A cup of joe.

Today was my day to drive carpool. That makes my morning crazier than usual and the struggle even real-er than it is at baseline.

Grrr.

I was hustling out the door so fast that I spilled half of my coffee in the driveway. Which, if you know how much I love a good cup of joe in the morning, is a really big deal.

Grrr.

I got stuck behind a train. Right by the kid's house that I was already running late to get. And fortunately, his mama is cool and so is he. But still. That mixed with no coffee wasn't my favorite.

Grrr.

I forgot my gloves. And I have those hands that turn fifty shades of ghastly grey when cold. They hurt, too. So after dropping kids off, I kept doing this thing where I'd stick one hand under my thigh while driving with hopes of the car seat warmer toasting it up. Let me tell you something: That doesn't work so well.

Grrr.

The Grady garage was already filling up. Which was annoying considering it wasn't even 9am. I circled up and up and up until I reached the roof. That is, the 10th floor. Which adds like 7 minutes to your commute home. And that's a lot when you are almost always on two wheels trying to get to a kid during hospital service time. Did I mention that I spilled almost all of my coffee?

Grrrrr.

Like always, I felt a little better when I got to work. But that was short lived because my office door was locked when I got to it. Which, for most people, is no big deal. But for me it is since I don't like my office locked nor do I carry around the key.

Grrrr.

Bump it. I decided to just grab my white coat and roll out across the street to the hospital. Fortunately, Linda, this super nice woman on our admin team had just made a fresh pot of coffee. She waved her hand from her cubicle and told me she could feel that I'd want some. She was right.

Sigh.

I pour a piping hot cup to go. Carefully, I place a top on it to be certain, certain, certain that I wouldn't spill it. My colleague friend waited for me beside the elevator because he was going to round, too. And we chatted about our teams and my icicles (both figurative and literal) started to melt.

Whew.

So we strut out of the office building and the cold hits us in the face like a mad ass pimp. (Yeah, I said it. Because that's what I was thinking.) But even that was fine because I had this really, really hot and really, really fresh cup of coffee that Linda had put love into. She even told me that I could have some of her fancy creamer if I wanted. I added a tiny splash. Which gave me something to look forward to.

Yup.

So we were just walking and talking. Really fast, too because it was, to quote my dad, cold as adunnawhat. So we are hustling quickly with our white coats pulled super tight. Making our way into Grady before freezing in place.

That's when I heard it.

"'Scuse me! Miss Doctor? 'Scuse me!"

I stopped and turned around to face him. It was the voice of what appeared to be a man at least 20 years my senior. This elder appeared to be living out in those elements. Shit. I braced myself for him to ask for cash. And immediately wished I'd placed a granola bar in my pocket.

Grrrr.

"Um, could you tell me where I can get coffee?" he said.

He had his hand wrapped around himself, rubbing his bony shoulders. His coat was not warm enough. Not at all.

"Um. Let me think,"I replied. "We have a coffee shop inside."

"Oh. Okay, thank you, hear?" He didn't walk toward the entrance, though. Instead, he turned the other direction. Maybe it was because he didn't have cash. I'm not sure.

I thought about just walking him into the coffee shop to get him a coffee. But I knew that, one, my team was waiting. Two, the line was going to be long at this time of day. And three, I never give cash money outside of the hospital. Plus I didn't have any money on me anyway.

Sorry, sir. That's what I said in my head before continuing on my way. We resumed talking and walking. I looked back over my shoulder as my brisk footsteps took me further away from him.

Then, I felt something. It was like God Himself grabbed my shoulder and said, "What about your coffee?"

"This one? With the special splash of creamer? Dude. Seriously?"

I stopped in my tracks. Spun on my heel and called out. "Sir!" He turned around. "You want my coffee? It's hot. I just got it."

His eyes widened. That's when it occurred to me that he never intended for me to do THAT. He just hoped I knew of some magic place to hook a brother hard on his luck up with a cup of coffee. Turns out I did.

"Oh yes. I would really, really like that," he said. And I knew when I put it in his hand that I would be going to round and into my day without that yummy special creamer and minus that perfect backup cup of joe.

Did birds start chirping and heavens open up? Nah. But that was okay. Because maybe, just maybe, God showed HImself to me today. And you know what? I saw Him.

Yeah.

***
Happy Wednesday.

Bias is heavy.

There is this thing I had to fight off the moment I laid eyes on you. This feeling, this bias that I wish I didn't have toward you but that I know I do. As soon as I stepped over the threshold into your room, I could feel my heart shadowboxing to try to press it down, hold it back.

Sigh.

They make whole television shows about you. And people tune in as appalled voyeurs, wondering how someone could reach the kind of weight that renders them immobile. Or totally isolated. Or maybe not isolated but still unable to fully participate in the kinds of things that most people can do. Admittedly, I don't watch. But I'd be lying if I said it was because of my tremendous empathy and disapproval of people making your reality into a spectacle. Instead, it just reminds me of those who come before me as my patients who are like you. And how helpless I always feel.

Yes. That.

See, that's my bias. I like feeling like I can do something. And a body mass index that matches my age always makes me feel like my hands are tied. And like there is nothing I can really, truly do. Especially when resources are low on top of it.

Sigh.

So after I saw you, I told my team what I am saying now. That I am struggling with my bias and I want to do better, be better. And that I would try. Like, really try.

"How?" my student asked me.
"I don't know," I said. "But I think first? I'm just gonna be still and think about it."

Which I did.

And so. I came back. And this time, I didn't just go through the motions. I sat down and spent some time talking to you. I told you flat out about how sometimes I struggle with seeing my patients who carry as much weight as you. And then I said sorry in case it sounded mean. You said it was cool.
But then we started talking. About music. About family. About parents saying crazy stuff and what we put them through as kids. We laughed about land lines and how kids now will never know how it feels to have somebody pick up the phone and start dialing while you're trying to ask somebody to go with you. Or pretend you ain't eavesdropping on a three-way call. We cracked up laughing.
Then, after that, you took out your phone and showed me a picture of yourself. Not in the hospital. Standing outside at a cookout. And yes, you were still as heavy as you are now, but your eyes were dancing and you looked alive. You did.

"You still struggling?" you asked me.
I thought for a minute. "You know what? No."
"People don't see me," you said.
"I didn't before. I do now," I replied.
"It's crazy because when you real, real big, people treat you bad and the world seem like they cool with it." You shook your head. "I'm not talking about being husky. I'm talking about when you get like me. Like people let they kids stare or they look at you and frown right to your face. Like 'Uggh.' And don't nobody say nothing."

"Dang." That's what I said.

Because that was all I could think to say. And because I felt my toes squishing under the weight of that truth.

I'm learning that confronting our biases head-on is one of the only ways to overcome them. I'm also constantly reminded that the longer you stay with someone, the more you'll find where you intersect. And the more you'll see them.

Because I saw you, I took better care of you. The plan became more meaningful and, as the leader of the team, allowed me to help my whole team see you, too. Like, for real see you. I also told them what you said and we all promised to do better. Or at least try, man.

Thanks for helping me to be a better doctor. I'm a work in progress for sure. But today--thanks to you--I think I progressed.

Yeah. 

***

Some type of way.

When I saw you on rounds today you were quiet. Your eyes looked in my direction but were otherwise vacant. This was a change.

Me: "You okay?"
You: "I'm okay."

I asked you to sit up in bed and carefully untied the back of your gown. Gently, I searched your back with my stethoscope, listening to see if you were improving.

Me: "Can you take a deep breath?"
You: *deep breath*
Me: "And let it out."
You: *let it out*

We repeating that exchange for a few more beats. The sounds emitted from your lungs confirmed what I'd been told. Things were improving.

I'd attempt to lift the mood.

Me: "You sound so much better!"
You: *head nod and shrug*

No such luck.

You'd been so upbeat the day before. So animated and full of light. Out of breath, yes. But still with eyes that twinkled. And so loquacious that I pulled up a chair to sit down and just let you talk. Today? None of that. Just quiet cooperation and a cloak of melancholy that didn't make sense.

Me: "What's wrong?"
You: "I'm okay."
Me: "Really? You seem sad today. Like you're not okay."
You: *silence*

Another shrug.

I slowed my movements and looked for a chair. Perhaps if you didn't feel like I was too busy to listen, you'd share. Something was wrong. And I didn't like the idea of you holding on to that something all by yourself while laying in a hospital bed. And so. I told you just that.

Me: "I don't like you in here by yourself with something heavy on your soul. If you feel like sharing, I want to hear. If you don't feel up to it, I can respect that."

A tear squeezed out of your eye and rolled under your chin. You sighed.

