Riding the wave.

"And everybody knows almost doesn't count."

- Brandy

I was walking into Grady this morning and ran into this man who appeared to be unstably housed. His clothes were somewhat soiled and his coarse hair was kind of matted. The dank odor from his body greeted me long before he did.

"Hey there, sir," I said as I passed him. Not particularly small talky. Just polite, you know?

"Good morning, miss lady." He pointed at the sticker on my chest and nodded hard. "I see you voted. Good job."

And you know? You'd think that this very light teaser statement wouldn't have been the least bit perplexing. I mean, this whole week has been filled with people and their ultra proud lapel/chest swag followed by their obligatory post vote sticker selfies on social media. I can't even count how many thumbs ups and fist bumps I gave to the residents, students and nurses I saw who'd voted--and could prove it via that coveted sticker.

But this? This was different. It was nine something in the morning and we were outside in front of the hospital. It didn't take a Phi Beta Kappa to realize that this guy hadn't just slipped from out of his house or just pulled up in a late model car and had just fed the meter.

Nope.

So I wondered. Like, is it even appropriate to say back to him what I say to everyone? I decided to stop overthinking it.

"Did you already vote?"

He pointed at his chest. "Who me?"

I stopped walking and faced him. "Yeah. You."

He curled his mouth and sucked in a deep breath. "Naw, man. I wasn't able to vote."

And yeah. I could tell that his life was mad complicated and that nothing at all was simple for him right about now. I mean, it was clear that things like where exactly will I sleep or what exactly will I eat were being given priority over getting to the polls on this day. But here's the thing--he seemed genuinely bothered when he said that. He did.

"You said you couldn't vote? Why not?" I queried. I asked because I was curious, actually. Like, was it that he was registered but needed a way to the poll? Or was it that he had no idea what site his assigned one? Or something altogether different? I mean, maybe it was something I could help find a solution to fix.

"Oh, so I'm homeless and I don't have no identification. To be honest, I did for real try to get registered one day when they was out here registering folks in front of Grady over the summer. I ain't have no license or no ID card and I don't have no address. So yeah. It was messed up."

"Awww man. Seems like there should have been something they could have done."

"Well they tried, you know what I'm saying? Like, the lady who was there she was going hard with me and trying to help. Pulled out her phone and called a whole slew of folks. She was determined! But we hit the wall when I start trying to figure out how to get some ID. You got to have a birth certificate and I don't have no way to get one."

"Are you a Grady baby?"

"Naww. I wish. This would be easy if I was born at Grady. But I'm not from Atlanta. I'm from the country. And, my peoples, they not alive no more or they in a place where I can't get they help. So I couldn't get no ID and I couldn't get registered. They was gonna let me use a shelter address so it wasn't that. But you got to have some way for them to know you who you say you is."

"Damn." That's what I said. And I was just kind of looking at him with one eye squinted like maybe some super, duper ah hah moment would fly down from the heavens and suddenly create a solution to let this man vote on this day in this election. "I'm real sorry to hear all that."

"Yeah. Me, too. I wanted to be able to have some say in all this stuff. 'Specially the judges and stuff. 'Cause like, the president help determine who gonna be the top judges. And from what I see, the president either somebody who give a damn about people that's losing or they don't give no piece of a damn. I want to pick the person who seem like they'd stop and talk to somebody like me."

"I feel you."

"You voted for her or ol' boy?"

I smiled at his reference to the two candidates this way. "Let's see. I voted for the one that would stop and talk to somebody like you."

He laughed when I said that and gave me a thumbs up. "That's what's up."

"I'm gonna try to find out what a person in your situation could do in the future. You should've been able to vote, man. I hate hearing that."

"Yeah. 'Cause it seem like a lot of people that hate us coming right on out with it and they giving the ones who don't care one way or the other about people like me a wave to ride on with 'em. I be having nightmares of it going the wrong way by just one vote and me feeling like it was mine."

I paused and thought about what he said. "Wow. That's kind of deep."

"But true, though."

I bit my cheek and nodded slowly. My team was waiting and I knew I had to get going. I smiled once more and reached out to shake his hand. "Alright then, sir."

"Alright then, miss lady. And thanks for voting."

I picked up my pace and headed to the door. But before I did, I spun around and called out while walking backwards, "Next time, okay?"

"Yes ma'am!"

Yeah, next time. That is, if there is one.


***
Happy Election Day.

I love loosey.

Today I was walking out of Grady to lunch and this dude was standing out on the sidewalk right in front of me. Every single one of his teeth was fractured and decayed. But still, he was smiling big and wide and looked pretty content. And since I've worked here a while and know that dental insurance in some places is  right up there with sightings of leprechauns and unicorns, I was cool with this happy man.

Sure was.

"Hey there, sir!" I said as I prepared to walk by.

"Hey there, sugar!"

And no. Names like "sugar" and "baby" don't really bother me at Grady. Unless the person is being fresh. And I can tell when they're being fresh. He wasn't.

Nope.

"You alright today, sir?"

"I'm blessed, baby. I'm blessed!"

He smiled again, unashamed. And that part made me pretty happy considering he seemed to be leading a pretty hard life. "Alright then, sir! Have a good day and be easy!"

I waved my hand and picked up my pace. Feet clicking on the asphalt as I headed up the street to get some food. Nothing about it unusual. I got just about to the corner when I heard his raspy voice calling out to me. "Doc! Doc!"

I swung around and saw him jogging up approaching me. I turned to face him and waited for a few moments on the corner for him to reach me. Nothing about it scared me. But I do always make sure to fully face people and keep my eyes aware of everything.

"Doctor. . .look here--thanks for waiting for me," he panted.

"No problem. What's up, sir?"

"Look here. . . can you let me hold a couple of dollars?"

I furrowed my brow. "Hold a couple of dollars?"

"Yes ma'am. I'd sure appreciate it."

"Why-- so you could get some lunch? Let me just get you something if you're hungry. I'm going to lunch now."

Suddenly a sheepish grin covered his face and his voice fell to a mumble. "Well, naw, it ain't that I'm hungry per se." He chuckled when he said that.

"What's that supposed to mean?" I teased back. "Okay. So what's so urgent that you need two bucks?"

"Okay, well jest give me one then."

My hand was in my white coat pocket and I could feel the few loose dollars in my pocket. I tried to decide whether or not I should just give it to him and head to Subway or keep asking questions. Being the nosey person I am, I asked more questions.

Duh.

"Okay. So not for food? For what then?"

Just then, a lady who'd been standing near him on the sidewalk yells out, "HE TRYING TO GET A LOOSEY!" Then she doubled over laughing as he waved his hand shooing her away. She kept giving him a hard time. "ALL HE WANT IS MONEY FOR A LOOSEY, DOCTOR! MAAAN! THAT LADY DOCTOR AIN'T GIVING YOU NO MONEY FOR NO LOOSEY!"

And that? That made me laugh out loud.

And made me acutely miss my sister. Here's why:

Deanna used to always say that I was just a little too square. "You cool and all. . . but you a square," she'd say. And that all started one day when I told her that I'd heard someone say that he has a square in the morning and a square after each meal. I had no idea what he was talking about. Once he explained that a "square" was a cigarette, I immediately stuck it on my "stuff to ask Deanna" list. Since she was the queen of all things urban and random.

"Hey Dee? You know what a 'square' is?"

"You mean a cigarette?"

I scowled. "How do you know that?"

"I know all kinds of shit. I'm smart but I'm still hood. It's a glorious combination, I tell you."

"A square? Like why do you know that a cigarette is a square?"

"'Cause I'm not a square!"

We both laughed. Then she added, "You probably don't even know what a 'loosey' is."

"A who?"

