The Supreme.

"This ain't no place to be if you planned on bein' a star."

~ from Rose Royce's Car Wash

There is this car wash here in Atlanta that always tries to add on a bunch of other services every time you go there. Like, if all you want is a simple car wash, you know, with bubbles first and water second, they start blasting you with this laundry list of other choices such as tire shine or Armor All on the dash or chassis wash or you name it.  I don't get my car washed too often but when I do, you can pretty much guarantee that I'm not looking for it to cost the same as a car payment.

The last time I went, I had plans for a preemptive strike.

"I'll have the regular wash--and nothing else unless it's included in the price of the regular wash."

"So, just want to be sure," the car wash dude replied, "You don't want any tire shine or to have the alloy wheels scrubbed, correct?"

"Is that included in the regular wash?"

"It's included in the supreme wash, ma'am. That's only five extra dollars."

"No thanks."

"You can also get tire shine or alloy wheel cleaning a la carte if you wish."

"Is it free?"

"It's only three additional dollars."

"Per wheel?"  I muttered that under my breath but he heard me.

"No. Per service."

I sat up in my car and beamed with my brightest, fake-est smile. "I'll have the regular wash, then. And nothing else unless it's included in the price of the regular wash."

Car wash dude finally conceded.


On Monday I was seeing this woman in the residents' clinic who was in her mid-sixties. She had high blood pressure, diabetes and high cholesterol.  She also smoked a pack of cigarettes daily and was fairly overweight.  But her approach to this clinic visit was quite similar to my preemptive strike at Cactus Car Wash.

"I just need to get my medications refilled--and nothing else," she stated matter-of-factly.

I looked at her electronic chart and what the resident physician had documented. Her blood pressure was well-controlled as was her cholesterol. Her insulin regimen could use a teeny-tiny tweak here and there, but on the grand scheme of blood sugar control, hers wasn't too bad.  She really needed to strongly consider quitting smoking and getting on some sort of exercise and dietary program would also be indicated. Oh yeah, and seeing as she was sixty-something she also needed some screening and health maintenance things.  According to her chart, she wasn't up to date on her mammography, a colonoscopy, bone density screening, a pneumonia vaccine or a flu vaccine.

In other words, she needed the supreme wash, not the regular one.

"Okay," I answered carefully, "We can refill your medicines. Your doctor is going to make a small increase to your insulin, but otherwise you've been managing your blood pressure and cholesterol just great."

"Alright then," she said with her eyebrows raised. She totally had my number.

"I see from your chart that you keep your appointments. I also see your key chain with the photographs. Are those your grandbabies?" I continued.

She looked at me suspiciously. "Yes. I gots twelve grands but this is the little ones. I got some that's older."

I smiled and said, "It looks like you have a lot to live for. I'd like to talk about ways to keep you at your best beyond your medication refills. Would that be okay?"

"Honestly, doctor? No, not really. I don't take no flu shots, mammograms hurt like hell and the last time I got one they said I had to do it again and nothin' was even wrong. Tha's when I said to hell with that test."

"I see. You know, the idea is to catch things before they become an issue. I agree--I've had a mammogram and it's certainly no fun. But you obviously care a lot about your health because you keep all of the appointments. Would you consider--"

"I'll consider getting my pressure pills, my cholesterol and my insulin. Y'all need to be glad I even let y'all give me them insulin shots. My grandmama lived to make ninety and she ain't never had none of that stuff. Including that camera up her rectum." She shuddered and shook her head. "I really ain't getting that one."

My resident chimed in. "Did your grandmama smoke?"


Fail.  What did he say that for?


"Naw. My grandmama did not smoke."  She looked like she really wanted to add on "smart ass" but chose not to. Thank goodness he had the sense to stop that line of questioning.


"Can we strike a deal?" I quickly added. "Like, maybe we could look at them and decide what could be the most important to you."


"I told you what was important to me."


"Can I at least tell you the reasoning behind offering these things so that you can think about it?"


