That's what the elderly lady said to me who'd just stepped onto the crowded Grady elevator to slide in right next to me. Even though the small space was filled with passengers standing shoulder to shoulder, my very pregnant silhouette was pretty hard to miss--even under my white coat. "No, ma'am," I responded cheerfully. "This is number two."
"Boy, ain't it?"
I chuckled at her accurate assessment--one I'd heard constantly throughout my pregnancy. "Yes, ma'am. Boy number two." The elder curled her lips downward and gave her head a smug nod.
The other people riding with us turned in my direction. I could feel everyone surveying the position of my belly to see if they agreed. Another woman looked me up and down and then chimed in. "Oh yeah. That's a boy all day and all night." A few others mumbled in agreement.
And you know? Nothing about this felt intrusive to me. All of it was Grady. So very Grady.
"It's because he's sitting high, right?" I patted the side of my stomach when I said that.
"Yeah. And 'cause your face ain't all splotched up and swoll up neither. Them girls rob your beauty every time." The crowd laughed at the Grady elder's unfiltered honesty even though she didn't mean it to be funny. "But you know you gon' have to turn right back around and try for that girl, don't you? Can't leave it at two boys."
I squinted one eye playfully in her direction. "Look at you already planning the next pregnancy! But no, ma'am. I don't think a girl is in my future. I'm pretty sure we might be done after this little boy joins us."
Her face became surprisingly serious. "Oh, now you need a girl. You got to have one."
"Uhhhh. . ." I let out a nervous laugh. Then I decided to break it up with a joke. "Can't you see I cut all my own hair off so I wouldn't have to comb any heads in the morning? God knew what He was doing. He knew I needed boys."
She still wasn't smiling. "Well. You gon' get old one day. It ain't got nothin' to do with buying baby dolls or combing hair. It's your girls that grow up to be the ones that see about you when you old. Even the boys that love they mama ain't no count when you get up in age and need 'em."
The rest of the passengers seemed to conveniently become silent. Even though I didn't want to do it, I started sifting through my head to see if her statement held any truth. Immediately, I imagined my brother, the one who lives only four houses away from his mother--and before that was only separated from her by two houses. "My brother sees about my mother. That's not always true."
"Yo' brother married?"
I swallowed hard and wished the elevator ride would end. Her sustained gaze over the top of her wire glasses was intimidating. I couldn't think of any witty comeback so just answered her question. "He is."
"And I bet she be the one seeing 'bout your mama. I bet."
Just then I was relieved to hear the elevator ping on my floor and the doors fling open. "Well. I hope that's not true of my boys." I offered a tight-lipped smile and eased my protuberant tummy around the crowd. "Have a good day, everybody!"
That Grady elder touched my arm and looked into my eyes. Her entire hand was splayed over my the shoulder of my white coat in that way church folks do when laying hands. "God bless you and your baby, sugar. Speaking health and wellness over you and a easy delivery. In the name of Jesus!" Others in earshot joined in as an amen choir. Just when I started feel a sweet wave of emotion, she added a sucker punch. "And go on have you that girl after this one, hear? For when you get to be a old woman like me. You gon' be glad you listened to me."
I tried to respond with a polite nonverbal expression of gratitude. Mostly I felt this weird mixture of moved, awkward and lightweight offended. Even though I knew she didn't mean it as anything but endearing.
I always remembered what that Grady elder said on that elevator ride. Just as I'd predicted, we were done after Zachary and didn't attempt to have more children. And honestly, I've never really felt much regret about my two boy/no girl household. From the rough and tumble play to the stinky socks to the never-let-down toilet seats, I've loved it all. Truly I have. And sure. I can totally see what is special and amazing about having daughters--especially considering that I am one. But being a boy mama hasn't felt like a mistake or a regret to me. I guess it's just always felt sort of meant to be.
Something about that statement of boys growing into inattentive men who "don't see about their elders" would occasionally niggle at me. Just occasionally. I'd find myself lying in bed cuddling one of the boys and saying things like, "Are you going to forget your mama when you grow up?" Only to feel my heart nearly explode when hearing the heartfelt elementary school declarations otherwise.
I'd still wonder though. In the back of my head, I would.
As silly as it sounds, subconsciously I've kept score ever since. Looking to find as many exceptions to that rule as possible in the family members accompanying in clinic or waiting at the bedsides of my patients. Eyes peeled back looking for those caring, doting, exemplary sons. And yes. There have been sons for sure. But a lot of times there were sisters and wives, too. In fact, nearly all of the times.
