necessary, and that they'll be better for it.


At the end of "James and the Giant Peach", James makes a home of the peach pit which turns out to be an oasis in the middle of New York's Central Park. Those insects end up being his very best lifelong friends--and they all live happily ever after. :)

Tuesday, July 27, 2010

Reflection on an Awesome Day: No Excuses

my sister, the trooper after early morning Pump

Today was awesome. My younger sister came to town from L.A. for her birthday and--get this--actually allowed me to drag her to my (as she calls it) "crickety crack o' dawn" Body Pump class. (Happy Birthday, sis. . tee hee hee.)


My sister, JoLai, has never been a "skinny girl." She has always had curves, going back as far as I can (sometimes painfully) remember. Okay, so enough time has passed for me to admit that my intense jealousy of the aforementioned curves was the source of some serious passive-aggressive "hateration" on my part back in the day.

For starters, JoLai is 10 months younger than me (yeah, yeah, 10 months is a narrow interval, we know, we know. . . .) Anyways, when her body got the memo to go into puberty like two years before mine, somehow my stick figure missed that memo and stayed painfully trapped in an African-american version of Olive Oyl. (Case in point: My uncle Woody gave me the nickname "Blade" back then, as in--uggghh-- a blade of grass. . but okay, I digress. . . .)

JoLai would nicely ask me to borrow my shirts in middle school which makes sense considering we are separated by less than one year, right? Ha. Too bad-- I'd promptly shut her down, insisting that I didn't want people to think we wore the same clothes, knowing all along that it was because, unlike her older sister, she actually needed that brassiere Mom bought each of us over the summer. (You kidding me? No way I was going to draw attention to the full house she'd been dealt while trying to overcome the inadequacies of my own low number pair from the same deck.)

In her adulthood, JoLai's had a few health problems and has also experienced some fluctuations in her weight. But that was then. I remember it like it was yesterday. She called me up one day and said, "I refuse to be unhealthy, and I refuse--do you hear me? REFUSE to be fat." And that was that.

Anyone who knows her will tell you: The girl has declared war. And not in that crazy-lose-50 lbs-by-next-week-way, but in a logical, consistent, sustained way. Yesterday, when I saw her in her gym clothes, I patted her flatter-than-mine tummy and said, "Girl, you wearing a Spanx?" She smiled and told me in the nicest way possible, "Hell no." The hateration did threaten to return, but frolicking into Pump with her this morning and enduring miserable lunges beside her made it go away.

In addition to the overall novelty of having my sister working out with me in my favorite class, there was an added highlight: I got to introduce my sister to one of my favorite people and inspirations in my Pump class--my friend Charles.

Charles in class celebrating his 75th birthday
(a GREAT sport for letting us put a tiara and sash on him!)


Okay, let me tell you about Charles. First of all, he's a 75 year old granddad who throws down in Body Pump like he is 35. No, take that back, 25. If you are under the age of 75 and never get up off of the couch because :

a) something hurts now that you are older,

b.) you are feeling kind of crotchety now that you are older or

c.) you are finally retired/off for the weekend and you ain't exercisin'/empty nesters/just had a baby/just had another baby/had a baby a long ago but, dammit, you look good to have two kids/busy with your kids/busy with your business/just got your hair done/just got married/just got divorced/just not a morning person/just not an evening person/"walk a lot" when you are at work (yeah right)/are naturally skinny/are naturally big boned-ed/are doing weight watchers/are gonna start Monday/are gonna really start Monday/are full of you know what, or

d.) all of the above. . .

I assure you that meeting my friend Charles will officially make you ashamed of yourself. Oh yeah, let me add that he lost over 100 lbs, like, a long, long time ago and has kept it off for more than a decade through a disciplined vegan (whew!) diet and regular exercise. (Yeah, I said 100+ pounds, you read that right.) One. Hundred. Plus.

What also makes Charles so cool is that he is really funny, but never crude, and even more than that, he's been married a long, long time and loves his wife (How do I know this? Because he speaks of her by her name which, I have come to learn from working at Grady and living almost 40 years, is actually a very loving gesture vs. "the wife," or "the ol' ball and chain" or. . .you get the picture.) Where was I? Oh, Charles. He knows the name of every person who has come to our class more than once, and warmly greets them by name even if it surprises the bejangles out of them that he remembers. He groans like really loud at all the right parts in class that every one else wants to but doesn't (like during scary repeater "bottom-half" squats, horrid slow push ups, and dreadfully dreadful side planks.) Best of all, he reminds me that a big part of my health and well being (as well as that of my patients) sits squarely in our own hands. For that reason more than any other, every time I see him, I feel inspired.


Today, I am reflecting on two people that regularly inspire me to take charge of my health and appreciate my body for what it can do. It was nice to see these two healthy parallels intersect this morning. Whenever I'm feeling like I don't want to exercise or pay attention to what I'm eating, they serve as constant reminders that I should stop bellyaching and just do what I have to do. And when I sit across from a patient who really needs to lose, like, 100+ pounds, and who really is motivated to do something about it, I think, "You actually can lose that much weight," instead of "No, you can't." JoLai and Charles, you both personify the mantra: "No excuses."