She nodded and at least gave us that, so I took what I could get.  My resident and I explained what could be prevented or caught early by getting a flu shot, a pneumo-vax, a bone density scan, a mammogram, and a colonoscopy.  We talked about which things disproportionately affect African-americans, which she happened to be, and described how missing an opportunity to make an early diagnosis could make a difference.  And she listened. She at least listened.

At the end of that visit, she got exactly what she came for--her medication refills and that's it.

I saw her in the hallway when she was leaving and she asked, "Miss Manning, have you had the colon test?"

"No, I haven't," I answered. "But my sister and my parents have. I hear it's not exactly fun, but I know from my patients that colon cancer is a lot worse."

She looked at me intently and nodded. "Hmmm. I might thank about that one," she finally said while folding her coat over her arm.

"Good," I replied with a genuine smile because I could respect that. I offered her a quick hand squeeze and wished her a great rest of the week.

That afternoon as I left Grady I stood looking at my car in the parking garage. I noticed the black smudge all over the fancy alloy wheels that I'd paid extra for back in 2004 when I got my car.  I imagined them gleaming like the way they looked back then and paused for a moment. Next I glanced at the dusty tires and narrowed my eyes. . . . 

Hmmm.  Maybe the tire shine and alloy wheel cleaner wouldn't be such a bad idea after all. I just might think about that one next time.

***
Happy Wednesday.

Now playing on my mental iPod. . . . Car Wash.

Blessed insurance.

"Blessed insurance

Health care is mine

Oh what a foretaste

of co-pays divine!

Not much selection

purchased by y'all

Flexible spending

no referrals . . ."

~ lyrics adapted by yours truly

(Thank you very muuuuch! I'll be here all week!)

 ____________________________________________________

"If I get in a car accident take me to Grady."

That's the catchy slogan that was printed onto a big stack of bumper stickers a few years ago.  Pull into the parking garage at Grady, and you'll still see at least five of them before you even get to the third level. Some slapped on the backs of fancy vehicles even--waving that proud flag that says, "I heart Grady."

Well. . . sort of.

Like a lot of county hospitals in major metropolitan areas, Grady is your go-to when it comes to trauma. If you're bleeding, burning, got road rash after someone had road rage, got your rear end smashed by a drunk driver or even by a sober texter--ask anyone in Atlanta and they'll tell you: Go to Grady. No question.

But what about when it isn't a car wreck or a surgical emergency? What about when it's something totally not trauma-induced like pneumonia or a urinary tract infection?

Recently, I cared for this patient who got me thinking about this question. I can't go into detail on the specifics with that actual patient. But here is an adapted story that underscores what we faced that day.

Oh. And details here are dramatically changed, are an amalgamation of true events, or are completely made up. The point, however, is the same.

Mr. Ingle

Mr. Ingle was this gentleman who'd been brought to Grady after calling 911 for a severe headache he had while spending time with friends one evening. Although he was an Atlanta native, Mr. Ingle didn't live here any more. He had a fine job as a Nashville executive and was back in his hometown for a business conference.

On this particular evening, he had slipped away from his Buckhead hotel to hit a cocktail party hosted by an old friend. One minute they were laughing, reminiscing and enjoying a few martinis on the swanky backyard deck. Commenting on the Atlanta skyline and how breathtaking it appeared from this regentrified downtown neighborhood. Clinking frosted art-deco-y glasses filled to the brim with overpriced vodkas. The next minute he was writhing around in pain on an ultrasuede chaise lounge; squeezing his right temple and asking someone to call 911.

"It's the worst headache of my life," he told the EMT when he arrived. Tears were rolling from his eyes and he rocked back and forth on the edge of his seat.

That kicked things into high gear. This could be serious. As in you-might-die-if-we-don't-hurry-up serious. Rushed him to the nearest hospital which, from this Grant Park locale, meant one thing and one thing only: Grady Memorial Hospital.

Oh, just Grady.

"Grady?"  asked one of his friends. "Yikes! Do we have to go there? He has Aetna, you know."

