Mass confusion.

It a little bit sound like the Charlie Brown-cartoon-grown-up voice. All wobbled up and hard for somebody to understand. I keep looking at her and she looking at me. I'm smiling so she won't think I'm confused.

But I am.

Okay. I ain't stupid. I know I ain't. But this? It's so much so fast. Something 'bout how at first there was one medicine but that one did something and now she want to try another one. Big words for no reason keep throwing me off. She seem like she in a hurry, too. At some point, I just said bump it. I'll just see if the man at the WalMart pharmacy can help me.

Keep smiling. Smiling while she looking over all my pill bottles.

"This one is renal protective. Since you have diabetes that's a medicine you need to be on but your potassium has been creeping up. We'd thought about holding that one but there's also the added benefit of ventricular remodeling with your heart failure. In other words, how the heart is shaped and how it responds to all that's going on with you."

She set that bottle down after she said that part. It felt like a door slamming on me. Right in my face.

"Uh huh."

Still smiling.

"You with me, Mr. Allen?"

I just nod 'cause I don't want her to start over.

Now. What the hell do RENOPROTECTIVE mean anyway? I don't know. But she been talking  so much and for so long that I don't even want to ask. She seem like she care so much, too. But she talk so fast and with all these fancy ways to say stuff. RENOPROTECTIVE? What? And the remodel part don't mean nothing to me. I hope it mean something to the man at the WalMart pharmacy.

Smiling. Head nodding.

"There's a lot of compelling data to support us keeping an eye on the the K since the benefits far outweigh the risks of you being on an ACE."

K? What the hell is that?

"Oh. I almost forgot. K is just our abbreviated name for potassium. It's a salt in your body."

"Oh, okay."

"So, we'll keep the ACE on board and the thiazide, too. I also think it's a good idea to switch this atenolol to Coreg. I have no idea what you were doing on that atenolol when you have known systolic dysfunction."

Because y'all prescribed it when I was in the hospital, that's why. "Okay, then."

"Carvedilol is the superior beta blocker for patients with heart failure. There's plenty of good data to support that. It's more potent, too, so I think we'll get the most bang for our buck there."

I thought you just said a different name. Now I'm confused.

"Question, sir?"

"Uhhh. . . what is Coreg?"

"Carvedilol. That's just the trade name for it."

"Oh, okay."

Trade name? Whatever that is. So why the hell are you going between two names for it anyway? I don't even know what it is. But something about it being superior or whatever the hell she keep saying sounds okay, I guess. I guess.

Smiling. Nodding my head some more.

Here's the thing. I don't get ninety percent of what she say to me. But it seem like she care and like she smart. So even if it sound crazy, I just go with what she say.

Now she studying all my pill bottles like somebody gon' test her on 'em later. I kind of have to pee but hopefully we almost finished.

"Hey! What's this?"

Now she's looking at another bottle and her face is all twisted. Shit, I don't know. I just brought in my bag with all my bottles like you said to do. They changed some medicines when I was in the hospital last month and I thought all this was in that computer. Why then, she got to act all surprised like nobody is talking to nobody?

"How long have you been on this clonidine?"

Cloni-who?

I take the bottle and look at it. "That's from when I was in the hospital. I started it after I left."

"Uggh. I hate clonidine. What the heck were these guys thinking? Clonidine? Atenolol? Are you kidding me?"

I don't think them questions was for me. It was for the air, the situation and for herself. Words that woulda probably been spoken even if I wasn't there. Here's what I just decided. It make me kinda uneasy when one doctor make it seem like another doctor ain't doing right by you. Seem to me like everybody need to get on one page.

But the cloni-whatever wasn't my favorite. I stopped it like a week ago since it didn't agree with me. Why not tell her?

"That pill make me feel a little bit drowsy so I don't always take it."

Damn. What did I say that for? Now she shaking her head and mumbling some more stuff about the other doctor who gave me that medicine. But I was just being honest.

"Clonidine isn't always best for everyone. Yes, it can make you drowsy and it also causes rebound hypertension."

Whatever that is.

"When was the last time you took it, sir?"

"Ummm, I think yesterday." And by yesterday, I mean last week.

"Yesterday? Ugggh. Okay."

Now she typing all fast into that computer. I kind of like that they put the notes in the computer. But  look to me like they'd have some better idea of what's happening if they looked at what each other was doing.

"Maybe I took the clonidine last week. Not yesterday."

"Okay. Well we're stopping that anyway. The Coreg should do the trick, I think." She paused for a moment like she was about to say something else. "You still smoking?"

Shit.

"Uuuuhhhh. . . "

"I can smell cigarettes on you, sir. It's okay, you can tell me."

I smell onions on your breath from your lunch break but I didn't just call your ass out on it. Damn.

"I cut back a lot, though."

"What's that mean?"

"A pack last me three days now. That's a lot less."

Now that part was true. Last time she was pushing me to make a 'quit date' and to get her off my back I just went on and said I'd quit on my birthday. That day came and went.

"Hmm, okay. I know we'd set that quit date before. How are you feeling about quitting?"

"I want to quit."

That's true, too. Eventually I want to quit. But as far as being real, real ready to quit right this second, no. I drive trucks. I ain't really in no position to not smoke. What truck driver don't smoke? Well. There's Jimmy who quit. I think Big Marsha quit, too and she was a chain smoker. They went cold turkeys and I ain't so sure about that.

"Okay. We can set another quit date and this time use some nicotine replacement. How's that sound?"

It sound good for somebody ready to quit. I said I want to not I'm ready to. And I heard them nicotine patches make your skin break out and make you feel all jittery. She looking all up in my face so I better not say nothing, though.

"I guess that's okay."

"Okay, great." She starts squinting at this calendar on the wall. "What do you think about Thanksgiving?"

"What do I think about it?"

"Yes. As a quit date?"

"For the cigarettes?"

"Yes, Mr. Allen. That would be a great way to celebrate your Thanksgiving. What do you think about Thanksgiving?"

Here's what I think about Thanksgiving. I think I'm gon' have me some pie and loosen up my belt buckle after a big plate of food. Maybe two plates. I think I'm gon' play some bid whist, spades and dominoes with my sister and my brothers and my sons and we gon' talk shit and drink Jim Beam. And we also gon' smoke. That's what I think about Thanksgiving.

"That might be a little soon."

"Okay. How about Christmas?"

How about changing the subject? How 'bout you recognizing that we do the same thing on Christmas as we do on Thanksgiving?

"What do you say, Mr. Allen?"

This time she winked at me.

"Um, yeah, okay."

"Great, sir. That's great!"

More typing.

"We have flu shots in. So we'll give you one of those today, okay?"

Today? Damn. I'm not so keen on those. Last time my arm hurt for two whole weeks. But if I say no she gon' say what she said last year about me having sugar and how if I get the flu I could die. I don't know anybody who got the flu and died. Not a one person.

"Can I wait on that?"

"I wouldn't recommend it. You know you have diabetes and heart failure and if you were to get influenza it could be life threatening."

Told you. Now it's heart failure, too that will kill me with the flu? I just don't have it in me to fight. Plus my bladder feels very, very full and I want to just pee and then leave. See? That's why I don't like taking my water pill on the day I see the doctor.

"Okay."

"Okay for the flu shot?"

"I guess."

She holds a thumbs up. I smile. Again.

The last part involve something about this colon test I have coming up in a month. How it's very, very important for me to get this, especially since I'm Afro-American. I don't even remember saying I wanted that test. Or us talking about it. I do remember when my brother Charles Edward got that test. He said that stuff they give him the day before had his bowels running off so bad he thought he had the choler-y.

"It's only every ten years. Unless they find a mass or something."

A mass? What the?

"You know, like a polyp or something."

Charles Edward didn't say nothing about that.

"What happen if you don't get that test?"

She already revved up. "Well, if you had a colonic mass and it went undetected you could have colon cancer spread all through your body. The most aggressive forms affect African-Americans."

Here we go with that again. When did we switch from being black? Are we still black? I don't even know. I know we ain't colored. But NAACP still got the word 'colored' in it. I wonder why? Hmm. Hell if I know. I'm just ready to go.

"So that's on the twenty-second, okay, sir?"

"That's fine, ma'am. Are we just about finished up? I want to get to this pharmacy, you know." And to this bathroom. "Plus my son waiting on me, you know, and he got to get on to work."

"Absolutely."

Typed some more. Said a few more things, this time even faster than all the other stuff. Then when she was done with all of that she reached out and touched my hand.

"I love taking care of you, Mr. Allen. I hope you know that."

I smiled because that was kind. "I like you, too, doctor."

"Let me know if there's ever anything I can do to take better care of you, okay?"

She still got her hand on my hand and she looking all in my face like she really want to hear what I got to say. And man, I do got so much stuff to say.

Like:

You can slow down. You can use some smaller words. You can maybe draw it on a piece of paper for me. You can know that ACE and K and COREG and CARVEDILOL and COMPELLING DATA are words that sound like another language to me but how you say them in my direction seem like you think I speak it. I don't. So you could know that.

And:

You can not say nothing bad about the other doctor that saw me in the hospital. You can look inside the computer to see what they did. You can let me see how I feel about cigarettes. And flu shots. And not scare and confuse the shit out of me by saying something about a mass on my colon. You can just overall explain stuff to me different. Slower. Less fancy-like. You can know that even though I can read and write it don't mean I get all that you say. You can remember that when you talk to me. All that. That would make it better for me.

It would. It really, really would.

But that's a lot. And saying all that would make my son wait longer in that waiting area and my bladder almost explode. Plus it might hurt her feelings 'cause Lord knows it seem like she thinking hard and long about me. So I keep it simple.

"Okay, doc. I will."

"Alright, Mr. Allen. See you in three months?"

"Yes, ma'am. Three months."

***
Happy Saturday.

What remains.

