The Youth Code.

"I guess it's crazy to think someone could run 13.1 miles and still have high blood pressure."

"Exactly. I just keep waiting for somebody to tell me they looking at the wrong chart."

________________________________________________________

This week in the Grady Primary Care Center

"We think it's a really good idea for us to go ahead and get you on blood pressure medicine. As a matter of fact, this particular medication gives you an added bang for your buck since it protects your kidneys and lowers your blood pressure." Our patient raised his eyebrows gently and tried not to look as reluctant as I know he felt.

My resident chimed in. "Since you have diabetes, this particular medication is shown to help keep your kidneys from becoming weaker. You know that can be a big issue with diabetes."

Mr. Amos* shifted in his chair nervously. "I hear you," he said. But from what I could see, hearing definitely didn't mean he was feeling this plan.

Nope.

If you saw Mr. Amos walking down an Atlanta street, he's the last person you'd expect to be carrying with him diagnoses of diabetes and high blood pressure. He was, by our standards, young. Just shy of his fourth decade and with boyish looks that suggested he was far younger. Lean in build and tall in stature--no spare tire in sight. "Amos," as he told his to call him, had been athletic all of his life and examining him quickly let any physician know that he still maintained that lifestyle.

Yup.

But Amos was a victim of genetics. His mama and his daddy had been affected by diabetes. Two sisters were diabetic and grandparents, aunties and uncles all up the family tree had equally representative medical histories. Diabetes and hypertension simply ran in his family. It wasn't a "you gained too much weight" thing or a "you smoke/drink/use thing" either. But nonetheless, for whatever reason, that high blood pressure dog didn't hunt with him.

Nope.

Now when it came to the diabetes? Amos was awesome. He took his insulin and counted carbs. He did the things we asked of him and, though he occasionally had a few dietary indiscretions, he mostly adhered to our recommended meal suggestions. His number always looked great which made seeing this young, fit man a joy.

But.

Somehow he always managed to shake his providers off when it came to starting something for his blood pressure. He'd come up with some compelling gameplan to increase his physical activity and watch his salt. And since he was generally such a motivated and great patient, it wasn't unreasonable for someone to give that a shot. That is, the first two times.

Mmm hmmm.

On this day, though, from the chart review it was clear. Amos' genes were just too stubborn. For us to do right by him, he'd need blood pressure medication. And you know? This wasn't personal. It was just the standard of care.

So in the hallway before we'd gone back together to see Amos, my resident told me that he was pretty adamant about not taking blood pressure pills. I asked my resident if he knew why our patient was so against taking something for his hypertension and he admitted that he honestly didn't know. And so. That was one of the first things I explored when I encountered him.

"So, Mr. Amos. What is it about blood pressure pills that gives you such a bad taste in your mouth?"

He squinted his eyes and seemed to be thinking. I could tell that my question caught him off guard. "I guess I just feel like I can control it, you know? Without an extra pill."

That was reasonable. I thought for a bit about who he was--young and male. I imagined him having some trepidation about the potential for erectile dysfunction, a very real concern in many men who take antihypertensives. So I asked.

"Do you feel concerned that taking something for your blood pressure might affect your nature?"

And yes, I said "nature" because this is Georgia and I've been working at Grady for a while. Long enough to know that "nature" is a safe and all encompassing way to discuss not only what is found in the nether region but its function as well.

Amos' eyes flung open at that question and then he chuckled. "Good Lord. I hadn't even thought of that." He shook his head and shuddered.

So that wasn't it. And what's funny is that I felt sort of lost at that point because I was so sure that this was his issue that I'd already lined up my talk points to counter his concerns.

What was it, then? What had this compliant with appointments guy so gun shy with taking something for his blood pressure?

"You know what? I guess I just. . it's weird. . .I just see myself as too healthy for all that. And too young." Amos laughed again, this time at his admission to us. "I know it probably sounds crazy. But something about having high blood pressure just doesn't seem like it should be attached to me. It's like I just can't accept that, you know?"

"You don't feel that way about the diabetes, though?" I asked.

"Naw. Little kids get diabetes. Skinny folks and all sorts of folks, you know? Jay Cutler is a pro football player and he's got sugar. So I know that happens to people like me. But high blood pressure is something that just seem like it goes with smoking and eating bad and needing to lose weight. And even though I know it ain't personal, I always feel lightweight offended when folks come at me talking about my blood pressure. It's like I feel like they mixing me up with somebody else."

"I guess it's crazy to think that somebody could run 13.1 miles and still have high blood pressure."

"Exactly. Especially when they do all the right stuff along with it and they aren't that old. I just keep waiting for somebody to tell me they looking at the wrong chart."

Wow.

Now this? This was some real talk. Amos stuck a pin straight into the thing that stops so many youngish people from seeking a doctor's care. Hell, it's stopped me from getting care as regularly as I should, too.

Yup.

It seems like there's this line in the sand where some of us feel it's reasonable for us to have certain diseases. Hypertension and high cholesterol? Those are for the older folks. So a lot of the young ones look at it as some kind of fluke when you tell them they have it. Like you aren't talking to them in real life. Just for pretend.

And this? This is a tough mountain to move. Our myopic view of our reflection and how that plays into the likelihood of anything being awry with our health. Amos gave me a lot to think about.

So you know what I did? I told him just what I'm telling you. That I understood how he felt and got it that it seemed like some kind of crazy betrayal to keep tacking this diagnosis of high blood pressure on to his chart. Then we discussed family history and how "essential hypertension," that is, the kind that runs in families, works. And how people like him--despite their half marathons and burpees in the morning--needed some pharmocologic interventions in the morning, too.

This resonated with him. I mean, it did enough to get him to take that medication. And no, he didn't like the idea but he did get it that continuing to put this off was like him drinking poison but expecting someone else to die from it.

Yep.

So what's my take away from this encounter? Hmmm. Well, first of all it's this idea that it really benefits me and my patients when I really push myself to think about the WHY of a patient's position instead of just my own agenda. I also was reminded to just slow down and listen instead of tracking ahead with my scripted comeback since real people improvise and canned/planned dialogues feel like exactly that. And lastly? I think I recognized the power of just being honest with my patients about what's going on in my head and giving them a platform to share what's happening in theirs.

I learn so much from my patients at Grady. And I'm glad.

Yeah.

***
Happy Friday.

*details/names always changed to protect anonymity. Duh.

The pied piper of empathy.

Pleased to meet you

Hope you guess my name

But what's puzzling you

Is the nature of my game

~ The Rolling Stones

I was sitting at a lunch counter the other day chatting with one of my former small group advisees about his career interests. Gunan, who is now an intern, was rotating on the oncology service. During our conversation he told me about how much he was enjoying his experience.

"That's right in line with your chosen field of radiation oncology, right?"

"Yep."

"Good stuff," I replied.

"I think I just . . I don't know.  . I just like taking care of people with cancer."

Wait, huh?

I wasn't sure what to say to that. I mean, can a person technically like cancer? Is it even okay to say that? I wasn't so sure.

Gunan saw my wheels turning and clarified, "I've figured out what it is about cancer that makes me like it."

Like. Cancer. Uh, okay. 

I raised my eyebrows. "Oh yeah? What's that?"

Gunan paused for a moment to find his words. I think he wanted to be sure that it didn't come out wrong. After a few seconds he finished chewing his bite of sandwich and spoke. "You know what it is? People respect the cancer diagnosis. No matter who they are, they do."

I squinted my eyes at this concept which pushed him to go on.  From there he fleshed out the idea pointing out that there aren't too many other things that every person old or young fully respects like a cancer diagnosis. He described how even the most difficult patients straighten up the moment it gets uttered. Family members step in to help--even estranged ones come from the woodworks--because it's cancer. Almost like having a U.S. president walk into a room. Essentially, it's kind of like the universal last word of diagnoses.

Now this? This was a pretty thought provoking idea. And especially so since I'd never thought of diagnoses as rungs on some sort of ladder of respect.

Hmmmm.

"That's deep, man."

Lame reply, I know. But that's all I could say because this was such an interesting perspective--and one that I believe was extremely accurate.

Yep.

Gunan gave me something to really chew on that day. This idea of diseases being hierarchal and having one that is the President Obama of them all--cancer.

