It's a cold one.

Temperature this morning in Atlanta:  33 degrees F.  A pretty dramatic plummet since the weekend. Bad enough to clear the shelves at Kroger when the man on the TV said something about "possible snow."

Like those people up in Kroger, this time I was ready. Kids bundled up appropriately with hats and even gloves that I guarantee will not return home from school, but that's okay. Coffee extra hot for both Harry and me. I even used the insulated mug for my commute to work. Car warmed up including a push of the "seat warmer" button. Radio turned on and NPR man saying repeatedly between news bites that "it's going to be a cold one."

But that was okay too because I was toasty and heated-up-and-seated-up in my dusty Volvo and, for once, my kids were dressed right for the weather which is huge because I only get this right 36% of the time.

Hmmm.

Since the weather wasn't an issue for me, I let my mind wander to all sorts of things. Today it was worries. Things that I have decided to worry about since the elements weren't my problem.

Like how this economy stinks. And how it really stinks if one of the people in your household owns a small business. Yeah.

And like wanting my children to have better table manners or to enjoy doing their homework a little more than they do. And sure, I'm happy that they're great kids, but must they get out of their seats twelve trillion times during every meal? Must they?

Or. Just wishing I could have just slept in or curled up in my bed with the good book I'm reading instead of having to go to work in the clinic this morning.  Yeah.

I felt kind of blah.  Perfect for a cold, gray day, I suppose.

I turned the corner on Coca-Cola Avenue right near the back side of Grady and began heading toward the highway underpass. For whatever reason, there was traffic, which annoyed me because I was four minutes late already.

Blah.

I slow down and patiently wait behind the other brake lights. I look to my left and see this:

iPhone shot, straight out of my rolled down window

The bed of someone who had to get out of bed for different reasons than mine. Maybe they felt ill and had to go around the corner to be seen at Grady. Maybe. Or. Maybe it was just too damn cold out there to lay on the concrete. So much for wanting to sleep in.

Damn.

Chin up. Fight back in me. Feeling blessed and ready to go get 'em.

But even more, feeling thankful that the bed I left this morning wasn't that one.

***

Back to life, back to reality.

(image from The Shawshank Redemption)

"Back to life, back to the present time

Back from a fantasy, yes

Tell me now, take the initiative

I'll leave it in your hands 

until you're ready. . . "

from "Back to life" by Soul II Soul

Recently I saw this man with one of the residents in the clinic who we'd seen before. He'd had his fair share of medical problems most of which were secondary to some bad habits he'd picked up over the years. Habits like crack cocaine, gin, and cigarettes. Well, turns out that those habits all got kicked when he was incarcerated for getting caught with a crack rock in his pocket. For that he went to prison.

Now he's out of prison and has a low-paying but "real, honest" job. This job let him off that day for his appointment at Grady. And he appreciated that. I know he did because he told me.

Prison was awful according to him and he described it as being in a "time warp." When he was released, he found that his teenage daughter had become a woman with her own children. And his once scrawny son was "big enough to take me down."  Lucky him, those children believed in redemption and welcomed their daddy right back into their lives just like the prodigal son. . . . .fatted calf, ring of gold and all that.

And their timing was perfect because he was ready to value his life. Prison was awful, yes, but also a gift he'd told us. Because it brought him out of the cloud he was in and brought him back to life and back to reality.

So now? He wanted to live. He cared about his health and wanted to preserve what he hadn't destroyed.

On this day, he looked a little distracted.

Oh no. Relapse? 

I hoped not. So I just flat out asked. "Sir, you look a little distracted today. Are you alright?"

And he wiped his face with his hand and shook his head. "I'm jest flustered, tha's all. I was late so that got me real flustered."

Justin, the resident with whom I was working, followed up with a little more information. "The clerk up front mentioned that you'd come to check in on time but then you left out?"

"Yeah," he answered quickly, almost cutting my resident off. He dragged the heel of his hand across his forehead. "Yeah, it was just some stuff, you know, I had to take care of."

Rut roh.