You: "Somebody came to talk to me about all this. Told me that if I don't do better I'm not gon' be here this time next year."
Me: *listening*
You: "Saying 'You need to lose weight and take your medicines! And stop missing appointments! And why you don't exercise and why you keep eating the wrong stuff and smoking cigarettes? You keep this up and you gon' die!' That's what they said to me."
Me: "Hmm."
You: "They kept on saying it was 'tough love.' Like every few words it was 'tough love' this and 'tough love' that. But to me? It wasn't no love in it."

Another tear slipped over your nose and disappeared into your nostril.

You: "I wanted to say, 'Do you know my life? Do you live where I live? Like, do you even know? I want to be healthy, too!' But all I did was just wait for it to be over. I just said, 'Okay' and acted like it was cool." *shaking your head*
Me: "Man. I'm sorry."
You: "That hurt my feelings, Miss Manning. For real. I know that doctor meant well but I felt some type of way about that."
Me: *silence*
You: "Like, I think when a doctor speak to you they should look you in your eye and see where you at. And if your face say this ain't okay? They need to do something else. Or just stop talking."
Me: "That's good advice for anyone."
You: "Know what? You right."

After that, we talked more about what makes it hard for you to get your medicines and make appointments and eat healthier and move your body and move toward being a non-smoker. You told me about where you live and who you live with and what it's like and how you get the things you need and what makes your nerves bad. Then we talked about a few strategies to help you make steps in the right direction. And the whole time I watched your face to see where you were.

Or if I needed to just stop talking.

The doctor who gave you what was believed to be "tough love" is a good one who, I have to believe, was looking to motivate you not be unkind to you. And I told you that, too. That we are all works in progress with blind spots and ball drops. All of us.

This seemed to resonate with you.

We didn't fix all your problems. But you were smiling when I left. Which, to me, was a start.

Yeah.

***
Happy Sunday.

The Gospel.

I was told one thing. That your aortic heart valve was narrow and tight and that, just maybe, one day very soon you would need that valve replaced.

Aortic stenosis. That's what I was told. With clear certainty and not so much as an eye twitch or a blink. From his lips to my ears like it was the gospel. Aortic stenosis.

I entered the room alone. Armed with the gospel that I had been told about you. Aortic stenosis. I spoke to you for a few moments and talked about what was going on. "What is your understanding of what is happening with your heart valve?"

"The blood rush over it in a way that's not normal. They heart valves don't open and close like they s'posed to."

I nodded because, for the most part, that was true. It was. And I went into a description of what it all meant. Your tight and narrow heart valve. I said the words over and over again. "Aortic stenosis" this. "Aortic stenosis" that. You looked a little bit confused but when I asked if you understood you said, "I think so."

I think so.

Next I pulled my stethoscope from my pocket. Slipping the rubber tips into my ears, I looked at you and smiled. You smiled back. Then I gave the diaphragm a vigorous rub with my palm remembering that a Grady elder had told me once: "Even though it don't do much to warm it up, something 'bout seeing you try make me feel good."

So I did that. And I do that. Most times, I do.

I close my eyes and place the instrument on your chest. I follow the map of listening areas taught to me as a medical student and quietly listen for the tell tale sounds of aortic stenosis:

First a soft sssssssshhhh. Then it grows louder to a SSSSSHHHHH. Falling down quickly to the that soft hush again.

I know it when I hear it now. And so, instead of fighting to discern what it is, I am armed with experience. You patiently allow me to confirm what we both already know. My breathing slows. My hand glides with the stethoscope over your skin.

You are so cooperative and kind, I wish I wasn't alone and that a student could be beside me. To hear and learn right next to me. Aortic stenosis.

My eyes open.

Wait huh?

I am hearing sounds, yes. But they are NOT the ones I expect. I squint my eyes and listen harder (as if this changes what the ears hear.) "Can you hold your breath?" I ask. And you do.

Same thing.

A soft whoosh followed by what sounded like a deep sigh between heart sounds. Again and again I listen. And again and again, I hear the same thing.

Shit.

"They told you your heart valve was small? Like tight and stiff?"

"They told me something. I don't know if it sounded like that."

"What about a leaky valve? Did somebody say that?"

"I don't know, Miss Manning. Y'all be saying so much sometimes."

And you're right. We do.

You don't have aortic stenosis. And while you do have an issue with your aortic valve, it isn't that. And though I am not a cardiologist, I can say that right now it doesn't look like you need surgery either.

You were gracious when I told you I was wrong. You shrugged and laughed a little. Like none of it was a big deal.

While my face burned hot like coals.

This happened a while ago. But what it taught me was that, like all gospels, I need to listen for myself, examine for myself and interpret for myself. Because even though a lot of times there is no discrepancy. . .sometimes there is. When telling someone life impacting information, it's good to have at least checked for yourself before talking.

Whew. Preach, pastor.

I also learned that there is a lot we say that gets missed. Yeah, so I work at doing a better job in that area, too. Explaining until you know so. Not just think so.

Yeah.

Last I checked, you hadn't had your aortic valve replaced. You were still doing well and seeing the cardiologists regularly. Today I am hoping and praying that you know exactly why. This is what I am hoping. And that the gospel you hear is the gospel indeed.

Yeah.
***

Without question.

I was taking care of this grown man who was sick. His mama was at the bedside and she was worried about her manchild. Which makes sense because she's his mama.

Now.

This patient of mine has his own life, his own house, his own kids, and his own concerns about his health. And when I first rounded on him that first day, I was explaining everything that was happening to his body while his mama sat at on a chair holding her pocket book and nodding deferentially. She asked one or two super generic questions, but only if I paused and asked. There was a lot going on with him and I knew it was a big thing to get their heads around. His mom looked kind of like a deer in headlights.

"You sure you don't have any questions?" I asked them both. Even though I was mostly aiming my thoughts at the mother.

The patient answered, not his mom. "Um, no. I think you've explained it all to me."

"What about you, ma'am?"

She simply smiled, lifted one hand and said she was fine. And all of it was pleasant and good. Albeit a little bit unsettling.

Yeah.

So after that first day, for whatever reason, I always seemed to round on him when no visitors were there. I'd come in and he'd say, "Dang. You just missed my mom!" That would make me feel like his mom had more questions for me. And I would reassure him that he could have the nurses page me when his mother was there if she wanted to talk to me. He said he would and that was that.

No one ever called.

The last hospital day came. I walked into his room early that afternoon and prepared to examine him. He was the last person I was planning to see before heading over to the medical school across town for a small group teaching session.

"What you know good, sir?" I asked. After three or four days in the hospital, we'd moved to more informal greetings.

"Nothing, Miss Manning! I'm just waiting on you to give me the verdict."

"Okay. How are you feeling?"

"As well as I think I'm gon' feel 'fore I leave here. I'm ready to get up out of here."

"Okay. Well it looks like we're in a place where it's safe to discharge you." He pumped his fist when I said that. "Sounds like we're on the same page."

"Good stuff."

I asked if he had any questions and he said he had none. I reached out to shake his hand and my eyes wandered over to the window sill. What appeared to be a pair of multicolored reading glasses were resting there next to a McDonald's coffee cup. There was lipstick on the edge of the cup, too.

"Did I miss your mama again?"

"Man. She just can't win for losin'. She went to go feed the meter and I said, 'Watch Dr. Manning come in soon as you go.'"

"Aww man."

"She all worried 'bout me and stuff."

"I hear you. Being a mama is hard like that." That made him chuckle when I said that.

We made a little more small talk and I headed out. I picked my tote bag up from where the clerk was hiding it for me in the nurses station and scuttled up the hall toward the elevators. I looked at my watch and I was making excellent time for my commute over to main campus.

Yup.

I stepped onto the lift and took a deep breath as it stopped on what seems to be every single floor. After what felt like a million years, I finally make it out of the hospital. Checking the time once more, I smile since I know I'll make it with time to spare.

But then something happened.

I saw this man paying to meter for his car. And he looked relieved as he was doing it since the city of Atlanta will ticket you in less than one second if your meter dies. For some reason, I just sort of froze for a moment, watching him stick the "PAID" coupon on his dashboard. And, of course, imagining my patient's loved one doing the same.

Aaagggh.

I squeezed my eyes shut and gave and exaggerated sigh. My head swung to the right and stared up at the hospital. And then I made up my mind.

Five flights of stairs and five minutes later, I was back at my patient's room, panting and out of breath. Just as anticipated, as soon as I came trotting in I saw his mother settling back down into the chair--reading glasses in one hand and coffee cup in the other. And when she saw me huffing and puffing in that doorway, her eyes widened and a big smile erupted over her face.

You know? I'm not sure why but something made me feel intensely like I needed to go back to see her. Which, in a way, is pretty ridiculous, you know? I mean this patient was grown, man. And sure, he'd been handed a pretty heavy diagnosis, but still. This was not child.

