Saturday, May 12, 2012

Anemia of Chronic Disease.

Anemia is a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body tissues. There are many types of anemia.

Anemia of chronic disease is a blood disorder that refers to anemia that is found in people with certain long-term (chronic) medical conditions.

~ Source: Pub Med Health


I walked into the room behind the resident and initially saw exactly what I expected based on the resident's description: A forty-something year-old man perched on top of the examining table patiently waiting for our return.

"Good morning, sir. My name is Dr. Manning and I'm the senior doctor in the clinic today." Right after I said that I realized that it sounded kind of canned so I decided to personalize it. "I saw from your chart that you not only quit smoking but lost a few pounds. That's awesome, sir!"

He smiled at me and nodded his head. "I'm trying, doctor. Just trying to do what I can."

I smiled right back at him and said exactly what I was thinking, "That sounds perfect to me."  That made him chuckle a bit which warmed my heart and the room just enough to break any ice that needed to be broken on that encounter.

And so. I quickly repeated a few parts of the examination as my resident looked on. Then I reaffirmed parts of our plan for the visit. He listened and kept smiling and nodding because this was just that kind of visit. Kind of like going to the dentist for a cleaning and having not a single cavity or gum issue or any such thing. A good news kind of doctor's appointment where no one has to hang their head or take deep sighs or promise to do better.

"I'm trying, doctor. Just trying to do what I can." 

I replayed that in my head and put it on a post-it note for later.

So my part of the encounter was pretty uncomplicated. There was no conundrum to sort out or difficult situation to overcome. This was just as basic as it could get in the clinic--A man with high blood pressure, elevated cholesterol, pre-diabetes and a spare tire around his waist that he was diligently whittling down. Smiling and proud because in addition to shaving off some pounds, he'd also quit smoking cold turkey since that last visit.

And that was cool with me because when things aren't overly complicated, I get to notice other things that may be missed otherwise. Like the fact that his cologne seemed to be so much a part of him that it emanated from his pores. Not in that oppressive or overbearing way, either. Just in that way that someday will provide his loved ones solace many years from now when he is gone. Because certain scents can do that to you.

I also noticed how rough the calluses on his palm felt when I shook his hand during our introduction. A lumpy strip of labor's aftermath pressing into my own hand which made me ask about things completely unrelated to his blood pressure or his cholesterol or his pre-diabetes. Like how he used to be in construction but wasn't any more because of the economy. So, yeah, we talked about that part, too.

Then I heard a little sound that made me look over my shoulder. I was surprised to find what I estimated to be an eight or nine year old boy sitting in a chair behind me. He was playing some kind of game on what I am guessing was my patient's phone. The boy had been so quiet through our visit that I hadn't even realized he was there until he'd released a tiny clearing of his throat.

"Hey there!" I announced in his direction. "I didn't even see you there, buddy!"

And he looked up and turned the corners of his mouth upward in a way that was just as canned as my initial "Good morning."

"This is my nephew. He's hanging out with me today," my patient said. The look on his face was gentle when he spoke those words. His nephew looked up and offered his uncle the very expression he'd just given to me.

"Playing some video games?" I asked. He nodded. And, of course, I was curious about why this seemingly healthy elementary school-aged kid was here in our office and not at his school. So I asked him. "Why aren't you in school today?"

"Ma'am? Oh, because today was a field trip."

You'd think that I would have just left it there, but honestly, the encounter with his uncle was so easy and familiar that I extended that into my exchange with this boy. But the problem with easy and familiar is that words float out of your lips so effortlessly that they often get ahead of your thoughts.

"What? How come you aren't on the field trip?"

And he looked up at me just as matter-of-factly as either of my children and answered, "It cost too much so we couldn't afford it."


The room fell silent. It felt awkward and awful because it was both of those things.

"But you get to hang out with your uncle today, don't you?"  our patient finally said.

"And play video games on his phone," I added.

The boy gave us all that same anemic smile and returned to playing his game. And when I say his smile was "anemic" I mean it. It was watered-down, thinned-out, and scarce. On top of that, it came too natural which told me that this? This was a chronic anemia. Chronic as hell and just a part of the fabric of his life. No, this child did not break down and cry when he told me he had to miss his field trip. His lip didn't quiver a single time nor did his chest heave. Because this was his life and his truth and his existence. And this didn't just start with a permission slip for this field trip, either.

When doctors see that kind of anemia on a person's bloodwork, we call it "anemia of chronic disease." Everything about this child and his vacant smile was exactly like that. Longstanding. Persistent. And enough to create a slow damage that, just like "chronic disease", is hard to put your finger on.

And that? That I did notice.

Look. I am not politically savvy. I do listen to NPR on my way to and from work and while I wash dishes and okay, I try my hardest to understand words like "pundit" and "insurgents." But I don't always get it.

Admittedly I struggle with exactly who is the GOP or the Tea Party people. . . or the difference between conservative versus ultra-conservative. I get confused about whether they are all one team or many different teams or how the guys who said all the mean things last month about someone can now wholeheartedly endorse the same person.

But even still. Whether I fully understand what the hell they are talking about and even if I pretty much disagree with nearly all of the parts I do understand,  I respect the opinions of all of those people on their chosen teams. Because just like me they are people with thoughts and ideas and upbringings that brought them to where they are.

Yes, they are.