*names and details changed to protect anonymity. . .yeah, yeah. . .you know the drill.

image from here

In Shel Silverstein's children's classic "The Giving Tree" he tells the story of a boy and his best friend, a tree. And though some people have real strong and sometimes negative feelings about the meaning behind this book--I mostly think the story is beautiful and selfless . . . .in that prodigal-son-kind-of-way, you know?

Kind of like many of the people who have given selflessly to me in my lifetime.

Anyways.

Early on, all that the tree has to offer the boy is obvious--outstretched branches for shade from the summer, sprawling limbs to climb, and ripe, juicy apples to eat. But later in that book the boy grows older. Eventually as an older man, the boy comes to the tree, who is now a stump.  At this point the tree feels convinced that he doesn't have what the boy is looking for but as it turns out his request is simple and doable; he wanted a place to sit.

Aaaaaah. 

My children are only six and four, so they generally need me for most things. I often wonder what things will be like when they grow older, and then secretly cross my fingers behind my back hoping they will always need me (but in that gainfully employed, fully independent kind of way, of course.) Just when I start to worry, I think of how much my parents have had to offer me in my adulthood and breathe a sigh of relief. And I tell myself of Isaiah and Zachary--of course, they'll need me.  Of course they will.

But raising up doctors is different. Especially resident doctors. They come to you as clinical babies, cooing and sometimes crying. Over those three to four years you stand behind them as they take their first steps, applaud their every achievement, place band-aids on their boo-boos, and offer tough love and redirection when they make mistakes.  Their learning trajectory is fast and furious, and one day, when you least expect it, they're just as tall as you.  Some even taller.

And so they grow. You sit across from them in clinic or stroll the wards on rounds realizing that your shoulders are at the same level. They speak of things cutting edge that just maybe you haven't heard yet and pull out electronics that perhaps you've never even seen. They prove to be responsible drivers so you let them drive sometimes without you, and when you do get in the passenger seat, you find yourself surprised at how well they can maneuver a five speed without your two cents. 

So you wonder. What can I do?  You've climbed my limbs and basked in my shade. What can I do?

Today I am reflecting on something that recently reminded me of the answer to that question.

image credit

Grady Hospital Primary Care Clinic, Spring 2011

"Okay, so we'll see how things go with diet and exercise in terms of his blood pressure. I think he's pretty motivated to work on shedding a few pounds."

"Didn't you say he had diabetes?" I asked with my eyes squinted.  With diabetes and a blood pressure reading of 161/94, "diet and exercise" didn't sound like the best game plan. At all.

I was slightly surprised considering who I was talking to. This resident was in the last half of his final year of training and usually gave such pristine patient presentations that I'd find myself grasping for teaching points. With some of our strongest trainees in the latter portions of their residencies, finding something to "teach" or "correct" can be downright intimidating. But this? This was odd.  And hearing this guy say that someone with diabetes and such poorly controlled hypertension should simply move more and eat less--without any medication changes--didn't quite make sense.

He sighed and looked down at the ink pen twirling nervously in his hand. "I know, Dr. M. But this guy?" He sighed again and chose his words carefully. "I mean, he's just. . .I mean he's totally against being put on more medication. I mean. . .and he's such a great patient. . .like. . .he really takes an interest in what's going on with his body. I just. . .I don't know. . .I just want to respect his wish and see what we can do without adding new medication that's all."

I stared at him and nodded slowly. My eyes then darted back over to the monitor displaying the patient's electronic medical record.  A few mouse clicks later and it was quickly confirmed that a conservative approach had been taken to his blood pressure at the last visit.  "Wow. His blood pressure wasn't controlled at this visit either." I scrolled downward and then brought up a page trending his blood pressures. Initially "borderline" but for the last two encounters, officially uncontrolled.

Next I moved to the page with lab values. Highlighted in bright red was one abnormal result--the patient's kidney function. I winced and peeked back at  my resident with an eyebrow raised.

"I know," he whispered. My resident pressed his lips together and shook his head.

I leaned my elbow on the counter and rested my chin in my hand. Keeping my eyes on him I said exactly what was on my mind. "Okay, I'm confused. What's going on?"

Because something was going on. This resident was an all-star. I was 100% certain that he knew the specific guidelines and the exact literature on management of high blood pressure in patients with diabetes and kidney disease. In fact, at this point he more than likely knew these kinds of details even better than me, his supervisory attending. So the question was simple. What was going on?

He shrugged his shoulders. "Dr. M? I need some help with this. Like help communicating," he finally said. "I mean. . .this patient is super nice, like I said. . .but so opinionated and firm in his resolve, you know? Like he's taking notes and asking questions and. . . it's hard to explain."

I nodded and waited for him to try.

"I think I want to. . . .like. . .I think it might help me to watch you talk to him. What I want to do is add a second medication.  He's maxed on an ACE inhibitor and I'd really like to add a calcium channel blocker. I mean, honestly? His cholesterol is slightly over goal, too, but I didn't even touch that today. I just didn't know how. He's not angry or difficult or anything. Just. . . .determined. I need help with this, Dr. M. Can I just watch you talk to him?"

And no, he wasn't throwing me under the bus. This all-star senior resident who could recite journals like the alphabet and conjure up obscure facts like a computer was asking me to teach him something. And it felt wonderful. Like that way I suppose parents feel when their kids are blossoming adolescents or savvy young adults but still come back for help with something simple. Or like in The Giving Tree when the boy just wanted to sit on the stump and that was it.

Watch me? Watch me talk to your patient and that's it?

And so I did my best to conceal the tiny wave of emotion that rolled over me and said, "Okay. I can try."

Mr. McCutcheon

When we came into Mr. McCutcheon's room, he immediately stood in deference. "Good morning, doctor!"

"Oh my," I laughed, "You don't have to stand!"

I liked his firm hand shake and pleasant demeanor.  My resident leaned against the sink as I initiated encounter.  With Mr. McCutcheon's permission, I repeated a few key elements of the examination and then gestured for him to sit down across from me.  The first thing I noticed on the desk was a neat stack of colorful papers.

"What is this, sir?" I inquired.

He turned two of the sheets around to face me.  One was a computerized graph of his blood sugars which had been beautifully controlled.  The other was just as colorful and consisted of two months worth of blood pressure readings, all averaging somewhere between 140's and 160's systolic (top number) and 80's to high 90's diastolic (bottom number.)

"This is amazing."  I said that because it was amazing.  I decided then to cut to the chase. "Mr. McCutcheon, sir, it's my understanding that you and your doctor have been trying to avoid adding more medications."

"Correct.  I lost four pounds since the last visit, and just started a walking club a few months back. I cut out bread and it's been going well. I am pretty sure I can do without another medication if I keep this up."  His face was still pleasant and just like my resident said, motivated.  Nothing about him was confrontational or difficult. Just. . . determined.

"I see."  I picked up the sheet with the blood pressure readings on it, and beneath that was a piece of notebook paper with a few notes he'd taken.  "I'd bet you were a good student during your school days."

"You know, Dr. Manning? I just always loved learning. Always.  School didn't come easy to me, but I always tried hard, you know?  My mama always said that I was hungry to learn."  He chuckled a bit, which made the redundant folds on his chin shake a little.

"Okay, Mr. McCutcheon. . . well that gives me an idea on how we can proceed."  He looked a little puzzled for a moment, but mostly intrigued.  I pulled out my pen and grabbed a sheet of blank paper. He scooted up his chair and craned his neck to show that he was fully engaged.  "What I want to do is talk about your visit as I would to another doctor or a medical student. Is that okay?"

His face lit up as he nodded in the affirmative. He reached for a steno pad out of his bag in case he needed to take more notes which warmed my heart.

And so the lesson started. First I explained to him the classifications for hypertension or high blood pressure. I wrote at the top of the paper--PRE-HYPERTENSION, STAGE I HYPERTENSION and STAGE 2 HYPERTENSION. "Once the top number or systolic is consistently160 or more, this is stage 2. And the thing I always remember about stage 2 is that 'two means two.'"

"What does that mean?" Mr. M stopped from his notetaking to ask.

"It basically means that if you have stage 2 hypertension, you almost always will need at least two medications to treat it." He nodded to show me that he was with me. "Okay, but now here's a more tricky part. You have diabetes, sir. Your last lab work also showed that your kidneys have weakened just a little bit--not so much that it is terribly alarming--but it's something we need to pay attention to. Were you aware of this?"

"Yes, ma'am, my doctor told me. Does that mean dialysis or what does that mean?"

"No, it definitely isn't at that point. See, we look at this test called the creatinine. It's something your body breaks down from muscle and your kidneys should be able to filter it out. We check the blood to see the level of the creatinine and if it creeps up, we know that filter is off some. Your number was 1.6. It really should be under 1.4.  Since we know that diabetes and high blood pressure affect your kidneys, experts recommend that we get pretty hard core when it comes to getting blood pressure down in people with both diabetes and kidneys that are getting weaker. We call the weaker kidneys 'nephropathy.'"

"Like a nephron, right? A kidney cell?"

"Exactly, sir. Exactly." I drew in a sigh and continued.  In block numbers I wrote a 140 and a 130 on the sheet with a big arrow next to the 130.  "In people without diabetes, we want to see the top number under 140.  But in people with diabetes and especially with diabetic nephropathy, that number needs to be even lower." I drew an 'x' over the 140 and circled the 130.

"Like under 130?"

I nodded.  From there I even launched into cholesterol guidelines and how they relate to heart disease prevention in diabetics and simple things like taking a daily aspirin. Mr. McCutcheon hung onto every word and yes, his mama was right--he was hungry to learn it all. "So here's what I need you to do for me.  With the student doctors and resident doctors, this is the point where I ask them to tell me what should be the next step in the treatment plan. I want you to take a second to look at your notes. Then look over this blood pressure graph you brought in, your cholesterol level and at your medications. Now what I want you to do for me is tell me how you would manage yourself as a patient if you were the doctor--not based on what you want, but now that you know what you know. You are the doctor trying to prevent a patient from getting worsening kidney function or heart disease."