But. He was her child. And, it appears, she was a big piece of his support team--a team he was definitely going to need.

And so. I came on in, pulled up another chair and sat down. I leaned on my elbows and tried not to look like I was in a hurry.

"Oh! I thought I'd missed you, Dr. Manning!"

"You know? I was leaving out and decided to come back. Just in case you wanted to talk."

And you know what? She did want to talk. Talk about her son and his prognosis and how she could be of support. Of how she felt scared and how even when they are all grown up, they're still our babies. She wanted to know if I had kids and if they were boys or girls. And really, she just wanted to talk long enough to feel just a little less anxious about what her boy was up against. Not really questions. But there was more to discuss. There was.

Yeah.

So here's what I learned: I learned that sometimes people don't have questions. But that doesn't mean they don't want to talk. In that quick little instant, I shifted a piece of my practice based on a subtle new realization.

Yes.

 I will still finish my discussions with "What questions do you have for me?"  I sure will. But from now on, I'm going to start following up with one more question--"Is there anything else related to you hospitalization that you'd like to talk to me about?"

Yes. That.

And you know what? I've only been doing this for a couple of weeks now. But it's astounded me how many people bite on that second request. Questions? No. More you want to talk about? Yes.

Ah hah.

And no. The whole "listening to that hunch that you need to go back" lesson wasn't the take away for me. Although it is a very important thing to recognize when it happens and one that I've learned previously the hard way.

Anyways.

By the time we finished, there was only ten minutes remaining before my teaching session was to start. I texted my second year student small group and asked them for a last minute modification in our meeting plans. I apologized profusely and felt appreciative for their understanding. We ended up meeting outdoors on the patio of a local restaurant closer in than campus--which was easier for me coming from Grady. They were gracious and easygoing and that lightened my load.

Tremendously.

When we finished, I said I'd stick around in case anyone had questions.

Or things they wanted to talk to me about.

You know what? No one had questions. But two people did have something they wanted to talk about. Important stuff, too.

Imagine that.

I'm so glad that I'm still learning, man. Still listening and learning and growing and trying.

Yeah.

***
Happy Saturday.

Being bothered.

There is this lady. This lady that I see every day at a point in my day. Pretty much at the same time. Like, if I walk the direction I need to walk to get where I need to get, I will see her. See her in the path of where I am going. That is, if I take the way that is fastest to get where I need to go. Which is mostly what I do.

Yep.

So every day, there she is. Doing what she does while I go where I go. But then, whenever I get closer she eases in my direction. Comes nearby and says a cheerful hello, like always. Includes some open ended questions that call for me to open it into a conversation. And then, if I don't run any form of interference, she will pause to chat. A little bit about this. A little bit about that. And a little bit about the other, too.

Yeah.

All of it takes no more than 2 minutes, really. And sometimes less than that if all she wants his a hello and a hug. She is a hugger. One who puts her whole body into those hugs, too. Both arms, torso to torso, and pressing into you. Complete with the "mmmmm-mmmm!" sound effects. Yes, she does that.

She does.

But. There are some days. Like, some days where I feel like I'm super busy and feeling harried. Or where I'm late.  Like, where I really just want to get to where I am trying to get without stopping to chit or chat or hey or hug. Even for a moment. Telling myself that I am just "focused" today and want to just stay on my task. Whatever that task may be.

And so. On those days, my walk is more brisk. My body language is fast and deliberately standoffish. I typed and deleted that last sentence twice. That word "standoffish" made me cringe. Especially when connected to me. I had to add it back because it is true of what happens. That is what I do. Like,  on those days, I do this thing to demonstrate that I don't want to be interrupted. Not even for a hug.

Nope.

So on those days, she will call to me in her singsongy voice as I whisk past going wherever I need to go. She simply calls out a "hello" that floats out into the vacuous hallway then swirls down to the ground like some kind of lonely feather. My salutation in return shoots out and hits it like a fast ball. Quick, pressured. Making it clear that it would be this one pitch. And that's it.

Yeah.

Doing that always feels bad. I mean, because it's not nice really. I'm old enough to know that. So on a lot of days, I just take this really circuitous route to the place I need to go that doesn't take me past the place where I would pass her. But fickle fate somehow always reroutes her path to overlie my own at some point. It does. So then, I'm back to where I was. Either cooling my jets or deciding to turn them on high.

Sigh.

I am not proud of this. I'm writing about this because I am just thinking this morning. I'm thinking about those two minutes (or less) that I so stingily clasp in my hand. My decision to withhold some piece of me, albeit a fleeting piece, because I just sort of don't feel like being bothered. And you know? I am really not sure why I don't want to be bothered by this very sweet individual on some days.

There is this melancholia about her. Like this piece of her that I can tell needs a human interaction as much as she can get it. And I think it's even worse that I am not always forthcoming with it since I know that. Like some sort of middle school mean girl who has decided not to be your friend. On certain days.

Maybe the sadness in her eyes overwhelms me. Makes me feel like what I give needs to be all or none. And like the all isn't necessarily my job since I work a job where I have to give that kind of all all the time.

I don't know.

I know about pieces of her world. Even though I don't have a lot of contact with her, there is the stuff she has told me. And, no, I don't know what her full world is like away from the place where I pass her each day. But what I am processing this morning is this realization that I am a tiny sliver of her world.

I am.

There's probably some complicated piece of my psyche that this underscores. And I don't know what that is since I'm not a psychiatrist. But what I do know is that I love people. And I want to be a good person.

So today, I've made up my mind. To be bothered. And interrupted. By her.

And before you say that, from what you read on this here blog, I seem very good about being bothered, I will say that on some accounts I am. Like, I am very, very good about say, a stranger, in the Grady hallway hitting my pause button because they are lost. Or that wayward medical student who wants to pick my brain. But this? This is different. This interruption is like that movie Groundhog Day. I know what's going to happen. Yet I find myself using some energy to redefine the outcome and order of events.

I'm not really even sure why.

Withholding kindness isn't cool. Even if on other days you give an extra heaping helping of it, it's not.  And so. I am going to work on that. With her. With me. Because two minutes is nothing. Except for when it's something.

Yeah.

***
Happy Sunday

Hearsay.

*details changed to protect anonymity.

"Believe half of what you see and none of what you hear." 

~ Anonymous

A few years back, I was in clinic and went into a room to listen to a patient's heart sounds. A resident physician working with me that day had already seen the patient first. Before I entered the room, he'd described everything about the past medical history including a "easily audible" heart murmur. Even though it was pretty straight forward, I still wanted to listen. And so I did.

"It is an early peaking, systolic murmur," he said as we walked up the hall, "radiating to the carotids. But super loud." That description was suggestive of a narrow aortic valve. I figured that a murmur this loud had been assessed with imaging in the past.

"Did she get an echocardiogram?" I asked. The two dimensional ultrasound of the heart, or echocardiogram, visualizes the blood flow and the heart valves. Though the physical findings lead us to where we are going in heart disease, actual images tear the roof off of the sucker to confirm things. The clinic was busy. And this was an upper level resident. So I cut to the chase. I wanted the echo results.

"She did," he replied. "I need to double check the final read but I'm pretty sure it confirmed aortic stenosis."

"Do you know how severe?"

"No. I'll have to look again when we go back into the room. But I know she doesn't have any symptoms which is good."

"Yeah."

So he went on to tell me a few other things about her before we reached the room. After a quick knock, we entered the clinic room together. Nothing about it was unusual.

"Hi there, ma'am. My name is Dr. Manning and I'm one of the senior doctors in the clinic working with your doctor. We always put our heads together about your health and figure two brains is better than one." She smiled and I smiled back. After a quick review of her concerns and the plan of care, I reached into my pocket to pull out my stethoscope. "Mind if I listen to your heart?"

"Not at all," the patient replied. "Guess four ears is better than two, huh?"

I chuckled and nodded while placing the rubber tips of the stethoscope into my ears. And honestly? I wasn't even thinking too hard when I did that. I reached over to her chest and searched the classic listening areas--aortic, pulmonic, tricuspid and mitral--with the cold diaphragm.

Sure did.

The whole "not thinking too hard" thing wasn't because she didn't matter. It was just that I'd heard the story and exam already including the echo results. This was mostly a formality, honestly. I even made  comment about the pretty necklace she was wearing as I slid it out of the way to reach her chest. The patient began sharing that she'd splurged on it during on a vacation once and how she hasn't removed it since. I raised my eyebrows and nodded, then lifted one finger to let her know we'd need to hit the pause button for a few moments.

You know. So I could hear the murmur that already had a diagnosis.