Instead of telling me, she just threw her head back and cackled out loud. At me. Hard.  "Such a square, man. I'm revoking your Inglewood card."

Ha. I remember looking it up right then and there on Urban Dictionary.

loosey: (n)
a single cigarette that you buy from a store clerk for a minimal price. (rather than buying a whole pack of cigarettes)
I was broke as shit so i bought a loosey from the clerk.

Good ol' Urban Dictionary. Who knew?

Yeah. So thanks to that moment, today I knew exactly what a loosey was. Surely did. And there was no way I was sponsoring one.

Ha.

"Dude. Are you trying to get me to buy you a cigarette?"

"My nerves is bad." That was his legit response.

"A loosey costs a whole two dollars? That's crazy!"

"Naw. I needed a lighter, too"

0_o

I shook my head and started laughing before heading across the street. "I can't buy you a loosey, friend. But thanks for making me laugh today. For real."

"Hell, you have not 'cause you ask not, right?"

"Right. Good luck with the loosey. And the lighter."

"I'm feeling lucky, baby!" And with that, he showed me every single tarnished tooth in his mouth--without any shame in his game.

I loved it.


Not sure why I shared that. I think it's because if Deanna were here, I would have told her about me getting to use the word "loosey" in a real life situation. As proof that I'm not as square is she thinks.

Ha.

***
Happy Friday.

On second thought.

I saw a man the other day who mostly spoke Spanish, but who also spoke relatively okay English. So I came to see him and, because of his limited vocabulary in English, had a very "business only" encounter with him. Because of his pride, he didn't want me to go off to get an interpreter. And so. I saw him and evaluated him. And that was that.

Another patient on the same floor spoke pretty much only Spanish. So I called the interpreter line and sat quietly at a computer charting while waiting for the interpreter to come to my rescue. After about ten minutes, up comes my blue-smocked comrade Ana, poised and prepared to bridge the gap between his Espanol solamente and my English only.

Ana was great and things went well so all was fine. We prepared to leave and Ana kindly bid me adieu. But just then, someone spoke words to her in Spanish from across the room. She walked a bit closer and we learned that my first patient, upon seeing me with an interpreter, had a change of heart about not communicating through his native tongue. Ana was super gracious and obliged.

And so. I will keep this simple. Here are ten things I learned about my patient today after I'd already evaluated him but then returning to him with an interpreter. Some of the details are changed, of course, to protect anonymity.

1. He has been married for 38 years.
2. The part of Mexico that he is from is right in the center of the country which helps him to not mind about how landlocked Atlanta is.
3. The key to staying married for 38 years is to talk things out and share your feelings. Even if you get into a big argument, listen to each other and don't just walk away. And always stick together.
4. Sons can be trouble. Girls are easier.
5. He has 9 children, 5 of them sons. But fortunately only one is really big trouble. The girls are all angels.
6. He has 29 grandchildren and more on the way. As in literally more on the way.
7. Atlanta has been his home for the last 25 years but since his whole community is Spanish speaking, he hasn't fully mastered English. But he has come a really long way.
8. Even though his daughters are easier, the child that takes care of him the most and is the most helpful is one of his sons. (Who has 3 kids of his own and one on the way.)
9. Dialysis is frustrating.
10. Family gatherings at his house never have any less than 100 people.

And for the record? Not a single thing changed about my assessment and plan. But I know for certain that coming back to him and truly humanizing him was therapeutic for us both. 

Yeah.

***

Happy Thursday.

What I sent my ward team after that encounter. I wanted them to understand why it's important to get an interpreter for the human connection.

"Read this to understand my feelings about the power of getting interpreters. It explains better than I could today on rounds. 

http://www.gradydoctor.com/2013/03/los-dedos-azules.html

Dr. M."

The other day at Grady.

"Then I look at you. 

And the world's alright with me.

Just one look at you. And I know it's gonna be. . . 

. . . .a lovely day."

~ Bill Withers

I was making good time the other morning. I wish I could say that this is always the case, but it isn't. On this day, though, I was turning into the garage exactly ten minutes before I was expected to be in the clinic. A miracle, I tell you.

The day was pristine--the sun shining bright like a diamond and the temperature not oppressively hot either. The minute I saw that blue-blue sky I knew that it was going to be a good day. I just knew it.

On the way to work, the radio personalities were all talking about a whole bunch of nothing and NPR was feeling a little bit overwhelming. The latter half of my commute that day was in silence as a result. And that part was cool.

So, boom, I swing into the employee parking garage and I see the same person I always see: Mr. Lewis, the security officer in the parking deck. His big, booming, jovial greeting was as bright as that sun. "Heeeeeey there, doctor! How you doing?"  he announced. And, like usual, I returned his welcome with the same thing I always say, "If I was any better, it'd take two of me!"

I realized in that moment that seeing him is one of my favorite things about Grady. And any person who pulls into Grady in the morning knows exactly who I'm speaking about.

Anyways. I had great parking lot karma that day and snagged a ground level space. Another miracle, I tell you. And a welcomed one at that.

I walk across the street and into Grady. I see the regular sights along the way. The people smoking in the smoking area. For amusement, I always look to see if anyone is puffing in the nonsmoking area, too. And, as usual, someone always is. I sort of enjoy that for its Seinfeldesque irony and always feel a little tickled inside when I see that.

One of the environmental services workers gave me a high five as I walked by him in the hallway. And that made me extremely proud for some reason. I think it's because he initiated it -- not me -- and did so because he had to know I'd oblige him. It made me happy that he saw me that way and it felt far more endearing than disrespectful.

Yep.

I strode into the main atrium and waved at the man selling newspapers across the way. "Hey there, Miss Manning!" he shouted. And I shouted right back to him even though his name escaped me. "Hey there, sir!"  Ms. Renee in the gift shop was taking in some inventory at the door and winked in between signing off on boxes. I'm a terrible winker but I winked back. I sure did.

Another Grady employee passed me as I entered the stairwell and called me "Miss Lady." And that made me smile because when I first met Harry he used to always call me that on our earliest phone calls.

"Hey, Miss Lady."

And you know? Even when Harry said it, it wasn't fresh. It was just friendly and chivalrous-sounding to me. That morning I took it the same way.

"What you know good, sir?" I asked.

"Awww, Miss Lady, I don't know nothin'."

And that was enough to take me up the stairs because anyone who knows about certain pockets of down South lingo knows that "what you know good?" is a perfectly acceptable way to ask "how are you?" And, of course, "I don't know nothin'" or "I ain't no count" are also absolutely reasonable replies to that question.

Mmmm hmmm.

Once I entered the clinic, I saw Lex, one of our patient access reps. He always, always seems happy to see me which makes me equally happy to see him. He also wears a collection of very cool glasses which, for some reason, he didn't have on this day. "No specs today, Lex?" And he just chuckled and told me that sometimes you have to change things up on people to keep 'em guessing.

But I still think of him as Lex with the cool specs. Which rhymes now that I think about it. Ha.

The clinic wasn't too busy yet when I got there so I checked my email. One of my emails was from Joe, the Grady transporter. Remember him? The guy who wanted to know the inner workings of a hospital like Grady so decided to work NOT as a tech or even someone shadowing physicians. Nope. He took a job as one of the people pushing patients from place to place at Grady Hospital. And when he told me that, it blew my mind. Even more amazing though, is that he did that for over two years while in grad school.

Sure did.

Well. Joe is officially applying to medical school this year and wanted me to read his application essay. That's why he "cold call" emailed me, opening up with "You probably don't even remember me but. . ." Ha. He must have forgotten who he was talking to. So yeah. He emailed me some two plus years later. And can I just say that this also made me feel happy inside, too? Kind of like that high five did. One, I was happy to hear that he was actually applying. But two, I was so glad he also felt like he could reach out to me once he did.