Justin and I exchanged glances. Not sure why but we did. Both of us were wondering what that was all about and hoping it wasn't some symptom of a slippery slope.  I'm ashamed to admit that I immediately thought of those "Lock up" reality shows--you know where people get out of jail and then just before the credits roll some message tells you in big block letters that they got rearrested for the same thing. I studied him carefully--wanting to be wrong.

His face was covered with a thin film of sweat. His hair was a little unkempt and I wasn't sure if it was because he'd just pulled off the knitted skull cap he was wringing in his hands or simply hadn't combed his hair. The tail of his shirt was out on one side and he kept nervously tapping his right foot.  The whole sight of it made me cringe a little.  Damn. I'd seen that look before. Five years in prison and now this? Damn.

Just as I was parting my lips to speak, Justin spoke before me. "You just don't seem like yourself. What did you have to take care of?"

I shot him an almost scolding glance. What kind of question was that? Especially when your suspicion isn't exactly one that folks readily admit to? But Justin is kind-hearted and not the least bit passive aggressive. I think he just sincerely wanted to know.

"I had to pay a bill I wasn't expecting yesterday. The electric had a reconnect charge, and I didn't plan on that. So then I didn't have my co-pay when I got up here."  He looked down at his shoes. "But man. . .I really needed to keep my appointment. And I'm sayin' . . . I needed to see the doctor."

I wasn't sure what to say to that, so I said nothing. He kept talking.  "And they wasn't mean about it, you know, but the thing is I am supposed to pay ten dollars for my visit and that's a discount, you know?"

"So they worked it out for you?" Justin queried, still trying to sort it out in his head. Now that I think of it, there was some redemption in that question, too. He was determined to give our patient the benefit of the doubt.

"Well, you know, they couldn't since this isn't, like, the emergency or nothin'.  I called my daughter and she helped me out."

"How?" I blurted out before I could stop myself. Now if anyone should have been getting a scolding glance, it should have been me for that dumb-ass question. What difference did it make how his daughter helped him? He was here so obviously it worked out.

But that question didn't faze him one bit. He answered like it was as relevant as "did you take your medicine this morning?" or "have you been experiencing any shortness of breath?"  No big deal.

"She was at work, but she was able to get away for a second to wire it to me, so I had to catch the bus up the street to get the Western Union she sent me."  Justin and I locked eyes instinctively, yet again. "Yeah, so tha's why I was late. I had to walk up to Boulevard to get the bus."

Wait, huh?

Hold up. So let me get this straight. This fifty-something year-old man caught a city train to his appointment at Grady on his off day. Had to get the lights turned back on the day before so didn't have the co-pay for his visit today? So he subsequently called his daughter to wire him TEN DOLLARS? And caught a BUS to go get it? To see US??? 

Wow.

"She wired you ten dollars for your visit?" I asked him almost a little bit too incredulously--even though he'd just told us that and I knew he was serious.

"Well, really she wired me twenty. She was mad because it had to be in a multiple of twenty. I 'idn't realize that and neither did she 'til she got there." He shrugged. "So yeah. I'm sorry I'm all flustered. I just really needed to see my doctor and make sure my pressure and my lab work is okay."  He meant that.

Alright, so check it.  I will not make this unnecessarily heavy. This was just an eye-opening smack across my face. A grown ass man had already come over the river and through the woods to see us. Trying to get his life and his health right, and wanting so bad to do so that he called his daughter AT WORK and asked her to wire him TEN DOLLARS for his doctor's visit. THIS required him to walk a little over a mile, catch a bus, and go up into a CVS pharmacy to get TWENTY dollars.  Seriously? Seriously.

I won't even go into what an ass I felt like for assuming he was sweaty and "flustered" because he'd gone around the corner and gotten a hit. And let me tell you--this man was 100% serious and wasn't lying. This man was clean and thank God his kids believe in redemption because I needed that reminder provided by their example.

And.

TEN DOLLARS? Really?  Man. I can probably locate ten dollars in change inside my couch as we speak. And here I am sitting across from this dude who is at least fifteen years my senior and this is what he has to deal with?  Damn.