And so. I lean in and quickly listen. And just like that, I recognize that what I was hearing isn't at all what had been described to me. I raised my eyebrows. "What did you say this murmur was from?"

"Aortic stenosis."

I squinted my eye and listened again. "Hmmm. This murmur sounds diastolic to me. Hmmm."

"She definitely has aortic stenosis. I heard a crescendo-decrescendo murmur. And it was during systole."

"Okay." I carefully listened again. I then felt the patient's pulse and listened some more while timing it out with the rhythm of the heart. And still what I heard sounded like the flow of turbulent blood during the relaxation phase of the heart cycle. I listened some more. And then once more. "Aortic stenosis, huh? Okay. I guess my hearing is off today." And that was that.

I conceded since I knew that the imaging supported his assessment. But honestly? That murmur sounded nothing like what he was saying to me. The whole thing made me uncomfortable, especially feeling so off on something like this--a bread and butter physical finding.

"Yup. Stenosis. But let me just confirm how severe, okay?" He pecked into the computer and clicked a few screens. And while he did, the patient asked a few questions.

"Is my heart okay?"

"Have you been told about your heart murmur?"

"Yes'm."

"We're just talking about your heart murmur. That's just the flow of blood rushing over your heart valves. Have you been lightheaded or dizzy?"

"Naw. Never that."

"Okay. We're just checking to see how narrow your heart valve is but it sounds like this is an old issue, okay?"

"Oh alright then."

She asked a few questions about aortic stenosis and what that meant while he moved through screens to confirm for me the final reading on the echocardiogram images. Since I was less occupied, I pitched in and explained. Even though my ears were telling me of a different diagnosis.

Yeah.

So as we discussed all of that, suddenly I notice a funny look on the resident's face. "Oh must've misread that," he mumbled to himself. "Um, Dr. M? It's actually moderate to severe aortic regurgitation."

He said that right after I'd finished my soliloquy on aortic STENOSIS and right after I'd finally talked myself out of what I knew to be true based upon what I'd heard with my own ears.

Shit.

And no. It didn't turn into a big thing with the patient at all. I apologized and told her that I'd misspoken and that her heart murmur was more of the kind you get form a leaky heart valve instead of a narrow one. My face felt like it was a million degrees. She laughed and said, "I was wondering. I been told before my valve was leaky. I ain't never heard of it being stiff and narrow before so that was news to me."

Sigh.

So here's my point of telling you all of this:

The things that happen to me at Grady are simply metaphors for life. Trust your gut and what you know. Listen with your own ears and then listen again. Believe your ears, especially when they've heard a lot of things. Same goes for your eyes. But especially believe yourself even when odds stack against what you think. That is, when you feel sure.

I doubted myself. And honestly? It wasn't even a soft call. I felt embarrassed for my initial instinct to doubt the echo report when I shouldn't have. I shouldn't have at all. Plus, I hadn't seen that echo result with my own eyes. That's a lesson, too.

And no. I am not always sure. But this time I was. And I'm still mad at myself for not laying down my nickel and betting on me. I recognize it's okay to be wrong. But I think my "ah hah" moment is in that I need to be just as okay with being right.

Does this even make sense?

As for my resident, I gave him some feedback. I'm pretty sure he, too, convinced himself of what he heard based on what he thought the images showed or could have just been so junior that he misjudged what he heard altogether.  So yeah, I gave him feedback right away. But as I did, I showed my own clay feet and revealed what I'd done wrong as well. I'm senior to him yet I needed him to understand that even after 20 years of being a doctor, we are still works in progress. I let him know that being scared of looking silly isn't a good reason to not push when you feel pretty sure. And mostly, I was sure, even though I was being told otherwise. I was just two seconds away from saying, "Well, I don't know what that echo is saying, but this murmur isn't consistent with aortic stenosis at all." But I didn't. After all, the echo said it was aortic stenosis.

That is, until it didn't.

Yeah.

***
Happy Tuesday.

It don't stop.

"Hey Dr. M! You've been sitting in the same place for a while now. What are you doing?"

"Reading," I replied.

"Reading what?"

"Reading up," I said.

"Reading up on what?"

"On my patients." I didn't even look away from the computer screen when I said that.

"Like a paper or doing a literature search or what?"

"No. Just background stuff. And literature searches. And more. I don't know what's wrong with a lot of my patients. So I'm reading."

"Wait, what?"

"You heard me."

"You don't know what's wrong?"

"Nope. I like, don't. So I'm reading. So I can."

"But you're an attending. You're supposed to know what's wrong with everyone!"

*silence*

"Dr. Manning? Dr. Manning!"

"SSSSHHHHHH!!!!  Can't you see I'm reading!"

"Oh, okay. Sorry."


Hey students and residents! Newsflash: We DON'T know everything. And guess what? When we get home we grab some dinner, wash the dishes and then read up, too. Just like you. The only difference is that the exam is somebody's mama, somebody's daddy or somebody's child.

Higher stakes, yo.

Alright. Let me get back to reading, okay? I have a test tomorrow.

***
Happy Humpday.

What I signed up for.

"I'm glad you came back."

"You are?"

"Yeah, I am. 'Cause when you was here earlier, I felt kind of like you was rushing me. Like you needed to hurry on up."

"You did? Oh shoot. I'm so sorry. Ugggh. I'm sorry, ma'am."

"It's okay, Dr. Manning." 

"No, it's not." 

"You know what? You right. It's not really okay. It's not. 'Cause, for me, I'm the only patient you got. I mean, when it's my turn."

I looked into my patient's eyes when she said that to let her know I was hearing her. Then she smiled and spoke again.

"But I do accept your apology, Dr. Manning. And I'm glad you came back, okay?"

You know what? I'm glad I did, too.

***
Happy Friday.

Feet of clay.

"I'm just saying, you could do better."

~ Drake

I was a few steps behind her as she climbed up the three or four stairs leading into Grady Hospital. In her hand I saw that she was carrying one of those venti sized coffee milkshake drinks complete with whipped cream and what looked like chocolate syrup on top. She wrapped her lips around the unusually large-diametered straw and slurped hard. My pace was faster than hers. It didn't take very long for me to catch up with her.

"G'morning," I said in what was likely the most mundane way ever. She pulled the straw from her mouth, nodded at me and returned the gesture.

By my estimation, she was definitely younger than me. That said, her face lacked the mischief or innocence of youth so I'd say that she was definitely "grown" and maybe even somebody's mother. Her skin was of a deep pecan color with eyes peeking from above her ample cheeks like two tiny slits. The sides of her face looked to be almost painted with this darker brown hyper pigmentation and, in that moment, the doctor in me sifted through my brain for the mechanism behind when such a thing happens when people carry lots of extra weight.

Hmmm. Acanthosis nigricans, maybe? Or even kind of like melasma or "the mask of pregnancy," I thought to myself. Except this she didn't appear to be pregnant at all. Just obese.

Very, very obese, to be clear.

example of facial acanthosis, from this source (not the person)

Even without trying I could hear her laborious breaths as I walked along side her. She was mouth breathing, yet balancing it with savoring deep swallows of what was surely a beverage well over her daily allowance of calories. Without even stopping myself, I made an unfair inventory of what I imagined to be her morning diet--some unrestricted three thousand calories, most likely. She pulled back on the straw once more, her cheeks hollowing at the sides followed by more panting.

Ugggh.

Confession: I could already feel my insides cringing, my nose metaphorically wrinkling with disdain. With each slurp, I noticed more things about her. The ill-fitting stretch pants that did little to hide the amorphous lumps that made up her buttocks and thighs, the wide feet folding over her distressed flip flops, the rippled upper arms that easily exceeded the size of my thighs--or likely even both of them.

Now she knows that she doesn't need to be drinking that. Words I mostly thought, but that I probably would have uttered to Harry under my breath had he been beside me at the time.

Just then, I caught a glimpse of the crumpled McDonald's bag in her other hand and immediately formed more unsolicited opinions about that choice as well. Judging. Disapproving. And almost--dare I say it? Disgusted to some degree. And you know? I'd be lying if I said that wasn't  true of what went on in my head. I'm also ashamed to say that such thoughts have probably entered my mind countless times before. Even though they were fleeting--seconds at most--they were there. They were.

Yeah.

It was in the morning at Grady Hospital so there were many other passersby with me. They cast their glances in her direction as she shuffled up through the lobby. I could tell that many of them had those same thoughts yet the vast majority did little if anything to mask them. And so I let myself see what was happening--around me, in me--as it related to this innocent woman. The more I watched, the more I could see them; adjectives swirling all around her, pasting themselves to her swarthy cheekbones, her gelatinous arms, her abundant abdominal folds.

Fat. Lazy. Shiftless. Disgusting. Morbid. Invisible.