Heart disease is exponentially more likely to take out any person than cancer. It also has a much, much greater chance of disabling or redefining a life than cancer. And, though a lot about cancer is terrifyingly mysterious, when it comes to heart disease? Meh. Not so much. High blood pressure, obesity, inactivity, elevated cholesterol, and family history are just a few things that greatly increase the chance of a person getting heart disease. And you know? Society has done a pretty darn good job of getting that memo out.

Yup.

And sure, if someone doesn't seem so stressed about potentially getting something like heart disease, surely they'd feel the wake up call if they actually had it, right? In my experience, I'd say that answer isn't in the affirmative. While some folks definitely straighten up and fly right after a heart attack or some other cardiac event, many, many people don't. Nor do the people around them.

But cancer? That's a whole different story.

The other diagnosis that doesn't get it's full respect is HIV.  All of the aforementioned things about heart disease ring true for HIV. This virus? We know about it. Like, all about it. There are ways to prevent and treat it, too. But perhaps even more than heart disease, it gets treated like an annoying tick on a dog's butt--something to ignore or not even look for until your forced.

I've told people that they were HIV positive. I've held their hand and walked them through the process of getting into care, too. But unlike cancer, it doesn't arrive with the same amount of boundless empathy. And worse, many times it prompts people to run in the other direction.

The patients are usually somewhere between really, really adherent to all that you suggest or totally in denial. And you know? That doesn't happen so much with cancer.

Nope.

Compared to cancer, HIV, as the late comedian Rodney Dangerfield would say, gets "no respect at all."

Nope.




It's true. AIDS and heart disease just don't get the respect that they absolutely deserve, man. And don't even get me started on mental illness which really gets disrespected.

But cancer? For some reason it's on a lonely list of diseases that somehow escapes all that. Even the most ill-equipped, contentious, poorly resourced and opinionated patients and families respond swiftly to that six letter word. They become more pleasant, cooperative and agreeable. They try what you suggest and listen when you speak. It's pretty damn remarkable.

Yeah. My former advisee was totally right. And it's a fascinating observation, isn't it?

So what is it about cancer? Is it the terminal nature of many of its forms? Is it the ruthlessness of it in how it strikes or the triumph of those who overcome its prickly grasp? Is it our universal fear of it that makes us all feel some need to show strong empathy lest we awaken the cancer-gods and find ourselves stricken out of some punitive wrath? Maybe it's all of this. Or none of it. Whatever it is, there's just something about malignancy that makes everybody listen just a little bit closer, follow up a little more carefully, and immediately get onto our best behavior.

And you know? It's not just the patients and their families, either. Doctors are also in this same camp. Our empathy heightens for patients carrying a cancer diagnosis. I know for sure that this is so because I've felt it inside of me and witnessed it time and time again at Grady Hospital.

Let me give you an example.

I took care of this super-cantankerous gent named Mr. Kelly with a longstanding stronghold of alcohol abuse on my service recently. He'd been admitted several times over the years for withdrawal and complications of his alcoholism. That man had a very sick liver and never once got hospitalized on a "soft call."

Nope.

But even though he didn't walk the line on illness severity, that didn't make him nicer or uniquely appreciative of his healthcare providers. He was difficult. Due to his illness and unstable housing, Mr. Kelly's hygiene was poor and frankly, that made it unpleasant to care for him. And, if I man be frank, downright noxious. He also argued with staff and, due to fear and frustration, wasn't so nice most days. The team and nursing staff lost empathy for him. People went in only when absolutely imperative. And even though people held their eye rolls, you could feel them whenever his name came up in a discussion.

Yup.

But then he had that MRI that showed a mass on his liver. A mass with features pathognomonic for hepatocellular carcinoma--that is, liver cancer. A blood test and additional studies confirmed what we thought. Not only did Mr. Kelly have this bad diagnosis--he wasn't really a candidate for any interventions that could lead to a meaningful recovery.

Nope.

And that moment? That second when we scrolled through the MRI images and hit that big oval mass on his liver? It was a turning point. Suddenly we all began rooting for him in a different way. And I'm embarrassed to admit it but something about knowing this about him made me want to see him more and spend time in his room. The heavy cloak of foul dank odor that hit you when walking through the threshold somehow seemed insignificant now. And his "difficulties" suddenly seemed like "quirks" instead.

Yeah.

But you know? Mr. Kelly changed, too. The minute we sat in that room at eye level and shared that information, a switch turned on in him. Or off. Or whatever it was, he changed. He asked questions and listened. His family members took his calls and he took theirs. There were cards on his window sill and balloons tied to his bed rail. And the nurses, like me, in unspoken solidarity rallied around him to make sure he was comfortable and that all was well.

Yup.

One could argue that his advanced liver disease, cirrhosis and alcoholism were already equally as life threatening if not more than this new diagnosis. His life expectancy, chance for recovery from his liver damage, all of it already portended a very poor prognosis. And we, the physicians and nurse, knew that. Yet somehow when someone threw hepacellular carcinoma into the mix, we lined our ducks up and offered this man a new dignity. It's true.

And you know? I'm not sure how I feel about that. I'm not.

I talked to my friend Wendy A. about this whole concept. This idea of disease hierarchy and how some illnesses we throw our shoulders back to salute and how others get a head nod and that's it. I asked her thoughts on how cancer especially wins when it comes to that and why that was. And her take on it is that no person is exempt from the potential cancer diagnosis. She said, for this reason, perhaps, we all revere it.

Perhaps.

And I still don't know how even the ones that some cancer patients seduced into their lives through tobacco use or other finger-wag worthy habits garners the same empathy. But they do. Like, not these attitudes that the man who has sex with men got what what he had coming to him when he found out he had AIDS or how the lady who had a stroke after using crack cocaine got what she deserved. Again, regardless of the etiology, cancer escapes all that. Somehow it just does.

Yeah.

So the Pollyanna positive girl in me has decided that this speaks to some innate thread of good in all of human kind. And how, as awful as cancer can be, it's amazing that there exists something that stands out as a pied piper for humanism and care for human suffering made palpable.

Yes. That.

You know? I don't even know why I wrote about all of this. But I do know this: The complexity of what we do is mind-blowing, man.

Yeah.

***
Happy Humpday.

Now playing on my mental iPod. . . .The Rolling Stones performing "Sympathy for the Devil."  (Well technically the remix done by Pharrell but still, it's the Stones and it's awesome.)

Saturday Night.

The other day I went to see one of my patients in the evening. The nursing staff had paged and said this patient was feeling anxious and upset and had asked for me. Me specifically. I had some things to do at Grady and was in the vicinity anyway so decided to just come on in.

Yep.

A lot has been going on with my patient. A lot. There was fear involved. A lot of fear. And frustration, too. And the thing about fear and frustration is that they can make us behave in ways that aren't always in our character. And since I get that usually I don't take such things personally. I recite the mantra that I tell my students: "This isn't about you." Because it almost never is.

But still.

At, like, 8-something PM on a Saturday night, I went to see my patient. I tapped on that door and creaked open the hinge expecting to be met with relief. Or at least some raw emotion and readiness to talk which I could have easily worked with, you know?

Instead, fear flipped an ugly switch on and I walked into a barrage of really unkind words and behaviors. Passive-aggressive. Or rather just sort of nasty-aggressive. Not dangerous or threatening. Just mean, you know? And I've truly grown to care for this patient so not only did those words catch me by surprise--they hurt. My feelings were genuinely hurt.

Yep.

When the nurses called me, I was sure that the combination of the rapport we'd built so far and the fact that I was up there after visiting hours when the lights get turned down would allay whatever had been going on. I was wrong.

I removed myself from that room and headed out to elevator. I snapped this photo of myself in the vestibule because I wanted to look at it and reflect on how I was feeling. Because my feelings were complicated.

Very.

The hospital was so empty at that hour that I stepped onto an empty lift and leaned my head against the wall on the way down. I could feel my pulse quickening and my face getting hot. Next thing I knew, my eyes welled up with tears and, before I could even stop them, I started to cry.

Kind of hard, actually.

I can't fully explain what I was feeling. Some of it was that my feelings were hurt. But that was only part of it. Mostly, I was just sad. Sad for my patient and this fear and this ugly behavior that came with it. Because that kind of thing almost always impedes excellent patient care by robbing even the most well meaning providers of their empathy. And empathy is a necessary element in quality patient care if you ask me. This patient didn't need anything else to work against all that was already happening.

Not at all.