Look. Everyone knows that folks are struggling all over the place. But working at Grady Hospital makes this waaaaay more than a damn notion.  I opened a magazine and read about Kim Kardashian and her fifty trillion dollar wedding extravaganza for her 72 day marriage. I read that and then thought about this man interrupting his daughter at work to wire him a ten dollar bill. And her having a discussion with him about the perils of it being a twenty and not a ten that she had to send. Damn, now if that don't make you feel glad for what you have, I don't know what does.

You know. . . this situation reminded me of that day that patient wouldn't stay for his cardiac catheterization. He told me flat out that folks out here "is losin'" and sometimes you have to make some hard decisions. Those decisions seem simple or crazy to me but not to someone like him with a felony charge and a second chance he's trying to hold onto. Damn.

Some folks wonder how we do it. Hearing all this stuff day in day out.  But honestly? I left that man feeling inspired and grateful as hell for what I have.  And if that isn't a reason to keep coming back to do what you do every day, I don't know what is.

Turns out that his blood pressure was just fine. And so were his labs.

Sigh.

Yeah, man. Back to life, back to reality.


***
Now playing on my mental iPod. . . ."Back to life" by Soul II Soul.

Who's your Daddy?

Father's Day 2011, Breakfast-on-couch

Ankle shackled to a bed. Eyes wild and angry. Mouth spewing vitriol in every direction. This time, admitted with some kind of infection. Last time, some kind of drug ingestion. Looking through his archival it became obvious that he wasn't a stranger to Grady. The dictations described prior hospitalizations with similar circumstances--in police custody, positive urine drug screens, abusive and impossible behavior on the ward. And not even thirty years old.

"Hey there, sir. I'm Dr. Manning."

"Okay. Get to it 'cause I don't feel like a whole bunch of extra shit." He rolled on his back, folded his lean brown arms and placed his hands behind his head. The security officer mandated to sit at his bedside cut her eyes sideways in his direction and then rolled them with a tiny shake of her head. She gave her finger tip an exaggerated lick and turned the page in the paperback novel sitting on her lap.

"I came to see about you this morning along with the rest of my team of doctors. We'll be the ones taking care of you while we try to get this infection under better control."

"Tell them to bring me a double portion. I want a double portion on my tray."

I looked at the shining metal cuff locked snugly around his right ankle. The left foot was covered with a blanket, but occasionally the other that was bare and exposed would reflexively fight against being restrained with a backward pull. A telling red ring on his skin was evidence.

His body smelled of rebellion, and his matted hair and poor oral hygiene made it a little hard to look at him. Especially when combined with how unabashedly rude he was.

"I think we can get you a double portion. That's not a big deal."

I then asked his permission to examine him. Normally, I would ask more questions or recap what the residents had told me on rounds, but in this instance I knew that he could kick us all out at any minute. I carefully inspected his thin and muscular body, searching for clues about his recurrent infections. The skin was smattered with excoriated bumps and picked scabs, likely related to his lifestyle outside of the hospital. I moved on to start pulling back dressings and gingerly removing packing from an infected wound.

"This seems to be draining pretty well, sir. You know the packing helps you as it heals. We're also giving you some antibiotics through an IV because this infection is hard to treat with just pills."

"Hey!" he suddenly yelled out to a nurse's aid that walked in to pick up a pill cup. "Why you didn't get me the apple juice I asked for? Get me two. And some ice!" He shook his head hard and muttered under his breath (but quite audibly) some expletives involving his feelings about Grady Hospital.

"Are you from here?" I asked, working to quickly deflect him from further picking on the aid.

"Bankhead, shawty." He smiled wide, like he was proud of his west side Atlanta neighborhood. "What you know about Bankhead?"

I smiled back and shrugged. "Not that much. . . .but. . .isn't that where the rapper T.I. is from?" I recognized how lame I sounded by using the words "the rapper" before the artist's name. So forty-something of me.

"Aaiight, then, Doc. You know wha's up! Yeah, he from the west side. He from Bowen Homes. Tha's al-right that you know that!"

I felt a bit of relief wash over me as his eyes softened in my direction. After looking at his arms and palms, I reached for his hand. Surprisingly, he allowed me to hold it.

My purple glove and yellow infection control gown separated our contact somewhat, but in that moment, he stilled. I covered this hand with my other hand and allowed the team of onlooking interns, students and residents to blur in my peripheral vision.