JoLai, thanks for demonstrating to me and all who know you the power of the human spirit. And Charles, thank you for inspiring me and a whole lot of other folks to be healthier--even if it is at the crickety-crack o' dawn.

Now. . . .what's YOUR excuse?

Sunday, July 25, 2010

Reflections on a Sunday: The Doctor in the Family

“This anti-inflammatory medicine or whatever it's suppose to be doesn’t work for my knee,” my husband grumbled one morning while walking into the bathroom. This was the first week after his outpatient knee surgery for an old army injury. “It keeps hurting,” he added for emphasis. This was my signal to stop and take notice.

“Are you taking it around the clock?” I replied over the sound of water rushing from the faucet.

“What?” he asked while massaging the knee with his hand.

I held up one finger and finished brushing my teeth. “The anti-inflammatory. Did you take it around the clock like it was prescribed?” I turned off the water and patted by mouth with a towel. “Babe, the key is that you have to take it even when you don’t have pain to get the best benefit.”

"No, I just took it when my knee hurt. I thought it was a pain medicine? You know I'm not big on popping pills. I've been taking at least one or two of these horse pills a day." He reached into the cabinet and grabbed the bottle of ibuprofen prescribed by the orthopedic surgeon. “Around the clock? So should I take one now?”

“Go ahead and eat something first, or at least drink something so you won’t get nauseated,” I answered. I opened the door to our bedroom and tip-toed down the hall toward the kitchen, using care not to prematurely awaken Isaiah and Zachary. I returned with a banana in one hand and a bag of frozen peas in the other. “Eat this banana to coat your stomach first, and here. . .” I tossed him the banana first and then the peas, “take it easy for a little bit and ice your knee with these frozen peas. They’ll form around your knee, and won’t get all melty. And remember to take the ibuprofen every eight hours with something on your stomach.” He nodded and did as I said. Two to three days later he didn't need the ibuprofen, and the knee felt much better.

Later that day, a friend called and asked me a question about her baby before calling her pediatrician. Her newborn had "a terrible rash on her face" and it wasn't getting better. "These icky white bumps," she said, "almost like acne, but it can't be that because she is only 6 days old. This is not normal!"

I looked at the time on my cell phone. 5:20 p.m. If she called her pediatrician, they would route her to the on-call person. If she wasn't comfortable speaking to an advice nurse or on-call person, or if the on-call person was one of those "just go to emergency" people, she'd be spending the evening in the ER--exposing her newborn to who-knows-what. I thought about all the things people tell you about giving medical advice to people that aren't in your immediate family. (Things like "don't.") But the more I listened to her escalating new-mom anxiety, the more I knew I'd figure out a way to break that rule.

I had an idea. "Can you send me a picture of it? Like maybe a multi-media text?"

"Sure!" she answered. In a flash (literally), we were off the phone and the picture had come over my iPhone. And the photo was exactly what I predicted it would be. I chuckled to myself and then called her right back.

neonatal acne courtesy of "dermeister" (not my friend's baby)

"Hey, girl," I started.

She interrupted me. "Isn't it just awful? Should I go in tonight? Do you think they will have to draw blood?"

"Umm, no. . .not at all, actually. This looks like neonatal acne. You called it right the first time. They have such immature little sweat glands that they get all clogged up. It's nothing to worry about especially since you told me she is wetting diapers and nursing just fine. In fact, it's a really classic newborn rash."

There was silence on the other end. Finally my friend said, "Really?"

"Yup, really." I then had her to "Google image" the term neonatal acne while we were on the phone, which seemed to allay her fears far more than me.

"OMG! This is exactly like what she has, girl!"

I smiled as I held the phone on my shoulder and emptied the dishwasher. "Yup."

"I was about to be up in the emergency room paying $150 for something that didn't even require an emergency room! Girl, what do people do who don't have a doctor in their family?"

"Or their sorority," I laughed making the gentle correction.

"Exactly, girl. But I'm serious, though. Imagine how many little things people worry about when they don't have a doctor or a nurse on speed dial to break stuff down!"

And just like that, the once life threatening "terrible rash" on her baby's face was but a blink on the radar of burps, coos, and diaper changes. We exchanged a few more pleasantries about completely unrelated topics, and then hung up.

Today I am reflecting on her question, "What do people do who don't have a doctor in their family?" I am recalling the countless times that I have been a simple go-between either for my parents or even the parents of good friends who aren't sure how to take a medication. This isn't my first time writing about this--and I guess that is because it is one of those things that I think about often. It used to annoy me when my dad would call me to ask a question on behalf of a friend on the golf course, or when he'd nudge me to call one of my uncles or aunts that I hadn't spoken to in ages. Now that I am older, I see the whole thing differently.

On most days, I see medicine as a ministry, and nowadays, I look at having a knack for teaching people and empathic communication skills as spiritual gifts of sorts. Answering a simple question for a loved one can translate, literally, into hundreds of dollars saved and countless hours of time spent smiling instead of worrying. I imagine myself as some working piece in a much bigger puzzle--one that becomes a perfect picture when I willingly do my part. Now, instead of being annoyed, I recognize it as walking in my purpose.