Her eyes kept shifting downward and away from those she encountered. It was automatic, a part of a shield of armor that immediately formed around her in such situations. The more I watched the more I saw. Person after person grimacing their faces or even shaking their heads--right out in the open where she could see, feel, and be stung by it all.

Yes.

Of course, many of those who tsk-tsked her could stand to shed a few of their own pounds. But now she was in a different realm. She had the kind of body habitus that had crossed over into the kind that drew stares and widened eyes from little children who don't know any better and adults who should. The kind that made single seats on commercial airplanes out of the question and even seatbelt restraints in a car a gamble. So yes, she'd moved into that public spectacle kind of obesity, making her a target for all of the stares, yes. But none of the pity.

Wow.

Just that morning, I'd turned the radio station away from NPR because I was just too tired of hearing about all of these unfortunate examples of discrimination against black people making the headlines. Black boys gunned down in Missouri, the President of the free world who gets openly dissed day after day, and yet another NBA franchise owner spitting out venomous words about the fans who look like me or even having those same ideas discovered via email. Ugggh. Too much. Next my mind wandered to the op-ed pieces I've read on these same subjects, my eyes scrolling down to those nasty, racial slurs in the comment section from those internet trolls, all crouching tigers and hidden dragons in their anonymous virtual worlds.

But this? This, that I was not only seeing but even participating in, was as messed up and discriminatory as anything. And worse--none of it was even hidden from sight. Blatant, open, egregious prejudices not because of race or sexual orientation or identity. . . . but because of something universally affecting someone in every one of every group you can think of: weight.

Yep. And here I was, no less guilty than the rest of making her a pariah. Yes. That. A pariah.

Terrible.

Movies have won awards for complex tales of interracial loves fighting for familial acceptance. And, it seems, that the world has gotten or at least is getting the memo that it isn't cool to just outwardly let the world know that NO your child can't marry some black person or HELL NO you aren't interested in meeting the man your boy has fallen in love with and now calls his "soul mate." I mean, not publicly it isn't. Your job is to bury it under concerns like "cultural difficulties" or "religious beliefs" -- because everybody knows that you can't just come right on out and say, "I just don't approve because I think black people are gross and have tails" or "I'm glad to watch them, the gays, on TV but beyond that I want them no where near me and my family" And sure, okay, people still do it but when they do, the backlash is swift and mighty. Those are the ones that lead to "closed comments" on the NYTimes from all of the folks marching on Washington in those free-text boxes.

Yes.

Yet somehow with obesity it's different. Socially acceptable to shudder where others can see you or text some hurtful observation to a friend. No one is super pissed, or rather, as pissed off as they would be about such open discrimination in any other group. And even worse, with obesity, the good guys are often in cahoots with the bad guys making it all exponentially worse.

So here's what I am trying to work through: I'm trying to rage against my own machine--the imperfect human being with not nice thoughts. I am thinking of the hurt I have felt when watching the news or listening to news radio about my own people being mistreated and how important it is for me to push myself to see my own shortcomings toward others. My hope is that it will give me more empathy toward those who think negatively of me just from looking in my direction.

Whew. I just sort of need to unpack on this today. This idea that Michael Jackson had about starting with the man--or rather woman--in the mirror.

Oh. And let me be clear: I get it. Obese people were not brought here against their will on slave ships, oppressed for hundreds of years and horrifically disadvantaged historically. But I guess my point is that I don't think there needs to be a pissing contest to see who has been treated the worst. Instead, as we all fight for equality for the groups closest to our hearts, families and identities, that can't ever happen if we aren't willing to self reflect on what we are doing, feeling and thinking about the ones that aren't.

Does that even make sense?

Here's the truth:

I didn't even know that woman. I don't know her life story, her trials, her upbringing, her resources, her support, or any such thing about her. I don't. And while I think it is perfectly okay for me to want a healthier life for her (and myself, too) I know it's not okay for me to make up my mind that all of this represents laziness and self-loathing. I know as well as anyone that obesity isn't that simple and can't just be chalked up to being unmotivated. And you know? Even if it were, is it kind of me to focus just on that part without considering all of the things that may have led to that point? Hell no it isn't.

In my opinion, society graduates discrimination, you know? Like . . . for example. . . . .the most obese people have it the worst but even still those who are still heavy but haven't quite reached a pariah-status body mass index still have it tough. Surely the most effeminate gay man or the most masculine lesbian woman or the transgender individual has a harder row to hoe than the queer-ish person with a  phenotypically vanilla identity. And last, I am keenly aware that the darkest of my brothers and sisters with the most afrocentric features, particularly when combined with the most limitations on socioeconomic status, struggle more than perhaps I do with my smattering of freckles and more delicate facial features. It's just the truth. But even still, the discrimination is there and it hurts that it is.

Try compounding a few of these things together--particularly with obesity or even some mental or physical disability. Very, very obese and black. BMI over 40 and transgender. Or all of these things plus a cerebral palsy or a cognitive disability? Better yet, don't. It will only depress you.

I guess a big part of me always embracing members of, for example,  the LGBTQ community has been about this shared understanding of how it feels to be prejudged and mistreated as a group and how vital it is to us all to just be seen, man. But I wonder sometimes if part of it is just because it is socially acceptable for me to do so? I mean, I hope not. Either way, today I am working to expand my views to include more than just what is "sexy."

You know what? I'm a work in progress, man. And I'm going to work as hard as I can to "see" even more people than I ever have before. . . .but to especially keep self reflecting enough to see--and deal with--my own feet of clay in the process.

Yeah.

³¹ “Your Majesty looked, and there before you stood a large statue—an enormous, dazzling statue, awesome in appearance. ³² The head of the statue was made of pure gold, its chest and arms of silver, its belly and thighs of bronze, ³³ its legs of iron, its feet partly of iron and partly of baked clay. ³⁴ While you were watching, a rock was cut out, but not by human hands. It struck the statue on its feet of iron and clay and smashed them."

- Daniel 2:31-34 

***
Happy Wednesday. And I'm just saying, we can do better. Me included.

 Oh, and if you haven't seen this? Watch it and be intrigued. It's complicated, man.

                                                                    

Worry-wonder.

image credit

There are some patients that we discharge from the hospital and it feels so right. Like, there is a family member at the bedside who has appeared with a fresh set of clothes, a coat and a fleece hat for their loved one. The balloons and cards that they and the rest of the doting family had sent fill their arms as the nurse helps the patient into a wheelchair. Out they go. Mylar balloons floating behind them like some kind of flag signaling to all that this part is over. The patient is well enough to go home. And that there is a home to go to.

And when that happens? I don't worry so much. I can't say I don't worry at all but perhaps "worry" isn't the best word. "Wonder" might be good because I do find myself wondering about how they're doing and if they're okay. I open the electronic chart and "chart stalk" to make sure appointments have been kept and medications have been picked up. And the ones who have that kind of support usually quickly allay my concerns with just one glance at the record.

I wish they all had that kind of support.

There was the sweetest man that I cared for a few months ago. His stunning eyes were like two symmetric pieces of amber; I always gasped a little when he looked at me. His skin was a warm chocolate hue and his strong teeth seemed divinely protected from the harsh life he lived. And it was a harsh life. A combination of substance abuse and mental illness had likely peeled him away from his family and, at this point, rendered him without any stable housing.

"How are you today?" I asked him on the last day.

"Me? I am good. Good doctor."  Then he smiled and widened his eyes. I gasped.

"Things look a lot better. I mean, with your health. So we can let you go home today." I winced when I said that part. I cleared my throat and made the correction. "We will be able to discharge you from the hospital."

"That is okay with me."

His voice was staccato. His native tongue wasn't English but he'd been here long enough to have full mastery of it. Admittedly, that part perplexed me the most. It was unusual to see an immigrant person without the balloon-toting brigade. When I saw his name and then met him for the first time I assumed that regardless of how debilitating his mental illness and addiction was, they'd be filling the room sooner than later. Speaking in hushed voices in languages that I don't understand but that would provide me, the doctor, great comfort at the time of discharge.

But they never came for him.

"Where is your family?" It was a simple enough question. I wanted to know. Because this was unusual. It was. And nothing against American families at all. It's just an observation that people who aren't born-and-bred mainland Americans seem to have some kind of family support regardless of the gravity of the issue or amount of their financial resources.

"My family? No family."  And he smiled after he said that. This smile that was either knowing and telling or just completely inappropriate due to the depth of his mental illness. I wasn't sure.

"None? At all? I mean, are they here but you just don't talk to them? Do they want to talk to you?"

"No family."

"Is there something about that question that you want to talk about? Like about your family?"

He shook his head, still smiling.

"Are you hearing voices today?"

"I always hear the voices."

"Are they saying bad things to you?"