So right now I'm feeling so sad. Like, every time I even think about the gigantic mountains that so many of my patients like this one are up against I want to steal away over and over again into the quietest elevators to weep into the crook of my white coat--just like I did on Saturday night. With no one looking or hearing or judging. Then, just maybe, even crying out into a vacuous airspace to my God or the Grady gods or any being with powers willing to take this on. Something, anything to defy the suffocating pragmatism and wrestle down the hopelessness I feel in such moments.

Maybe that would make me feel better, you know?

Then, when the doors pop back open, I can shadow box before re-emerging. Pop out of that elevator like a rejuvenated ninja with a new fight and a thicker skin. Believing in the little rays of light that sometimes seep through the darkness faced by so many of my patients, this one included. Or maybe even embracing some lofty idea that I could be that ray of light.

Maybe.

I am realizing that our patients aren't the only vulnerable people in the hospital. We are vulnerable, too. We so very are. Our universal precautions don't protect us from one of the most infectious exposures we face in caring for patients. . . .love.

On Saturday night, my patient was mean to me. Really mean. And yes, it was about fear but still. I have nothing in my little bag of Internal Medicine tricks to eradicate the effects of all that. I don't.

You know? Sometimes? Sometimes, this job is hard, man.

Yeah.

***

Reconcilable differences.

During med reconciliation with a patient recently

"You're taking the pills in this bottle?"

"That bottle there?" The Grady elder picked it up and studied it for a few beats. "Yes, ma'am, so this bottle here. . .I teks one pill with my breakfast and one with my supper. Every day."

"Hmmm. It looks like you have a lot of different pills mixed up in here together. Is that on purpose?" I know that sometimes people do all sorts of things for convenience. I didn't want to assume anything.

"Well. I don't see so good so I jest know which bottle is the one time a day ones and what bottle the two time ones."

"So this one, you just open up and take out one in the morning and one at supper, correct?"

"Yes'm."

"Okay."

And you know?  I have no idea how those pills got mixed up like that. This kind of thing--that is, this exact thing--is not unusual for us to see at all. And you know what else? It's easy to look at this medication mashup and generalize it to his life--and then make a sweeping statement about his need for a nursing home ASAP. Or to, at least, push to make sure he isn't able to live alone. I get that it seems like a no-brainer when you see something as worrisome as this and then try to wrap your brain around someone taking a random assortment of cholesterol, antihypertensive, and memory pills all willy nilly.

But.

Let the record show. This man lived alone. He was dressed and groomed appropriately and had taken public transportation to the hospital (no easy feat in downtown Atlanta.) Every day he cooks for himself, cleans for himself, does for himself and, for the most part, seems to get on just fine. He does. And has. For more years than most of his doctors have been alive.

Yep.

And see, this? This is one of the hard things we navigate in patient care, particularly when it involves our geriatric population. The lumpy bedspread that the patient can't quite smooth out on their own any more. The one that requires a little help to lay flat but that isn't to the point of needing to find new linens altogether.

Does this even make sense? Sigh. 

Okay. So check it: This sweet man, this dear, dear elder needed somebody to--as the southerners say--"see about him." And he didn't have that. He'd outlived or out-healthed a lot of his family members. And a lot of the other ones had lives and families and he didn't want to be a bother.

Nope.

Yeah man. This man needed somebody to see about him. To come by and check in and make sure things like this were okay. He wasn't significantly cognitively impaired or visually disabled that he couldn't get along. He did have a very limited education and admitted to being uncomfortable with most reading. But he'd worked for nearly his whole life and had managed his life quite fine. Taking him out of his home--the one that he built and paid for--is way more than a notion. Way, way more.

Fortunately, at Grady we have a lot of things we can offer someone like this patient. Some of it simple, some less so but all mostly doable and reasonable options to allow him to both remain safe and in his home at the same time.

Yeah.

Do I sometimes facilitate getting people into nursing care facilities? Definitely. But not without stopping what I'm doing and really, truly thinking about it. I reflect on the magnanimity of it and how it will make the patient feel. Will they be sad? Happy? Lonely? Scared? Will they feel robbed of dignity? Betrayed? Relieved? Or will they be none of these things?

A lot of folks are completely okay with nursing home placement. Others not so much. And a lot of times the patient doesn't seem to fully grasp what is happening one way or the other.

But I think about them, too.

I guess what I'm saying is that there are so many people who are in, what I believe, is this limbo space. The one where they can live independently just fine if somebody just sees about them regularly. Checks to make sure area rugs aren't heaped up and creating a fall risk or taking a box off of the porch. Runs to the store for them or throws a few old things out from the fridge. Resets whatever got unset when the electricity blinked and puts new batteries in the remote controls. And who asks about the pills and, if they can, does things like arrange them in daily pill containers and throws out the ones that the doctor either discontinued or changed.

And if that person or those people exist, I try to find them. And talk to them. Before jumping to nursing home placement or moving them out of their home to live with someone else. I talk to our pharmacists and social workers and nurses, too. We explore who their support is, like, if they have a church home or some other people out there who really care but who just didn't know. And who would help with something like reconciling medications or pulling the garbage cans to the curb and back if someone asked. Or just slowed them down long enough to think about it.

Moving too fast to notice doesn't mean folks don't care. I mean, not always it doesn't. In fact, many times it doesn't.

Sigh. I'm rambling. I know.

Look. I pray to grow old in this life. There is much that I want to do and see and experience and I think having the wisdom of an elder will make some of those things just that much more awesome. It is my wish to keep my wits about me and my ability to do things on my own indefinitely. But what I know for sure is that, over time, that latter part can hover somewhere between very possible and impossible. I guess what I'm saying is that when that time comes,  I hope someone steps in see about me and advocate for me, too.

Oh, and before someone misunderstands this as me being anti-nursing home, please recognize that nothing could be further from the truth. My point is that function is a spectrum. I'm learning to consider that more. Sometimes there are reasonable work arounds. And sometimes there aren't.

Yeah. Sometimes there just aren't.

But this time? There were some things that we could do. And so we did them. We did. 

Yeah.

***
Happy Saturday. And shout out to the social workers, the family members, the neighbors and the community people out there who see about our elders. You make a difference. You do.

Now playing on my mental iPod. . . .

The hold over.

The first thing I saw when I entered that clinic room was a worn and tattered Air Jordan sneaker hanging off of the edge of the examining table. It was the only thing peeking out from under the mound of sheets and blankets that he'd piled on top of him before curling up into a fetal position. He'd purposely turned his body to face the wall; that blanket tucked tightly between his chin and shoulder like some kind of angry spouse determined to prove that this wasn't an "in the mood" kind of evening.

And see, all of this was super awkward-appearing considering we were in a regular clinic room and not on the inpatient service.  I hadn't snuck up on him in the wee hours of the morning for some quick post op assessment on rounds. No. This man wasn't in a bed so this was weirdly indulgent and a bit odd, particularly since that short little table was no match for a six foot four inch man. I paused with my hand on the door knob the moment I stepped into the room and squinted my eyes, a gesture I knew he couldn't see. Instinctively I began to coach myself to be patient.

Instead of perking up or turning to face the door when I came in with the resident, he didn't flinch. "Good morning, Mr. Ashby," I said to his back. "My name is Dr. Manning and I'm one of the senior doctors working in the clinic today. I've been putting my head together with your primary doctor and wanted to come by to see you, too." He didn't move.

Nope.

Now. I'd already been briefed on the details of his clinical concern. He had some very treatable medical problems that warranted taking medications and keeping appointments. They were the kind of medical problems that could become life threatening over time without specific interventions and lifestyle modifications. But, in addition to missing appointments, he never wanted to talk about any of that.

Nope.

Mr. Ashby wanted to talk about the fact that his back hurt. He'd been in a fender bender two or three years before and had complained of back pain ever since. MRI films, orthopedics consults, and visits to physical therapy were arranged for him which never came to much. No acute findings on those magnetic images, not even a slipped disk or so much as a degenerative change. He missed the ortho appointments and PT discharged him after he skipped the first three sessions and then cursed out the therapist on the other one.

Yup.

See, Mr. Ashby had a fairly clear agenda on each visit. And that was to get some kind of narcotic pain medication. He was pretty much about as uninterested as anyone could get when it came to discussing anything else.

I'd looked through his chart already. I'd spoken to the resident doctor and we truly looked to see if there was any indication for narcotics or high level pain management. There wasn't. That said, he'd been to several emergency departments and clinics and somehow got narcotics every single time. That is, enough to "hold him over" until he saw the next provider.