So in other words, these days I see it as a blessing to be the doctor in the family. Sometimes it's as simple as telling your better half to put peas on his knee and to take Motrin around the clock instead of just as needed. On other days it's as serious as ordering your father to go straight to the emergency department for what will eventually lead to urgent bypass surgery. Regardless of the circumstance, I now know one thing to be true: This doctoring thing is much bigger than us, and the best doctors never clock out, no matter how hard they try.

Tuesday, July 20, 2010

Rhyming Rant!

I wrote a blog post just for you
and hoped it'd make you say "woo hoo!
another post for me to read
and fill my pseudo-bookworm need."

I thought it out and typed it straight
and since you're worth it, stayed up late
I thought of you and said, "oh boy!
i'm sure that this one you'll enjoy."

And if you did, I shall not know
for under "comments" was ze-ro.
though I liked your email, loved your text
i'm not ashamed to say this next
it may be silly and quite lame
but leaving those are not the same
as logging on to the surprise
of brand new comments for my eyes

your ha ha texts
or email notes
or cell phone calls
don't float my boat
like real true comments if you dare
instead of mr. zero there

to those who comment
and who read
I thank you three, I do indeed
and if you never comment never
i'll pretend you did and called me "clever"

sorry I am out of rhymes
and if you don't comment. . .fine, fine, FINE!

Thank ya. . .thank ya very maaaach. . . . . .

Reflection on a Tuesday: Throwing Salt in the Wound and in the Game

True story--This week at Grady:

Me: "We could probably get your blood pressure down quite a bit by making some changes to your diet. That can be as helpful as adding a medication.

Patient: "Oh, I already eat a no salt diet, so that definitely ain't my issue.

Me: "Wow. . . I've heard of a low salt diet, but seems like it would be tough to have a no salt diet."

Patient: "Yep, well it ain't that hard. You just gots to put your mind to it, you know what I'm sayin'?"

Me: "I hear you. You know sometimes salt can be hiding in stuff."

Patient: "Not my food. I prepares all the food in my house. So it ain't no salt in none of it. Matter of fact, we don't even have no shakers in our house." She smacked her lips between each sentence for emphasis.

Me: "Wow, that's impressive. . . uh. . I mean, great. What do you season your food with?"

Patient: "Mostly Accent or Zatarain's."

Me: "Umm, Accent or Zatarain's?"

Zatarains = creole-seasoned salt, Accent = MSG

Patient: "Yeah ma'am. Or just bouillon. You don't never cook with no bouillon? I drops me a block off in jest about everything. Make it taste so good without salt." Alrighty then.

Me: "Umm, bouillon? In everything?"

Patient: "Oh yeeeeeeaaah. Vegetables, rice, all that stuff."

bouillon = meat stock flavored SALT

Me: "Uhhh. . . . okay. . . so. . .tell me this--what'd you have for breakfast this morning."

Patient: "A sandwich and some coffee. Biscuit with a little piece of meat. . .some leftover fatback, tha's all. But I didn't sprankle no salt, though, and this time, no bouillon." She smiled and still smacked her lips with each point.

a little piece of fatback on a biscuit

Me: "What about dinner last night?" I could feel myself breaking out in a cold sweat.

Patient: "Chicken and some butterbeans, oh and some white rice."

Me: "The chicken. . .baked, fried? And how'd you season the butterbeans?" Please don't say it. Please don't say it.

Patient: "I ain't gon' lie, it was fried. But I seasoned it only with the Zatarain's. The butterbeans just had a ham hock in it, tha's all." Tha's all. Sigh. I looked at her stout middle, and thought about her initial complaint, How can I lose some of this weight? I keep trying but nothin' is happening. . . .

Me: "A ham hock. . . .did you. . .eat it?"

Patient: "Ummm hmmm. I ate only part of it, but not all of it. But no salt, though. Definitely no salt."

smoked ham hocks, unsalted. . . .?

She was so proud of herself. Chest all poked out and proud about her no salt diet. It hurt my heart to have to burst her bubble about the foods she'd grown up on like ham hocks and fat back. This particular patient was low literate, and wasn't very good at reading labels. It felt so enormous, trying to think about how to start explaining sodium intake to her. Like Zatarain's is seasoned salt. And a bouillon cube is pretty much dehydrated chicken or beef stock and, well, salt. And Accent? It wakes up the flavor because of the sodium. Sodium wakes everything up. Sigh. The fat back is salt cured, and so is the smoked ham hock. So, in other words, don't eat any of the things that you call comfort foods. Your specialty? Don't cook it. And all those foods that don't perish in 3 days that your fixed income can afford you? Out of the question.

Some of these interactions start out funny, but then quickly evolve to not funny at all. Fresh food costs money. Education and exposure to different things in life is a privilege that often comes with, well, money. I truly believe that this woman was really giving her personal best. She deeply believed that her diet was indeed a "no salt diet."