"No."

I looked at the notes I had written on him. According to social worker, we had arranged for him to go to a nearby shelter after he'd declined a personal care home. I twisted my mouth and sighed. I knew I'd add him to the queue of those that I worry-wonder about and not just wonder about.

"Why don't you want to go to the personal care home?"

He shrugged. "I just can go to the shelter, no problem. No problem I can go to the shelter."

And what could I say to that? I was the fourth member of the team who'd asked him that same question and, like them, was met with the same answer.

And so. We discharged him. Out of the hospital with a seven day supply of his medications and out to a nearby shelter. A ride was provided to be sure he'd make it there and that was that.

Of course, I chart stalked him. When he didn't get his medications, I tried the number he provided and it didn't work. A medical student on my team even called the shelter but he'd since left. So I just kept watching to see what was happening electronically. And surprisingly, there wasn't much activity in the chart.

That was a few months ago. After doing six ward stints in the past six months, my worry-wonder list has grown long. It gets reorganized by acuity and height of stakes so I found him eking down on the list. Admittedly, I hadn't thought of him in several weeks. Plus life goes on, you know? And I am not sure what my worry-wonder capacity is. Even though I think that Grady doctors get added storage when it comes to this.

At least that's what I think.

Yeah, so life goes on. Like life with children and husbands and work and other patients and commitments, too. And on Friday that commitment ended up being a holiday party with a group of children and friends from our old pre-school. I was riding in the car with the kids and they were chattering non-stop about school and video games and sports. And me, I just sat in front periodically saying, "Uh huh, uh huh, oh yeah?" And all was well.

Dusk had fallen and I could feel that the temperature was dropping. The cabin of the car felt cool as we drew nearer to the intown neighborhood where the party was being held. I turned on my seat warmers and also the heat as I slowed down at a red light.

"That man seems mad!"

"What man?"

"That man right there," Isaiah clarified. "He's like he's in an argument but with nobody there."

"Maybe he's just pretending," Zachary replied.

Just then, the man in discussion began waving his arms wildly. He was pointing at the passing cars and then swinging to look over his shoulder, only to start swinging fists in the air. And honestly? He was on the corner and technically harming no one. But it was clear from what I saw that in his mind there was a war going on and he was fighting it as hard as he could.

We sat in silence watching him until the light changed. And just before I pulled off he began to cross the street, still talking, pointing and shadow boxing. I lightly tapped the brake to allow him to pass by the front of my car. And he did.

But just as he did, he turned his head in the direction of my car. And I can't say he looked at me because really, he didn't seem to be looking anywhere. But what I did see was that he was smiling this dichotomous grin that didn't match his aggressive hand gestures. Then the headlights captured his eyes and right then I knew. They were amber.

I gasped.

It was him. My patient from my worry-wonder list. Clearly decompensated with his schizophrenia or very, very high. Or perhaps both. I don't know. But not near any of the shelters and likely not going to one since it was after the 5PM check in time for most of them and since he more than likely was still using.

And that? That sucks. Like, really, really, really sucks.

That's a weird part of this job. The worry-wonder list. You see people and try your best to help but sometimes the enormity of it all is just . . . .yeah. As I drove on and he slipped from my sight, I wondered if there was something, anything right then that I could have done. Like immediately, you know? And since I didn't know what that was, I just said a little prayer for him right then and there and added him back to my worry-wonder list in a higher position. Which maybe was helpful or maybe wasn't helpful at all but at least was a start.

Sigh.

So today I worry-wonder. Which is something I do often. I worry-wonder if he is somewhere safe and if he is okay. I worry-wonder if he became hypothermic and was brought to Grady. (Per the record today, no.) Then I worry-wonder if he came to Grady anyway but couldn't talk so got entered as a John Doe or something like that. And I also worry-wonder if that doting family is somewhere crying and praying and wishing they could find him and blanket him with love and mylar balloons.

I have none of those answers. But I want to believe that there is something good that comes from worry-wondering about people. At least, when you work at a place like Grady Hospital there is. That's what I believe.

Yeah.

***
Happy Sunday.

Oh me, oh my.

I was talking to a friend recently who has been going through some tough times. These tough times put some hard decisions before her and she was talking to me about what she should do. I was mostly listening because this friend is wise. I know she's wise because I've been on the other end of her advice.

"What would you tell a friend?" I asked.

"What?" she replied.

"A friend. If this were me or a good friend, what would be your advice?"

And when I said that I knew I'd struck a cord. She pressed her lips together and furrowed her brow. I could tell those wheels were turning. A few days later I received a text from her telling me what she'd decided to do. And she told me that she advised herself as she would a friend. Which really, really helped.

That got me thinking. Isn't it funny how liberal we are with our good advice and kind words to our friends yet stingy with them when it comes to ourselves? Like, so many times I find myself sitting with a girlfriend sipping wine and hashing through some sort of issue. Sometimes I'm the hasher and other times I'm the hashee. Either way, someone at some point speaks a good word that convicts the other. And after that we pour one more glass of wine and clink glasses in honor of having great and wise friends in your corner.

Yeah.

So today I was sitting on the couch chatting with Harry. I was fretting as I often do about the kids and school and social interactions and anything else I could think of to fret about. So I'd stored up all of my monkeys to put onto the BHE's back so that I wouldn't have to worry alone.

"I need you to calm down, babe." That's what my man said to me matter-of-factly. "Everything can't always be so heavy. We have great kids."

"We do. But this note from school said this. And I don't want anyone misunderstanding my son. We are raising black men."

"You don't think I know that we're raising black men? I do. But worrying only makes you crazy."

I sighed. "I do feel crazy sometimes."

"Babe. You are right about a lot of this stuff. But some of the stuff you get all worked up over are little day-to-day things. With some stuff you have to let kids just work that shit out. You can't go overanalyzing every single thing your kids say every single day. Some shit you just have to let them live through and figure out."

And yes he uses the expletives. What can I say? He's an ex-military dude.

Anyways. My point is that I spend a crap-ton of time hoping and praying that I'm getting parenting right. I constantly pray that my kids will remember and embrace every good thing I've done and have amnesia for the not-so-good things. I ask God to show me what to do and ask for forgiveness when I say and do things that I don't think are so good.

Yeah.

So today, despite my admonishment from the BHE, I found myself in a fretful do-loop again. This time it was in response to yet another shenanigan of some sort that one of my sons was involved in while at school. And. I will say that in no way did anyone make a huge deal out of it but me being me, I did. I started applying it to my son's future as an adult and started already preparing to lecture him about the perils of poor choices. Then I tossed the monkey over to Harry (again) who listened but then reminded me (again) that everything that happens is not some wretched foreshadowing of a tainted future.

Okay, okay--those are my words. But you get the picture.

Anywho. There was a point in all of this. My point is that I know for sure that I often give my friends good and thoughtful advice. And I even thought about me suggesting to my friend that she provide counsel to HERSELF as she would a friend and had to say, "Hmmmm. That's a damn good suggestion."

Yeah, man. So tonight I decided that I'd take my own advice. I'd be a friend to me and talk to me like a girlfriend. And see, the good thing about girlfriends is that they know all the background so they can pull it out and apply it where necessary. As opposed to, like, Dr. Phil or somebody.

Not that I have a problem with Dr. Phil. I'm just saying, that's all.

So yeah. Today I sat down with me and talked me off of the ledge. As only a sisterfriend can. And you know what? I think I'm going to do this more often. 'Cause me? I'm a damn good sisterfriend.

Yeah, I am.

*****
Me talking to Me today:

I'm kind of freaking out. I know I shouldn't be but I am. 

Now what?

Isaiah was horsing around in school today. And I need him not to be doing that. I mean. . . .he's at a new school and I just. . . yeah. I don't want anyone misunderstanding him, you know?

What do you mean by that?

I mean. . . like. . . misunderstand him and think he's a not a good kid. He's such a good kid, you know? And then I don't want him not realizing that there is a time to work and a time to play. He's going to have to understand that someday or it's going to be hard for him as a man.

He's eight, Kimberly. Eight.

So what? You're suggesting I just blow it off? I mean, that's not the answer either. 

No, I'm not saying that. I'm saying that there should be a consequence for his actions. But him horsing around today doesn't mean you need to brand him with a scarlet letter. Damn.

But these things add up. Some of the stuff both of those boys do I find myself saying, "Dude. Seriously?" And I just really don't want my boys growing up making a bunch of dumb ass choices because they don't know when to be serious.

Uhhh, okay.

What's that supposed to mean?

It means relax. You love them. Harry loves them. And they have a ridiculously huge village helping you and Harry out. They will be fine. Even people who make dumb ass choices in elementary school grow up to be upstanding adults.