I am rooting for Joe. I am. I've since spoken to him on the phone for over thirty minutes, hashing out his beast mode med school strategy. "Tell them you took a job as a patient transporter at Grady for two years. Tell them what you learned because I know it changed your life."

"It did," he said. "It has." And we talked about other things, too, but Grady was the main topic.

Yup.

Look man. I just want my light to shine. So little things like a high five from a dude pushing a giant floor waxer and a young guy I met for five minutes reaching out to me made me feel like, just maybe, I sometimes get it right.

Okay. So the truth is that I could do this for another thousand words about every little tiny thing that happened around me. I could. Suffice it to say, I loved my day in clinic that day. I noticed as much as I could. The encounters were rich and the conversations were ordinary but pivotal. We took really good care of people and I could feel it in my bones that we were. I could.

But I have to share this last thing, okay?

On my way to see one of my last patients, I saw a familiar face.

"Dr. Manning? Hey!"

"Hey!" I responded. I stopped and turned my head sideways. I knew I'd cared for this patient before but I couldn't place when or where.

"You don't remember me?"

As soon as she said that, I did. This was a young woman who I'd cared for more than a year before. She was supposed to have a few months to live after failing treatment after treatment for a very advanced blood-borne cancer. And you know what? There she was. Standing right there in front of me on her way out of a clinic appointment.

And here is the truth: When I discharged her from the hospital back then, I was sure I'd never see her again. And that made me so sad. It truly did. I remember crying many a day in my office or on my drive home about her. So seeing her . . . alive. . .it just. . .wow. I said, "Of course I remember you. Of course I do!"

I walked down the hall straight to her and, as if scripted, we embraced tight. A long, telling hug. I pulled back, put my hands on her shoulders and studied her, then pulled back in and hugged her once more.

"I'm doing really good," she said. And I didn't even care about that being grammatically incorrect because "really good" sounded even better than "well." It did.

"You look wonderful. And healthy. I'm so happy you stopped me. I'm so happy to see you." I said that because I meant it. She looked very different now. Much thinner and hair now grown out from her chemo-induced alopecia that I'd come to know during her hospitalizations. I would have never recognized her.

"It's good to see you, too," she said. "How are your sons?"

And I immediately wanted to cry when she said that. How could she remember anything about me when she'd been so ill? Just. . . .how?  "They are good," I replied. "Very good. Is your sister doing better?"

I wanted her to know I that I remembered her story, too. Her sister was very, very close in age to her and so worried about my patient that she'd left college to be by her side. This decision was a big deal to my patient who wanted her sister to stay where she was. My patient believed that she was dying and saw no point in robbing her sister of a future since the chance of meaningful recovery was so slim. She'd urged her sister to go back to her university but her sister vehemently refused.

A true Ruth indeed.

Just like Ruth and her beloved Naomi of biblical fame, both were now thriving. "She's back in school. Going to graduate this year actually."

"That's great. Just great." I hugged her one more time before leaving. If I stayed two more seconds, I'd have broke down crying.

Especially because I know how awful it feels to lose a sister and I was so, so happy this wouldn't be something her sister would have to live or know in the near future. I said a little prayer in my head as I walked away and stuck them on a post it note in my head for prayers later.

The rest of that day was great, too. Quiet moments of wonderful bookmarked by teeny-tiny whispers of grace. All of it so very ordinary. Yet so very extraordinary. Which, like always, is very, very Grady.

Yeah.

I love this job. And damn, I'm just glad to be here.

***
Happy Sunday. And think positive thoughts about Joe and his journey as well as my young patient in remission, okay? Thanks.

Now playing on my mental iPod. . . . . if you read this post, imagine this playing in the background the entire time. Because it was.

Permission to speak freely.

• Assessment: Poorly Controlled Diabetes

• Plan: Initiate Insulin Therapy

___________________________

Grady Primary Care Center, Summer 2014

"I think I can manage this with diet and exercise."

"I believe that being careful about your diet and getting more exercise will help. But my recommendation is that we start you on insulin. I  know you don't like needles, but--"

"I'm definitely not taking insulin. That's out of the question."

"I see. Remember that blood test we checked? The A1C test?"

"The one that says how your sugars have been for a whole month?"

"Sort of. More like three months. But yes, that."

"I remember."

"Well. Yours was very high. In the double digits."

"Where should it be?"

"I'd be ecstatic if it was between 6 and 7%. It was 12.5%. That calls for insulin."

"I hate needles. You'll have to try something else."

"You've tried pills already. They aren't working. You need insulin."

"Is there an insulin that isn't given through needles?"

"Not that I have to offer."

"Oh well."

"I'm sorry. I wasn't sure what you meant by 'oh well.'"

"I meant, 'Oh well, guess we in a jam, ain't we?'"

"Aaaah. I see. I guess we are then."

"Insulin ain't gonna happen."

"I hear you. And I've already talked to you at length about the things that can happen if you ignore your high blood sugar, right?"

"You have. And I'm not 'ignoring' it."

"Well, I meant not doing whatever it takes to control it. Sorry about that."

"I'll do anything. Just no insulin."

*pause for a moment*

"Okay. Well listen--I'm pretty disappointed that I can't convince you to go with my recommendations. I have the pharmacists here and everything to teach you about using insulin. But I guess you've made up your mind."

"So what pills are you going to add?"

"None."

"None?"

"None."

"What the hell?"

"You need insulin. And that is my recommendation. You're already on three different pills for diabetes. They aren't enough. At this point, you need insulin."

"Well, I am letting you know that I need an alternative."

"I don't have one."

"So that's just it? Insulin or nothing? That's crazy."

"I'm sorry you feel that way."

"Why can't you just up my pills some more?"

"Because that isn't right. And it won't be enough."

"Hmmmph."

"Ma'am? Can I ask you a question?"

"You just did."

"Okay. Well a statement."

*eyeroll*

"Okay, so check it--if your blood pressure was sky high and I needed you to take pills for that. . . . but instead you said, 'No, Dr. Manning! I think I just want to take apple cider vinegar and mustard for my blood pressure!' You know what?  I wouldn't go along with that as a viable option, either."

"Vinegar and mustard?"

"Some people use that for high blood pressure as a home remedy."

"Does that even work?"

"Uhhhh, that would be a no."

"I feel like you're forcing insulin on me."

"I'm sorry you see it that way. I just care."

"You care about making money."

"Making money? Um. No. Definitely not the case. You just need insulin."

"I have a question. If I was your own sister what would you do? Your own sister with high blood sugar who really, really, really didn't want to take insulin."

"My sister? Oh, that's easy."

"Well?"

"I'd pin you to the ground with my knee in your chest and hold you there until you got your insulin. I'd sit right on top of your and draw it up and stick you in the back of the arm. Sure would. And I'd do it every single day until your A1C was under 7."

*silence*

"Are you serious? That's what you'd do to your sister?"

"Dead serious."

"You'd put your knee in her chest?"

"You'd better believe it. Or I'd just put her in a headlock."

*laughter*

"Damn. I'm just not ready for insulin."

"I hear you, sis. But listen--insulin is ready for you."

"I hear you, doctor."

"Do you? Like really hear me?"

"Yes. And I can feel your knee on my chest."

"You can?"

"I can."

"Good."

*both smiling*

***
Happy Tuesday. And yes, she took insulin.

You are my sunshine.

The Grady coffee shop

You are my sunshine, my only sunshine

You make me happy when skies are gray. . .

No. Like, literally, you do.