And so, first, I congratulated her on her effort. I told her that effort is where it all starts, and that she was ahead of most for that reason. I silently berated myself for allowing the six ridiculously expensive organic peaches I bought from Whole Foods last week go bad. Then I took a deep breath and then slowly began explaining sodium to her. Showing her labels so that she could know the word by sight. And after looking crestfallen, she finally said, "Damn, I can't eat nothing."

And you know what? Considering that I was sitting across from her in a public hospital where she'd just told me that she could barely afford her medicines, the co-pays for her visits, or even the cost of public transportation to come and see us, it was hard to argue with her.

"The percentage of food shoppers who are obese is almost 10 times higher at low-cost grocery stores compared with upscale markets, a small new study shows. In the Seattle area, a region with an average obesity rate of about 20 percent, only about 4 percent of shoppers who filled their carts at Whole Foods Market stores were obese, compared with nearly 40 percent of shoppers at lower-priced Albertsons stores."

-University of Washington Study

celeb Rachel Bilson doing some swanky grocery shopping. . .but definitely not on a fixed income!

Verbatim at Grady: A Sweet Connection

Verbatim at Grady:

Lady walking through the Grady hallway. Catches the eye of a dude walking through the corridor, who decides try his luck.

Man: "Hey there, Miss Lady. . . how you doin'?" (definitely being fresh.)

Miss Lady: "Oh, I'm good. You?" (not minding him being fresh at all.)

Man: "I'm just chillin' going over here to see my doctors 'bout my sugars."

Miss Lady: "You got diabetes???" (Fireworks go off. Points at Man. Now pats her buxom bosom gleefully.) "Whaaaat? Oh my GOSH! I got diabetes, too!!"

Man: "You DO? That's why you seem so sweet." (Whoops, threw up in my mouth a little bit.) "You go to Diabetes Clinic or regular clinic?" (This is truly their "moment." Like, a "OMG, you went to Morningside High? Me, too!" moment. Fraught with peril, I say. . .)

Miss Lady: "I go to both. Diabetes Clinic be giving you free stuff. They don't give you nothin' free up in regular clinic." (I work in "regular clinic" so I take offense to that.)

Man: "Alright then. . .I'mma remember that. . . . I know they gon' flip out when they see my sugar today 'cause it was higher than 400."

Miss Lady: "400! Damn! What you ate this morning?"

Man: "A sausage biscuit from McDonalds." (Starts laughing hard) "But shooot, I be hongry when I'm waiting." (Laughs some more. The connection gets even tighter.)

Miss Lady: "I hear you." (A little bit flirtatious.)

Man: "I hope they don't try to make me go to emergency 'cause my sugar so high."

Miss Lady: "Naww, chile please. They gon' make you drank a big ol' pitcher of water and then they gon' let you go long as your sugar come down good. Trust me."

Man: "Good." (Flashes her his big ol' smile with missing canine on right.)

Miss Lady: (She obviously liked his smile, missing canine and all.) "You know you wasn't 'posed to be eatin' no sausage biscuit for you came up here!" (laughing, even more flirty, batting what appears to be glue on lashes. Eeeww.)

Man: "Shiiiit, you know I'm gon' tell 'em I'm fasting." (Now they both laugh. My mouth falls wide open.)

They look at me and catch me eavesdropping and then both laugh some more. Not sure it they were laughing at me for believing that people are actually fasting when they say they are (cause I generally do believe them) or just laughing 'cause I overheard them. I think it was the former and not the latter.

Man: "Alright then Miss Lady. I hope to see you around." (Is he gonna ask for the number? Hmmm. . .)

Miss Lady: "Maybe we'll see each other in the Diabetes Clinic." (Bats scary lashes again. . .so wants to give him her number.)

Man: "That's what's up." (Winks at her and gives her one more once over before walking into "regular clinic." Eeeww. Oh, but left her hanging on asking for the digits. She almost wistfully watches him disappear through the door. And somehow I detect a wee bit of disappointment from her. . . .disappointment about missing out on a diabetic mack daddy with a missing canine, a receding hairline, and a blood sugar of 400. :::w-ow:::)

***Love, love, love this job.***


Sunday, July 18, 2010

Reflection from a Sunday: Literary License, A Southern Tradition

The old bible: The keeper of family lineages
Me: "Sir what does the 'J R' stand for in your name?"

JR: "It stands for J R."

Me: "No, I mean what's your real name."

JR: "It's J R."

Me: "Like on your birth certificate?"

JR: "I ain't never seen my birth certificate. Matter of fact, I ain't sure I even have one. But that is the name my mama and my daddy wrote in the front of the bible when I was born."

*Note: Back in the day (and probably still) folks used to keep track of lineage by scrawling down births and deaths in the front of the family bible. Many of my Grady patients, especially those in rural areas, weren't born in hospitals and never received birth certificates.

J R. That was his "God-given name." Not J R, short for John Ramsey or James Robert. Just J R, short for. . .well. . .J R. Just another one of those random things I love about working at Grady and the south in general. Like, what exactly went down in the moment when he was named? Somebody said, "Let's name him J R!" and somebody else said, "Jasper Ralph?" and somebody else said, "Naw, just J R." And that was the end of it. (Picture me looking so, so amused as I type this.) Aaaaah. . . . there is something about the deep south that gave folks such literary license when naming their children back in the day. King David, Queen Esther. . . .of course, the daughters named for fathers like "Charlesetta, Henrietta, and Lou-ella". . . oh and my favorite-- the middle initial that doesn't stand for anything in particular. . . just a letter and nothing else . . .awesome.