This. This is what I'm thinking about this morning. The easy wrong versus the hard right. And "hold over" prescriptions for patients who try your. . well. . patience? That's one of the world's easiest wrongs.

Ugggh.

It starts with the body language. Strange contortions that aren't commensurate with the problem or situation. A lady lying on her back on the floor in the waiting area with her feet up on the wall moaning out loud and saying that this is the only comfortable position. A gentleman crying and pacing the moment you get close to him. And on this day? Mr. Ashby--tucked under a pile of blankets that he'd likely dug from one of the supply drawers coupled with the very definition of making oneself at home. All of it off putting and usually the first thing that pops the valve on the patience reserve.

Now. I'm sure this reads like a lack of empathy but I swear I don't mean for it to sound that way. I don't. In these situations, I coach myself to find the indication for, say, hydromorphone or oxycodone. I mean, I really do. And sometimes there is a patient who has truly been misunderstood and who absolutely has been getting their pain undertreated. But then there are the others who've regrettably encountered enough irresponsible or burnt out providers and received such liberal amounts of habit forming medications that now they feel sick without them.

Yup.

And so. A while ago I made up my mind not to participate in the "hold over." I made this decision after repeatedly feeling the pain of seeing the patient who'd been held over. Being unable to arrange some follow up with the treatem-and-streetem provider they'd seen before and tired of feeling bullied into doing something that didn't make me feel good.

So now? I look at the chart and the patient. Then I make an assessment. If, in my medical opinion, Percocet or Dilaudid or Vicodin or whatever isn't indicated? It's a no. A firm, unwavering no. But in the kindest way.

Here's what that means, though: sticky, prickly encounters sometimes. That's what makes hard rights hard, you know? That feeling like you're rubbing a dog's fur in the wrong direction. Nothing about it is ever smooth. And since it is human nature to not like such a feeling, the most natural thing to do is to avoid it at all costs.

Yup.

So. A man treating a clinic exam table like a California King bed and who is trying to negotiate with me on how "if I give him something for pain, he'll let me treat his high blood" might wear a lot of folks down. But not me.

No, sir. No, ma'am.

See, it isn't a pride thing with me either. It's just that giving someone things that they don't need--especially medications that have consequences to health--isn't okay. And I'm thankful that I've been at Grady long enough to see how awesome it is when people get providers who are willing to fight for them. Even when it is uncomfortable to do so.

So yeah. I guess this is just a way to fight for the patient. Though I doubt Mr. Ashby saw it that way.

He told me to go to hell and walked out of the room without even being discharged. His blood pressure was too high and his cholesterol was, too. The cigarettes in his front shirt pocket rattled as he pointed at us and called us names. Mean names. And all of that happened after he'd been lying like Eeyore on that table barely moving.

I'd asked him to sit up and he said he couldn't. I told him I thought that he could and that I couldn't talk to him that way. So when he finally was upright, he pulled the covers over his shoulders and hunched down like Yoda. And yeah, I'm sorry for all of the comparisons but I need you to see what I was seeing. So amidst all of his psychomotor hypo-activity somewhere in there a light switched on to "now I'm going to try to scare you" mode. I cracked the door open and positioned myself in front of my resident.

Yup.

And he yelled and cussed and paced all around. Calling Grady names and me names and all sorts of things. And yes, I listen to my spirit and respond when my fight or flight instinct button gets pushed but most of these times--the ones like this one, it doesn't. I wasn't afraid. Instead I was just sad. For my patient.

He wasn't going to wear me down into a hold over. And I know for certain that this was exactly the way it had happened before.

"I really want to take good care of you, Mr. Ashby. These medications aren't good for you. I can't prescribe you Percocet, sir. But please, let's talk about another way we can address your pain, okay? I think we can come up with something. It won't work exactly like Percocet but you'll start to feel better when your body isn't used to Percocet."

"None of that shit works! Can't you understand? NONE OF THAT SHIT TOUCHES ME!"

"I understand, sir. And part of the problem is that you've been getting Percocet. We have to get you off of it. Away from it. It's habit forming."

"Not for me it ain't. It ain't! I need something that WORK. Can I at least get like a seven day supply until I see my doctor?"

And that's where it happens. The hold over. The chart told it all. Nearly 17 encounters in the last 4 months. Most ending in just that. A few more. To hold him over.

"We won't be prescribing you any form of narcotic pain medication today. We won't administer it here and we can't give you a prescription for it. Do you want to talk about some other options we've thought of?"

And that was the end of it. Him telling us to go to hell. Which is a much nicer way of describing what he really said which involved an F-bomb and a recommendation that I do just that to myself.

Yup.

But you know what? I looked myself in the mirror that afternoon and felt fine with my decision. I did and do think of him but not in the way I think of those I've done wrong.  I hope in my heart he someday realizes that we were trying to care and do right by him. So that's what I think about. Just as much, I think of those other providers he'll see and hope that he doesn't push them into easy wrongs that will hurt his body more.

My job is hard sometimes. It is. Loving people and trying to do right by them is tough. . . . but especially so if it isn't something a person is used to experiencing.

Yeah.

***
Happy Saturday.

Exchange on a regular day in clinic.

"How much do you drink?"

"Not as much as I used to."

"How much would you say that is now?"

"Two to three cans a day. But it used to be six or seven."

"Cans of beer?"

"Yes, ma'am."

"What kind of beer?"

"Usually Colt 45."

"Okay. Um. Okay."

"But no hard liquor."

"Gotcha. Question: What size cans? Twelves, sixteens, twenty-twos or twenty-fours?"

"Twenty-fours is always your best deal."

"So three twenty-fours?"

"Yeah. That sound about right."

"Okay."

"But it's less than before."

"That's good that you cut down."

"Why you still looking at me like that's still too much? I just like beer. That's just me."

"Mostly I'm just looking at you and thinking, that's all."

"Thinking 'bout what?"

"Well. For starters, the fact that you're here. At 8:30 in the morning for a doctor's appointment, you're here. Not demanding anything or with any ulterior motive. Just here to see about yourself. So you care. So I guess I'm just wondering if you realize how this could hurt you. The beer, I mean."

"It ain't as bad as hard liquor. That's what my daddy drank. Hard liquor. Every day 'til he died."

"I hear you. But as for it not being as bad that depends. Beer can be sneaky. You want to talk some about where your drinking falls in terms of your body?"

"I guess. Naw. I mean, yeah. I kinda think I do."

"Okay. So essentially if you're a guy--I mean, a man, you should limit yourself to no more than 4 drinks in a day or 14 drinks in a week."

(interrupts with a laugh) "Ha! See, doc? I drink only 3 per day!"

"Well, not so fast, friend. Ha ha. . .  we base it on a standard drink. So a standard drink for a regular beer is like a 12 ounce Budweiser. But a standard drink of malt liquor like Colt 45 is more like 8 to 9 ounces."

>_<  "Go on."

"Yeah. So that means you're actually having about 9 drinks each day. And about 63 per week."

"Real talk? Probably more like 70 something in a week. I drink a bunch more on the weekends. Just being honest."

"Thanks for that. My point in telling you that is that when you go over those recommended amounts, that's when you start having stuff happen to your body. Like bad stuff that you've probably heard of."

"Damn. For real?"

"Yeah."

"Wow."

"What were you hoping would happen when you came here today? Like. . .do you want to be healthy? I mean, you take your blood pressure pills and you keep these early morning appointments. It seems like you care about your health."

(laughing) "I guess I sorta do. Yeah. I do."

"Okay. Then we'll need to keep talking more about the beer going forward, okay?"

"Okay."

"Maybe between now and when you come back, you can just spend a little time imagining what your life would be like if you didn't drink beer. Or drink at all."

"Totally different. A whole 'nother world, actually."

"Right. Which would probably be the hardest part, you know?"

"Yeah."

"But here's what I'll do on my end: I promise to look at you like you can be a person who doesn't wake up in the morning and drink a beer. And like you can be a nondrinker and like you aren't a lost cause."

"Dang. How you know I had a beer this morning?"

0_o

"Dang. Okay, I'm busted."

0_~

"Being honest, doc? I can't even imagine me without a beer in my hand."

"I can."

"You can?"

"Yup."

"Damn."

"Why 'damn?'"

"Ain't nobody ever looked at me how you looking at me right now."