That EMT didn't even bother to answer. He slammed the door shut and whisked Mr. Ingle away. Him and his Aetna. 

A young man who was previously healthy now has the "worst headache of his life?" The ER team heard this story and leaped into action. IV in, CT scanner hot and ready, and lumbar puncture good to go-- all within moments of hitting the door.  This was a subarachnoid hemorrhage (read: a life-threatening brain bleed) until proven otherwise. This requires everyone to move fast because time is brain. Period.

Head scanned. No evidence of bleeding.

Hmm.

Lumbar puncture obtained.  Again, no evidence of blood.

Hmmm again.

The spinal fluid came back from the lab and it had 55 white blood cells in it.  55. Not high. Not normal.

Uhh, okay. What does that mean?

His blood pressure was high, too--that, plus this entire scary headache scenario got him admitted to the Internal Medicine service, which is where we came into the picture.

But here's the thing. This patient didn't exactly fit your standard indigent patient care setting demographic. His friend had tried to clue the EMTs in on that but they weren't having it. But the minute his sister arrived at the hospital, she was determined to make this crystal clear.

"Um, I'm not sure who we need to talk to about getting him transferred to another hospital, but that needs to happen."  His sister stared straight into the eyes of my intern and told her this point blank. She gripped the handle of her designer handbag with one hand and nervously rubbed the end of her sleek pony tail with the other. "I think there's been some mistake. He has insurance."

"Yes, ma'am," answered the intern, "we actually do care for some patients who have insurance."

"That's good. But this isn't where we prefer for him to be. How do we proceed?"

And my intern didn't know what to do.  Fortunately, the senior resident standing beside her had a few ideas of what to say. "Well, ma'am. Right now we're trying to sort out what's going on with your brother. We can't transfer him, but I can assure you that the same doctors who work here at Grady are the ones that work at Emory Hospital. Like, for example, I work at both places."

She could have cared less about that. She politely yet firmly repeated herself. "Yes, but my brother makes good money and has excellent insurance and would prefer to be elsewhere." She looked over her shoulder at her brother who looked slightly embarrassed. Sister ignored him and kept rubbing her pony tail. "How does this work? The transfer?"

All of these questions came up before I got there. Them trying to figure out what the hell was going on with this young out-of-towner with his splitting head pain while keeping his six-figure sister from litigating right then and right there. When I spoke to the team they let out their frustration.

"This is interrupting care," my intern lamented with a heavy sigh. "It's totally distracting us from doing what's needed for him. She is criticizing our every move and it seems like nothing we have done is enough."

Hmmm. 

The story was intriguing. First the clinical part, and then the rest. Young, healthy guy throws back some martinis and gets a splitting headache. Stabbing like an ice pick, feels like he'll die. Work up is negative for subarachnoid bleed and surprisingly there are a few white blood cells in the cerebral spinal fluid.  The medicine nerd in me combed my mind for a differential diagnosis.

• Really early viral meningits? I mean it is the summer and it's the time for it. That's possible. Awfully sudden in onset, though. Naaaah.
• Cluster headache? If I recall correctly, alcohol can set cluster headaches off. More common in the dudes than the ladies. Usually stabbing. Like an ice pick. And he said "ice pick" not me. But why the white blood cells? Beats me.
• Aseptic meningitis and a cluster headache? Damn. Sure would be an unlucky chap, now wouldn't he. But the story sounds really cluster-y yet those pesky white cells still need to be explained. Can you get white cells with a cluster headache? I don't think so. Hmm. Need to look that up.
• Atypical migraine headache?
• Hypertensive emergency?
• HIV related?

Hmmm.

"Had he ever had headaches before?" I queried. I wanted to know. But honestly? That answer got buried under all of this talk of his sister and her stabs she was taking at Grady. Every question I asked was met with distracted mumblings about what to do with not so much him and his headache, but the headache of that situation.

"Were his symptoms all on the right side or also bilateral?" I continued with my questions.