So me, the mom of boys, is always hoping, you know? Hoping this isn't how it is. Or, at least, hoping some wonderful women marry my manchildren by the time Harry and I get as old as that woman in the elevator.
Not even kidding.
But, see, that was before I met Mr. Moreland.
I met him in the emergency department one day when my team was on call. He was sitting in the corner with his feet crossed and resting on the edge of the stretcher like it was some kind of ottoman. He was holding on to a folded piece of the Atlanta Journal Constitution and had reading glasses on top of his head. Mr. Moreland stood up the minute I stepped over the threshold into the room. "Frank Moreland," he said shaking my hand. "I'm Mrs. Eloise Moreland's son."
"Nice to meet you, sir. I'm Dr. Manning and I'll be one of the senior doctors taking care of your mother while she's in the hospital, okay?"
"Yes, ma'am," he replied. The "ma'am" felt funny coming from him given that he was easily ten or fifteen years my senior.
Mrs. Eloise had a high fever and a urinary tract infection. Her nearly ninety year old body wasn't much of a match for it, either. She'd been brought to the emergency department confused and moaning. This was a huge change from how she'd been described at baseline.
"Does your mother live alone?"
"No, she live with me." I felt my heart leap a little and scolded myself internally for getting off focus. "She fully self sufficient, though. Real, real independent. She just prefer to not be alone, you know? So she been in my house for quite some time."
"I see. Who else is in the home?"
"It's just me and her. My wife passed a few years back and my kids all grown. But all our family all around so everybody be over there all the time. She got a lot of people looking in on her and coming to see about her."
"Yeah. I'm one of eight. And everybody still living 'cept my oldest sister who passed in '13. I'm the only boy, though." Again an internal pirouette for team boy-mamas.
"Did they used to call you 'brother?'"
"You know it. Still do." He took off his weathered cap and tucked it under his arm with the newspaper. Rubbing his balding head, he yawned. "All them girls and just one boy. That sho' is something, ain't it?"
It was clear that he was exhausted. But interestingly he didn't seem the least bit bitter or bothered by it. And for that, I liked him immediately. I sure did.
For several days I watched Mr. Moreland come and go. One day he'd have a fluffy fleece blanket and another day would be a hot water bottle to put under her neck. And right along with him were those sisters and grandchildren and some great-grandchildren, too. All surrounding their Big Mama with the love and attention she needed to get better. They brought in balloons and cards and rubbed her feet with salve. And all of it was awesome. It was.
But let me be clear. That manchild of hers? He was the one in charge. And Brother was anything but "no count" as my elevator companion suggested. He was conscientious, devoted and there. And it was all so natural. I loved every second of it.
On the day that Mother was discharged from the hospital, I was sitting at the nurses' station writing a note. Mr. Moreland walked up and made some small talk then clarified a few disposition concerns. Just as he prepared to step away, I spoke his name. "Mr. Moreland?"
He turned around with the discharge folder in his hand and raised his eyebrows. "Ma'am?" He never stopped calling me that.
"Can I ask you something? Or rather tell you and ask you something?" He stepped back over to the counter and positioned himself to let me know I had his full attention. And so. I went ahead and told him what was on my mind. I shared with him what that lady said to me ten years before and how seeing him with his mother had given me hope. Then I asked, "What did your mother do? I need to know her secret." I chuckled when I said it although I was only partially joking.
Mr. Moreland narrowed his eyes and sighed. "Oh now it take a village, that's for sure. But my mama loved hard on all of us. Every last one. And I was just the one in the position to move her in with me, you know? I feel sure my sisters woulda done the same. But I had more room and mama got on well with my wife. I guess I ain't never thought about it as strange."
"That lady said I needed a daughter because boys grow up to be no count when it comes to seeing about their elders."
He laughed out loud at that. "I think folk that's no count when it come to their kinfolk is no count everywhere. You ain't got to wait 'til somebody grow old to see that."
"I say just love 'em. Sacrifice for 'em and show them they matter to you. Like they ain't never no afterthought. When they grow up? It won't even call for no arm twisting. It'll just feel like what they 'posed to do. Like it's in order. You mark my words."
"I hope you're right. Because I'm too old to have a daughter now."
"Daughters can be no count, too."