"And how his that?"

"Like I can win."

"That's because you can."

"You think?"

"I think."

*smile*

*smile back*

 \o/

Yay. Love this place.

****
Happy Tuesday.

Chance of parole.

Your numbers were perfect, actually. Systolic blood pressure at a solid 128 nestled cozily on top of a diastolic reading of 72. Just what the doctor ordered. To make things even better, your blood sugar reading on finger stick that morning was right at 80 and the little paper book into which you'd logged all of the other values you'd clocked over the last several weeks were similar.

I couldn't help but smile as I scrolled through the results of your recent lab tests because, on top of all of the other excellent stats today, your blood work cosigned that everything was indeed under control. Bad cholesterol, lowered. Good cholesterol, decent. Chemistry panel, reassuring with normal kidney function and electrolyte measurements. Even the hemoglobin A1C--the long range blood sugar tracker--was right at goal.

You, my friend, were a doctor's dream. Not only had you followed the directions and recommendations of your physicians, you always seemed to do so with a smile. Lucky for you, your efforts were paying off. The medications that you so diligently took each day were actually doing what they were intended to do without any annoying side effects or, perhaps more annoying, refractory response.

Admittedly, I've always found it difficult to reconcile you with your list of medical issues. Here you are--this mostly fit and youngish person with a metabolic trifecta that seemed more fitting for someone older or heavier in stature. High blood pressure, hypercholesterolemia, and diabetes, too. All attached to you thanks to the power of genetics.

"I try to do exactly what y'all told me," you said with a nod of your head. "Then on top of that, I do more. Like I track my food in a app on my phone and keep track of my work outs, too."

"That's amazing," I said. And I said that because it was true.

"I go as hard as I can because my goal is to get up off of all this stuff. These diabetes pills, these blood pressure pills, and the cholesterol pills, I'm trying to eventually not need none of that stuff."

I raised my eyebrows when you said that. Not knowingly, but I did.

"I'm for real!" you contended. That's how I knew my facial expression may have suggested otherwise.

"Oh, I didn't mean to seem like I was trying to discourage you." I said that even though what I was thinking would likely do just that.

"I play a full court a basketball three days per week, I lift weights and I take every pill at the exact same time every day. I'm glad everything is on point because that means I'm on the right track."

I couldn't disagree with that. We made some more small talk and eventually began to wrap up the visit. "We'll just go ahead and give you 12 months worth of refills, okay?"

"What? On all these pills?"

"On your current meds, I meant. Nothing new."

"Well. I was hoping we could cut something back. Or even out." Your eyes were fixed on mine letting me know that you were completely serious. "I was thinking I could drop one of the blood pressure pills. Or cut down on my diabetes stuff so that I can ease on over to getting off of it."

Damn.

You were putting in the work. Of course you wanted to be rewarded with having things erased off of the chalkboard when it came to you and your list of health problems. As far as lifestyle modifications went, you were already doing everything tried and true and you weren't struggling with being centrally obese, either. So really, all I could say to that was damn. Damn because this was the point where I'd have to tell you that this wasn't a bad behavior thing but, instead, all about the genetic hand you'd been dealt.

"Um. . . . your numbers, I think, look so good because of your hard work but also the current medicines you take. I kind of think what we are seeing is a working plan with regards to you and keeping you healthy."

"But don't you think since I'm doing good, we could cut out a medicine?"

I swallowed hard and bit the side of my cheek. I hated to burst bubbles. "I think if we changed your medicines, things wouldn't be so well controlled, you know?"

"Can't a person eventually get off all this stuff though?" You wanted to know.

The fast answer was sometimes. Because sometimes people who have a lot of weight to lose or changes to make can overhaul their entire situations enough to get off of everything. But that wasn't your story line. Not one bit.

And so I told you that. I let you know that these were likely problems that you'd be living with for good. And I want you to know that sharing this little revelation with you sucked. It did.

"So I'm doing all this working out for nothing?"

"No! It's all making a huge difference. We're where we want to be now. So I think you exercising and all that you're doing is partly why everything looks so good."

I could see that your body language had changed. Your shoulders were now a bit rounded downward and your previously dancing eyes were quiet. "Damn. So I got life without a chance of parole is what you're saying."

That analogy stung when I heard it. And everyone knows that it is the truth that hurts the most."Well," I started, "I like to think of it more as a ball that you're running with. Just keep your hands on the ball and don't drop it. But, yes. For you, you'll have to keep running with the ball."

"Running the ball all the time gets tiring."

"I know."

You looked down, sighed, and then tried your best to sit up in your chair to look hopeful again. "I hear what you're saying. But I'm going to keep fighting. And trying to pass this ball. Or get parole for my good behavior." We both chuckled when you said that. But I could tell you were serious.

"You should."

"I will."
 
 You know? Nothing would please me more than to have you wave a finger in my face and tell me I was wrong. I mean that.

 ***
Happy Friday.

Transitions of care.

"Why live a life from dream to dream

and dread the day that dreaming ends?"

~ Joe Sample

________________________________________

"Tomorrow is March 16. That means that another senior doctor will be taking over for me. I wanted to be sure you knew that since I've been seeing you every day."

"Really? You leaving me, Dr. Kim?"  You feigned a pout but then as it faded I caught something else in your expression. Less playful, more serious. It was hard to put my finger on.

You are young. You'd been very ill this hospitalization with something that would be chronic and life-altering. Over those last two weeks, you'd been through a lot. You appreciated my pictures on the dry erase board detailing exactly what was happening with your body. It didn't bother you when I erased the pain scale for which that hanging board was originally intended (even though the nurses weren't so keen on it.)

Yeah. This had been quite a ride.

"You know? I'm kind of sad about it," I said.  I sat on a chair across from you and twisted my mouth sideways. "You've been my F.P., man."

That made you release a weak chuckle. "Ha. F.P. What's that--favorite patient?" I nodded and you did the same from your bed. "Ha ha. That's what's up, doc."

That was what was up and it was true. Completely true without a single drop of exaggeration.

"How are you?"

"Real talk? I don't even know how I am. This shit is a lot. Like a whole lot."

"Yeah." That was real talk because all of this is a lot.

You looked at my face and seemed to want to counter that with something positive. This was your way; it didn't surprise me. "You kind of made it not as bad. The way you explained stuff. But I think because of that your whole team been real good about coming in and talking to me to make sure I know what the plan is. They do a real good job of that." The side corner of your mouth turned up when you said that.

"Well, that's good, sir, because all of them will likely be with you until you get discharged."

You smiled. "Oh, so you're the only one bouncing on me?"

"That's why they pay me the big bucks."  I leaned down on my knee and rested my chin in my palm. Our eyes locked for a beat and we both smiled.

"People need to know what's going on. Like sometimes? You just lay here feeling scared that they saying one thing in front of you but a whole 'nother thing outside, you know? That's scary."

I was still leaning forward when you said that and chose to remain silent to see if you had more to say.

"I think that's why I was always so happy to see you. I knew you were gon' keep it real."

"What made you know that?" I wanted to know.

"That one day when they did that one test and things had gotten worse? You came in and broke that shit down. Like, you wasn't mean about it but you was like, 'This is your body and you need to know what all of this mean.' And in my heart, I knew something was bad happening but before then I felt like nobody was really saying it all the way. That's the first day you was drawing pictures on that board." You laughed at that. "And that nurse came in here going off when you left."

That made me smile, too. I sort of didn't know what to say, so I just said the first thing to pop into my head. "You deserve to know everything."

"I agree," you quickly replied.

I waited a few more seconds and then added, "You know? There've been times when I felt like I jumped the gun on explaining too much. Like it hurt and didn't help. So . . .you know? I appreciate those words. I do."

You nodded hard and that was my affirmation that you meant what you said.

I stood up to leave. "Alright then, friend."

"Okay, then, Dr. Kim." You put out your fist and I knew the drill. This was our fist bump of departure which, with your youth and your illness, seemed perfect.

I spun on my heel and started out of the room. Just as I reached for the light switch to turn it back off, you spoke once more. "Dr. Kim?"

"Sir?"

"Do you mind stopping by to see about me? Or at least keeping tabs on me from the computer? That would make me feel a lot better."

I cocked my head sideways and let that request settle in. "You know what? You didn't even have to ask."

"I know," you said softly, "I know."