"Sir. . . Where is your family?"

"I don't have no family," he quickly responded. I could hear the venom rising up in his voice again as he drew his hand back.

"No family? Where was your family? Your peoples? Like. . .who raised you up?" I had to know because black folks in the south rarely have nobody. Everyone has a "mama'nem" or "play cuzzin" or two.

"Nobody, like I said. The state. The system. Shit, nobody." He laughed when he said that part. This inappropriate chuckle that was laced with pain and cynicism. I didn't flinch so he kept talking. "Yeah. My mama was a crack fiend. My daddy was a n--a she prob'ly let do her for a five dollar rock." Again that strange and unsettling laugh. His use of "the n-word" made it even more uncomfortable than it already was in the room. The security officer lifted her head the minute he said it, freezing for an instant and then returning to her book.

"I'm sorry." I squinted my eyes and then asked, "Did you get much time with your mom? I mean, before she . . I mean, before you had to go to foster care?"

"Yeah, shit. . .too much time. Basic'ly I was right there while she was gettin' smoked out and f--d by anybody and everybody so she could get right. I remember all that shit. Somebody would come in there and beat her ass like a dog in the street and she turn around and get on her knees." Another laugh.

"On her knees?"

"Yeah, you know what I'm talking about. On her knees talking 'bout, 'Daddy I'll be good' so she could get high. Gettin' dudes off right in front of me. A lot of them cats was dealers, and my mom was pretty even though she was a crack fiend so they would still do her. But you know, them cats ain't stupid. . . they wasn't lookin' to die or nothin' so they would just let her take care of them with her mouth, you know. 'Cause shit you don't have no idea what these fiends out here got. The AIDS, whatever. But yeah. I was right there seein' all that shit. And I was just a little man, too."

"Did anybody ever try to touch you?"

"Touch me? No. Shit, nobody even knew half the time I was even there."

"Then what happened? How did you get out?"

"One day some white people came in there and saw how f--d up everything was and took me out. But where they took me was just as f--d up." I noticed a pattern. With all of the most disturbing parts of his story, he chuckled.

"There wasn't any other family?"

"Naaah. Plus I had behavior problems and nobody was trying to f--k with all that, so yeah, I went to foster care so yeah whatever, you know? It's f--ked up out there. Ha ha ha. . .now here I am." He held his hands out like tah dah.

"Hmmm."

He leaned back in the bed and scratched his abdomen. It was covered with crude, jail tattoos. With a bored yawn he asked, "So, why you want to know all that? Wha's that got to do with anything?"

"I want to know because I'm looking at your eyes and your face and wondering who let you down when you were a little boy." He gave me a puzzled expression, like genuinely puzzled. I went on. "That's the truth. That's why I'm asking all that."

Because that was why I was asking and I did want to know that. I looked at him and wanted to know-- who let him down? Who? And yeah, I know. A lot of folks have hard lives and yet they somehow at some point pull themselves up by the bootstraps and get their act together.

But what about when you don't even have any boots to pull straps on?


So that's what I'm reflecting on this morning. It's Father's Day and, honestly Father's Day always gets me thinking about parents in general. Probably because there's so much symbolism tied up in the role of the patriarch. Like, your dad is supposed to be your bridge over troubled waters; he's the one you jump behind when something goes bump in the night. And for a lot of folks--and I do mean a whole lot of folks--that father in the traditional sense wasn't there. But if they were lucky somebody else stepped up to the plate. So I guess that's what gets me thinking about Father's Day this way. I think about it in terms of what having one affords you. And what it denies those who don't.

This morning while standing in my kitchen I was thinking of that patient. . . this beautiful, cocoa-complexioned manchild whose ankle was locked to the end of a bed. I remembered his round brown eyes and dark, lush lashes. I could see the chicken pox scar on his cheek and the distinct facial features. I wondered if he was, perhaps, the spitting image of someone who never knew or cared to know of his existence and what that might have meant to his entire life. I also wondered how it all would have turned out if he'd just had someone looking at him lovingly on a daily basis.

Damn.