And you can guess what happened next. Mr. McCutcheon obliged me--big time.  Over the next three minutes, he looked over those notes and jotted things down on his paper. He circled things and drew arrows and scratched the side of his head.  Finally, I playfully told him that his time was up.

"Okay, doc, tell me how you have assessed this patient and what you plan to do for him." We both smiled, feeling connected during our little role play.

My was he a great sport.  Mr. McCutcheon broke everything down and then some. He told me that his 'patient' had stage 2 hypertension, yet was only on one agent.  He explained that 'two means two' and that although the patient was reluctant to do so, the right thing to do was add another medicine. Then he added that if the patient continued losing weight, that maybe we could revisit it. Genius! Next he told me that having 'sugar' is like having had a heart attack before so the cholesterol level needs to be lower.  "The LDL," he said firmly, "and just remember that the 'L' stands for 'lousy' because that's the bad one."

I glanced up at my resident for the first time during the encounter whose face was painted with a big, proud smile.  Mr. McCutcheon recommended that in addition to the daily aspirin to protect the patient's heart that it's time for us to go ahead and get him on some cholesterol medication, too.  But of course, if he keeps losing weight, we could revisit that, too.

And so, that's exactly what we did. We followed every one of Mr. McCutcheon's recommendations and he willingly accepted them all.  It was one of the greatest patient-doctor communication moments I've had in a very long time.

When clinic ended that day, my resident pulled me to the side. "Thank you so much for taking all that time with Mr. McCutcheon, Dr. Manning.  You have no idea how much I learned.  But you know what? I always learn something when we work together."

You do?  

See? The person who criticized "The Giving Tree" missed the point. They misunderstood it all, thinking that the tree gave and gave but got nothing in return. . . .

Au contraire, mon frère.

Yes. There's something in it for us. We are more than just old stumps . . . and no matter how much time goes by, our branches are still sprawling and fit for climbing whether we realize it or not.

***
Happy Tuesday. May you, too, be a giver that takes the time to also recognize the gift.

***

Oh yeah, and if after all that you are still feeling like reading-slash-goofing off-slash-not studying-slash-not working-slash-whatever important thing you are supposed to be doing instead of reading my ramblings, you might enjoy this post from last year (full of more ramblings) on "The Gospel According to Shel Silverstein." ('Cause I love me some Shel Silverstein, y'all.)

You had me at "Oh, Hell No!"

The other day I was working with a resident who'd just seen a patient for a medication refill. According to the resident, this fifty-something year-old woman had missed three out of the last four continuity care visits opting for quickfire "med refill only" encounters instead. Fortunately, her only medical problem was high blood pressure, and despite her less than ideal approach to having it managed, it was under control. She'd even had labs drawn after the last refill, all of which were 100% normal.

"Did you review health maintenance screening tests with her?" I asked thinking of things like mammograms and colonoscopies. I noted her age--over fifty--and wondered if this lady had kept appointments for these things even if she wasn't too keen on getting a full physical.

"Screening tests? No way. She pretty much shut down everything except the occasional pap test."

I furrowed my brow and sighed. "Did you ask her why?"

"I did, Dr. Manning. And it was kind of odd. She just kept saying no. Even when I asked why, she just kept saying 'I just don't want it, that's all.' And when I asked if she'd ever had a mammogram or a colonoscopy, she squished up her face and shook her head."

"That's unfortunate," I responded. "Do any cancers run in her family?"

"That's the part that stinks the most, Dr. M. One of her immediate family members died of colon cancer like in their forties. I tried to get her to reconsider using everything I could but she wasn't budging. She just kept on saying no. As a matter of fact, she kept saying. . ."she paused and seemed to be deciding whether or not to go on. She glanced back up and finished, "she kept saying, 'Oh hell no.'"

We both let out a nervous chuckle. Then my wheels started turning. . . .

A black woman in her fifties refusing screenings and missing appointments in an indigent care setting? In the southern United States, no less? Hmmmm. Why is this happening? Is it a trust issue? Or what if this is a literacy issue? Wait. What if it's a financial issue? Or a little bit of several things? Hmmm.

Instead of speaking those thoughts aloud, I just kept staring at the resident intently. She knew I was thinking, so she waited patiently. "Let's go talk to her."

And my resident replied, "I'd like that."

My guess is that this intern was banking on me closing some cultural divide that she, a well-meaning, blonde hair/blue-eyed doctor, might be lost inside of with this woman who could sho nuff pass for one of my first cousins. And I have to admit--she wasn't the only one.

When we walked into the room, we found the patient reading some kind of romance novel. "What's that you're reading?" I asked. She turned it over and showed me the cover. Some Fabio-looking dude held a Raquel Welch-looking woman tightly in his arms.

"Romance," she answered with a timid smile while dog-earing the page.

I remembered some fleeting teaching point I'd once heard about people carrying books as a deterrent when literacy was an issue. Considering that limited literacy is a major issue in this part of the country and at our hospital, I had to at least consider it. But this didn't seem like the case with her. This lady was doing exactly what she told us -- reading about some Fabio-looking dude putting the moves on people during the wait.

We chatted for a few moments about her blood pressure, weight, and keeping appointments. I implored her to see us at least every six months, especially since she was on three different blood pressure medications. We listened as she explained about the hassle of "all that other stuff they want to talk about" during the continuity appointments when all she is interested in is getting her high blood dealt with.

Hmmm.

I sat as still as possible to keep her from feeling rushed and allowed her to finish her thoughts.

"Sometime you jest wont to get in and get ya medicines," she said with a sideways smile. "Y'all be on to some whole other thang. Tellin' somebody they need to lose weight. Signin' 'em up for a bunch a other thangs that they ain't even in-trested in."

Yikes. I didn't even know where to begin. "Uuuuhhh. . . . yeah. . .Dr. Ashley was telling me that you aren't too keen on some of the screening tests." I decided to dip my toe in the water with this to see what she'd say. She simply stared at me expectantly, mindlessly shuffling the pages of the Fabio-book under her thumb. She totally had my number.

"Listen," I spoke carefully, "I just want more of an idea as to why you don't want to get a colonoscopy in particular. I mean, you definitely need the mammogram, but you lost a parent to colon cancer so I just . . . look, I just don't want to miss an opportunity to--"

"I don't want a colonoscopy." She held my gaze and wouldn't move.

"Is there. . .like. . .some particular reason why you don't?"

"The reason is that I don't want it. Somebody ever offer you something and you say, 'No thank you?' You ain't got to tell nobody why. Jest a 'No thank you' is sometimes all you gon' get."

I nodded my head slowly as our eyes continued to face off. "If I offer you a stick of gum and you say 'No, thanks' I'm okay with that, you know? Because that's not life-threatening. But if you lose your mama or your daddy to colon cancer and you don't want me to check out your colon, that's different."

"Not to me," she shot back. "If I say I don't wont no gum, I don't want no gum. Don't care how fresh iss gon' make my breath."

Damn. This was tough. I nervously cleared my throat and gave a nod that said touche. I drummed my fingertips on my lips thinking of what to say next. She still watched me, barely blinking.

"Ms. Johnson, you have a right to make your own decision. But. . .I'm not going to just shrug my shoulders and say, 'Whatever.' I mean, yes. That would be a lot easier than discussing it, but it wouldn't be right." I stopped to see if she was okay, and her face softened a bit. I went on.

"Look. You're a black woman, and the truth is -- when it comes to a lot of these cancers, we were dealt a crappy hand. Guess who is way more likely to die of breast cancer?" I pointed at the brown side of my hand and then aimed the same finger back and forth to us both. "Guess who colon cancer is the most aggressive in and the most likely to take out?" I repeated the same gesture.

"Why is that?" she asked. I felt super excited that she even did because it was the first olive branch I'd received during the whole discussion.

"Partly because we don't always get our screening tests. But it's some other reasons, too, like how we are made genetically. . .you know. . .like what we're made of." And sure, my use of "we" might have seemed like a shameless attempt at bringing home my point, but regardless of all that, it was true. "I mean. . . . look. You just. . I mean we just. . .are the main ones that need to be getting signed up for colonoscopies and mammograms. For real."

The room fell silent as she nervously flipped the pages over and over. After a few moments, it became a bit uncomfortable, so I finally broke the silence. "What do you think?"

"I think I don't want a colonoscopy. Or a mammogram. But I'm gon' think about both of 'em." Then she looked over at the resident doctor and added, "And nen we could talk more 'bout what I'm feelin' when I come back in four weeks."

"You will come back to see me in four weeks?" my resident chimed in incredulously.

"Yeah, I'm gon' come back to see you. And I'm on' thank more about what y'all told me. I might not change my mind, but I like that y'all took the time. Both a y'all. 'Specially when all I signed up for was the refill. I 'preciate that."

And so that's how the encounter ended. We typed into the plan that she'd come back in four weeks. . . and that she'd think about getting a colonoscopy and a mammogram.

And you know what? Something inside of me tells me that at some point she will.

***

Claims adjustment.

*Names, details, etc. changed. . . .you know what's up. . . .

image credit

"I can't take this, Dr. Manning," my resident, Fiona said to me one day near the end of rounds. "This is bordering on abuse. Seriously."

She was referring to the overbearing sister of our patient, Mr. Denton who had been admitted to our service the day before. He had an unfortunate stroke a little under one year ago--very likely as a result of active cocaine use. Up until then, he'd been living on the streets, shackled onto a crack cocaine chain gang that he couldn't escape. A massive brain hemorrhage finally did what no one else could--peel him away from a gripping stronghold that had alienated him from everyone he loved for years.