***
Happy Tuesday.

Now playing on my mental iPod. . . . Thank you, Mr. Sample and Ms. Crawford for ministering to my soul this early Tuesday morning. Please listen to these fluttery, smoky vocals and spectacular piano accompaniment.

Paradigm shift.

"Oh man, I heard you guys got him on your team last night. Oooo weee."

"I think this is my first time taking care of him," I replied.

"Really? Damn, how could that even be possible?  Dude. Everyone has had him before."


This was the exchange I had with a colleague the day after my team admitted this frequently admitted man to our service. Yes, him. He was well known to nearly every physician in our hospital because of his constant revolving door hospitalizations for his underlying--and yes, complicated--medical problems.

But mostly, he was also known for being difficult.  Real, real difficult.

"He will cuss you out and then throw you out." This was what one of the senior nurses had to say about him. She went on to say, "Chile please. . . . I've taken care of him so many times that I don't even take it personally any more. He's just a miserable, miserable little soul." She shook her head and punched in a code into the pixis system.

Hmmm.

Him. That difficult guy of legendary status. Challenging enough to grate on the nerves of even the most seasoned Grady nurses--which is pretty difficult to do. Him. Also known as "a miserable, miserable little soul." Guaranteed to either demand that I get out of his room or yell expletives in my direction until I turned red in the face and am rendered completely useless as a clinician. This was the word on the street about him.  Demanding and difficult. Demanding his pain medications. Demanding someone to "cave" in the face of his unruly behavior. And just downright demanding a whole bunch of things.

Yes. This was the rundown that I'd heard.  And no. Nothing about him sounded appealing. At all.


Even one of the nicest people in the entire hospital had this to say:

"Look, there's just no other way to spin it. He's just an asshole." 

Damn.

An asshole?

Look. We're all grown folks here and sure, I'd like to pretend like every single health care professional is SO professional that he or she would never, ever even go so far as to THINK of a patient as "an asshole"--let alone actually say it. But the reality is. . . .members of health care teams are human. They have feelings and nerves that, despite their altruistic origins, can be stepped on. And deep down inside of every single one of them is that "OH HEEELLLL NAW!" button that some patients just push.  If they can find it.

And this guy? He seemed to know exactly where to find it in every person he encountered.

So the count was now at "oo wee" and "miserable, miserable little soul" and now, "an asshole."

My team had seen him first and I knew they would tell me all about him on rounds. A palpable heaviness came over the entire team as we got closer to his room.

Everyone who had already met him looked so tired. The intern. The resident. Even the bright-eyed bushy-tailed medical student. This man had found their button and pushed it hard. They looked so tired. Which immediately made me feel tired.  And I hadn't even met the dude.

Before I could even get down the corridor in the ward, another person saw us approaching and chimed in their jovial two cents.  With a thumb pointing in the direction of his room, the passerby laughed and said to me sarcastically:

"Wow.  . . . Good times, Dr. M."

This was getting nuts. I offered a half-hearted smile and nodded as I watched the passerby disappear into the neighboring room.

Uggghhh.

We paused in front of the door and all focused our attention on the intern. The same tired-looking intern who'd been given the distinct pleasure of admitting him to the hospital. Not tired-looking as in I-was-up-all-night-and-might-be-an-assassin. More tired-looking as in this-dude-is-working-my-nerves-so-bad-that-I-am-dangerously-close-to-catching-a-case.

The intern's face was twisted and emotionally exhausted as he reached into his pocket for his notes.. He shifted between his feet and did his best to channel the most empathic part of his psyche. Next, he launched into this patient's story. The same story that seemed to be playing like a broken record all over Grady Hospital.

Suddenly I heard someone hollering from the other side of the door.

"Jest get the f--k out of my room! I ain't doin' none of that! Get the f--k out!"

My intern looked over his shoulder at the door and then down at his shoe laces. Kind of like a child that was being forced to do something he really, really, really didn't want to do.

"Wow," I said wincing as one of the patient techs passed through the door after being kicked out.

"It's bad," my resident said.

"It's awful," the intern cosigned.

"Oo wee"
"Miserable, miserable little soul"
"Asshole"
"Bad"
"Awful"

I felt like a person who was waiting for a fight after the school bell. All this build up was just too much for me to stand any more.

"Alright, y'all."  I finally interrupted my own thoughts and the intern's presentation that he'd just resumed. "Let's think about this for a minute."  The whole team paused, almost like they were all being operated by a DVR remote controller. I sighed hard and was honest with my intern. "I'm feeling completely drained by this patient and I haven't even met him yet."

"Dr. M. . .he's difficult. Like. . .so manipulative. . .it's just. . .I don't know. I'm sorry."

"No, I hear you." I stared at the card with my notes scrawled all over it and looked over at his door again. "Okay. Let's make a pact. Regardless of how he treats us, we will treat him with kindness and respect. And we won't fight with him. No passive aggressive stuff from us, either." That statement seemed to make my team bristle a bit, so I quickly tried to clean it up. "I mean. . .there is no way that this guy is getting the warm and fuzzy treatment here. No way. I haven't even been in there yet and nearly five people have already made it very clear that being tazed by the Atlanta Police would be far more pleasant than being the person caring for him."

"Tazed?"  one of the medical students asked.

"Yeah, tazed," I repeated. I reached in my pocket for my phone and pretended to jolt him in the arm with it. The team released a bit of much needed nervous laughter. "I'm just saying, guys. How about we just decide right here and right now to throw everyone a curve ball?" I had their attention so kept going. "Look, y'all. Every body was once somebody's baby. This man could not have aspired to be in and out of Grady Hospital infuriating ER staff and ward teams when he was five years old. Like, do you really think he drew himself like this with his crayons when he was in kindergarten? I don't think so." No one said anything. "I know it probably sounds corny but. . . .I say we just try to see that five year old."


Yep. Corny indeed, Dr. Manning.

So in we went. We talked to him as a team and examined him, too. And you know? It wasn't so bad.

I'd be lying if I told you some lovely story of a cosmically heartfelt interaction shared between us. Okay. . .yeah. . .  wouldn't it have been nice if I told you that the heavens opened up and that he'd become wonderfully angelic? Wouldn't a perfect ending have been for us sing kumbayah and all cry together? Yeah.  He was still 100% difficult, 200% unreasonable, and 300% annoying and manipulative.

Yes. I said it. Annoying and manipulative.

But you know what? Sometimes my kids can be annoying and manipulative. And hell, depending upon what's going on with me and my husband, I can be the same way--especially when I'm dealt a hand that I don't like.

Hmmmm.


Shortly after we saw him that day, someone walked up to our team and made another negative comment about this patient. In unison, we all just sort of looked at each other and didn't really respond. For the rest of his hospitalization, we spoke of him with compassion, paid no attention to references about his prior behavior, and . . .dare I say it? Simply showed him some love.

Cliche, I know.

And you know what happened next?

By the end of his hospitalization, nearly everyone else did, too.

***
Happy Sunday.

"The greatest healing therapy is friendship and love."  ~ Hubert Humphrey.

You make a grown man cry.

"You make a grown man cry. . . ."

~ Mick Jagger in "Start me up."

That first day you went off on me and everyone else.

"I'm in pain!" you yelled in no particular direction.

"I will work on your pain," I said back to you, my voice decidedly softer than yours.

"Yeah, right." That's what you retorted. Phtooo. Take that.

The next day I ask you, "How do you feel?"

Again you light me up, this time threatening to kick me out altogether.  "Worse! Worse! I'm in pain! Y'all got my medicines all confused and I'm still in pain!"

And see, you have a reason to be in pain. This is not some "soft call" where you have a little ache in your back or a visit from Arthur-itis.  No, this pain is legit. And this analgesia you're calling out for is warranted.

I take your venom and withstand your anger because I know it's really at the pain and not me. And, seeing as you're a born-at-Grady elder who happens to be old enough to remember the segregated "Gradys", then that gives you license to go off whenever you feel ready.

"Okay, let me compare your home medications to what we are doing here," I reply.  "Were your home medications helping at all?"

"They were working better than what y'all doing! This don't even seem like it's as much as what I was getting at home and I thought I was s'posed to be getting my pain medicines worked out. This is some bullshit."

"Sir. . .I'm sorry. Please. . .let me look at--"

"Get out, please. Just get out. I need some rest. I'm tired and my body is hurting. Just go."

"Okay. I'm going to put you back on your home medicines and then move up from there. Okay, I'll leave now."