Okay, before you accuse me of making fun of my patients, I can assure you that I am not. As a matter of fact, I would be a hypocrite to do any such thing. And to help you understand just what I mean by this-- and to explain why I'm so. . .uh. . . creative--I'll share with you a piece of my own family history that, I promise you, is 100% true.

The Draper Family

Manning is my married name; in fact, when I first started working at Grady Hospital, my name was still "Dr. Draper." Anyways, my father's name is William Ralph Draper--but everyone calls him "Tony." Why? Because at some point in his life, somebody looked at him and thought he looked more like a "Tony" than a "William." Yep. Now my brother and all of my brother's friends mutated Tony into their affectionate nickname for him: "T-Tone." As a matter of fact, the name "T-Tone" has even evolved into a verb that is used to describe any tirade where someone gets torn a new you-know-what. We call it "pulling a T-Tone." (Dad used to be pretty feisty back in the day. . .what can I say?)

For example:

"I was in Kroger and the cashier lady threw my change at me and rolled her eyes! It was crazy!"

"Whaaaat? Then what happened?"

"I called the manager but she was lucky since I was two beats away from pulling a T-Tone up in there."

Although I have been pushed into "pulling a T-Tone" on a few folks in my lifetime, I don't call my dad by that name. I call my dad "Poopdeck." For me, it went from Daddy to Pops to Poppy to Pappy to Pappy Poopdeck (like Popeye's dad) and now just Poopdeck. Might sound crazy to you, but understand--this is what my family does. We butcher names until they are minced meat and unrecognizable--but as an act of love.

Friend: "Hey Kim, why does your sister call you 'Mizzolini?' "

Me: "She used to call me K.D. and then she changed it when I got married to K.M. but then she changed it to K-Mizzle (as in fo' shizzle) and then that just became Mizzle. It kind of goes back and forth between Mizzle, Miz, and Mizzolini."

Friend: "Uuhhhhh, yeah okay."

My mother's name is Cheryl. But her nickname growing up was "Sugar." So a lot of people call her "Shug" or "Shugsie" (or as my younger sister calls her "Boog-sie." Sigh.) I don't call her that, though. One day, I randomly started calling my mom "Toonces" (as in Toonces the driving cat from SNL.) I think it was because we were riding in the car and she was gripping the steering wheel like Toonces one day, which amused me. I have called her Toonces ever since, and when she calls me, she even says, "Hey, it's Toonces." Funny.

Poopdeck (Dad) is one of 11 kids, just about all of whom were born in their house (told you that was true.) His father, my late grandfather, was known to everyone as "Pipes." My father's eldest brother could not properly pronounce the word "papa" so he said "pipe-a." Pipe-a became "Pipes" and stuck. The real country folk say "Pipe" even though they think they are saying "Pipes." (Just an observation.) My maternal grandmother was called "Mudear" by everyone, short for "mother dear." Not really unusual for rural Alabama or the south in general. But that's where the not-really-unusual ends. . . .

The Draper Saga continues. . . .

Back to dad's eldest brother. His real name, written in the front of the bible, was Ponce de Leon Draper. Yep. Ponce de Leon. Like the dude who discovered the fountain of youth. Yep. Like that main thoroughfare in Midtown Atlanta. Oh, and the eldest sister's name was Mattie Henry Draper. Family legend has it that it was originally "Matt Henry" but somehow that became "Mattie." And that middle name? Um, yeah. . .you read that right. Henry. Why? Well for starters, Pipes middle name was Henry. And he just sort of thought Mattie Henry was a pretty name. Nice.

The Edsel Ford

Another son came along that Pipes and Mudear named, sigh, Edsel Ford Draper. Yep. Like the car pictured above. My Uncle Edsel Ford later legally changed his name to Edward Ford. But that doesn't really matter considering no one in our family ever called him either of those names. Most folks knew him as "Chief" or "Wolf." Why? I'm not sure. I mean, it's not like he looked like a Chief or a Wolf nor did he have the personality of either of those things either. In fact, he was the most incredibly gentle, easygoing and sweet-spirited man ever. Uncle Chief was one of my most favorite uncles. Isaiah was born on his birthday, but I didn't have the heart to name the kid "Edsel." (Sorry, Uncle Chief.)

It gets better. Another brother was named Hiawatha Draper. Oh yeah, no typo, Hiawatha. As in Hiawatha, the founder of the Iroquois Nation. Sigh. No middle name, thank goodness. Guess my grandparents felt that "Hiawatha" was enough for the poor kid. The family all calls him "Skeeter" since he used to be skinny like a . . well. . .mo-skeeter. But the rest of the world? Oh yeah, baby, they call him by his sho' nuff and bonified name: HIA-WATHA. And the best thing about him is that he totally owns the name and has somehow made it cool. Talk about bad ass.