________________________________________

There I was standing at the counter. Feeling a bit fancy on this day and a little like splurging on a latte of some sort instead of something regular. Definitely more regular than the regular drip coffee of the day. Anyways. In that time I spent in queue behind those other two people, you'd think that I'd have made up my mind about what I wanted to order. And mostly, I had made a final decision--I mean, it was definitely going to be some sort of latte--but, again, since I was feeling like something fancy today, the added part of selecting a flavor shot was a little more than I could fully handle on demand.

Vanilla, Caramel, Cinnamon, Hazelnut, Almond, Irish Creme, Coconut, and . . wait. . .Peppermint. Yum. Wait. Then there were these sugar-free versions of nearly all of those flavors, too. I imagined myself saying, "Can I have a sugar free hazelnut soy latte?" Blecch. Yeah, so even though the thought of those sugar-free ones sort of grosses me out, the fact that they were thrown into the option pool made me go even slower.

Yeah.

I realized that I was just standing there tapping my lip and squinting my eye while the cashier-lady just stood there quietly. And by quietly I mean like she wished I would get the hell on with it. She had yet to greet me with a "top o' the morning!" or hell, even a surly up nod. Instead she just stood there like a statue with one hand on the register and the other on her hip.

Mmm hmmm.

Now. It seems to me that there just has to be some barista rules in this place. And technically I know that there are some when it comes to Starbucks. This, however, wasn't a Starbucks--although it was just as nice and served up all the Starbucks stuff. To be transparent, this was in the newish coffee shop that we have in Grady Hospital now which, again, is just as fine as any Starbucks.

Mmmm hmmmm.

Even still, I'm not sure if the woman standing in front of me saw herself as a "barista". I'm also not sure if she was annoyed with me, bored, having a bad morning, or all of the above. Either way, I wasn't getting too much warm and fuzzy from her. I was not.

So she sort of shifted on her feet at the register which was a subtle-ish way of saying, "Come on, lady" which I got right away. And me? I was having a good morning mostly, so I flashed her this big smile and started a conversation.

"Good morning!" My voice was all musical. She was professional for the most part but definitely not seeing the point in giving back to me all that chipper energy.

"Hello. What can we get you."  I didn't put a question mark on it because she said it like a statement. No soft and fuzzy query tone to it, just a factual string of words.

"Well. . . .I was thinking of a latte. So definitely having a latte."

She positioned her hand to punch in the order and then looked up like AND?

"Umm. . .wait. . .do y'all have soy milk?"

She nodded. Then she turned to her barista-buddy and said, "Soy latte." Her barista buddy looked equally as business as she when she reached down and pulled out the vanilla soy milk.

"Thank goodness. . . you definitely don't want me drinking the regular milk latte!" I laughed at my own joke. And kind of snorted a little bit which, I know, was kind of dorky. The two others waiting behind me in line chuckled, too. But my barista? Not even the tiniest smirk.

Dang.

"What size you want?"

"Uhhhh, let's see. Wait. First, I think I want some flavor in it."

So instead of asking more, she just waited.

I took a deep breath and selected. "Okay. I'll have a small size or tall or whatever you call it with a shot of . . . uhhh. . . peppermint."

"That's seasonal."

"Pardon me?"

"That's seasonal so we ain't got that any more."

 "No peppermint?"

"Peppermint seasonal."

"So y'all don't have it anywhere?"

She shook her head and clearly was coaching herself not to yell out, "NO. DAMN. PEPPER. MINT." I knew there were a few folks behind me so I quickly chose an alternative. "How 'bout some almond, then? Yes. Almond."

She swung over to the barista-buddy and called the order out. "Small Almond Soy Latte." Next she rang up the order and told me the price. I handed her a five dollar bill and added for good measure what I hoped would warm things up. "Here you go, pretty lady!" The very edge of her mouth made the teeniest, tiniest of smiles in response.

But that was about it.

When she handed me the change, I smiled at her again. Still, not much in return.

Now.

My first inclination was to be annoyed. To start on some tirade in my head about how service is lacking these days and feeling like this was evoking some PTSD from Teenage Mutant Target Checkout Chick. I even thought of finding some manager with whom I could pull aside and share my disdain. But instead, I just paused and thought before doing anything.

My experience in that coffee shop has always been positive. I'm even pretty certain that this very woman had assisted me before--and was just fine. In fact, I can say identical things about the cafeteria, the gift shop and pretty much any service-related place within Grady hospital. So admittedly, this was a bit of a detour. It was. 

I thought for a moment. Maybe she was having a not-so-great morning. Maybe the last twenty-five doctors who'd entered before me had treated her like "the help" and refused to even make eye contact with her. What if this was one of two jobs or what if she'd just gotten a call from her child's daycare saying that his eye was pinkish and that she'd need to come and get him?  Maybe it was all of that. Or some of that. Or none of that.

Maybe.

And so, I decided to keep things light. I made up my mind to give this seemingly indifferent young barista-woman the benefit of the doubt. It was as simple as that--making up my mind to see it a certain kind of way.

"Have a good day." She said that to me as she finished up the transaction and placed my receipt in my hand. And, okay, it wasn't that kind of "have a good day" that makes you feel all warm inside and ready to go out and really, truly have a good day. Instead it felt more like some drone-like, pre-programmed and scripted line that came from hours of working on retail autopilot.

Have a good day.

"Hey," I finally said while looking into her eyes. She widened hers, wondering what I was about to say. I quickly took my serious gaze to something more mischievous--right along with the tone of my voice. "Dag girlfriend! Why you gots to look so mean up in here today?"

And yes, I said "why you gots to" instead of  "why must you look so" -- not because I didn't think she'd be fine with standard English, but instead because I knew that would make this a little less heavy and judgey-judgey. I also knew that because of our cultural similarities that those words would be easy and authentic.

"Excuse me?"

I repeated myself for good measure. "Why you gots to be so mean up in here this morning?" That time I even rolled my neck a little--which I knew would be a funny sight from a doctor in a long, stiff white coat.

"Me?"

My expression was playful instead of accusatory. She saw that and immediately cracked the first real smile I'd seen the whole time I was there. "Yeah, you! You're all like, 'Tha's seasonal.' No love in it, nothin'." My impersonation was exaggerated which made her laugh. Her barista-buddy chuckled, too. "Don't be laughin' at her! You're the accomplice. I saw you over there all like, 'Soy milk? Aiight then.'"

This time every person there, including the baristas, erupted into fluffy laughs.

She defended herself the best she could to the lighthearted onlookers. "I didn't say it like that! I didn't sound that mean, did I?" She covered her mouth and looked around. People nodded all together which made us laugh even more. Her mouth fell open. "Oh my gosh! Really y'all?"

That's when I decided to make it a full on stand up routine. Not even kidding. Right in the middle of the Grady coffee shop.

"This is you--you ready?" She and the rest went along with it. I made my face as flat and surly as ever.  "Mmmm hmmm. What you want, lady? And here's me: 'Uhhhh, can I have a latte?' And you're all like 'What size you want? What flavor--wait. We ain't got that.'" She reached out and pretended like she was swatting at me. I pulled back and kept with my funny business. "'Hey! How 'bout some peppermint?' 'Tha's seasonal.'"

She was doubling over the counter cracking up. So was her buddy. "I didn't say it like that!"

I put my hand on my hip and twisted my lips extra hard. "THA'SS SEASONAL."

She was a great sport about it. None of it was awkward or angry or judging. But there was a message in there that I wanted her to get. And so I made sure of that. "Look at that beautiful smile on that beautiful face! That's more like it!"

She couldn't help but grin. And her face really was gorgeous. As was that of her barista-buddy who was now smiling, too.

"You're our sunshine when we first come in here, pretty lady. I mean that." I glanced at both women over the counter. "Let your lights shine, okay y'all?"