"And turn my television that YOU shut off back on 'fore you go."

"Yes, sir."

"And get that bright ass light, too."

I click it off on the way out and leave with my tail between my legs.

As a team we carefully reconcile your home medicines with your hospital medicines. Looks like we were a few milligrams under what you'd been getting, and we bring it all to speed by changing the orders.

The third day I come in to see you and your back is to me.

"Hey there, sir. I'm making my rounds and I'm here to see about you."

No answer.

"How are you feeling?"

"Terrible."

"Terrible?"

"Terrible."

"The medicines aren't taking the edge off?"

"It helped a little bit, but now I feel sick to my stomach. My bowels are loose, too."  Your voice is quiet and defeated. This is different. . . and it scares me.

"We put you back on what you were getting at home and--"

"I know that. Soon as you said that yesterday I started. But now all I feel is sick."

"I'm sorry. . . what do you mean by 'as soon as I said that?' Do you mean the nurses told you it was a new dose?"

"What?"

"The medicines. You said you started as soon as I said something? That part confused me. Just wanted to get clear."

You reach under the bed and pull out a plastic Kroger bag full of pills. "No, I'm talking about my home medicines that you said to get back on. These here."

Wait, huh?

"Sir. . .wait. You're taking. . .hold up. . . you're taking these . . . and the ones we're prescribing in the hospital?"

"I did what you said." You point straight at me. You are talking about ME. Not my intern. Not my resident.

"What I said? You mean you are opening these bottles and taking these pills in the hospital?"

"Just the pain pills. Just those like you was talking about." You pull out a bottle and show me. "I took two of these here."

I look and then read the bottle. You have just shown me some Reglan to help with digestion. This is not a pain medicine at all. "This is what you took, sir?"

"Yes, I took my pain pills from home. That's what you said!"  Your voice is rising higher and cracking a bit. Your repeat yourself. "You said to get back on my pills from home!"

Briefly, I'm relieved that you didn't take double the amount of narcotic pain medicine, but that is only fleeting.  I squeeze my eyes and rub my forehead with the heel of my hand and sigh. "Sirrrr. . ." My voice sounds scolding, even though I don't mean for it to sound that way. "Noooo. .  .noooo. . . .you're never supposed to take your pills from home when you're in the hospital. This could really--"

That was it. That was the straw that broke the camel's back.

Your face melted into frustration and tears began shooting out of your crinkled eyes. You shriek out, "I DON'T KNOW!!! I DON'T KNOW!!!  I DON'T UNDERSTAND THIS! I DON'T UNDERSTAND THESE MEDICINES!!!"  Your body is limp and your shoulders slump. And you weep. An exhausted, exasperated, tired weep.  "I'm tired of the pain. I just want to stop my body from hurting. This illness going all through my body. . . I know it ain't a cure but they said. . . you said you would help my pain. Please, please. . . .help me."

Your hands are shaking and your lips are quivering. Each word is punctuated by your throaty cry. That cry sounded like it had been bottled up for all seven of your decades and I had just rubbed it out just like some kind of genie. It rose out into the hallway, first slithering around my head and strangling my neck.

I stood there dumbfounded.  My face felt like it was on fire and my eyes blinked like some kind of involuntary tick to fight back the rapidly forming tears. I dared not talk. I had done enough.

I reached down and patted the bed, looking at you for permission to sit beside you. You nod, still crying. . . now trickling off into restrained manly crying instead.

And so I sat next to you in silence. I held your hand and wiped your cheek with some paper towel since it was the only thing sitting on your tray table. Then, when you were ready, we started over. Going through each medicine one by one. . . opening the bottles, pouring out each pill, and making it more concrete.

You told me that sometimes it's hard to see the words on the pill bottles and that even when you can, sometimes it's hard to read them depending on the words involved.  I tell you I should have asked that and I apologize for what feels like the one hundred-trillionth time.

Then, eventually we get somewhere.  I excuse myself with your permission and share this with the other members of our team. The intern, the resident, the pharmacist, the students. I let them see how ashamed I feel and how much it hurt my heart to see you cry. Yes, you. A grown man. Their faces look sorry, too, and I say nothing to blow it over or shrug it off because you being confused and in pain and frustrated just isn't acceptable. So together, we vow to do better.


And so we do.


On the fourth day you were smiling. A big beautiful, nearly toothless smile. . . lighting up the room and even the hallway.


"How do you feel today?"


"Spectacular."


"Spectacular?"


"Spectacular."


***
Happy Wednesday.

Side effects.

This picture was taken on rounds the other day. . .just two seconds after my resident and I sang "Happy Birthday" to one of our patients. We sang it loud and proud and our patient just smiled and smiled.  Man, how she smiled. My favorite part was the part where she was singing with us and substituted "Happy Birthdaaaay, dear ME-EEEE" for the part where we said her name. I also loved how she was waving her fingers high and animated like a conductor leading an orchestra through a beautiful masterpiece concerto.

People were wondering what the commotion was about and sticking their head in there and everything. That made her smile even more and us sing even louder and prouder. She then said, "Wow. I feel so special."

Yeah.  That's what she said. And isn't it cool for someone to say that to you on their birthday? Because really, isn't that your goal on somebody's birthday? Like, isn't it really?

We examined her carefully and compared our findings that day on rounds. Next we wrote orders for her medications and discussed the progress of what had her hospitalized. Yes, we did the business part and answered all of the questions, too. We crossed the 't's' and dotted the 'i's' and made sure about the things that needed to be made sure of. We sure did.

But the best therapy we had to offer that morning on rounds was when we sang "Happy Birthday." Loud and proud. . . .


Man. I love it when "feeling special" is a side effect of our treatment.

***
Happy Sunday.

Who cares?

Just don't deny it,
Don't try to fight this

and deal with it
and that's just part of it. . .

from Apocalyptica "I don't care"

A colleague that I don't know personally read a story I wrote about one of my F.P's that was recently published. Using the author correspondence, he sent me a kind email and said some things in it that got me thinking. . .

One of the things he said was this:

"I've never been to a patient's funeral, nor am I sure I ever would or could."

He went on to share about how he struggles with personal and professional interactions with patients. In other words, he seemed to be trying to figure out how to manage that thin line between caring for patients and caring for patients. His approach to date had been a "just the facts" one--where he focuses as much as possible on the medical issues at hand instead of holding someone's hand.

Hmmm.

I'm not sure this method is too unusual. Like many people, this guy had a bad experience early in his training with caring too much. He'd gotten his heart all wrapped up in a sick child that, although he didn't refer to him as such, had become his F.P. for sure. Suddenly things took a turn for the worse on call one night. Yes. His F.P. on his watch. Unexpectedly things went crazy and the superhuman response required to right the ship was beyond his intern expertise. Senior folks swooped in with their big professor red cape-brains and saved the day. And that child's life.

That's when he realized something. Here he was sitting there holding this boy's hand and asking what his favorite color was. . . .and exploring action heroes and how to do the perfect handstand. . . . which seemed to make his patient feel better but at the end of the day, was not what saved his life. Medical knowledge right here, right now did. Not him and his pesky hand-holding and stargazing. And this guy? He wanted to save lives.

He closed that thoughtful email by saying something along the lines of how he deliberately tries to keep his heart out of it. But. My patient's story did make him wonder about this approach.

Wow.

So today I guess I'm simply reflecting on all of this. I'm wondering about this notion of going to a special patient's homegoing or funeral or memorial service and whether it's just too weird or not. Like. . .is attending a funeral as a doctor--even if you've been invited--too intrusive or too much? Does it cross a line that caregivers should clearly stay behind?

And.

What about the rest of it--the things like holding hands and asking about all sorts of plans? You know--those plans that have nada to do with nada and that simply serve to create a bond between two human beings. . . . the ones that, when you find out about them, make you care. When all you were supposed to be there for was care.

I can't say that I've ever tried the "all business" approach. Like that guy, I have been frustrated by what I don't know or by those times when me and my little bag of medicine tricks are no match for fickle fate. But when I'm caring for human beings I always want to know. . . .like I can't help it. . . .who are you? Or sometimes. . . who were you? And see, the problem with that kind of curiosity is that your heart gets all up in it. So you find yourself crying in locked bathrooms. Or wrestling down the ugly cry at a funeral.