"What's going on?" I asked.

"First of all, she's yelling at the nurses, the intern, and me. She's demanding all sorts of things and it's just unreasonable. He shouldn't have even been admitted." Fiona sighed and shook her head. "I'm sorry, Dr. M. I'm just frustrated."

"Why the hostility?" I clarified the statement. "I mean from his sister. Where do you sense it's coming from?"

Fiona paused and squinted her eyes. I could tell she hadn't considered that question. "I don't know. I mean, we've been nothing but polite. . .but the minute I suggested that he be discharged, she lost it. She wants to know why we don't have physical therapy in here trying to get him up and trying to walk." She emphasized the word "walk" by furrowing her brow and shrugging her shoulders. Her mounting frustration was evident; a pink flush over her cheeks resembled that of someone who'd just been outdoors running.

This wasn't an unprofessional resident. Fiona was an effective communicator, an empathic caregiver, and a thoughtful leader. Her other strength was that she was an advocate for her interns, students, and the nurses. She wasn't the one to fool with when it came to tongue lashings by patients or their family members.

"How should we proceed?"

"I don't know, Dr. M." she said with a heavy sigh. "I mean, I know this isn't about me, but it's exhausting. I say we go in together, but I'm telling you. . . .it could be ugly."

I nodded and pressed my hand under the hand sanitizer dispenser. I bit the side of my cheek and looked at Fiona with trepidation before opening the door. The thing is, I wasn't sure what to expect. I knew that a resident this strong had given it a college try. I hoped that something with this repeat encounter would be better.

We entered the room to find Mr. Denton lying quietly in bed. His vacant stare and expressionless face were consistent with the regrettable extent of his brain injury. His arms were flexed upward and his wrists downward; his eyes somewhere very distant. It hurt to see.

His sister immediately rose from her chair and walked toward me with a pad of paper. "What is your name?" she asked while positioning her pen. The intonation of her question was confrontational; too much emphasis on the 'what' in that question.

"Dr. Manning. M-A-N-N-I-N-G."

"M-A-N-N-I-N-G?"

"Yes, ma'am. That's correct." I waited a moment while she jotted it down. "I just wanted to come by to introduce myself to you and to examine your brother."

"Well, I need to know why isn't there a physical therapist here working with him? He really needs that. They need to get him up and walking. How can we know if he can or can't walk if we don't try? And nobody is feeding him. How can he get better if he isn't eating?" She moved around his bed, smoothing the covers and fluffing the pillows. She wiped some saliva from his lip and then spoke to him. "Junior, you hungry, ain't you?"

I stood there quietly; my eyes scanned the perimeter of the hospital bed. A bag hung on a pump on the right side of his bed filled with milky liquid. I traced the attached tubing as far as I could until it disappeared beneath the blanket near his torso. There was no point in pulling back the covers; I knew there was a gastroenteral feeding tube doing the work that his brain would no longer allow his esophagus to do.

I finally got to my examination. Mr. Denton's sister folded her arms and stood right next to me during the entire assessment.

The exam didn't reveal anything active. Other than this very sad state that had now become his new norm, I could only admit that I agreed with Fiona's assessment--there was no reason why he couldn't return to the nursing home.

I felt my pulse beginning to quicken as I searched for the right words to begin what would surely be a difficult exchange. "Ms. . . I'm sorry, I didn't get your name?"


"Alicia Mays. I'm his older sister," she quickly answered. "So what are you planning to do? Can we please get somebody in here to help him eat and get him up to walk?" Alicia blotted her brother's brow with a washcloth and then looked up at me.


"Ms. Mays. . . ." I started, "The thing is that. . . .your brother. . . his stroke has really damaged his brain pretty bad. Because so many of his nerves were hurt, that's why, like, walking would be really tough for him. Like the part of his brain that stayed okay is telling the muscles and nerves to tense up, but the part of the brain that got hurt is the part that tells it when to relax. Without both working together, it's hard."


"He's a fighter," she countered. "We ain't afraid of 'hard', are we Junior?" He lay still, without any change in expression.


"I can tell he is a fighter. . . .I mean. . .with such a big stroke, the fact that he . . . I mean. . .I can tell he is a fighter."


"Yeah. He is."


"Ms. Mays, you need to be aware, though. With all he has been through, right now, he seems to be doing okay. There isn't an active problem that we want to keep him in the hospital for. I think we could coordinate some things between our social worker and the nursing---"


"No, he needs to be eating before he leaves. And also to get up and work on his walking. A lot of people use a walker after strokes, so I'm thinking y'all could call somebody over here to get him a walker."


"Ms. Mays. . . .he can't swallow food because he could choke. That's because of the stroke, so I wouldn't expect him to eat other than the tube feeds. With the walking. . . . I just want to be honest. . . .walking may be unlikely, too. The stroke made it hard for him to breathe at first, and his oxygen was really low. That hurt his brain more. . . and. . " I looked over at Fiona who seemed to already be in a wincing recoil. ". . . .and the chance of him recovering to a point of walking and eating is low."

"Oh. Well, that's fine if you think that, Dr. Manning. But we ain't claiming that. My brother will beat this. He's gonna walk out of here and go to get himself a hamburger and fries." She chuckled a rather odd chuckle. "Ain't that right, Junior? We ain't claimin' that, are we? We know the Lord is able."

Fiona looked at me with pleading eyes and also a bit of confusion. This was hard.


"We ain't claiming that." Sigh. I know this phrase well. When you know the souls of black folks like I do, not only have you heard this spoken more times than you can count, you've probably uttered it once or twice yourself.

"Claiming" something means accepting it as so. "Claiming" something releases it into the universe as a possibility or even, a plausible outcome. You see, trusting in God means, as many folks in these parts put it, "claiming the victory" in advance--the victory promised to those who love God--and specifically Jesus.

I've had my share of "claims."

A few weeks ago, we learned that our home address was being redistricted out of the wonderful elementary school that attracted us to our neighborhood in the first place. All hell was breaking loose, and this house that we'd bought at great sacrifice in 2006 was suddenly going to sharply decline in value. But more than that, our kids wouldn't get to go to the school that we've waited, literally, four years to attend. Snuffed out just like that with Isaiah only in kindergarten.

But I wasn't claiming it.

We prayed about it. We went to meetings. We talked to other parents. And at some point, I said to Harry, "I'm not claiming it. Isaiah and Zachary will go to that school. They will." And the truth? It was a long shot. That awesome school is overfilled and the other one we were getting zoned for is underfilled. I knew it wasn't really personal, and that similar things were being proposed all over the county.

I talked to my dad who used to be on the school board in our county when I was growing up, and asked him what the chances were that there'd be a change of heart and we'd get to stay at our school. Based on his experience? Slim to none.

But still. I wasn't claiming it.

Or rather, I wasn't claiming a negative outcome. Now I do admit. . .at some point, I had a bit of a "claims adjustment" and decided that rather than blindly saying I "wouldn't claim it", I'd shift my focus to wanting what was meant to be. Somewhere in all of it, I really, really believed that we'd be okay. Slim chance or not. And as it turned out, the revised zoning kept our address intact.

Faith won.

So I got what she was saying. God answers some pretty tall orders, so who was I to argue with her, especially since I have plenty of my own testimonies? Though my approach wasn't exactly like hers. . .definitely. . .I got where she was coming from.

"Ms. Mays?" I finally spoke. She rummaged through her purse pulling out papers and writing things down as I spoke. "Ms. Mays. . . .this. . .this is not a good situation. And . . .I, too, am a woman of faith . . . .but if you can just listen to me for a moment. . ."

"I'm listening."

"I can only tell you what I know based upon my medical knowledge. Based upon that. . . .your brother's stroke has changed him where for him to walk or talk or eat on his own would be a miracle. And yes, Ms. Mays, miracles take place, they do. But. . . I cannot be dishonest and tell you there is something I can do in the hospital to make that miracle happen right now. But I can make sure the things he needs, he has. I can make sure he is not in discomfort, and I can answer your questions. . ."

In my head, I was thinking that I could and would pray for them, but I decided to keep that to myself.

"This is ridiculous!" she huffed. "Everybody thinks my brother is dead and he AIN'T DEAD!" Her voice rose up and startled me. "He AIN'T DEAD! He's GONNA WALK! He's GONNA TALK! He's GONNA BE ALRIGHT! You AIN'T GOD!!!" She aimed her index finger directly at me with her arm fully outstretched.

My chest was heaving as I sifted my brain for the right words. I needed to wring out my mind to get my emotions in check. "I don't. . . ." I felt my voice getting tiny and wobbly and my face getting warm. ". . I don't think I'm God. I don't."

"Y'all do. Y'all DO, but you AIN'T!" She pointed skyward with her right hand emphatically, the skin below her ample arms shaking. "He's a HEALER, do you hear me? He's a WAYMAKER!!" she bellowed. Just like I didn't like her "what" earlier, this time I didn't like the accusatory tone of her "He." I glanced at Fiona, whose face was now beet red. She almost looked like she would be sick. I turned my attention back to Alicia.

"Ms. Mays. . . . listen. . .I . . .I know who has the final word. . .I do. And if He intends for something more to happen, it will. . .whether your brother is in this hospital or at his nursing home." I abruptly stared at the floor and then looked back up at her. I felt my voice quivering. "And let me tell you one thing for sure. I do not think I am God."

She stared at me intently as Mr. Denton lay with the same blank expression, possibly oblivious to it all. I repeated myself, knowing that I sounded like a broken record . . .I needed to say it again for me more than anyone else. . .my voice almost a whisper, "I don't think I'm God."

The room fell into an awkward silence. I cast my eyes back down toward the linoleum squares below my feet. I could hear the clock ticking, a phone ringing at the nurses' station, and someone chatting in the hallway. Fiona's eyes were glued to her shoe laces, her mouth sealed into a terse line.