"Yes, ma'am," they replied in unison. Both were nodding their heads like they meant that, too.

The barista buddy handed me the almond latte with the biggest, widest smile ever. And I returned the favor which really felt awesome.

As I prepared to leave, I noticed that the atmosphere was decidedly lighter. Their greetings were more pleasant and those 'have a nice days' were more genuine. And it was good. All of it was very, very good.


I'm not sure if that young woman was just tired that morning or if something altogether different had stolen her joy before I'd walked in. But whatever it was, now I realize the power of human interactions. It doesn't always have to involve a manager or a supervisor. Sometimes something as simple as a smile and some playful teasing could be enough to get the ship back on the right course. And, sure. Sometimes that may not be enough. But a lot of times-- if we give it the chance-- it is. It is.

Yeah.

***
Happy Tuesday.

Renegades and Reality Checks.

*Names, details, all that stuff changed. You know what's up.

"If you looked in my life
And see what I've seen... 

If you looked in my life
And see what I've seen... "

~ from Mary J. Blige's "My Life"

__________________________________________

The census was light. We were down to seven patients total on the inpatient service and those seven weren't terribly active. They had problems that our team could get our hands firmly around and their clinical courses seemed to make sense. I was leaning on the nurses' station holding a cup of tepid coffee that I'd been guarding for over two hours. I knew that if I sat it down for even two seconds it would be swept out of the way in an OSHA-compliant whirlwind.

"What you daydreamin' about, Miss Kim?"

I glanced over and saw the kind gentleman who transports IV Fluids and supplies pushing his little rolling cart. Like always his smile was broad like linebacker shoulders and, like always, he approached me for the one-armed hug I'm always privy to when we meet in hallways. My eyes softened and my arm extended almost reflexively.

"Mmmm-mmmm!" We made that sound in unison. Our hugs always had sound effects, which I loved. He started it, I think, way back when I was pregnant with Isaiah. I remember him saying, "You got to hug like you mean it!" That's where the sound part came into it and, even when I don't make that sound, I often think of those words when doling out hugs because that was a good word.

"Well. I'm finished with my work already. And it's not even twelve noon." I went back to his question to let him know that I hadn't forgotten it. I twisted my face like I was trying to think of what to do next. Partly as an exaggeration but also because I really was.

"You don't even know what to do with yo'self, do you, Miss Kim?" He let out a laugh that rolled down the hall like a bowling ball. It immediately made me laugh, too.

"I reckon I don't." And I did say "reckon" because something about talking to Southerners makes me adopt my own Southern-ness, too.

"Well. I say you go and jest sit with somebody. Whoever don't have nobody to see about 'em go and spend some time. Whenever I been in the hospital that always make me feel better to get a visitor."

I held his gaze for a beat and recognized that he knew what he was talking about. Though I'd never cared for him in the hospital, it was hard not to notice what appeared to be some kind of neurologic problems. There was an irregularity of his gait; an asymmetric and irregular limp. I never knew if it was from a leg-length discrepancy, some kind of congenital palsy or even a remote stroke. Either way, it didn't surprise me that he'd had some experience with being a patient in a hospital.

I jutted out my lip and nodded in response. "That's a good idea, my friend."

"Alright then, Miss Kim. You be sweet now, hear?" And before I could answer he was on his way back to work, leaning over the wire cart and hiking up his left hip with every other step. I noticed the joy coming from him despite what he was up against and put that on a post-it note in my head for later.

"Alright then, sir." Even though he was out of earshot I felt the need to acknowledge yet another good word from him.

Instead of moving I just stood there frozen and trying to think about what to do next and who to go and "see about." I reached into my pocket and scanned my short list of patients. Two were off the floor having procedures. One did not speak very good English and was a little delirious. Another was nonverbal and rather somnolent. That left three patients. Two of them always had visitors standing vigil at the bedside. With the selection framework I'd been given in mind, I settled on the only one of remaining--the one who "don't have nobody to see about 'em."

Or at least the one who seemed that way.

I knocked on the wall near the second bed in the room and announced my entrance. She offered me an expression of pleasant surprise.

"Hi there," I said with a smile. "Just stopping back by to check on you."

They had just passed the lunch trays. I waited quietly as she lifted the green plastic cover to her lunch plate and surveyed the afternoon's offerings. Turkey, green peas, and a sweet potato. Instead of peeking under the lid of the accompanying soup, she simply peeled back the lid and gave it a sniff. She shrugged and took a sip of it. "Broth. Yuck." She shuddered and then sat it on the table, exiling it from the rest of her food.

"Mind if I sit?" I asked. I was already pulling over the bedside chair as I made that request and fortunately she didn't seem to mind.

"You ain't got no bad news, do you?" She didn't even look at me when she said that part. At this point she was sprinkling the last of the three pepper packets over everything on her plate. That sight made me smile inside because I always tease Harry for peppering everything before even tasting it.

"Nope. Just came by to say hey."

She paused with a butter pat on her plastic knife and gave me a smile. "Well, hey!"

"I can come back later. Really I was just stopping by to visit with you. Believe it or not, I had some extra time and thought I'd spend a little more time with you. You look like you're about to throw down so I can come another time."

"If you don't mind me eating while you here, I don't mind at all. Matter of fact, that make me feel kind of special that you here." She bit into her buttered roll and then stopped. Pointing the piece of bread in my direction she said, "Don't you be on television?"

"I used to be on every week. Not as much now."

"I knew that was you," she replied with a mouthful of food.

"Yes, ma'am."

So for the next few moments I simply sat next to her bed as she dug into the "double portion" that we'd ordered for her the night before. Whoopi Goldberg was fussing at that Elizabeth Hassel-something-or-other on The View and Barbara Walters was rolling her eyes. I never watch that show but felt convinced that every single time that I have that this is exactly what is happening no matter what the topic of the day.

My patient asked me to call her by her first name as soon as we met. "Call me Sheila," she'd insisted after my standard last name greeting earlier in her hospitalization. Even when I responded by calling her "Miss Sheila" she quickly corrected me by saying "Sheila is just fine."

Sheila it would be.

Sheila seemed a lot older than her age. It was like she'd lived her life in dog years, cramming a centennial's worth of hard knocks and horrors into her four decades. Her upbringing had been "rough" as she described it and the last twenty years revolved around her addiction to crack cocaine. She had "some kids" and "some grandkids, too" -- none of whom were in her custody. When she told me that--let me tell you--her lip didn't quiver not one bit, nor did her eyes water. This was her reality. Those tears had dried up long before.

"Do you remember the very first time you used?" We'd been talking for a while at this point so I figured I'd ask. It's a question that I'm always curious about. The first time--how did it happen? Or even what was going through the person's head?

Sheila wasn't a fifty-something or sixty-something year-old. She wasn't of that age that shake-shake-shaked their booties in discotheques in the seventies, tooted powder lines to feel relaxed, and then took a naiive hit of this "new stuff" called free base. She wasn't a part of the era that got blindsided by the crack cocaine epidemic as it unfolded on urban street corners in the eighties--making squirrelly gangsters uber-rich and working poor folks disturbingly poorer.

Nope. Not her. She was of the age that I was. Plus or minus no more than three years. The age that turned on televisions and heard First Ladies telling kids to "Just say no to drugs!"  Like me, I bet she probably sat cross legged on the floor and sang along with that infectious "GET HIGH ON YOURSELF" NBC jingle aimed at little kids like us, imploring us to believe that "being high on yourself" is actually rather cool.

Maybe. But my point is. . .she came up in the era that had been given the memo. The genre who cringed at the eighties movie Less Than Zero and who still try to shake those awful scenes from that movie from our heads when we see this reinvented version of Robert Downey, Jr. in movies like Iron Man. And even if she didn't see any of that, kids our age were told. Crack is bad. It's addictive. It's whack. Don't use it. Don't touch it. Or else.