As I cracked eggs into a sizzling frying pan and sauteed steak for Harry's Father's Day breakfast in bed, I asked myself--What is the best thing a parent can do for a child besides love them? And then, while stirring creamer into a steaming cup of coffee, I thought about this:

A parent, in whatever capacity they are a parent, should fight tooth and nail to stop anyone or anything from robbing their child's innocence before it's time. Period.

Kid eyes just don't seem wired for processing overly mature and overly awful visual images. Hell, adult eyes don't do such a great job at it either. But it's worse for kids. And I'm not sure how you can have a fighting chance when at seven years old you saw your mama on her knees calling somebody who just called her a bitch to her face "Daddy."

Up until I was about twenty years old, nearly everything I did or did not do was out of wanting to make my parents proud of me (or not disappointed in me.) At some point, things shifted and I wanted to do the right thing because of myself, but sometimes I wonder what it would have been like to have been forced to figure out all the things I've figured out with the help of loving parents on my own. I needed those wagging fingers and swats on my behind for coming in after the street lights came on, and I thank God for the standing ovations I received for fourth grade performances and at medical school graduations. More than all of those things, though. . . working at Grady has shown me how blessed I am that my eyes were shielded from things not meant for them. And for real? I thank God for that.

For some folks, it's in their DNA to make it despite a hard childhood. But most folks? It isn't. At all. Turn on a television and watch those Penitentiary/Lock up reality shows and you'll know it's true. Story after story of childhoods ruined by innocence lost followed by broken adult existences. Which sucks because there's not a whole bunch you can do to fix that.

Damn. Father's Day is supposed to be a feel good day. I didn't mean to get heavy like this. But the point of it all is this--if you had somebody waiting at home for you, expecting the world for you, covering your eyes for you, and sacrificing for you, you might want to call them up and tell them thanks. Not just "Happy Father's Day" but, for real, thank you for slugging it out for me. Thanks for letting me be a kid during the time when I was supposed to be a kid and for kicking me squarely in my behind when I tried not to be one. And if your parent failed at some parts of it, tell them I love you anyway because at least you tried. Because one thing I know for sure is that a whole, whole lot of people for a whole, whole lot of really complicated reasons don't try. At all.

Our plan was to deliver Harry breakfast in bed. We took longer than expected so it ended up being breakfast on couch, but he seemed to like it all the same. I knelt down next to Isaiah and Zachary outside of the kitchen and whispered to them before we brought the tray to Harry. I wanted to make sure they knew what to say.

"Tell him Happy Father's Day," I said. "But make sure--no matter what--that you tell him 'Thank you for being a good daddy to me.'"

And Isaiah asked, "Mom, is it hard to be a daddy?"

I grabbed his face with both hands and looked in his brown eyes--round with sprawling lashes just like my patient's. Then I answered, "No, son. . . .not when you know how."

***
Happy Father's Day. To all y'all.


Now playing on my mental iPod. . . .the song I danced to with my father on my wedding day. Eva Cassidy sings this in a way that stirs my soul. Maybe you can add it to your mental iTunes, too.

Food for thought: Hard times?

image credit

Today I'm reflecting on just a few of the things I heard from patients in just a single half-day at Grady Hospital . . . . .