Finally, I shook my head and spoke quietly. "Ms. Alicia. . . .I'm so sorry this happened. I. . .I have a brother and. . . I'm so sorry."

Suddenly I heard Alicia quietly weeping. A tired, frustrated, complicated cry. She immediately began patting her eyes with a frayed piece of tissue fished from her handbag and turned away from us. For a fleeting moment I thought she was going to fully break down, confessing how guilty the family had felt for allowing him to be swallowed up by the world. I was sure a story was coming about how the family turned their back on him; unable to peel his fingers away from his crack pipes or their precious treasures that always seemed to disappear whenever he was around. We'd give her knowing nods, hugs even--embracing the pain that manifested as anger and suspicion--letting her know through our empathy that we understood.

But that didn't happen. She regained her composure before it ever had the chance to be lost.

"Just let me know when he will be discharged back to the nursing home," she mumbled while reaching for her cell phone. She refused my desperate attempts at eye contact.

"Ms. Mays, if--"

"Can you just please just let me know when he will be going back to the nursing home?" she interrupted me. "Please."

"Yes, ma'am."

She began dialing her Blackberry, and then paused to dismiss me with eye contact so searing that it immediately made me wish I'd not been looking in her direction. I obediently stepped toward the door.

I stammered as I reached for the handle, "Ummm. . . . .if you have any other questions. . .my name is--"

"Yeah, I got it," she said, "Manning. M-A-N-N-I-N-G."

Perspective.

Same-day-sick Appointment in the Grady Primary Care Center:


"I can't sleep, doc."

"Really?"

"Yeah. And it ain't like I ain't sleepy, either. I just be sitting there. Just up and bored."

"Tell me about your evenings."

"I get in bed at like eleven. I turn on my television and just watch some TV. You know, Leno and the news."

"Okay."

"My old lady falls asleep and then I just sit there. Wide awake.  After while, I shut off my television and just lay there."

"Hmmm."

"I know . . . .  I ain't supposed to watch TV in bed, but I'm telling you, doc, it ain't that."

"That television can be harder on you than you think. Has it always been hard for you to sleep?"

"No, ma'am. I used to sleep fine. And as for that TV? Naw, it ain't that. I been sleeping with my TV for years."

"What kind of work do you do?"

"I'm run a barber shop so I have some long days. I walk around a lot, spend a lot of time on my feet. So I know I should be good and tired. I just can't fall asleep."

"Hmmm."

"But see, I know just what the problem is."

"What's that?"

"I'm a light sleeper and the noise-- it keep me awake."

I needed more information. "Noise? Does your ladyfriend. . . uhhh. . . snore?"

"Naw!" He chuckled at the very suggestion which made me imagine his better half as a dainty, princess like woman who gently sighed all night. "She sleep quiet as a mouse." I smiled at the image.

"So. . . you mean the TV noise? I'm confused."

"Naw.  Not the TV. This."  He pointed at his chest.

I looked puzzled. Was he some kind of human beatbox that played involuntarily? I didn't get it. He saw the confusion in my face and elaborated.

"This, doc." He pulled down his shirt to show me his midline sternotomy scar from what was obviously some kind of open heart surgery. I narrowed my eyes and tried to get his point.

"I got this mechanical valve put in my heart almost a year ago. And doc, I promise to God, when it get real, real quiet in my house, I can hear it. Loud. I'm for real."

Wow. This was a new one for me. Though surely this was not a new problem under the sun, it was definitely my first time sitting across from a patient who had it as their chief complaint. His chart said, "Can't sleep."  Now that, I could deal with. In fact, I'd grabbed his chart to help move things along in the clinic thinking I could knock this out (and him out) in two seconds flat. In my head,  I was already preparing to launch into my shpiel on "sleep hygiene." Insomnia is such a common issue, and almost always, the patient is doing something that can be easily modified. Like watching television or sitting on their laptop/Kindle/iPad all night sending light to the brain and telling it that it's time to get up and boogie. I thought this guy had me at "television", but never expected this. Dang.

"So. . .what are you hearing?"

"The click. That thang click nonstop. Same thing you hear when you put your thing on my chest to listen, tha's what I hear up in my ear.  Like somebody snapping some metal fingers."

I furrowed my brow and tried to think.

"Messed up, ain't it doc? How anybody 'posed to sleep with that in they ear all night?"

Wow. That was messed up. I had no answer for that question. I really didn't. I leaned my chin into my hand and sighed. A concerned, perplexed, mindsearching sigh.

"Have you. . . . tried a noise machine? You know. . .like one of those ones that has all the soothing sounds?"

"What you mean 'soothing sounds?'"

"Like rain. . and thunder. . .the beach. They have machines that do that. Stuff like that?"

"I think it ain't nothin' I can turn up that will be louder than some metal clicking in my body."

Pretty much, he was right. So I just sat there, staring at him kind of like the way a dog stares at you when you are eating. Alert, but sort of dumb-looking.  I realized that it was like someone trying to drown out their own hum--covering the ears only makes it worse.  I wanted him to get some rest. I really did. But the truth was that I had no answers.  None whatsoever.

***

Today I'm reflecting on the fact that (more often than folks realize) sometimes doctors just don't have an answer to your problem. Or as I once heard a medical student say, "I got nothin'."

The good news is that, since common things are common, this is usually not the norm. Most of the time, we do have a strong idea of what's going on, and with that we can set out on a clear cut plan toward reaching a solution. But sometimes the problem or complaint or ailment is one that, for the life of you, all you can say (under your breath, of course) is, "I got nothin'."

You can't sleep because you are disturbed by the mechanical click of your life-saving artificial heart valve?

Earplugs? You'll still hear it.
White noise? You'll still hear it.
Sleeping medicine? Ability to sleep isn't the issue and you'd  be too groggy to cut hair.

Yeah. I got nothin'.


Over the years, I have learned that one of the best things to do in those "I got nothin'" times is something I should be doing all the time anyway: enlisting the patient as my consultant and collaborator on the plan. There's something called the "explanatory model" that we teach medical students to use during the history-taking portion of their patient encounters. The explanatory model is this point where you essentially ask the patient what they think is going on.  Some wise medical educator finally put two and two together and recognized that patients often are spot on when it comes to pinning the diagnosis.

Case in point:

"I have back pain."

"Did you injure yourself? Pull a muscle? Lose weight? Gain weight? Do something new? Do a new exercise? Sleep somewhere unusual?"

"No. No. No. No. No. No. No."

"What were you thinking this could be?"

"I think it's a urinary tract infection, because it's exactly like the last time I had one."

"Aaaah."

Urinalysis comes back ten minutes later:  > 100 white blood cells per high power field--diagnostic of exactly what the patient said.

Aaaahhh.

So, yeah. We often use the explanatory model to assist us with diagnoses, but I've come to lean on it a lot more for treatment plans--especially the ones that don't involve prescriptions or procedures. This day, more than ever, I needed my patient as a consult.

"Sir. . . . I'm going to be honest with you. I am wracking my brain trying to think of what you can do for this. I'm just not sure how to make it where you can't hear that clicking.  How 'bout we put our heads together on this one, okay?"

"That sounds good."

I turned the computer monitor around and started doing a literature search on the noise of mechanical heart valves. "First, I'm looking to see if any experts have any ideas." I punched in a few terms into a search engine. "What kinds of things have you tried?"

"Honest, doc? I tried having on the TV. I tried having a couple drinks, but then I knew that getting myself drunk wasn't gon' be something I could do every night."  We both laughed.

"Yeah, you're probably right about that solution," I said with a playful wink. "Hmmm.  Everything I'm seeing here just talks about the fact that some valves are noisier than others."

"Mine is the St. Jude."

"Yeah. . .that's a noisy one according to this. . . . Let's see what the patients are saying, okay?"

St. Jude Mechanical Valve

"Okay." He closed one eye like he was debating telling me something for a moment. Then he said, "You know what I did try one time that did kinda work, Miss Manning?"

I offered him a quick glance while still skimming a few message board. "What's that?"

"I slept with a pillow over my chest, and my old lady gave me one of them eyeball masks. Something about that mask make you sleep good."

I stopped what I was doing and looked at him. A mask. Hmmm.  I never thought about a mask. Good thought, actually. Closing out light is good for melatonin production which is good for restful sleep. Hmmm.

"I felt so funny with that mask on," he went on with a slightly sheepish grin, "like I was some kind of . . .I don't know. . . what my old lady call it? A diva."

I cocked my head to the side and then giggled. He was anything but. "You are so not a diva, Mr. Jefferson." We shared a smile before I went back to reviewing the comments on one of the patient web sites. "I'm seeing here that one person said they learned to love the click since it reminds them that it's working." I'm not sure why I mentioned that, but something about that suggestion stood out to me.

"That's a good way to think about it."

"Have you worn the mask any more than the one time your ladyfriend gave it to you? I like that option because they really can help you get good sleep even if you can hear the sound."

He sat there for a moment and squinted his eyes.  "You know, what? I can try that. I only wore that thang once or twice and -- real talk-- it did help even though it don't cover my ears. Why don't I try that."

"You cool with that?"

"Yeah, doc. I'm cool with that. Plus I take enough medicines."

I nodded my head and charted our plan into the computer.

"And you know what else I'm thinkin?" he added as I typed into the electronic medical record. I raised my eyebrows and turned in his direction.

"I'm thankin' that I like that part about seeing my click as my reminder that my heart got fixed." I paused again and gave him my full attention.  "I almost died before they changed out my valve, Miss Manning.  It was infected and they said I could almost die. I was in the intensive care and everything."

"Wow."

"Yeah. And I got kids, and even a grandbaby now."

"So I guess it's like every click is another second that you get to be here loving your family."  I let that marinate for a second.

"Kinda like every click got a testimony in it. My testimony."

Wow. 