Isaiah and Uncle Hiawatha a.k.a. Uncle Skeeter

Hungry for more of my lineage? You shall be fed! How about my dad's younger brother who's sho' nuff, front of the bible name is . . .wait for it. . .wait for it. . . .Woodrow Wilson Draper. Woo hoo!! Is that awesome or what? There's also Eula Bernice, who everyone calls "Renee." Why? I don't know. (Hell, why not?) Oh yeah, and I almost forgot-- Billie Joan Draper, who we all knew as "Auntie Tina." Maybe she looked more like a Tina? You got me.

More funny Draper Family factoids. . . .

I am perpetually amused by the fact that my dad was the fourth son, yet his dad decided that after naming the first three boys Ponce de Leon, Hiawatha and Edsel, that he'd name the fourth one William--after himself. How random is that? Well, if you believe like me that nothing is ever really random you'd have to just accept that, just maybe, there was some method to Pipes' madness when he divvied out all those whoppers. Ponce de Leon? Edsel Ford? Woodrow Wilson? Really Granddad? Really? (Oh yeah, and in case you wondered-- no matter what anyone says, I will always believe that the only reason dad didn't get Pipes' full moniker William Henry Draper was because the name Henry had already been taken--by his sister.)


And so the moral of this is simple: names around Grady and down south can mean everything or absolutely nothing. Some are on birth certificates or just written in the spines of old family bibles. The good news is that in these parts if you do get a name that you don't like--don't worry. The chances that anyone will actually call you by it are pretty slim. :)

P.S. If for some reason I call you anything other than your name, now you know to charge it to heredity and not my heart.

the Moo-Mooskis

With love,

The mother of Isaiah (aka Zay Zay aka Poops aka Poopy Santana aka Sunshine Boy) and Zachary (aka Zachariah aka Zacharoony Positoony aka Zack Attack aka Pooda aka The Great Poodowski aka Toogie aka Zachy Poo). . . .both of whom are collectively known as Thing 1 and Thing 2 aka The Cocopugs aka Los Chimichangos aka Mommy's Moo-Moos aka The Moo-Moos aka The Moo-Mooskis. . . .

Any funny names in your family?

Friday, July 16, 2010

The Internship and Residency Chronicles Volume 2: Follow the Yellow Brick Road

*most names and details changed. . . . . .you know what's up.
"You, my friend, are a victim of disorganized thinking.

You are under the unfortunate impression

that just because you run away,

you have no courage.

You're confusing courage with wisdom."

~ The Wizard of Oz in "The Wizard of Oz" 1939

I remember looking at the schedule for inpatient ward assignments during the winter of my intern year. I found my name with my index finger and then dragged it across the paper to find who my fearless leaders would be. My resident was this feisty third year woman. . . . . excellent reputation for being smart although tough. I could handle that. I followed the column upward until it landed squarely on a name that I wasn't so sure I could handle: Dr. Olds. Gasp. My attending that month was. . . .eek. . . the Chairman of Medicine? Great.

Here's the thing: I was in a combined training program where every three months I switched from assignments in Pediatrics to Internal Medicine, and then back again. My yellow brick road was convoluted, to say the least, and finding my footing during those early days wasn't always easy. This upcoming ward month would be my "back to Medicine" month after three rigorous months of Pediatrics. I still had NICU, newborn nursery, and pediatric emergencies on the brain. Those first few days after the switch always felt a little shaky; I'd mastered the art of looking confident when deep down inside I was a quivering blob of jello. But this was even more terrifying than usual. In addition to my normal freak-out, I was given the privilege of having a potential meltdown in front of the Wizard himself: the Chairman. Super.

Okay, so I was a PGY (post-graduate-year) 1 back then, but can I say that even now, as a PGY 13, I would find it equally mortifying to be under the microscope of my Chairman? Picture it. Every day, you get to present your patients, what you discerned from your history and physical, and subsequently do your best to field the barrage of Socratic questioning that would surely ensue. From your Chairman. This meant that a screw up or a bad day could have monumental consequences. A category 1 nausea hurricane quickly organized in the pit of my stomach with every ingredient for growth into category 5.

The good news is that despite how intimidated I was by my Chairman-turned-ward attending, he was pretty nice. In fact, he was more than that--he was really, really nice and surprisingly approachable. The other good thing is that my resident was excellent that month, and she cracked a mean whip on us interns. She'd make us present our patients to her first, and would pick our write-ups apart and then reassemble them before rounds every day. In other words, there was never a performance without a dress rehearsal and a sound check. I mean, this was the Chairman of Medicine, which in case you haven't figured out yet, was kind of a big deal.

Follow the yellow brick road. . . . .

One night on call, I was being covered by a different resident. I was no longer under the watchful and protective eye of my trusted PGY3, but instead was the orphan intern of someone less familiar to me. His name was Gary; a second year resident who was smart, but much less confident than the mini-general that I'd become so accustomed to. This resident would ask me what I thought we should do. And not just in that obligatory way that folks often do when talking to medical students or interns. This guy really needed me to co-sign his decisions. Even though I was feeling more and more comfortable with clinical decision making, his anemic leadership was terrifying. And even more so since my attending was--had he gotten the memo? Uhhh, the freakin' Chairman of Medicine.