• Hurt in an accident so now have chronic back and neck pain due to a disk injury. Due to poor performance on a job that involves manual labor, was "let go."  Tried to get a few other jobs but never went beyond middle school and "not too good with secretary stuff that involve reading." This month got an eviction notice. Will likely have to move into a shelter.  
• Off drugs and alcohol for almost fifteen years.  Lost job. Has three adult kids--one with a family living in a one bedroom and another with unstable housing due to mental illness. Other child just got married and patient "don't want to be a burden on nobody." Could move back with "old man" but not her first choice since "he still use and still drank" and "he one of them 'mad drunks' that like to hit on you when he get to drankin' too much." Probably will live in her car until gets another job. Drank an entire six pack of malt liquor last night due to "nerves bein' bad."
• Overweight but affected by an illness that required high doses of steroids. Gained more weight due to steroids. Due to being overweight has terrible arthritis. Needs to exercise but finds it hard due to weight and pain. Needs to lose weight but on fixed income and relies upon "meals on wheels" for food which is not low fat at all. Can barely walk due to pain and probably needs knee and/or hip replacement. Can't get replacements due to weight. Needs to lose weight before replacements will be done, at least seventy five pounds. Can't exercise or change diet because. . . . .
• Terrible toothache and mouth full of decayed teeth. Thought this appointment was with a dentist. Gets referred to dentist to get tooth extraction but will need at least the minimum co-pay. Doesn't have a single penny. Literally.  Received some pain medicine and antibiotics. Found a place that will give the antibiotic for free but for pain medication has to pay. Really needs the pain medicine. On way to see dentist who decides on no pay treatment on a case by case basis. If isn't deemed a suitable "no pay" patient, will either have to find the money or just deal with it.
• Makes exactly three dollars too much to qualify for medicaid and exactly sixteen dollars too much to qualify for food stamps. Pays for medications out of pocket. All ten of them.
• Previously homeless, likely due to mental illness. Came to Grady, and finally got a diagnosis. Has never been gainfully employed due to uncontrolled mental illness and incarceration. Receives disability due to mental illness, just enough to pay for apartment and live in government housing.  Two months ago, check cut in half due to child support judgment. Getting evicted in a week. Can't go to family because estranged due to mental illness. . . .

Wait. . . . .what did I have to complain about again? Oh, yeah. . .that would be a whole bunch of nothing.

***
Happy Tuesday.

Related, yes--but Can You Really Relate?

"Well, son, I'll tell you:
Life for me ain't been no crystal stair.
It's had tacks in it,
And splinters,
And boards torn up,
And places with no carpet on the floor—
Bare.

But all the time
I'se been a-climbin' on,
And reachin' landin's,
And turnin' corners,
And sometimes goin' in the dark
Where there ain't been no light.
So, boy, don't you turn back.
Don't you set down on the steps.
'Cause you finds it's kinder hard.
Don't you fall now—
For I'se still goin', honey,
I'se still climbin',
And life for me ain't been no crystal stair."

- Langston Hughes "Mother to Son"

____________________________________________________


"I'm leaving. Somebody need to take this IV out my arm."

"But sir, you had a heart attack. We need to have you stay for this procedure. It's important."

"I got stuff to do." He began looking around the bed for his shoes. He wasn't bluffing.

"But sir, you had a heart attack. What could you possibly have to do that is more important than getting this taken care of?"

He turned and looked at me like I was stupid. I immediately regretted that rhetorical question.

"I got to get to work that's what. If I don't get to work, then I might lose my job. And I can't lose this job. . . .man, look--where that paper you said I got to sign? I got to go."

"But sir, you aren't even 50 years old. You really should stay for this cardiac catheterization. It's the only way for us to tell exactly what is going on with your heart vessels."

"And the only way for me to check on my mail to make sure nobody mess with it and check on my job to make sure I don't lose it-- is to go." This guy simply needed to go. Simple as that. I needed to take it up a notch.

::sigh::

"Sir?"

"Yes, ma'am?"

"Do you have children?"

"Yes, ma'am."

"How many?"

"Three boys."

"How old?"

"13, 9, and 7." I then asked their names, and he lit up when he rattled their names off and showed me a snapshot of them on his cell phone.

"Hmm. What about them? I mean your three boys, sir? This is life or death. Your boys could--"

He cut me off.

"Look, doc. I know you mean well and all, but don't you get it? Stuff is f---d up out here. Folks is out here working they fingers to the bone and still getting let go off they jobs! Maybe you don't know 'cause you up in this hospital with some kind of security that most of us don't know sh-t about. Yeah, I do care about my health. I do. But I also care about my house. . .and my kids having a house. . .and my wife having a house. Man, it's somebody just waiting for me to drop the ball . . .to take my place on my job."

What to say? He had a point. I wanted him to stay and get his cardiac catheterization. I really felt convinced that some kind of intervention in the cath lab might save him from a future event. I felt that this new knowledge of him having 3 manchildren made it even more important that I fight for their dad. But his point was a good one. 

I implored him one last time. "But your boys, sir. Your boys need you alive. They do. I hear what you're saying, I really do. But when it comes to your heart--"

He interrupted me again, this time his voice rising over mine in firm authority. Somewhere between anger and frustration which I couldn't tell whether was directed at me or not.