So much for my answers. Instead, it was more and more about how bitter Mr. Ingles' "peoples" were about being here and about how "his sister is a judge or a defense attorney" or something legal up in North Fulton County which makes having her not-in-a-car-wreck brother even scarier for the intern and resident.

"She just won't listen," sighed the senior resident. He was right. To every word they said to try to allay Sister's concerns, all she would say was, "We have insurance, thank you."

Dang.

Let me tell you. . . .the team found this 100% uncool. It was obvious that they thought this woman was entitled and rude. I never gave them a green light to tear into Mr. Ingle's sister by saying a snide remark. Calling her a "hoity-toity" something-or-other would have nicely broken the seal, allowing for a nice little verbal bashing to vent the frustration. But I didn't, so nobody actually said it. They just huffed and eye-rolled when telling me about it and warned me of the fire pit I was about to walk into as we approached the room.

When I knocked on the door of his room, I was surprised to find him alone. I shook his hand and introduced myself. "Hi, Mr. Ingle, sir. I'm Dr. Manning and I'm the senior doctor on the team."

"Manning?" he asked confirming he heard right.

"Yep," I replied while showing him my badge. I tried not to fall prey to the paranoia my team had about this patient and his family but some tiny voice somewhere said, Mmmm hmmm. He's getting your name right in case his sister needs it later. I shook my head and decided that this was simply a patient that wanted to know his doctor's name.  I smiled and said, "That's right. Manning. Just like the football players but without their money." We both chuckled and I'm pretty sure I caught a twinkle in his blue eyes.  "How are you feeling compared to when you first got here?"

"A little better, actually."  He smoothed out the covers and patted around the bed for his phone. Quickly grabbing his iPhone, he switched it to a silent position.  How gentlemanly of him.

"Your blood pressure looks much better."

"That's good. Thanks."  Mr. Ingle smiled and it was as genuine as genuine could be. Honestly, he didn't look too bothered by the whole Grady thing. In fact, he seemed glad to be getting care and gladder to be getting better.

I briefly recounted the history and asked his permission to examine him. Once he obliged, I found him to be quite trusting. By the time I finished examining him he looked almost completely well. "How are you feeling now?"

"It's kind of weird," he replied, "I feel almost back to myself. Kind of crazy, I know."

And this is what convinced me that he probably had a cluster headache.  No, I still couldn't explain those 55 white blood cells in his CSF (cerebrospinal fluid) but 55 sure isn't 1,055.  The blood pressure was likely from the pain.  Just as I prepared to discuss this, in walked his sister.

Her  body language was terse and suspicious. She smelled like expensive cologne and kept her arms near her body almost as if touching something there could be a lot worse than death. I made direct and firm eye contact with her.  "Hello, ma'am. My name is Dr. Manning. I'm the attending physician on the team. It's good to have family here."

"Are you the person who can get him transferred? We don't want to be here."  Sister didn't waste any time. "Mark has insurance. I don't -- I mean he doesn't want to stay here."  Every time she reached up to rub her sleek brown pony tail her wrist full of David Yurman bracelets made a clinking sound.

I glanced at the patient and he looked away. Sister was in control and he wasn't going to challenge her. I stood there watching her and thinking. What do I say? How do we handle this?  I really wasn't sure.

"Ms. . . ?"

"Katherine Elliot. You can call me Katherine. I'm his older sister."

"Okay, Ms. Katherine. Listen, your brother is doing much better. His headache has resolved and his blood pressure is now normal. We're very pleased with--"

"Look, doctor. I don't really want to keep talking. Can you tell me what needs to happen for him to be transferred?"

"Well, honestly? He is looking so good that I'm not sure he needs to be in the hospital. I'd like to speak with my Infectious Disease colleagues to see what they say about --"

"We'd like another opinion. How do we get him moved to Northside?"

Whew.  This lady was rough.  I felt myself getting a little frustrated--with her for cutting me off and with him for not speaking for himself. Finally, I took a deep breath and decided to stop beating around the bush.