"That's a beautiful way to look at it, Mr. Jefferson." I thought about his poignant statement and shook my head. "Mmm mmm mmm. Every click is a testimony. I love that."

He looked down at his chest and then up at me. "You know what, doc? I love it, too."

Terms of endearment.

*names, details, etc. changed. . . .yadda, yadda, yadda. . .

 "You need anything, sweetie?"

"Mrs. Jasper?  Mrs. Charlesetta Jasper?" I overheard a nurse calling from the door  dividing the clinic from the waiting room.  Shortly after, a very snappily dressed Grady ultra-elder shuffled her way to the door with all of her weight leaning on her four pronged cane.  The nurse stepped backward and leaned her back on to the door to create more space for the patient. "You're gonna come right on through here, sweetie," she said while pointing toward the triage room.                                               

Mrs. Jasper pushed and stepped along with her cane, but inadvertently bypassed the triage door.  "No, no, sweetie. . . .over here," the nurse gently instructed her.

"Oh. . .I thought we was gon' go strett to the room," replied Mrs. Jasper in a wobbly voice.

"No, love, we're going right in here." The nurse gestured to the entrance and helped her into a chair to get her vital signs measured.

"Thank you," spoke Mrs. Jasper.

"Yes, ma'am, no problem." Mrs. Jasper smiled warmly and stuck out her left arm for the blood pressure cuff.

A few hours later, I walked downstairs to the gift shop to grab a quick diet Coke.  I was immediately greeted by Shanika, one of the cashiers.  "Hey, Dr. Manning!  How you doing?"

"I am so sleepy!" I replied with an exaggerated shake of my head. "I need a diet Coke fix!"

"And your granola bar, too?"  We both paused for a moment and shared a laugh, acknowledging how completely predictable these pitstops have become for me. 

"You doing alright, Miss Shanika?" I smalltalked as I rummaged through the refrigerator. I have this dumb practice of placing my hand on several drinks in an effort to choose the coldest one (probably one of the most completely asinine things I do on a daily basis.)

"I'm fine, baby," she answered with a broad smile. I liked her confidence and decided that the gleaming gold in her front tooth was fitting. I smile in return. Next, I sift through the granola bars and predictably choose the same "Peanut Butter" one. Finally, I hand it, along with the winning cola to Shanika.

I studied the cursive tattoos across her forearms and her long, curved acrylic nails as she rang up my two items.  She caught my eye and flashed that glowing smile once more.

"You want a bag, baby?" she asked.

"Naaah, I'm fine."

"Alright then, baby," she said pushing my purchase over toward me. "It's  good seeing you as always." Shanika dropped my change into my hand and nodded.

"Thanks, Miss Shanika!"

"Okay, babe."

I twisted open the bottle, took a few swigs and scurried back to the clinic.

As I headed up the stairs I found myself reflecting on words like "sweetie", "love", and "baby."  I recognize in that moment that Miss Shanika, who was easily fifteen years my junior, and the nurse who spoke to Mrs. Jasper, who could have been her granddaughter, both freely used the terms.

I asked myself if hearing Shanika call me "baby" offended me, and quickly admitted to myself that, for some reason, it did not. It's not like she is my close friend, or even someone who is old enough to be anything other than my "baby" sister. Maybe I should have been put off. Yet the "baby" that she kept using to address me sort of rolled off her tongue in a way that felt . . .I don't know. . .endearing. 

I thought about Mrs. Jasper. I could still see her appreciative smile, and decided that maybe she didn't mind her "sweeties" and "loves" so much either.

Or did she?

I still remember that time when I had my first pelvic exam, and the doctor kept calling me "sweetie" and "honey."  I hated it.  It made me feel creepy and patronized, even though I was only sixteen and a half and not yet fully aware that what I was feeling was even called "patronized."  Since then, subconsciously more than likely, I've never been a huge fan or user of those terms of "endearment" for my own patients.

But I'm still guilty.

Confession: I totally change my intonation when speaking to my Grady elders, and especially the Grady ultra-elders like Mrs. Jasper.  I ramp up my Southern hospitality and especially my "ma'am's" and "sirs." I even fine tune my "beg pardons?" and my "Good mornings." Now that I think of it. . . I have also convinced myself that tacking a "Miss" in front of someone's name when I don't know them or I'm younger than them makes me more respectful. . . but is it really? Couldn't that be bothersome, too?  And somehow it's like it just happens without me even thinking of it, just as I'm sure that nurse gave little thought to her pet names for Mrs. Jasper.  Without the "sweeties", yes, but could the musical quality of my voice be equally as. . .what do you call it. . . patronizing?


Hmmm.  

My friend Lesley M's kids attend a school where they call their teachers by their first names. Some deep thought has clearly gone into that decision, and that award-winning school is just as much in the bible belt as Grady Hospital.  But for some reason, I cringe when my kids roll up on adults and call them by any name that isn't preceded by a "Ms", "Mr.", an "Auntie" or an "Uncle." (And it ain't like I'm an award-winning child educator like that school. . . hello?) I wonder how their school would feel about "sweetie."


"Sweetie"
"Love"
"Baby"
"Honey"
"Dearheart"

Is it okay if you mean well and are deferential? How about if you're syrupy sweet and with a masterful southern twang?  Would mixing it in with "ma'am" or stirring it up with"sir" make it more okay? And is there some accepted age differential that must be present to make it cool? Like, if you can qualify for Medicare, do you have carte blanche to use these words, or if you're old enough to pay a mortgage and the recipient isn't--does that make it alright?

I mean, that gynecologist that left me with feelings of violation back in 1987 was quite senior to me--yet the thought of his words and actions still make me bristle to this day. (Just bristled.)

Hmmm.  (This time with a head scratch and a slow head nod.)

I'll throw this one out to y'all.  . . . . and this time, comment--okay sweetie?

Knowing better.

Still on the Zachary's birthday high. . . . .

photo credit

October 22, 2006

"Pregnancy turns your bladder into the most useless organ ever."

Harry looked over at me and my very pregnant self sitting in the passenger seat of his car and laughed. "What's that supposed to mean?"

"Exactly what I said!" I replied with a chuckle, "It can't hold much of anything, and if you do so much as sneeze you wish you'd wore a Depends."

Harry kept driving while shaking his head. "Not the Depends, babe!" He glanced over at me and we both laughed out loud. "Not a sexy image to give your husband. At all."

"Don't make me laugh!" I playfully scolded him and then looked down. "Aww man!"

We both cackled again, and then instinctively looked over our shoulders to be sure we hadn't awoken 16-month-old Isaiah who was fast asleep in his car seat behind us.

I thought for a moment as the wheels turned beneath the car. "Hey, babe?" Harry raised is eyebrows in response. "What if I don't just have a faulty bladder? Like, what if this is amniotic fluid? You know. . like my water is slowly breaking."

"I thought when your water broke it was like a water balloon?" he countered while hitting the blinker. Then, for emphasis, he slapped his hands on the steering wheel and said, "SPLASH!" After which he looked over in my direction. "Like that."

"No, I'm for real, you goofball! And it isn't necessarily like a water balloon. Although, I don't really know first hand since they broke my water for me last time."

"See? Don't call me a goofball! Why don't you just call Tracey? I'm not your OB."

"I know I'm probably tripping, but you're right. I'm no OB either," I said as I pulled out my cell phone. "Dang. And it's Sunday. But I guess when you catch babies for a living, this is your thing."

We were on our way home from a lovely dinner with Lesley M., her husband and three other Grady doctor friends/fams that evening when this whole conversation transpired. I was two days shy of my due date with Zachary and, other than feeling like my bladder would explode 24-7, I felt pretty darn great for the entire pregnancy. Even still, I know that I have a tendency to undercall things when it comes to my own health. I went ahead and called Tracey L., my OB-slash-med school classmate-slash-very good friend, to discuss my questions. She promptly instructed me to go to the labor and delivery to get checked out.

Damn.

I threw my stuff in a bag (nope on baby #2, you don't already have it packed) and headed to the hospital. By 10 PM, I was checked in and by 10:45 I was being checked by the nurse.

"Chile, you don't have nothin' goin' on in there!" the nurse teased. "That cervix is as tight as a drum. We'll see you back in like two weeks." She laughed at her own joke which was, in my opinion--one point five days before my due date--only a '2' on a funniness scale of 1 to 10.

"Hey, do you think you could draw my blood just in case I do go into labor? Like my CBC and platelets so that I can get an epidural right away if something happens in the next 48 hours?" I knew that the anesthesia guys needed to be sure you had normal clotting before harpooning your spine.

Let's just be clear here. I'm not one of those super-bad moms who toughed it out sans analgesia. Well, I take that back. For the first 12 hours of labor with Isaiah I thought I was going to be one of those "Yeah, girl, I did it natural!" moms, but 12 seconds after entering otherworldly pain-free bliss, I wondered what I was thinking and changed my tune big time. This time, I didn't want any delays in pain relief, just in case things didn't happen as Nurse Know-it-all predicted.

"Chile please! You ain't goin' into no labor no time soon. That wasn't amniotic fluid and your cervix could not be more closed. That baby boy wants to float a little longer." She laughed one more time. I know she didn't mean to be annoying. But she was. Very.

Then, as obnoxious as it sounds, I decided to pull the faculty card, since I was at one of our teaching hospitals. "I'm actually on the Emory faculty," I said (eeewww, name-droppy and lame, I know!)"Would it be okay if--"

She didn't even let me finish. "Then you should know better, Dr. Manning. Go home and get some rest. And enjoy these next two weeks before he gets here. You know, they're a lot easier to care for in there than on the outside." Seeing as she was about twenty years older than me, there wasn't much more I could say.