"Doc! DOC! We muh-f--kin' LOSIN' out here, do you hear me? LOSIN'!"

He slammed his hand down on the tray table next to the bed, and it made me jump. His eyes were sparkling with fresh lacrimation that no way, no how would he let become tears. The mounting emotion froze me in my tracks. I backed into the bedside chair and sat down quietly.

And I stopped talking. I finally. Stopped. Talking.

"We LOSIN' out here. . . .Muh-f--kin' LOSIN'! I'm a grown man and my house could get foreclosed on ANY DAY now. ANY DAY, do you hear me?" I kept staring at him without blinking. Don't talk. Just listen. "F--K a CARDIAC CATHERATION. I need a JOB to feed my FAMILY. Sh-t, I'm already muh-f--kin LOSIN' and I GOT a job." He put his head in his hands and shook it. He took a deep drag of air in and sighed an exasperated breath. He looked up and softened his voice apologetically. "Look here, doc. . .I get it. I really do. I know what could happen. This heart thing is some serious sh-t, I know. But what I need you to know is that a man needing to feed his family is also some serious sh-t. Some real, real serious sh-t."

I felt like I was being suffocated by my ignorance. Simply assuming that this patient, this man, lacked insight into his illness when it wasn't that at all. I still didn't know what to say so I just pressed my lips together to keep them from parting and saying the wrong thing. . . . . . . watching him talk with these animated hand gestures that seemed to be in slow motion. I did my best to internalize his words. I asked myself:

Do you have to chose between getting life saving treatment and getting to work to clock in? Or get to your mailbox to make sure your mail isn't stolen? I mean, comparatively speaking, hasn't your life been a. . .well. . . crystal stair?

"You see this, doc?" He held his forearm out for me to see. Snapping out of my silent dialogue, I took in the crude tattoos scrawled on his arm. "This from the pen, doc. The penitentary. Dealing them drugs. . .servin' them crack fiends around the way. You know how hard it is to get a job when you a convicted felon? You know how hard it is to keep your job when you a convicted felon?" The eye contact was searing. I was scared to even blink out of respect to him. "I didn't have sh-t growin' up. Not sh-t. Now, I'm sayin'. . . I ain't never got high or nothin', but I did serve crack to people in the hood for years. . .goin' way back to junior high school when crack first got hot. Man, I had money fallin' out my pants. . . .fly cars. . .jewelry. . .all that sh-t. All the dudes I looked up to--this is what they did. Sold rocks. So that was all I knew. But then that sh-t ended real ugly when I got locked up. 5 years, doc. I was locked up for 5 years--when my little man was still in Pampers. It was real f--ked up. I hated that my little man had to see me like that." He paused for moment, almost like he needed to process the memory before going on. "And I'm sayin', doc. . . that sh-t was some real easy money. . . .and bad as sh-t is out here right now. . . ."

He wiped his face with his hand . . .like he was wiping the whole thought of that memory away. . .the easy money. . .all of it. "I can't go back to that life. I won't go back. That's why I got to get out of here. Gotta get to my job. If I lose my job. . . man. . . Where that paper? I got to go. " He leaned on his back in the bed and began pulling up his pants and fastening his belt buckle. He was 100% serious and his mind was made up.

::silence::

I numbly slid the "Against Medical Advice" form toward him on the tray table.

"I'm sorry," I murmured softly while looking away sheepishly. "I'm. . .sorry."

He signed the sheet and handed back to me. He looked back up with sad eyes . . . . full of troubles and knowledge of a hard life with tacks and splinters and boards all torn up . . .

"Yeah, doc. I'm sorry, too."

***

When I left his room, I replayed all of the hard choices that he had to make every single day, and how, for him, they are just as "life or death" as his decision to not have a cardiac catheterization. And I thought about my own life, too. And the fact that all I knew about "splinters, boards all torn up and places with no carpet on the floor" was when the poet Langston Hughes penned those words--and when my college-educated mother and father recited them to me as a child. A far cry from how my patient came to know the same.

I then resolved that my patient was "still climbin'." The only way he knew how.