So why? So how? How did that first time happen? How could it have happened even?

Her answer was pretty nondescript. "I was nineteen and it was a bad day," she said. She left it there.

"A bad day?" That was it? That was all? I wanted to know more.

Now she was slurping her coffee. She winced on the first sip and I suspected that her fractured teeth were sensitive to the temperature. I was glad that she didn't seem annoyed by my queries. In fact, she seemed to welcome them. "I left home when I was like fifteen. I was working on the track from sixteen on. That was rough, you know?"

"The track?" I'd heard the term before but I wanted to get clarity just to be sure.

"You know. The track. Where you walk to get picked up. That's where they drop you off and where the girls go when they, you know." She made a rolling gesture with her hand to fill in the blank. "You know."

You know. Sell their bodies.

Sigh.

"You were sixteen? Damn."

"Yeah. Sixteen is hot on the streets. Fifteen even better. I looked-ed young so they was at me tough. First I was a renegade, then I got chose so I had some protection."

"Chose? Like you got a . . .pimp?"  It almost felt cartoon-like to say it aloud. I'd never uttered the word "pimp" to someone in the context of them really, truly having one.

"Unnnh hunnh." She hitched her breath again after a little more coffee passed over her lips.

"What's a renegade?" I continued. This one I didn't know and hadn't heard.

"That's when you just on the track and ain't been chose. But that's dangerous."

"So like. . . .where is 'the track?'"

That made her laugh out loud. "You funny, doc. The track is everywhere that it's girls walking. Or the boy-girls 'cause some people into that, too. Every city got tracks. It just depend on what you looking for, you know? Like if you want young girls, big girls, white girls, black girls, boy-girls. You go to that track. That's before the computers, too. Now it's kind a different but they still be out there getting they money on them streets. Getting that paper!"

The whole thing made me shudder. At sixteen I was crying after a bad experience with my first pelvic exam. That was as close as I'd ever been to being penetrated and here she was--around the same point in time--getting penetrated over and over again to stay alive. I tried to look calm, like this was talk I'd heard all the time. It wasn't, though. It so very wasn't.

"It seems like you had a lot of bad days before you turned nineteen, though. Wow."

"You know? When you don't have no family, the girls become your family. We used to be close and have fun together. People don't think that but we did."

"I can see that."

"I got tired. Tired of doing that all the time and I had been thinking about trying to get out the game. But that's hard." I leaned my chin on my hand and stayed silent. She went on. "My daddy had good girls. We was all young and fine and pretty, too. Them dudes stayed at us, they always wanted his girls. He kept our hair did and us looking nice. But he didn't like it when you got messed up. Like if you got old or too big or whatever. He also didn't like no crackheads."

I was confused for a moment but then a light bulb came on. She said she wanted out. It was hard to get out. And her "daddy" didn't like when his girls got tied up with drugs? I hoped she wasn't saying what I thought she was saying. "So. . . .you said it was a bad day?"

"I had got hit by this dude and he robbed me. And my jaw was hurting but he put me right back out on that track. The fiends was always out there and the hustlers was out there serving 'em. They didn't bother us 'cause the crack fiends always would do stuff for a hit so they didn't need to be bothered with us. And that day, I was just like eff it."

"Eff it?"

"Yeah. I bought a rock and smoked that shit. Sure did. Smoked some more and just like they say, I wanted more. My jaw didn't hurt, my feet didn't hurt, nothing. Next thing I know, I was hooked. Spending my money on it and just waiting to get my ass whooped for it."

"Did you?"

"Hell yeah! Almost left me for dead. But you know what? That's how I got out. He fired me when he found out I was a fiend."

"Wow." I didn't know what to say or ask next. Trading in prostitution for crack addiction sounded like the same kind of choice given to people inside of towering infernos--jump out from a twenty-story window or burn to a crisp. Both are equally shitty options. I wiped my face to get that out of my head and went on. "So. . . when you . . got fired. . . like. . . how did you feel?"

She paused for a second and thought before answering. "Sad, a little bit. Because I missed my other girls. But relieved, too. I mean, I knew how to get money. Now instead of money it was just rocks, you know, to get high."

And all through this conversation she kept doing mundane things like sipping coffee and sprinkling pepper which was really off-putting. It made the dichotomy between our lives just that much more palpable; her everyday existence so far, far away from my own.

"I'm sorry."

She shrugged once again and smiled at me with those decaying teeth. Behind the matted hair and weathered skin, I could see flickers of that once beautiful young teen. I mourned her loss and wished someone had been there to protect her. Instead, all I could do was hear her truth and recognize that there are lots of harsh realities going down right here, right now in the United States of America.

"You sorry? Shoot, I'm sorry that I got to wait until five o'clock to get some more food!" She announced that ironic response while covering the plate again. "Or that Sprite ain't on the menu." She laughed a raspy laugh that somehow gave me another pang in my stomach.

"You want some Sprite?" I asked.

"Yes. But in a can, not a bottle. It's colder in a can."

And with that, I stood to my feet and went to do just that. Because Sprite in a can was something I could do. I couldn't just pop some quarters into her universe and wait for a new life to pop out of the bottom. But an ice cold lemon-lime soda from the machine in the family waiting area? That I could do.

When I came back to her room, she had already nestled under the covers and was dozing off. I gently placed the can of soda on her tray table and grabbed a napkin from her tray to leave her a note.

Thanks for letting me visit with you and for telling me about your life. Here is your Sprite. I hope it's still cold when you wake up. 

Dr. Manning

When I prepared to walk out, the last thing I heard was Whoopi Goldberg still fussing at somebody on The View.  I hit the mute button on the side of her bed, pulled the divider curtain, and then went on with the rest of my day . . . . marveling at what can happen but for the grace of God or for the luck of the draw--whichever you believe in.

***
Welcome to Tuesday.

And now playing on my mental iPod. . .first, the talented Ms. Mary J. Blige singing "My Life." It made me imagine Sheila singing it with her raspy voice and just as much soul. (I always have to stomp my foot and say, "You betta SING, Mary!" when I hear this song.) Turn it up and you will, too.



Second. . . .the ridiculously cheesy 1981 "Get High on Yourself" commercial -- check out all the celebrities back then! I was in the fifth grade when this came out and my best friend and I sang it on the bus every single day.



And lastly. . . . I'm just saying. . . Clint Eastwood didn't just start going off the script. . . peep this from the unveiling of Nancy Reagan's "Just Say No" campaign. 

I'm here.

Got my house

It still keeps the cold out

Got my chair

When my body can't hold out

Got my hands doin' things like they s'posed to

Showing my heart to the folks that I'm close to

I got my eyes though they don't see as far now

They see more 'bout how things really are now

And I'm thankful for each day that I'm given

Both the easy and the hard ones I'm liven'

But most of all

Yes, I'm thankful for lovin' 

who I really am. . .

I'm beautiful

Yes, I'm beautiful

And I'm here.

~ "I'm Here" from The Color Purple 

_________________________________________________

I saw a lady recently whose chart wasn't making sense. Kept all of her appointments but wasn't following through on the plans her doctors gave her.

"That's weird, don't you think?" I said to the resident caring for her. "Doesn't make sense to come to the doctor but not do what the doctor tells you to do."

"It is kind of weird." My resident squinted one eye and thought for a bit then shrugged. "I'm not sure if she has some. . .I don't know. . .cognitive issues. I give her clear instructions and, I kid you not, when I see her again it's like it never happened. It's crazy."

"Who does she live with?"