I've said it here before and have heard other folks say it, too--let your love be a verb. When it comes to being a doctor--especially a Grady doctor--I think I feel the same way about caring. Sure, I read the journals and work to acquire the knowledge, but that's never been enough for me. Even though it's the noun that I get paid for, "care" always ends up being a verb for me.


I love that a one page story nestled in the back of a high impact journal rubbed a probably uber-successful scientist-slash-physician so raw that he just had to send that email. I also love that, after all those years, the feelings behind those moments he spent with that young patient were still so fresh on his mind that he could recount them in fine detail just like that (insert finger snap.) Kind of like the verb care never left him after all. . . . .

Hmmm.

Caring versus caring. Or rather caring verus caring + caring. Speaking at funerals. . . versus keeping it "all business". . .all that stuff. Okay. . . .tell me. . . .what do y'all think? For real, I want to know.


Now playing on my mental iPod. . . .

I think I know you .

*some details changed to protect anonymity.

image credit

__________________________________________________________

Yours was an overcomer's story.  Life had you on the ropes, pummeling you with quick jabs and followed by a firm left hook to the jaw. A near technical knock-out.  First, it was just beer. Occasionally there was alcohol, too, but mostly beer. Malt liquor, to be exact.  Then came the Mike Tyson of them all--crack cocaine.  Your defenses were weakened against this opponent.  Brought to your knees, you were down for the count.

One! Two! Three! Four! Five! Six! Seven! Eight! Nine. . . . . 

You stood up, all woozy, doing your best to regain focus.  And then you started swinging. And swinging. And swinging.  Until the ruthless tag team of Colt 45 and tiny plastic bags of white rocks fell bloodied and surrendering.  It had been almost a year, and you were winning.  The comeback kid, now in a recovery program and taking it "one day at a time."

So this was your story, your overcomer's story, told to me by this thoughtful intern in his careful and empathic tone. He wrapped your story up with a shiny red bow for me, such that I imagined you before I even made it into the room to see you for myself. The hard times you'd fallen upon, the periods of unstable housing and high risk activities you engaged in, not because you wanted to, but because back then, you were on the ropes.

The age on your chart was not far from my own, but I expected your struggles to have aged you. Like other overcomers I'd met along the way, I knew you'd have the light of someone reborn gleaming in your eyes and more than likely a body that yes, was still ticking, but that had clearly taken a licking.  Perhaps your teeth would be riddled and decaying from those years of neglect or your belly protuberant and taut with a cirrhotic's collection of peritoneal fluid.  Maybe your ankles would be swollen from the volume overload of alcoholic cardiomyopathy or your fingers scarred with burns from tiny glass crack pipes.  Maybe.

With every word the intern spoke, your image sharpened.  You. Now in recovery. For over a year. Now winning the welter-weight division. Taking care of yourself for the first time in a long time with a little help from your friends. You. The picture of the overcomer crystallizing even more in my mind. Would you have the freshly cut hair, those clean, clean socks they always issue, or be carrying a proud collection of Narcotics Anonymous key fobs? Or just maybe might you have a prominent crucifix around your neck and answer me by saying, "blessed and highly favored" when I ask how you are today or refer to your recovery from drug and alcohol addiction as "delivery" instead? Perhaps.

See, I am a Grady doctor so I already knew you. And I had heard your story before. See, yours was an overcomer's story.  And working at this place day in and day out, I've met you and been moved by you before.  I've shaken your hand and congratulated you for beating the odds. And sometimes on my way home from work, even prayed for you by name. Yeah. I knew you.

So even though I'd only heard your story rolled out like parchment paper by the young doctor who saw you first, I knew you already.  And since the younger doctor had now been at Grady for close to a year, perhaps by now, he knew you, too.

"Shall we go and see him?" I asked after listening to the assessment and plan.

"Sure, I'm ready," the intern replied.

This visit was a straightforward one.  A minor complaint and a focused visit with something easy to remedy. The intern selected a medication that wouldn't hurt your liver or get you in trouble at your recovery program.  I'd spend most of my time congratulating you on your recovery. You deserved to be congratulated, and because I knew you already, I figured you'd appreciate it very much if I did.

We knocked on the door and entered your room.  I smiled and introduced myself, arm outstretched to shake your hand.  Yours is a firm handshake, an overcomer's handshake.  I covered it with my other hand and said, "I've heard so much about you, and it's really an honor to meet you. Congratulations on all you've done."

And I meant that, because I hadn't been through what you have been through. Or overcome what you have overcome. So yes. It was an honor to meet you.

But then I look closer at you.  Surprisingly, you are healthier-appearing than my imagery; the mutinous body I expected had withstood that terrible beat down I'd just had described to me quite well. That part caught me off guard. But. . .like I suspected, you did have that light in your eyes. . .it was almost familiar. Our eyes lock for a moment.


Wait.

Your easy smile and twinkling eyes take me somewhere I've been before. No, not to a hospital bed or a clinic room, but somewhere altogether different.  Then you laugh, a slow and confident laugh. Like a southern drawl kind of laugh, decidedly unique. And undeniably familiar.

Wait. I have heard this laugh before.

My eyes dart down at your chart again. I read your name. And read it again. I look at your age. And then at your face.

Wait.  Are you . . . . ?

I cover my mouth and gasp. 

Immediately, an uncomfortable feeling washes over me as it registers. I know you-know you.  No, not in the biblical sense, but in the we-were-peers-at-some-point sense.   

What the. . .? 

Whoa! This image is the polar opposite of the one I'd had just five minutes earlier. You. Standing on our college campus with a heavy backpack full of books.  Surrounded by your fraternity brothers and always by flocks of swooning and giggly undergraduates. You. With that same molasses laugh while giving "man hugs" and secret shakes to those same fraternity brothers, a satin stole designating your summa cum laude status at our university commencement. I was younger and not necessarily in your inner circle. But our college was small. Small enough for me to know you.

"I think. . . ." I paused for a moment, deciding whether or not to acknowledge knowing you, " I think we know each other."  I know my facial expression was awkward.  And okay, I admit that part of me was intrigued. . . .but most of me was conflicted. 

You study my badge for a moment and then look at me with squinted eyes.  "This is my married name," I added, "oh, and back then my hair was a lot long--"

"Kim?" you suddenly interrupted incredulously. Then you smiled, stood up and repeated it louder, "Kim Draper?"  Without a moment's hesitation, you reached out and gave me a tight and welcoming hug. The kind of hugs people who went to our small college give each other when they run into each other in airports or shopping malls.  "Hey, Kim! Wow! It's so good to see you! What a small world!" Your face is beaming.  And genuine. And not the least bit ashamed.

I immediately relaxed, too.

"You look good!" I responded. And not "good" in that "you've been to hell and back and considering that you look good" kind of way. But good, for real, in that "you're forty-something and you don't have  a pot belly, a receding hairline, or seventy-five extra pounds" kind of way. 

"Thanks, man!" you replied still smiling as you took your seat again. "I never would have recognized you with that short hair.  Wow, man. . . . it's good to see an old friend."

I looked over at my intern who looked totally confused.  "This guy was the man when we were in college," I said to him with a chuckle. "And he was super smart.  You know I dropped Math 107 three times before finally passing it?"

"107, Kim? Damn!"  We both laughed out loud.

And so we got on to why you were there.  I reviewed your complaints. Repeated the intern's examination.  Discussed the plan, referring to you as "Mr. ___" the whole time during that part. Despite your reassuring laugh, I tried to keep the details of your time on the ropes as vanilla as possible; I wanted the mood to stay light. Like homecoming.

You referred to mutual friends of ours, and then asked about my sisters. "They're great," I told you.

"Tell them I said hello, will you?"

Your shoulders didn't coil inward once nor did your eyes become defeated a single time.  Nope, not once.  Of course, they didn't. I should have known they wouldn't. You were an overcomer.

"Hey, listen, Kim. . .it was good seeing you all in the doctor-mode and everything," you said to me as we wrapped up the visit.  You gave me this approving nod as I stood near the door in my stiff white coat. "Dang, K.D., I'm really proud of you, man."

I smiled and then said exactly what I was thinking. "Man, I'm really proud of you, too."

You get exactly what I mean by that, and so does my intern, which was really cool.

As we left your room, the intern looked over at me and said, "Wow, so you knew that guy?"

I recounted all my preconceived ideas of who I thought I would see before entering the room, took a deep breath and smiled.

"Yeah, I knew him," I replied, "but not like I thought I did."

***