We both laughed. "I loved watching you love on your mama." I felt my eyes starting to sting a little and rolled them skyward. "Ugh. I'm such a mush ball."
Mr. Moreland grinned wide showing the metal dental work along the sides of his back teeth. His face washed over with warmth. "Something tell me those boys of yours gon' be just fine. Don't you worry."
"I'm a son. And I know what it look like when a mama got love in her eyes."
After that, he tipped his cap, turned around and headed back to his mother's room to retrieve the bouquets of flowers, cards and clusters of mylar balloons. I'm super glad he did, too, because I was on the tippy-tip edge of crying. One or two even slid out.
I hope to grow old with Harry and need only love from my children someday. I want them to have full lives of their own. It is also my wish to forge meaningful adult relationships with them and the people with whom they partner. And now, after listening to and watching Mr. Moreland, I recognize that it isn't so much that I want them to move me in with them or deny others for me. I think it's more that I want them to evolve into the kind of empathic human beings that nurture out of love instead of burdensome obligation. And no. Not just toward aging me. But to people in general.
Something in my heart tells me that they will.
I'm a mother of boys. And you know? I'm cool with that.
Now playing on my mental iPod. . . . .
*Names and details changed to protect anonymity. You know the deal.
He was estranged from his family. No one could fully put their finger on just why that was but all of the notes in the chart underscored that fact. Even though I knew he'd been living in shelters, I wanted to hear it from him. "Where do you live?" I asked. He didn't answer.
Wait. I take that back.
He mumbled something that I couldn't understand. His eyes were at half mast when he spoke but then slowly drifted downward afterward leaving a teeny slit of the muddy whites of his eyes. And that? That was how most conversations with him went. Questions answered in shaky, garbled replies that slipped out of his mouth, rolled onto the floor and under the bed out of grasp.
According to the chart, he'd never been here. Well, unless you count the one fleeting visit he had to the ER triage some seven years back, he hadn't. And that made it just that much more difficult. His medical history gave us no point of reference upon which to reflect. No elaborate note from an earnest intern or dutiful social worker explaining all that had gone awry in his life and some glimmer of a clue about his mind or his world. Nope. There was none of that.
None at all.
And perhaps this wouldn't be such huge deal if he wasn't so sick. Not just sick. But sick-sick in that way that conveys an imminent demise unless some act of God occurs. The kind that calls for family members sitting around tables with long faces and troubled glances while doctors clear their throats and try their hardest to use only empathic body language. But, see, that wasn't happening in his case. Because there was no family to call.
None. As in, not one person who could step in and help navigate all of this awful while at his side. No worried soul wringing their hands or scowling suspiciously in my direction. And especially, there wasn't any person to step in and speak up for him should his mind not allow full decision making capacity.
By the time I came along, that's what was happening. His indiscernible speech sounded nonsensical during most interactions and had been deemed a lack of competence to make his own medical decisions. Which basically left us with tied hands since there was no one. No one at all.
Our social worker data mined and found a phone number for a granddaughter. After speaking to her once or twice, it became clear that she wouldn't be the go-to person. The follow up calls went straight to voice mail.
And so. It went very predictably day after day. Him sick-sick and muttering inaudible replies to our questions and us chasing our tails trying to figure out what to do. The overall prognosis progressively dismal, without any clear evidence of meaningful recovery anywhere in sight. So, really, death with dignity appeared to be the best option. At this point, that could be achieved only through a decision to do nothing heroic. But that? That calls for a shot-caller. A person who not only knows and loves the patient well enough to know their wishes. But especially who's also willing to step in as an advocate to assure the patient the gets the treatment they'd want. Or, in this case, doesn't get the treatment that they wouldn't want. He didn't have that, though.
So what it meant was a full court press. Doing it all even if it was mostly futile.
And wait. Let me be clear. No, I don't fancy myself the angel of death. I do think miracles can happen. That said, since I am a believer of said miracles, I know that they don't follow rhyme nor reason and happen regardless of what we do. Otherwise it's not as much a miracle as it is an intervention, you know?
So yeah, that's my thoughts on that.
Anyways. The point of this is really what happened the last time I saw the patient on rounds. We came in and it was that same thing as always. But at the very, very end of the encounter, something happened. He said something that struck a cord and gave me pause. "I'm all out of tears today." It was still gargly but this time, it was enough for me to understand.