And so, that was that. I was discharged at 11:30 PM, overnight bag and all. No blood draw. No "baby on the way!" phone calls to my parents. No amniotic fluid leak. Just a bladder that didn't enjoy having 8 pounds of baby pouncing on top of it every five seconds. Good night, Dr. Manning. See you in two weeks (when you have to get induced.) Ha. Ha.

Now.

By now, y'all have to know how Seinfeld-ish my life is. So clearly you know what happened next, right? Claro que si!

1:45 AM. Awaken suddenly with intense need to bear down, as in the feeling immediately preceding #2. (I worked hard to find a non-disgusting way to say that on this blog. I hope this was acceptable.) Left the bathroom after nothing happened and got back in bed. Exactly eleven minutes later, it happened again.

Hmmm.

And again. And again. Eleven minutes on the dot. I woke Harry up and told him flatly, "Dude, I think I'm in labor." Just like that. Then I added, "But my cervix was 'tight as a drum' less than 3 hours ago according to the L and D nurse, so no need in waking up. I'm going to just hang out downstairs and watch TV. I'll call Tracey, and then we can go to the hospital after we take Isaiah to daycare."

After one obligatory, "Are you sure?" my sleep-loving husband turned over and zonked out. (Can't you tell this wasn't our first baby?)

And so. I watched two DVR'd episodes of Entourage. Another of America's Next Top Model. I cleaned and cut up some collard greens. Did a load of laundry. And even made a turkey meat loaf. All while timing these intermittent episodes of feeling the need to do #2 without it actually being because of #2. (My description of contractions.)

7AM the bear-downs have evolved to uncomfortable. We quickly get Isaiah dressed and fed. Then get ourselves dressed and fed. (Can you believe that I was vain enough to shave my legs that morning? Ha ha ha!) Finally, by 8 AM, we are in the car and on the way to drop Isaiah at daycare and then to the hospital. Bear-downs officially hurt.

8:25 AM, Isaiah nearly thrown into daycare like a 16-month-old football (terrible, I know.) Bear-downs getting slightly un-bear-able. Oooh weee. Oooh wee.

8:45 completely at standstill in Atlanta Monday morning rush-hour traffic. Officially miserable.What. Were. We. Thinking? Harry did his best to make things better. He spent half the time trying to make me laugh and the other half rubbing my leg and saying the kinds of things that sweet husbands are supposed to say while you're in labor.

"Sssssh! Shssssshh! Sssshhhhssshh!" (That's me trying to breath through the contractions in the passenger seat.)

"What in the world are you doing?" Harry asked me with a chuckle.

"Breathing . . . .sshshh! shhssshhh! sshhhhh!" I replied. I was unable to hide my amusement with the situation so burst out laughing, too.

With both pregnancies, we never got our act together enough to go to any kind of birthing classes. All I could remember was what I once heard my grandmother say-- "Whether you get lessons or not, that baby is coming out of you." This became my mantra (read:excuse) for not giving up an evening or weekend to learn the proper way to breath/manage pain/etc.

Instead, I resorted to what I'd seen those women do with the doulas on "A Baby Story." It was a pretty darn hilariously awkward thing to see.

By the time we reached Emory Crawford Long Hospital at 9 AM, the bear-downs were every 5 minutes. The pain was mind-numbing, and I intensely wished I hadn't turned to Bravo during the parts on TLC's Baby Story when some very granola, yet knowledgeable midwife explained how to redirect one's mind away from the excruciating pain of an 8 pound human being forcing his way out of a very small, yet allegedly expandable trap door.

"Wait! What if I see one of our residents?" I asked Harry in terror. This was totally possible since it was the 9 o'clock hour at one of the Emory teaching hospitals. I looked at myself. Feet slid into sneakers that were unlaced. Nonmaternity Seven jeans unzipped halfway. Nonmaternity t-shirt with high rise in the front and low rise in the back (kind of like the t-shirt equivalent of a mullet.) Fortunately, I had my hair in braids, which was the only thing that looked even half-way presentable.

"Please don't let me see any residents. . . .Please don't let me see any med students," I muttered under my breath in between contractions, giggles and goofy breaths. The whole sight was pretty ridiculous, I'm sure. Harry and I could not stop laughing.

"Heeeeey Dr. M!"

O.M.(expletive)G.

It was a pack of residents and medical students. Walking in my direction. Waving. All jovial and chatty. Just as they approached, I felt a bear-down coming on. Lawd, lawd, lawd.

"Ummm, hey guys," I said with a wince. "Umm. . turns out, I'm in labor. Sooo. . .yeah. . . I'd better go before I have a baby in this hallway."

And before they could reply, I was around the corner. Mullet shirt and all.

When I get to the L and D, the nurse checks me and asks, "Aren't you a doctor? Honey, you're almost 8 centimeters! Now you know you should know better."

That was the second time I'd heard those words in 24 hours.

"Listen," I cut to the chase, "I need you to draw my blood right away so that I can get an epidural."

She laughed out loud. At me. So not with me. "Oh, honey, it's too late for that. You're there already."

This was the moment where I suddenly understood every single patient who went off on a health care professional when their agenda did not line up with that of the caregiver. Every drop of "professional" flew out of the window. All I could think of was the fact that Isaiah A. Manning was weighed just two seconds after I pushed him out, and that scale read "9 pounds and 2 ounces." This kid could be a ten pounder for all I knew.

"Oh, hells no!" I firmly declared. Harry looked at me sternly. I didn't care, so repeated myself. "Oh hells no, I'm getting something!"

She laughed again. Then she slapped my arm a few times and commenced to try to insert an IV in my arm. 3 times. Unsuccessfully. Oh hells no.

"Please, let me just put it in so you can draw my blood," I said. "I can do it. Give me the catheter."

Wait. Really? Yeah. That's what I said. I'm not proud of it.

"I can't let you place your own IV," the nurse responded.

"That doesn't make sense. Let me just do it because I'm about to jump off this table if nobody gives me something for this pain."

Harry leaned in to my ear and whisper, "Wow, you are being SO obnoxious."

The nurse knew she was in control of this. Despite my foul behavior. After what felt like 100 years, I finally received my IV, along with some kind of narcotic that made me start hallucinating. But not enough to stop demanding an epidural. Now I was just high and demanding.

Once Tracey L. arrived, I launched into begging. "Please, please, please call anesthesia. Please, Tracey. Remember? Isaiah was a 9-pounder. I'm scared. Please, please call them." I was on the verge of obnoxious, hallucinatory tears. "And tell them I'm faculty." Ugggh. There it was again.

The nurse rolled her eyes very obviously. I knew I deserved it, so I didn't get mad. When anesthesia arrived, I realized that I knew the anesthesiologist. Yes!

"Give me something! Anything!" I pleaded. "My first child was almost ten pounds!" I felt the need to exaggerate to make things move along. Plus I was hallucinating, remember?

A few moments later, I received what definitely wasn't an epidural, but what I'd like to call an "epidural-lite." And I am the first to admit--I should have just sucked it up considering literally one minute after they taped it in place, I rolled on my back to push.

Three pushes later, Zachary was here.

The main thing I remember is being so spaced out from Demerol that all I could say was (through trippy tears), "Awwwww, I love him! He's such a little pooda!! But I feel like I'm loopy so take him!" (Which my mom was very happy to do.)

7 pounds and 14.5 ounces. Not quite a ten-pounder, but definitely a respectable size to request an epidural-lite.

****

Okay, so today, I'm reflecting on how frustrating it can be for patients when the caregivers have one agenda and they have another. This experience made me realize how important it is to keep this in mind with every patient I encounter. Like, for some people, their agenda is as simple as "I'm a healthy person who took off work because I think this is strep throat and I need antibiotics" while as the doctor you think it's a straight forward case of allergic rhinitis with sore throat secondary to post nasal drip. If you don't reflect on the patient's agenda, you write them off as "demanding" or "antibiotic-seeking" or "annoying" or all of the above.

I'm not saying the nurse who saw me that Sunday was wrong to say no to a blood draw. But maybe a little more discussion would have been good. And even though I was able to get the epidural-lite, as a patient, I could have done a better job at recognizing the nurse's agenda to follow protocol. And I'm sure that my behavior didn't exactly help her IV placement skills too much.

In the end, it all comes down to listening, doesn't it? Just respecting each other enough to get where the other person is coming from. That's important for doctors, yes. But probably just as important for everyone else, too.

As for the birthing classes, while they do seem like a good idea for most folks, the fact that I didn't take any makes the story even more Seinfeld-esque, which I dig. And. My grandmother was sho'nuff right:
"Whether you get lessons or not, that baby's coming out of you."

And I'm so glad he did.

Loose Interpretations.

*patient names, details, and identifiers changed. . .but the message is the same.

image credit

There was this exercise I participated in once at some workshop at a medical meeting where we wrote narratives in patients' voices. Kind of like your interpretation of what they might be thinking or feeling.

It was pretty powerful. Man. What a great way to really connect to how a patient might feel and really humanize them. I revisit that little process every now and then to, as my advisee Antoinette and I always say to each other, "keep it human." Most times I just carry out the dialogue in my head, but other times I'll actually put it on paper.

By the way. . .even if you're not a doctor, you should try this sometime. Hospitals aren't the only places where empathy is needed. . . . . .

 photo credit

Mrs. Xie.

There was this sweet octagenarian woman from rural China who had been an inpatient on my hospital service once upon a time. She couldn't speak more than two or three words of English, so would only smile at most things said to her during her entire stay. I hated being unable to communicate with her, but she never seemed to let it ruffle her feathers. She always seemed to have such a sweet and gracious disposition. It pained me to see the confusion in her weathered eyes each time we entered the room. She deserved to be heard.

This trip was on her "bucket list". Family had fulfilled a lifelong dream of hers to visit to the U.S. and she was elated.