"Listen, Ms. Katherine. I need you to hear me for a moment."  She folded her arms and pulled her elbows in toward her torso. I had her attention. I took a big sigh and called out the elephant in the room. "Okay, so listen. I'm from Los Angeles and you guys are from Atlanta. One thing that most big cities have in common is that they have a hospital where all the poor people and car wrecks go.  In Atlanta, that's Grady." Sister didn't move. But she also didn't interrupt. I kept going. "You turn on television and you hear of the gunshot victims and immigrants coming here. You see the homeless people around the corner and hear of the drug-related incidents that find themselves here. Then you imagine your brother being in the same place or even room as someone addicted to crack or who just came from a shelter,  and the idea of it gives you the willies.  . . . ."

She cleared her throat nervously and continued to hold my gaze. "Well, listen Katherine. I get that. I really do. Like. . .I love Grady. I've worked here for ten years and I know the good we do. But honestly? I had two babies since I've lived here and didn't have either one at Grady.  And I'd like to say that it's because I didn't want to run into people I knew or residents or whatever but maybe it does have something to do with the fact that I had a choice."

The team cast nervous glances to each other.  They weren't sure where I was going with this.

"So what I'll say is that I get your concern. I really do. I won't stand here and insult your intelligence by telling you otherwise. Grady is different than some other places. When you're the only place that doesn't turn people away, your resources get used up fast. Things take longer and yes, you do run into some colorful people.  I get it. But Katherine, your brother is here now. And mostly everything that's going on with him is a lot better. I do need to review his spinal tap results with some specialists but he may not need further hospitalization."

"Well how do you know this isn't something more serious like a stroke?"

"Right now, the information we have doesn't suggest a stroke. His cat scan was negative. His spinal tap had no signs of blood--just some white blood cells but not really that many.  Our exam doesn't suggest a stroke either."  She loosened the grip on her elbows. Those icicles were beginning to melt. "I can't transfer him anywhere now. All I can do is tell you that I get your concern and that I'm not trivializing it. But at this point, it's hindering your brother's care to keep talking about moving him. Even though we have less resources here sometimes, as far as this goes, he got the same thing he would have gotten elsewhere."

He finally chimed in and said, "Thanks, Dr. Manning. Kath, I'm okay with this.  They've been great so far." She darted her eyes over to her brother and parted her lips to speak but nothing came out.

I added, "Again, I get it."

Katherine just stood there for a few beats and then slowly nodded her head. "You know what?  Thanks. Seriously, thanks for your honesty."

"Thanks for yours," I replied.

"Okay, so now what?"

"Now, we talk to Infectious Diseases to see if we need to do more about these white blood cells in the spinal fluid. If they say it's okay, we will discharge him. If not, we'll do what they recommend."  I turned my attention to Mr. Ingle. "How does that sound, sir?"

He gave me a thumbs up sign. "It sounds great."


So as the story goes, Infectious Diseases said that the white cells could have been some aseptic meningitis but more than likely weren't anything infectious. We even ran it by Neurology who agreed that this was all a bad cluster headache and that, though unusual, maybe those cells were from the inflammation of it all.  Mr. Ingle was discharged later that day.

I ran into his sister near the elevator a few hours later. She grabbed my hand and said, "I really appreciate you admitting what you admitted to me."

I smiled and shrugged.  I wasn't exactly proud of that fact.

"Dr. Manning? You know, doctors can really be some hypocrites. That's what made me appreciate that so much."

I didn't know what to say, so I just said "thanks" and waved good bye.


No. I am not marching through Grady announcing that I have insurance to every person who will listen. But . . . .not unlike her... . . something at some point has made me feel entitled to something other than Grady.  And right now, I'm just reflecting on that.  I'm also reflecting on how annoyed everyone was with Mr. Ingle's sister that day. . . .

And now I'm wondering just how many of the people on my team that day receive their care at Grady. I had to admit that I haven't. So? Who among us Grady doctors gets their paps and prenatal care and prostate exams and elective surgeries amidst our beloved indigent patients? Well?

Hmmm.

Guess I'm reflecting on that word "hypocrite"  a little bit, too.

***