It came to a head when we stood before a woman we'd just admitted with community-acquired pneumonia. Gary and I had just gone down to the Radiology suite to review her x-rays which, consistent with her lung exam, revealed a moderate sized fluid collection around her left lung. My wobbly leader discussed the next steps with me as we rode the elevator back up to the patient's room.

"She has a pleural effusion, so the next step is to sample the fluid with a thoracentesis, okay?" Gary asked/said. Then he reached in his pocket and thumbed through the Washington Manual under "Management of Pleural Effusions." He looked up at me and added, "I think that sounds like the right thing to do, don't you?"

I didn't like this co-sign thing. I needed him to speak with authority. I wanted him to be so comfortable with this situation that he could quiz me on the Light's criteria for pleural effusions while picking dirt out of his nails with the edge of an index card. Didn't he get it? I wanted to be his intern, not his co-resident. I furrowed my brow and answered him, "Uh, it's my understanding that an effusion that size needs to be tapped. And I guess depending on what it shows, you determine whether or not a chest tube is necessary."

What did I say that for? Gary's face went pale, and he swallowed hard. "Oh my gosh. I really, really hope she doesn't need a chest tube. Oh my gosh . . ." He shook his head and muttered while devouring the tiny paragraphs printed on the pages of the Washington Manual. Now, I somehow felt like a jinx.

But this patient looked good. In fact, the only thing that had prompted her admission was her abnormal x-ray. She'd had this fever for two days associated with a cough, and when it didn't go away, she decided to come to the emergency department. This patient was youngish--in her fifties--and had been in perfect health. Since she didn't usually get sick and made regular visits to her primary care doctor, she grew a bit worried. She didn't smoke, didn't use drugs or alcohol, and was breathing well enough to not require oxygen. During her visits to her PCP, she'd had regular lab work including several negative HIV antibody tests. And so, the truth is that this lady was not sick-sick by any stretch of the word. She just had an ugly x-ray which sometimes can be enough to make even the most bad-ass the Emergency Department doctors uncomfortable.

A third year senior from the ICU supervised me as I did the procedure since Gary wasn't comfortable being the overseer. The patient tolerated the thoracentesis quite well--in fact, what I remember the most about her was just how great she looked overall. In fact, she was so cool that I remember her talking to me about banana pudding during the procedure. So clinically? She looked cool. Clinically cool, yes. But radiographically cool? Uhhh, not so much.

After carefully removing a sample of fluid from the space around her lungs, I confirmed that we hadn't introduced air or caused any complications by checking on both her follow up x-rays and how she was doing. Just like when I'd seen her in the Emergency Department earlier that night, she looked great. My nervous upper level stood beside me as I led the conversation.

"How are you feeling, Mrs. Elmore?"

"I'm actually feeling a lot better. The cough seems to be loosening up some more, and now I'm bringing up more phlegm. I still have a little pain on my left side, but it seems a touch better since you guys took some of the fluid off of my lung." She really did look like she felt better. Even better than she looked before the thoracentesis. "I think my fever broke, too."

"Are you breathing alright?"

"Yeah, I'm okay. My nurse says I am still breathing a little faster than normal, but like I said, I was surprised when they wanted to keep me. I guess I'm glad you guys did since I had the fluid around my lung--what did you call that again?"

"A pleural effusion," I answered with careful annunciation of the technical terms.

"That's right, the pleural effusion. Yeah, but I am feeling a little better. I think I'm going to try to get me some rest," she said with a smile, "I hope you all get some, too." I glanced up at the clock on the wall beside us. 1:36 a.m. I smiled back at Mrs. Elmore and raised my eyebrows. Sleep? Yeah, right.

"You do the resting," I laughed. "I'll be checking on the results of your fluid, and will let you know what it says. The fluid looked pretty clear, so I won't wake you if it isn't too exciting. Right now, I'm anticipating that we won't see anything alarming." I did my best to speak with the authority that I knew my supervisor that night had not quite grown into yet. We both bid Mrs. Elmore adieu as she nodded and rolled over in her bed.

2:21 a.m.

I had my head down for a catnap at the nurses station when my pager startled me awake. It was the "Stat Lab"--I recognized the number. I whipped out my pen and a piece of paper in preparation of Mrs. Elmore's unexciting pleural fluid values.

"I have a critical lab value for you on patient Elmore," spoke the lab technician. He didn't waste any time. "I've got a pH on a pleural fluid specimen of 6.9."

I thought I'd heard him wrong. "Excuse me?"

"The pH on your pleural fluid sample. It's 6.9," he repeated firmly.

"6.9? On patient Elmore?" Again, he affirmed that this was indeed the patient, and no, he didn't stutter: 6.9 was indeed the value. I felt the hurricane swirling in the pit of my stomach again. A pH of less than 7.2 meant the fluid was likely pus, or what we refer to as an empyema. And one of the first things you learn in medical school is that "pus must pass." Uggh. Mrs. Elmore needed a chest tube--the only way for pus to pass out of the pleural space.