That is until she got sick. Headaches on and off. Pain in her leg and really, really high blood pressure. We admitted her for management of a hypertensive emergency, and to further explore the pain in her leg. Years of smoking had done a number on her arteries which decided to give up on sending blood to her right leg. A complete blockage at the femoral artery, right in the groin area, left her with a tender, mottled leg--all the way down to the toe.

To make matters worse, she spoke a Chinese dialect that few people (read: nobody) in the hospital had in common with her. These are the times that you kind of wish you lived in a city like New York or San Francisco, for real. (Interesting sidebar: My friend and former Grady doctor, Natalie L., works at Bellevue Hospital in NYC and they have an entire Chinese-language-speaking medical and psychiatric ward!) But we were in Atlanta, not New York City. Bummer.

We pointed at the sign for interpreter services.

"Mandarin?" Smile.

"Cantonese?" Smile.

It wasn't one of the ones on our in-house interpreter list. Or what if this was a literacy issue? This sucked.

One of the inpatient pharmacists, Val, came to help me out. Val is Chinese and was fortunate enough to learn both Mandarin and Cantonese as a child. In a pinch, she's always gracious about stepping in to interpret for me, despite her busy schedule. If the issue was that my patient could speak but not read Mandarin or Cantonese, this would be money.

Val spoke to the patient. The patient spoke back to her in a wobbly voice that, no matter what language you speak, seemed difficult to follow. Val looked at me and shrugged. Her eyes were apologetic.

"I'm sorry, Dr. Manning. This is some kind of dialect that I just can't make out. Her last name is a Mandarin last name so I thought she'd at least speak some Mandarin. But honestly, it's not unusual for older people from certain areas to only speak dialects other than Mandarin or Cantonese. Sorry I can't help."

Dang.

To make matters even worse than the worse that I mentioned before, she was sick-sick. That leg pain of hers turned out to be severe peripheral arterial disease. Her right leg was getting no blood supply and the clock was ticking. She needed surgery ASAP to either open up those blocked blood vessels or if that didn't work, an amputation.

But she was almost eighty nine years old. Would she want such aggressive treatment? How did she feel about the possibility of an amputation? Not getting surgery would be life threatening. Getting surgery could also be life threatening. Sometimes when people are sick-sick and well into their eighties, they don't mind life threatening situations. But for her, we didn't know any of that. And that sucked.

She had two family members that worked full time. They would come when they weren't at work (which wasn't often.) They owned a small business and had no choice but go to work each day. Most of the time, the patient was there alone. So there she was. . . . in this mystery land with a mystery language while fighting a mystery illness. I can only imagine how she must have felt. . .. .

6:08 a.m.

Can't sleep.  The television next to me is too loud.  I also think I need to move my bowels. I haven't had one in three days. My leg feels like a tooth that aches.

Lady with brown skin comes in smiling at me. She keeps nodding her head over and over again. I think I do understand that word, "MAM."  Always with two words I know in English: "yes" and "no." I think "mam" means thank you? Or please?

Brown lady shows me a pillow. But I think the pillow here is too itchy. Or something. That television. It is too loud.

"Mam." Thank you for offering, I really want to say, but this thank you will have to do.  I smile and shake my head. I don't want another pillow. I think she understands what I said.

My stomach is hurting. I need to have a bowel movement. Maybe this medicine is making it worse? I don't know. And my foot hurts, but just on my toe.  I move the cover over it softly because it hurts. Ouch.

Brown Lady is smiling at me again. Maybe she is a nurse? What is the word for nurse in English? I don't know. How do I say "excuse me" in English?  Is it "please?"  Oh man. I am not sure.

"Please."

Brown Nurse Lady just looks at me and smiles.  I squeeze my stomach. I want her to know I need to move my bowels and that my toe hurts. I think this medicine is making it worse. Helps my pain, hurts my bowels.

Brown Nurse Lady looks at me and smiles again. She says words that I do not understand that sound like that loud television next to me.

"Don't worry, they will be coming around shortly with the breakfast trays."

What? Does this mean she understood what I was saying with my hands? I hope so. I nod my head and say "thank you."

"YESMAM." I say. That is, Yes, thank you.

She leaves.  Television still too loud in bed next to me.  I don't even see a patient in there. I think they took her to a test. Maybe nice Brown Nurse Lady will come back and turn off the television for me.  Push the call button. Picture of a nurse lights up and a voice follows.

"How can I help you, Ms. ZEEE?"

Voice comes in saying words I do not know. Except the last part ZEEE which, I'm thinking she thinks is how I pronounce Xie. She speaks again. I still don't understand.

"How can I help you?"

"PLEASE?" Excuse me?

"Ma'am?"

Why is she saying thank you? Never mind.

I hear some voices. Laughing. Speaking in English and I still don't know what they are saying. Voices get closer.

Someone greets me. Then they go to town examining me.

"Mrs. ZYE. . . . "  They said a bunch of other stuff after that that made no sense to me. And they mispronounced my name. Again.

Hands near my groin. Pushing hard with gloved hands. Gloves off. Push again with fingertips. Now on the back of my leg. The top of my foot. Feeling for pulse? They look worried. Doctor in a short jacket runs out and comes back with device to look for my hiding pulse. They squirt clear jelly on my foot and move that thing around. Doctor in short jacket keeps looking scared. Doctor in long coat helps, but nobody can catch my pulse.

They look at each other and talk to each other. They look afraid which makes me afraid. Somebody tries to talk to me but all I can do is smile. I am grateful that they want to take care of me. But I wish I understood.

They wave good bye and prepare to leave.

"MAM." I say. Thank you. Want to ask about my bowel movement, but don't know how.

Brown Nurse Lady comes back. Still smiling. I point at the TV that is still too loud.

"PLEASE," I say to get her attention. Excuse me.

She comes over to me, smiles and squeezes my hand. I like this lady and also like her hair. I want to touch it, but I don't.

She turns my TV on. Not that loud one that isn't getting watched off. NO!  I don't want my television on. I want hers off. I hate the laughing sound from those recorded laughing voices. Why do they have that? Now I get to hear it double.

"PLEASE," I say. I point again. This time she turns it up a little louder.

My stomach hurts. Can I have something for that? She puts something inside the IV. I fall asleep.

I awaken to more hands groping my pulses. Everyone is wearing green uniforms like pajamas. Talking, pointing, nodding to each other. But not to me.

"She needs to go to the OR tonight," one of them said.

"Where is the family? How can we consent her?"

"Wait, is she a full code?"

"How is her cognitive function? Is she decisional?"

I have no idea what they are saying. But I am grateful.

"MAM," I say. Thank you.

Later on my nephew and his wife are there when I wake up. I am so happy. I feel like I've been locked in a tomb and they just arrived with the key. Now they can turn off that television and listen to me.

My foot is hurting like a really, really bad tooth. Tip of my toe looks a funny color to me. The team with the short jacket Doctor and the Green Pajama doctors are all there together. Everyone looks worried. Now I am worried.

Green doctors say a whole, whole bunch of words. Nephew looks to me and says,

You need surgery. There is no blood going to your right leg. So you need surgery. Or you will die.

Surgery? This is something I'm not sure about. I ask can he call my daughter. I know she is in China but I want to talk to her about this.

No, you need surgery, he says. It is an emergency. They said right now or you will die.

Feel sad about dying and not speaking to my daughter first. But otherwise, would rather make a peaceful transition than have surgery. I think my daughter would not object.

I tell my nephew. I don't want this right now. I want to speak to my daughter.

There is no time for that, he says. It is life or death.

They all talk some more. They all look at me.

"MAM," I say.  I am grateful that they are spending so much energy. But my life has been good. I want no leg pain, but surgery, I don't think I want this either. I want to tell my daughter. Can't we call her in China?

It's an emergency, my nephew says. If you were back home, then okay. But I cannot let you die here. You need the surgery. It is an emergency.

So that is that. I am afraid. I am nervous. I want to speak with my daughter. Had not seen this nephew since he was a little boy. Would rather speak to my daughter.

But I am grateful that they want me to feel better, though.

More medicine in the IV and I drift off.

Knuckles on my chest. Pushing in harder and harder.

"Ma'am. . .Ma'am?"

Why is she thanking me?

My eyes flutter open and I see young, young looking doctor with short jacket like that other one. Looks very  new at this. Feel very nervous at the sight of her. Younger than my youngest grandchild.

She says, "SHIH? SHIYE?"

She wants to say my name correctly. She is trying. I like her already. Close enough. I smile. She smiles back.

Short coat green doctor then takes out her phone from her pocket. Makes a phone call. More words I don't understand. Then she hands the phone to me.

I hear a voice through the phone. First I don't understand. Mandarin and then some kind of Cantonese. Then. I understand!

Her friend worked in something he calls Peace Corps. He told me about my leg. I told him that I did not want surgery. I want to call my daughter and tell her. He asked if I understood it could take my life. I tell him my life has been perfect. I ask him can we call my daughter. He says he is only a medical student, but will see if he can help.

Asks a few other questions, but these are silly. Where are you? What day is it? What is your full name? I tell them all of this. Phone-a-friend tells me that they will call me back. Short coat green pajamas young, young doctor leaves really fast.

Comes back with all of the Green Team. Takes out phone again and now it is a speaker. Phone-a-friend asks me the same questions over the speaker phone. I say the same answers. And also, Can I call my daughter? In China?

I also ask him how to say "thank you" in English.

It isn't "MAM."

12:35 a.m.

On a flight back to Beijing "at my own risk" and "against medical advice." Daughter flying to Beijing to meet me. No surgery. Just pain medicine. And pain is there but manageable. But that's okay because  Nice Stewardess keeps checking on me the whole time. She can only speak Mandarin and English, but she is nice and I appreciate the attention. I feel safe.

She puts a cover over me as I feel myself drifting to sleep. Before I do, I look up into her eyes and smile.

"THANK A-YOU," I say.  

 "Yes, ma'am," she replied.

 This time, nothing was lost in translation.