Not always. 

Yeah but what could be more dumb ass than swallowing a tack? *(explanation below, just keep reading)

Oh see. Now you're playing dirty.

But you have to admit--that was exponentially dumb-asser than what you're worried about today, wasn't it? Like. . . what were you thinking?

I was. . . .

You were. . . .horsing around. In elementary school. Precisely. Uhhh. . . DOCTOR Manning. See? You turned out okay.

I forgot about the tack-swallowing incident. That was pretty dumb. 

Uhhh. . .yeah. Imagine how psyched your mom was to get THAT call from school. "Hey! Your dumb ass daughter just swallowed a thumb tack!"

I know, right?

Right. And let's not forget the day you cut the girl's hair on the school bus in sixth grade. How dumb ass was that?

Awww man. That was so, so dumb. And I was just trying to be funny, too. That girl had a crap-ton of hair. I only pretend snipped a teeny weeny bit of it as a joke but accidentally really cut it. But it was funny, though.

Yeah. And I'm sure your mom was like "Ha ha, hell" when she had to come up to Frank D. Parent School to talk to the damn principal about it, too.

Yikes.

Yikes is right. You owe your mama an apology for being such a dumb ass.

Hey!

My point is that you turned out okay. Some things are going to be dumb ass. They just are. It has to be that way. You remember. There were consequences for all of those things but you are living proof that with love you can still turn out okay.

Yeah. I guess you're right.

Calm down.

Okay.

They're awesome kids.

I know.

You're an awesome and imperfect mom.

So imperfect.

But nobody loves them like you and Harry. Nobody.

That's true.

Relax.

I'll try.

Just keep on loving them. And loving Harry. And especially loving yourself. It will be okay.

Will it?

Yeah, dumb ass. You swallowed a tack, remember? And cut somebody's hair to be funny, remember?

Hey. And Deanna dyed her hair in the water fountain with Kool-Aid. How dumb ass was THAT?

Super dumb ass. See? You dumb asses turned out fine.

We did didn't we?

So chill.

Okay. I'm chillaxing.

Sigh.

What?

You're soooo lame with your lame slang.

So lame, I know.

But I love you, girl.

I love you, more. 

Then act like it sometimes.

Sigh.

***

Us randomly dressed up in cub scout gear one day with our cousins.

*Background information for clarity

Dumb ass thing number 1:

In second grade, I was working on a bulletin board with my class. Instead of doing what I was supposed to be doing on the project that morning, I decided I'd make people laugh by putting a thumbtack in between my teeth. Why, you ask? Well CLEARLY a thumbtack held just so between the teeth bears an uncanny resemblance to a silver tooth. OBVI. Yeah. So I walked around with a dead pan face and just when they least expected it. . . TING! I'd unleash my grill and bring down the house. Or in this case, the table.

Turns out that laughing out loud with your head back whilst holding a thumbtack in your mouth is not the best idea.

Whoops.

"Hey! I can't wait to rush up to my child's school to take her to an emergency department in case she perforates her bowel from swallowing a sharp metal object!"

Yeah. Said no mom EVER.

That was a dumb ass thing to do. (Ask my mom how she confirmed that the thumbtack was out of my system and then let her tell you how AWESOME an experience that was. Or not.)

Easter Sunday in our clothes sewn by our mama.

Dumb ass thing number 2:

Sixth grade, packed bus. This girl who was named after a season--her name was like Autumn or Winter or Summer or something--had the world's STANKEST attitude and always sat on the second row near the driver. She also had the world's thickest straightest hair. On this day I thought HOW FUNNY would it be if I sat on the third row behind her and used my school scissors to PRETEND CUT like two or three strands? I said PRETEND CUT. Well. How was I to know that PRETEND CUTTING can sometimes accidentally become REAL CUTTING if you hit a bump on the highway?

"Hey! I can't wait to meet with the principal and some freckle-faced kid's mama who is demanding to let her child cut MY child's hair to teach her a lesson for the DUMB ASS thing she did on a school bus the day before!!!"

Yeah. Said no mom EVER and especially not mine.

I will spare you Deanna and the Kool Aid hair dying incident. Yes, I will. Just know that it was a dumb ass thing to do.


Okay. So my point? Um. I sort of forgot it. But yeah. Just be a friend to yourself. Talk to you as you would a good friend. And remind yourself of all of the DUMB ASS things you've done in your life so that you'll feel reassured that your children will turn out just fine. And if you need a smile just imagine this:

TING!

That's all I got.


***
Happy Tuesday.

P.S. JoLai didn't do a single dumb ass thing. But we made up for her lack of dumb ass choices.

Feet of iron and clay.

image credit

 ³¹ “Your Majesty looked, and there before you stood a large statue—an enormous, dazzling statue, awesome in appearance. ³² The head of the statue was made of pure gold, its chest and arms of silver, its belly and thighs of bronze, ³³ its legs of iron, its feet partly of iron and partly of baked clay. ³⁴ While you were watching, a rock was cut out, but not by human hands. It struck the statue on its feet of iron and clay and smashed them."

- Daniel 2:31-34

 ____________________________________________

What would it be like if the world around you was just a cacophony of voices repeatedly trying to make you understand? Like, if your body was sick with complicated things that require a real, solid explanation and you couldn't get one because of something really simple? And okay, maybe it isn't simple, but mostly it's a hurdle that we can almost always find some way to jump with some effort. This time, that wasn't working out so well.

Especially because I was tired.

I admit that this has always been one of my deepest fears both as a caregiver and a human being. That I'd find myself somewhere where no matter how hard I tried or how many people I asked NO ONE could speak a shared language with me. And, perhaps, being a native English speaker who admittedly doesn't have much of a travel bug, it's a little less likely to happen to me in the first person sense but the truth is that, especially in a public hospital, this could happen while caring for a patient. Fortunately, even when it's super difficult, we generally find a way to overcome this for patients. So my fear has always been that someone would come who'd landed here through some obscure means. Wait. "Obscure" sounds pompous so I take that back. The word I'm looking for is one that describes a person making it some place without any clear explanation of how. And I took back that word because usually it is more tragic than obscure and perhaps not knowing the fine details isn't such a bad thing.

Sigh. I'm rambling. I know.

So check it. This is what happened to me recently. I saw this man who'd come to America from a very small village in a remote part of Africa. He spoke not a word of English. Hmmm. There I go exaggerating again. He spoke like ten words of English and one of them was his country of origin and another was what sounded like the dialect he spoke. My resident carefully teased out what he could and learned that, just maybe, his native tongue had enough similarities to French to use this to interpret. And so, through the language-line interpreter, he tried to see if this might break through and explain to our patient what was going on.

"This is not French or even close," the interpreter said. "And he is not understanding French. I'm afraid this won't help."

And this time the right word was selected because we were "afraid" too.

So we were back at square one. Looking into the eyes of this man with skin of such a strikingly dark hue that I longed to hear more of his story. Who are you? How did you get here? What brought you here? Where is your family?

None of these words were clicking. He just sort of smiled and nodded his head repeatedly. Which only made me want to communicate with him more.

Shit.

A few more phone calls were made. Dead end. Dead end. Dead end. Somebody speaks THIS but not THAT. And THAT is what we needed but thanks for offering THIS.

Shit, again. This was exhausting.

"These lab abnormalities are serious," my resident said. He pressed his lips together and sighed hard. "I don't know what to do. But let me think for a minute, Dr. M. There has to be something we can do."

And me, I admit that I was already feeling defeated. Like in my head saying those white flag rebuttals like "DO WHAT?" and "WE'VE DONE ALL WE CAN."  So thank goodness that resident was there with me with his fresh eyes and spirit to advocate for this patient in ways that I fell short in doing.

Yeah.

And so. Let me tell you what happened next. That resident started hunting even more people down. Two different refugee support organizations to be exact and even a phone number from the patient's cell phone. Eventually, like nearly an hour later, he found someone who spoke the patient's language. No, it wasn't easy at all, but he did. And that person assisted in at least helping our patient know where to go and why.

And, honestly, I was kind of amazed and ashamed at the same time. I call myself a patient-centered physician and I think I mostly am. But there are these days that I run out of steam. The road is muddled with speed breakers and my energy wanes. I know this is what happened to me. I know it is. I gave up. I admit it, I did. I'm so glad that my resident didn't.

"Thank you for standing up for him," I said quietly. "You made a difference today. I think I felt myself giving up. No, I know I did. I'm glad you were tenacious."

And that resident looked at me and half smiled. Then he said, "You know what, Dr. M? I said to myself, 'Somehow this guy figured out how to get this appointment at Grady and even get the lab work that has us all freaked out.' Even if you speak English that's no easy feat. But he managed it which told me that somebody, somewhere was helping him and that if we could find that person they'd help us, too."