And okay, I'll admit that I dug into a drawer and put my Obama t-shirt on this week because I felt good about wearing it this week more than ever. And even wore it again this morning for the same reasons, but still, what I am feeling right now is not a right wing or left wing thing. Right now, I need the man on my t-shirt and the GOP people and the Tea Party people and every version of conservative right along with the left wings, the right wings and the bat wings to hear what we are hearing every single day at Grady Hospital:

"I'm trying, doctor. Just trying to do what I can." 

You got that? People are trying. They are. But sometimes, Mr. and Mrs. Congress-folks, that is not enough. I have said here once and I will say it again. People are LOSING out here. LOSING.  They can't get jobs doing what they know and do the best and they can't afford ten dollar co-pays or fifteen dollar field trips for their children. They are heavily relying upon those government assistance programs that some of you wish to snip down to the bare minimum and no, not all of them are just standing around idly with their hands out.

They are trying. Just trying to do what they can. And their children are growing up in the center of it with their anemic smiles and quiet body language because even though they see their heroes and she-roes slugging it out with all of their might, the fact remains that they are still losing.


Real people in real households with real lives--losing. 

And me? I can't say I get every single thing that the lawmakers are up against, but I do know that at some point you just have to decide whether or not it bothers you in the deepest parts of your soul that so many good people are losing. Trying to do what they can but still LOSING. Even while you're winning because of how you grew up or what you have or even just by the grace of God.

So at the end of the day, it either bothers you or it doesn't. 

This? This bothers me. It bothers me a lot and enough to affect the way I think and feel and vote.

Even if, in the grand scheme of things, I'm a doctor who happens to be winning.

Funny. I started this post without much of a destination. I just wanted to tell this story to honor this uncle and his nephew who had caught two buses to see us that morning. Not get all political.


But honestly? This isn't political. This is real life. This is anemia of chronic disease. And this?  This is Grady. And it matters because Grady is America in every sense of the word.

Yes, it is.

Happy Saturday.

Now playing on my mental iPod. . . . Yolanda Adams sings "What about the children?" 

P.S.  This made me think of Kevin S. and Joelle R. and Cathy M. and all of the other students and people I know who are hard-wired to be bothered when people lose. Thanks for your example. I need it.


  1. Amen... couldn't have said it better myself.
    I love your Obama shirt btw :)

  2. This saddens me greatly. When I taught full time, we had a special fund - donations from teachers and our principal - so that ALL students were included in school functions. It was, literally, our own version of "No Child Left Behind". Perhaps there are just too many children and too many teacher furlough days to do this any more. I don't know.
    I couldn't help thinking about "Little Mama" and how much a part of losing is in her and this young boy's life.

    1. Here is the link to the "Little Mama" post:

      I can see how you'd think that, Mom. I see the similarities, too.

  3. Damn! You made me cry again!
    My sister is a highschool teacher. Cuts last year threatened to take away transportation for the highschool students. Sooo.. after the community and teacher's union held rallies and put up a fight, the highschool teachers now have a portion of their paycheck (after taxes) taken out to keep paying for a way to get their students to class.
    So many problems with this whole situation, that I can't even begin. No words of wisdom here just pointing out the epidemic of chronic anemia.

  4. It is great to hear about your patient who is losing weight and cut out smoking cold turkey.
    People need to know that a public school student cannot be denied participating in a field trip that is organized by the school due to solely the lack of payment. The permission slip to attend does need to be returned. The the multi-day, overnight, expensive field trips are few and far between these days, but the ones that are planned to enhance the curriculum are done so knowing that some can pay and some cannot.

  5. I loved this post... maybe not the sadness that is reality, but the fact that you talk about it as a consequence of chronic disease. My dad works in a high school, where he says more and more kids are ending up in DFCS care because the previously low/middle income parents are turning to bad habits to provide for their children. DFCS is beyond out of money, and these rural GA towns have few jobs to begin with. Such a vicious cycle!

  6. Beautiful reflection. Having worked at Grady, and in free clinics, and now on the Rez out west, it speaks so well to the experience and realization that many of our patients really are trying very hard, and that my life has been different largely by an accident of birth and situation.

  7. I recall when I was in 3rd grade my class went to an opera. I haven't a clue how much it cost only that my parents could not afford it and so I could not go. I was left behind with one other child. We were "guests" of another class for the day. I remember being mortified. It had nothing to do with yearning to see an opera at that age but was all about feeling singled out and different. The two of us were treated like royalty in the class we were left with. Within minutes it was all okay. The experience taught me firsthand of what you speak of with this young boy and his family. You know Dr. Manning, I have money earmarked in my trust for some kind of foundation that involves children. I stipulated that if I had not decided what that is before my time comes, my executors would make this decision. Your post, the quiet outrage I have that teachers, nannies and others who are entrusted with our most precious offspring get paid so little for the responsibility they are given, and my own experiences might be just be the fodder I've needed for the birth or furthering of a foundation to aid underprivileged children in these types of situations.

  8. P.S. You are adorably cute in your Obama shirt!

  9. Grady reflects an America that the politicians and the pundits do not want to see. If they had to take a good, hard, long look at what you see every day and what I see every day at the Shelter then they could not continue business as usual. We NEED change. We NEED to invest in our children. We NEED to care for those who cannot, for whatever reason, care for themselves. America should not be a country where children go hungry, where the mentally ill wander the streets, untreated, like animals,where some people must choose between paying for food and rent and paying for their medications. And you stand for that better America in your service to Grady...
    Love, Coach B

  10. I have honestly thought of endowing a field trip fund at Aidan's school just for this purpose. And, like you, I just don't see how "they" can't see it. And how they could honestly believe that if you're "losing", it's your own fault.


"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

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