"Wait. What did you say?" And he repeated it. This time it was unmistakeable. I rested my arm on the rail of the bed and spoke again, this time more softly. "This is a lot, I know." And when I said that he nodded, a tear trickling from his eye and rolling under his chin.
I paused to see if he'd say more but he didn't. "Sir? I am going to come back to talk to you some more, okay?" He grumbled an affirmative response.
We stepped out in the hall together. The interns and the med student studied my puzzled face. One finally bit and asked me what was on my mind.
"That last statement," I said. "It was abstract."
"What do you mean?" a student asked.
"I think he gets it. He knows what is going on. Like he's decisional."
One intern squinted an eye. "You think?"
"I do think."
And that was all I said.
We finished up our rounds and I returned to him as promised. This time, I pulled up a chair and sat as close to him as I could so I wouldn't miss a single word. "Hey there."
He looked both surprised and happy that I'd actually returned. He smiled, bony cheeks rising high on his face and lips so dry that they cracked a tiny tear revealing glistening drops of blood when he did.
"I came back to talk to you some more."
A string of sounds came out in response. I asked him to repeat what he'd just said and recognized it to be, "'preciate you for that." And so. I dug down deep to pull out all the patience I could to hold what I hoped could be a meaningful conversation with this man. A discussion that everyone said he was incapable of managing. Trusting my gut, trying to see if this hunch I'd had earlier that he was still in there might be true.
So we talked. Or rather, I asked questions and he mumbled responses. But this time I was listening more carefully and asking for instant replays on the pieces I didn't get. Eventually, he said something that couldn't be confused for anything else:
"M-m-m-my body sick. Y-y-you c-c-can't find nobody 'cause-cause-cause I bes to myself. B-b-but I'on't n-n-need nobody calling my shots. I-I-I can c-c-call'em my own self."
I asked to hear that again just make sure. And he said the exact same thing again. He sure did.
Was he a quirky man? Sure. And had his life taken the rocky terrain of never-stable housing and disconnection from family? Definitely. But that didn't mean he couldn't understand his health problems for himself and have his own say. No, it did not.
The chart had note after note that said he had no capacity to make decisions. Over and over again that's what was written. By important people with lots of knowledge in this area. And honestly, I could see how that happened to some degree. But now I knew otherwise. He was decisional. And yes, reversing all that had been said and determined about him would likely be super difficult and a huge headache.
First, I documented our conversation. Then I started dredging through what I knew would be a painstaking process with a lot of push back. Except something happened. It wasn't hard, actually. I called my psychiatry colleagues and the social workers and the physician who saw him before me and told them what he'd told me. And all of those people were happy, not prideful or resistant. Happy that this man would be able to call his own shots--for his own self.
He was discharged the very next day to the hospice care center that he chose himself. And it was seamless and free of any road blocks. He was smiling on his way out, this time without the cracked lips since somebody had slathered them down with petroleum jelly.
I learned a simple lesson and had another reinforced. The first was that I shouldn't assume things will be difficult. I mean, it's good to be aware and pragmatic, but I'm talking about dreading something to the point of thinking it's not worth the fight. A lot of times, it isn't as impossible as it looks. I think I'll fight harder for patients given that insight recognizing that I am not the only person who wants the patient to win.
And last is one I've always known but can always stand to think about again: Listen and decide for yourself. Clinical inertia is a mighty, mighty thing. You hear things and are told things that are life changing for patients. I was reminded to not let the exhaustion of a busy service of patients make me pull back and not look and listen with my own eyes and ears.
I hope if I'm ever in a situation where I'm up in age and very sick-sick but deep down inside can make my own decisions about my health that someone listens to me. I hope someone somewhere fights for me to call shots for my own self. I really do. And you know what else? If my lips get chapped, I hope they rub a little Vaseline on me, too.
Honestly? I write this blog to share the human aspects of medicine + teaching + work/life balance with others and myself -- and to honor the public hospital and her patients--but never at the expense of patient privacy or dignity.
Thanks for stopping by! :)
"One writes out of one thing only--one's own experience. Everything depends of how relentlessly one forces from this experience the last drop, sweet or bitter, it can possibly give."
~ James Baldwin (1924 - 1987)
"Do it for the story." ~ Antoinette Nguyen, MD, MPH
Details, names, time frames, etc. are always changed to protect anonymity. This may or may not be an amalgamation of true,quasi-true, or completely fictional events. But the lessons? They are always real and never, ever fictional. Got that?