"Shoot!" I said aloud thinking about how peaceful she'd looked when we'd left her bedside. I imagined us rustling her awake only to have some baby-faced surgical intern consent her for a hollow tube the size of her pinkie finger to be inserted into her chest. "Shoot!" I repeated. This stunk.

as heinous as it looks: a simulated-model patient with a chest tube

Before I could even fully process it all, Gary was flitting about me like some sort of anxious hummingbird. "You saw that the pH is 6.9!" he exclaimed, "I already called surgery for a chest tube. They're coming. You think she needs a chest tube? I mean, less than 7.2 then she does, right? This is awful. This is so, so awful." He looked like he was going to be sick, which made me feel the same. I longed for my drill sergeant day resident, who likely would have smacked Gary and told him to get a grip. He was making me anxious. I gathered my cards up and prepared myself to go and speak to Mrs. Elmore.

Gary shuffled beside me as I reached the foot of her bed. I could hear her breathing; peacefully sleeping without oxygen or any respiratory distress whatsoever. I whispered to Gary, "Don't you think she looks too good for that pH and way too good to need a chest tube?"

He gave me a puzzled look. "But the pH is 6.9," he spoke more firmly than he had all evening. He paused for a moment to make sure we didn't wake her before adding, "Despite how good she looks, she needs a chest tube!"

"Could it maybe be a lab error? I'm just worried because a chest tube is like a really big deal." We both stared at her quietly for a few moments. I turned and faced Gary before saying the unthinkable. "I think you should call the attending."

It was like my mouth moved in slow motion. I just suggested to my nervous upper-level that he call not just the attending, but the Chairman of Medicine--oh, at 2:40 in the morning to boot. Good luck with that.

"But it is clearly less than 7.2. It's even under 7.0, Kim. This is clear cut. She needs the chest tube."

Great. We've been on this yellow brick road all night, and now the lion finds his courage on the first decision of our call that I actually wanted him to get my input on. I decided to challenge him. "This doesn't make sense, Gary. Dr. Olds always tells us to pay attention when things don't make sense. I think we should call him. If you won't, I'm willing to."

"Call Olds?" he gasped. "You will not call our Chairman at 3 a.m. to ask him an obvious question. Absolutely not." He scowled and walked out of Mrs. Elmore's room to punctuate his position. Great. Now he'd found some heart, too.

I wouldn't give up. I finally convinced Gary to let me call Dr. Olds, but he made it clear that I should tell him I did so without his blessing. In other words, "If you have the audacity to kick open the gates of Emerald City and smack the Wizard on the back of his head in the middle of the night, you'll be doing it on your own." That was fine with me. I just didn't want to see this healthy woman be subjected to a chest tube that she surely wouldn't want and that possibly she didn't need.

And so I called the Wizard a.k.a. Dr. Olds at 3-something in the morning -- without a lion, the tin man or the scarecrow to back me up. Just PGY1 me, waking up first, the Chairman's wife who (as I sat there mortified) let me hear her calling my Chairman "honey" until he was wakeful enough to grab the receiver. Lawd.

Fortunately, just like he had been all month long, the Chairman was wonderfully patient when I got him on the phone. Once I got past my fear, I methodically ran down all that had happened--including her low grade temperature, bright smile/not-sick appearance, normal oxygenation, and then peaceful slumber I'd witnessed a moment before. "Could she look this good with a rip-roaring 6.9 pH empyema in her chest?"

"Call the lab and ask them to repeat it," spoke Dr. Olds decisively. "It sounds like a lab error. If she looks that good and it's still low, I'd retap her. It's possible that the specimen sat too long. Definitely don't put a thoracostomy tube in her without having them run it again."

"Okay," I eeked out while looking at Gary. He held his hands out to say, What? I wrote in all caps on an index card what Dr. Olds had just told me:

NO CHEST TUBE YET. And that's exactly what we did.

3:39 a.m.

Page from the Stat Lab.

"Repeat pleural fluid pH: 7.38." (normal.)


Today I'm reflecting on the importance of making sense of things in clinical medicine, but also the value of being an approachable leader and supervisor. Although I often point out the differences between my pre-duty hours reform training and the current regimented and humane training, I can proudly say that even then we always had invested faculty supervising us along the yellow brick road. Having a good fund of knowledge helps, but sometimes it takes experience to become a sho' nuf and bonified voice of reason. For this reason, I try hard to channel my inner Dr. Olds when called by residents in the middle of the night or other inopportune times. I make an effort to work through their thought processes, and when necessary, I use my PGY 13-ness to provide that 3 a.m. decisiveness that maybe they've yet to acquire.


Later that morning before rounds, I stood at the foot of Mrs. Elmore's bed as she continued to sleep. I looked at my pinkie finger, then back at her and sighed a breath of relief. She was discharged early the following day--without an extended hospitalization, complications, or a chest tube.

me with my former Chairman/Wizard, G. Richard Olds, MD, MACP
at the National ACP meeting, 2009

Still as approachable 12 years later (and just think, he's a med school Dean now!)