"Her daughter. . . I think. . . hmmm." She tapped her finger on her lip. "I don't really remember. I know her daughter is very involved. She usually comes with her to the visits but isn't here today."

I nodded my head. Okay. That gesture meant that I'd heard enough and wanted to talk to the patient for myself.

We knocked on the door and entered the room. I had just put hand sanitizer on my hands and rubbed them vigorously together in preparation to shake her hand.

"Good afternoon, Ms. Jane. I'm Dr. Manning and I'm the senior doctor working with your doctor today."

"Hi Miss Manning," she replied with a big smile. I returned the gesture because for whatever reason I find the "miss" instead of "doctor" thing more endearing than offensive.

I sat on a chair and repeated several of the points her doctor had already spoken to her about. We chatted about her diabetes and how concerned we were about her taking the insulin the wrong way. Next we talked about the anti-platelet medicine called Plavix that she was still supposed to be taking but had stopped. Lastly we sorted out the blood pressure medication and reaffirmed that it was good that she was taking the cholesterol pill at night like it was prescribed.

She was very engaged and followed every word. So earnest and focused. So respectful and invested. So why were the plans unraveling every time? This didn't make sense.

"I hear your daughter is normally here with you? I'm sorry I didn't get to meet her."

"She got a different job that don't let her off so easy," she said. "She normally like to come but haven't been to my last few doctor 'perntments because-a her job."

"Do you live with her?" I appreciated that natural segue.

"No ma'am. But she do see about me."

I nodded my head. What came next should be predictable to you at this point if you know me or you've been reading here for a while. Yep. I started exploring the story. Her story.

"Ms. Jane? Where'd you grow up?"

"I grew up in Alabama. In the country."

"Is that where school was for you?"

My resident watched, knowing this line of questioning well. Her facial expression said it all--Here we go with Dr. Manning's line of literacy questions. 

"Yes, ma'am."

"What grade did you make it to?" I continued.

"I made to the tenth. But tha's when school only went to the tenth so I finished."

My resident looked at me and somewhere in her eyes I saw a tiny flicker of triumph.Or perhaps relief that her attending hadn't just uncovered literacy as the reason for nonadherance to the medical plan.

"What kind of work did you used to do?" I recalled that the resident had told me she was retired.

"Housekeeping and such. But I been retired a long time."

I nodded again. Then I just sat there in silence thinking of what to say next. Polite Ms. Jane waited patiently for me to find the next question.

"Ms. Jane? Do you ever. . . like. . .does it ever get kind of confusing to you to keep track of all your medicines and directions from us?"

That question caught her off guard. Her eyebrows raised. "Beg pardon?"

"You make the appointments but some parts . . . I mean. . .it seems like maybe it was hard to keep track of."

Ms. Jane just watched me for a moment, studying my face to see where I was coming from. She carefully answered me.

"Sometime. Sometime if my daughter not there it's kind of hard."

"What does your daughter help with?"

"She help with telling me what I'm s'posed to be doing and what all y'all want me to do. She good with all that stuff."

"Ms. Jane? What about when we mail things to you or give you papers to read? Do you feel comfortable with looking over that stuff if your daughter is at work?"

Again she hesitated. Then finally she spoke. "Sometimes. . . .no."

"Does your daughter realize that? I mean. . .that like. . .if she isn't there that you might have some trouble with the papers?" I chose my words carefully.

"Do she realize? Realize that. . . what? You mean. . . . " She froze and then readjusted herself in her seat. That was enough to stop her from finishing her sentence.

Letting go of our eye contact I looked down at a piece of paper in front of me and spoke while doodling with a nearby ink pen. "Sometimes, Ms. Jane. . .even when you went all the way through school, it's some stuff you didn't get. And that's okay, you know? Because nobody knows everything perfect." I looked up again and reestablished our gaze.

This was cryptic, I knew it was. But I was trying my hardest not to come right out and ask. But Ms. Jane had my number and understood where I was going. Her eyes began to fill with tears.

"Ms. Jane?" I said her name again to hold her attention. "There's some stuff I didn't learn well in medical school. I think to myself. . .  sometimes . . . .if people knew the things I wasn't so sure about they might laugh at me, you know? Then I just tell myself that it's okay to not be sure about everything. It's always good to keep learning."

The tears began to spill onto her cheeks and she wiped them quickly. She placed her hands into her lap and began to wring them nervously. "One time," she started and then stopped. She took a deep breath and went on. "One time, my daughter was at her new job and I got a paper from Grady. I know the Grady red sign so knew it was from y'all. I took it next door to my neighbor and asked her to help me. I told her I couldn't see it without my readers and could she read it for me." Then she began to weep. Hard.

I handed her the tissue passed to me by the resident and waited for her to finish.

"My neighbor--she so nice--she turned around and came back with a pair of readers. 'I got a spare,' she said. And she gave me her readers and closed the door. And I was jest standing there with them readers and them papers not knowing what to do." Her face twisted up in this complex mixture of shame and relief. It was like we'd rubbed a genie out of a bottle.

I  tread delicately--careful not to make assumptions. "So. . . .the readers weren't enough?"

Ms. Jane shook her head and squeezed her eyes tight, like somebody bracing for impact. "I don't read good, Miss Manning." Then she crumbled into full-on weeping but pressed on. "I be wishing I could read good but I didn't never learn. I wanted to go back to learn but I never had no time. It make you feel so bad, too, not reading. Like you always got to count on somebody."

I felt a lump building in my throat. "Does your . . . daughter know?"

Her forlorn expression told me that answer. More tears. More shame.

"The newspaper. It come to my house every single day. Every morning I take it out the plastic, open it up and look at the words and the pictures. Hoping it's jest gon' unlock in me one day. And nobody think I can't read good since I get the paper, you know? But to me, it's jest words and pictures and nothing else."

Now my eyes were welling up, too. I could see the unfolded sheets sprawled across her kitchen table. I could feel the defeat she felt when her well-meaning neighbor handed her a pair of reading glasses.

Damn.

"I'm so glad you told us. I'm so, so glad." I reached out and squeezed her hand and I swear to you it felt like someone deflating a balloon under pressure.

"We can make it a lot easier for you, okay? Thank you for telling us that," her resident doctor said. And that resident smiled at her warm and genuine which Ms. Jane seemed to appreciate.

I did, too.

And so. We spoke to our Grady pharmacists who swooped right in to help. They smiled and listened an normalized something that she'd been ashamed of for more than sixty years. Then they gave her a card that explained all of her pills with pictures instead of words making it easy for her to follow whether she  had readers or not.

image credit

When the visit ended, we shifted off of the low-literacy issue out of fear that making such a big deal about it might make her feel self conscious. So I excused myself while they wrapped things up and shook her hand like it was really no big deal.

Even though it was.

Right before I left the room, I caught a glimpse of her pocketbook sitting beside her on the desk. Under it was a stack of papers from Grady tucked neatly into a manila folder. And peeking out of the mouth of that purse? Today's issue of the Atlanta Journal Constitution. Refolded because it had clearly been opened earlier that day.

Once I closed the door it dawned on me. Today, something did unlock. Right there in that room when one brave soul had the courage to tell her doctors that she could not read.

When I got into my car to head home and thought about that exchange, it hit me. Really hit me. I cried all the way home. No, Ms. Jane. You don't read good, but you're here.

You're here!

And now I'm crying again because I'm just so proud to be a Grady doctor. So appreciative to be where I am. So blessed to be here, too.

I'm here. We're here.

Yeah.

***
Happy Tuesday.

Now playing on my mental iPod. . . . Fantasia brings it home and puts me on my feet just like she did when I saw her singing this on Broadway. This is a song for every person who is still here. . . .damn, it is. (It sounds best when you periodically yell out, "Girrrrrl! You betta SANG that SONG!")