Simple enough. And not obscure at all.

"That makes perfect sense," I said.

"Yeah. I guess I just imagined this man walking all the way here. Maybe not literally but definitely figuratively, you know? Like he marched here all the way from his village and through whatever situation that was bad enough to have forced him away from everyone and everything he knows to be in this strange land. You know? That made me want to at least try."

And I liked the way he said that because it wasn't melodramatic or self-important or any such thing. It was just filled with the kind of humanity that you hope and pray more doctors have than don't.

We are not a perfect species by far, we doctors. Even the senior of our brood are works in progress. One of the hardest parts of our job is to allow ourselves to keep learning, keep growing and keep seeing. To be unafraid to examine our feet of iron and clay along with our patients in an effort to be better.

And so. This morning, I woke up and thought of this. I sip my coffee, stare out of the window and reflect. I imagine a man walking from sub-Saharan Africa all the way to Grady Hospital with his feet of iron and clay and imagine that it took more iron than clay to make it. And then I take a deep breath, dust off my own and prepare to fight for all of the people on journeys like him. I allow myself to learn from the examples of my junior colleagues and to be reinvigorated by their zeal. Then I try to do better.

I do and I will. 

Yeah.

***

Life threatening vs. Quality-of-life threatening.

Help me help you. Or rather help you help me.

 _____________________________________________________

What bothered you was simple. A big, dry patch of skin on your leg that was itchy and uncomfortable. Even with your self-prescribed remedies, that affected area was getting bigger and, to quote you, "worser." And no. This wasn't something that was life threatening by any stretch of the imagination. But you didn't care about that because to you it was quality-of-life threatening. Which at eighty something years old is perhaps more unacceptable than the former. 

Here's what was bothering us. Your cholesterol level was high. Too high for us to shrug off when you said with eye lids at half mast that, "Naaw, I ain't tekking no extra pills no matter what it's for." So instead of taking no for an answer, we tried to explain why this pill to reduce your LDL was a good idea. 

"It will protect you from heart attack and stroke, sir," my resident said. "That's important."

"And you are very independent, sir," I chimed in. "We should always do all that we can to lower that risk. With you having diabetes, too, it's really something we should do."

You shook your head hard. That let us know that you weren't interested in our closing argument for lipid-lowering agents. To underscore that, you returned to your original concern.

"So what y'all gon' do about this here?" You pulled up your pants leg again to reveal that same patch of skin. It had white stripes over it like chalk on a chalkboard from where you'd been scratching it. I raised my eyebrows when you did because to me, the diagnosis was clear.

Assessment: Dry and ashy.

Plan: Moisture.

Since I didn't think you'd like that so much, I decided to look at it more closely. Bringing my face closer I studied your leg and the skin all around it. That one area on the side of your leg had prominent hair follicles with dry whitish caps. The part surrounding it was also very parched and leathery. I wish my diagnosis could have been more exotic. But it wasn't. My assessment was essentially unchanged.

Assessment: Super-dry and super-ashy.

Plan: Super-moisture.

"You skin is really, really dry, sir. Some people call that eczema when it's a bit more extreme. Mostly, I'd say this is . . . hmmm. . .just really dry and ashy skin." I smiled after saying that word "ashy" because I thought you would, too. But you didn't. In fact, you didn't seem to appreciate me saying that one bit. 

"Ashy? Nawww. This here is more than jest ashy." You folded your arms and curled one side of your mouth upward. Your brow furrowed for a bit. Then you reached down with one of your hands to rub your leg. "This MORE than jest ashy!" 

That's when I realized that I'd hurt your feelings. Here I was being "cute" about something that was serious to you. My choice of words was trivializing and dismissed your concern. I was sorry immediately. 

"I'm sorry, sir. You're right. Let me think for a minute." I sat back in my chair and bit the side of my cheek. I wanted to allay your concern but I wasn't really sure how to do that. This didn't call for any steroid creams. It wasn't necessary to send you to a dermatologist either. But something had to be done. Something beyond just "moisture."

That's when it dawned on me that I'd missed something. Something doable and simple. Talk to you--my patient-- to build a therapeutic alliance. Instead of making fun of your concern that happened to be the least of my own.

"Let me ask you a few questions about your skin."

"Okay. Shoot."

"Do you take baths or showers?"

"I take baths. Sometime two a day." 

"Hot baths? Bubble baths?" I queried.

"Wheeewwwweeee! Hot as I can stand it. Look like when I'm off in that water it calm everything down. My joints, my muscles, and my skin. And yeah, I do put some bubbles in there. Well, really it's some kinda ol' bodywash or the other but it make good bubbles."

"I see. So two baths in a bathtub a day?"

"As opposed to two baths in where?"

I laughed when you said that. "Uhhh, as opposed to . . .yeah, that was a silly question. What kind of soap do you use?"

"Oh, I only use Ivory Soap. You know, cawse that's the purest kind."

"I'm sorry . . .did you say. . .Ivory?"

"Yes, ma'am. Tha's all I ever use. And I wash my body over two times, you know, jest in case."

I cleared my throat and blinked my eyes a few times. Your answers sounded like the kind planted for one of those standardized patient actors. You know -- the kind where they've been told all of the textbook replies to help some young medical student to make their first real-ish diagnosis.

"What about when you get out of the tub, sir? Do you put anything on your body?" I asked.

"Ma'am? Oh, yeah. I put some kinda ol' cream my daughter got me. Some ol' perfumey smelling thang in a vat from some shop in the mall." I pictured hands slathering down body butter from The Body Shop onto itchy legs. I took a big drag of air and glanced at my resident who was standing just out of your line of sight.

"So . . .let me get this straight," I recapped. "You take two hot baths in one day. You wash your body with Ivory soap. Not once, but twice. Then you use some kind of perfumed moisturizer."

"That's right. See? That's why all this itchiness on my body don't make no sense to me. Look to me like I shouldn't be itchin' nowhere."

And you know? One would think that this would be good for your skin. Especially because you seemed to be handling it with care. But the reason your resident doctor and I kept casting each other those looks was because you, sir, had given us all the information we needed to get you feeling better.

And so. I started with the baths and explained that this dried the skin out. "You know how you get out of the tub and you're like a prune sometimes?"

"Yeah!" you exclaimed with a slap of your knee. "Does that mean something?"

"Baths dry your skin out. Especially hot ones. And even though Ivory is 99.44% pure according to the commercial, it's pure soap. Which dries you out even more."

"Hush yo' mouth!"

"Nope. It strips all of the moisture out of your skin."

You nodded hard and then shook your head equally hard. You seemed gobsmacked by all of this information. "What else I'm doing wrong? I hope nothing else!" You laughed out loud when you said that because you assumed that was it. But it wasn't. Next I mentioned the perfumed lotion you were using and how this could potentially be more irritating than moisturizing.

"So what do I use to keep my skin from being dry when I get out the water?"

"You could use some good ol' fashioned Vaseline."

You swung your head over to my resident and widened your eyes for verification. "VAS-e-LINE?! I got a whole bunch of vaseline 'round my house!"

"Perfect."

"So . . .no hot baths jest a quick shower only once, switch to some other soap like. . .what you said?"

"Dove or something like that."

"Alright then. Dove. And then some Vaseline. That's all?"

"That's all."

You smiled at me and rolled your pants leg back down. It was the happiest I'd seen you for the whole visit. I stood to shake your hand and prepare to leave. You smiled back in return.

"What was the medicine you was asking me 'bout before?" you said.

""Uuuhhhh, I'm not sure," I replied. I cocked my head at you and then snapped my finger. "Oh! You mean the statin pill for your cholesterol?"

"Yeah, that one."

"Well. We think you should take it to protect your heart and your blood vessels from a stroke." I left it there because I didn't want to prompt you to launch into a new soliloquy about the perils of polypharmacy.

You pointed over at my resident and said with a flick of your index finger, "Go on 'head and add that on."

"Really?" my resident said with his mouth wide open. "Do you mean it?"

"Yeah, yeah. Go on 'head and give me that since you think it's good for me and all."

And so we did. Because indeed we did think that. We did.


Here is what you taught me to never forget: There is power in the therapeutic alliance. That comes through first hearing the patient's agenda and honoring it no matter how straightforward it seems. Perhaps the patient who feels honored and heard is the one that feels trusting of his or her caregiver.

Just maybe.

What was bothering you was a dry patch of skin. What was bothering me was your higher than our reference range cholesterol level. Thank you for reminding me that to tackle those life-threatening problems, we often need to wade through the quality-of-life threatening ones first.

Yeah.

***
Happy Wednesday.

Dude. Pure, but it could leave you ashy and itchy. Just sayin'.