Top Ten: Heard in Grady Today.

I'm back on the Grady wards. For those who don't regularly read this blog or who are new here, it means that I'm taking care of patients on the hospital service instead of just in the clinic. Even though it's hard work, the ward service is my favorite place to care for patients.

Rounds today were rich and good. My patients have already captured pieces of my heart and taken me on a roller coaster of emotions. And it's only the second day of the month.

And so. On day two I bring you:

THE TOP TEN THINGS I HEARD 

IN GRADY HOSPITAL TODAY

Like to hear it? Here it go!


#10  --  Response to a query:

Me:  "How are you feeling today?"

Him:  "Baby, just call me James Brown. I feel GOOD!"


#9  --  She said it, not me.

An elderly couple sees me sitting at the nurses' station writing notes. They are looking for a family member on the ward and decided to ask me to help them. Just as I am preparing to direct them to the unit clerk, a young woman walks by wearing the world's most obscenely short Daisy Duke shorts. The only thing more fraught with peril than the high percentage of butt cheek hanging out of the back of them was the cottage cheese appearance of everything else.

The elderly lady (who cannot be anything less than 90 years old) wrinkles her nose and purses her lips so hard I thought she'd just sucked a lemon. Then she looks over at her husband (who cannot be anything less than 100 years old) and says in her gravelly voice, "If that girl was my child, I'd pull a switch off the nearest bush and beat her tail for walking through a hospital looking like that."

His response?

"Yeah. That child look a HOT ASS MESS."

Love. This. Place.


#8 -- Man versus disease

Him:  "I'm not afraid to die. . . . I'm not."

Me:  "Wow."

Him:  "Are you?"

Me:  "Me? Kind of. Or rather. . . .yes. I mean, right now I would be."

Him:  "Not me. I'm only afraid of not knowing what's going on."

Me:  "Hmmm. Do you feel like you know what's going on?"

Him:  "I think so."

Me:  "So you're not afraid?"

Him:  "Naw, sugar."

Me:  Silence

Him:  "So don't you be afraid for me neither, hear?"


#7  -- As seen on TV.

Her:  "Don't you be on channel 5?"

Him:  "Sho' does. She sho' do be on channel 5."

Her:  "I thought you was waaay bigger."

Him: "TV make people look bigger."

Her: "Mmmm hmm. Waaaay bigger."


#6 -- DISS-oriented

Me:  "Sir, can you tell me where you are?"

Him:  "Grady!"

Me: "Great! Can you tell me what the year is?"

Him:  "Twelve!"

Me:  "Awesome! Can you tell me who the --"

Him:  "Obama the president and his wife name is Michelle. Now stop asking me all these stupid ass questions and get me up out of here."


#5  -- Tell me how you really feel.

Nurse #1: "Dr. Manning, I like your hair with the grey coming in!"

Nurse #2:  "Oooo-weeee! I don't. At all."


#4  -- Mistaken identity

Me:  "Hello there! This must be your lovely wife!"

Him:  "Naw, tha's just my old lady."

Old lady:  *TING* (sound effect for big, proud smile.)


#3  -- First one smell't it dealt it.

Her:  "Do you smell that?"

Me:  "Smell what?"

Her:  "I passed some gas under them covers so I was afraid you mighta smellt it when you pulled 'em back."

Me:  0_o


#2  --  A little bit of Marvin Gaye to set the mood.

Overheard someone singing this in a high falsetto while working:

"Dance with me, come on dance. . .with me baby. . .I want you. . .and you want me. . . .so why don't we. . . .get together after the dance. . . . When I first saw ya' babe. . . .you were lookin' good. . . on Soul Train. . .ohhh hoooooo. . . .

Complete with the old school Marvin Gaye finger snap. It was awesome.




#1  -- Youthful glow.

Nurse:  "Excuse me, doctor. Are you the intern for this team?"

Me:  "I'm not the intern for any team. But you're my new best friend for thinking I am."

***
Yeah, it was a good day. Happy Saturday.

And now playing on my mental iPod. . . . Mr. Marvin Gaye infuses the Star Spangled Banner with more soul than it has ever and will ever see again. Love, love, love this. Could watch it a million times. 

People, perspectives and train wrecks.

The patient

This room is suffocating. Like every bit of air in here has already been used up and somehow I was left with the air scraps. But at least I'm in here. I just hope this doctor will understand.

Motrin doesn't work. Naproxen doesn't work. That last stupid doctor I saw in that ER had the nerve to part his lips to say "acetaminophen." Like I'm so dumb that I don't even realize that's the same thing as Tylenol. I looked that dude straight in his eye and let him know. This, Mr. Asinine Doctor, is not a "tylenol" kind of pain.

Or an acetaminophen one.

I need some shit that will work. Let me sleep and not feel sick. And you know? I just wish I could see just one doctor who listened to that and got that and got up off that high horse long enough to just give me some shit that works. No, not your bullshit tramadol or Ultram or "prescription strength ibuprofen" like you like saying. But something real.

Real, yes. And no, not half-assed real either. Like some tylenol -- "but with codeine in it" or naproxen and "a few pills of Flexeril." That isn't what wipes this pain out. Or stops me from feeling sick and miserable and like I'm going to hurt somebody.

So it all becomes this stupid assed dog and pony show where I have to say the right words and pray to the heavens for a doctor that isn't a damn know it all detective. You know. Those ones that get all high and mighty and decide that you are an addict simply on a mission to get high.

What the eff?

I'm in pain. Real true pain. In my neck. My back. My stomach. All over. And now, on top of that, if I don't get what I need, I feel sick. And like I'm gonna go crazy. For real.

My old doctor was cool. At least at first he was. He used to give me what I needed for this pain. He didn't make me feel bad or like some kind of addict or nothing and he gave me what would work. Like the hydromorphone or the oxycodone. That dude didn't hold back on this pain.

He was the one who gave me this medicine in the first place. I told him about my back and my neck and all that and he said, "Here, take this." And it was some oxycodones and that shit knocked that pain back. And when my body started getting used to them, he was okay with giving me a higher dose and then even giving me something stronger. Because that doctor? That doctor cared about me.

Yeah, he was busy and no, he wasn't too touchy feely or anything but, shit, that was cool with me. He wasn't gun-shy with that ink pen when it came to them pain medicines and I appreciated him for that. Matter of fact, that's what he was known for.

Then one day. . .just like the rest. . . .it turned into something else. That main doctor took that vacation or leave or whatever the hell it was and that partner of his was one of those bullshit doctor detectives. Asking me about past history of IV drugs and drinking liquor and all this shit that, to me, don't have nothing to do with this pain or this sick that I feel when I don't get my medicine.

So next thing I know he talking some shit about "weaning" me off the medicine. No more hydromorphone or oxycodone. Just some bullshit he came up with after speaking with some kind of pharmacist. All with a goal "to help me."

Help me? Help me!?

Man, please. The only way you can help me is to do something about this pain. Period. End of story.

So here I am all over again. Seven different emergency departments in six weeks because I really have no choice. No choice but to go there or to do something stupid in the streets to keep myself from feeling sick and in pain.

No choice but to do what I have to do.

image credit

The intern

Shit.

That man is my patient. That man. I already saw him when I walked through the waiting room writhing all around and rocking back and forth. Eyes all wild and body positioned all funny. I swear he moaned louder when he saw me walking by in this white coat. Can't even lie -- I hoped that he didn't belong to me. But Murphy's law. He did. That man.

Shit.

I still have to go back to the wards. And this? It's just too much. I overheard them triaging him and even that was hard. He just wouldn't stop pushing and explaining and moaning -- and that was just his vital signs being taken. Every so often he would let out this yelping sound that sounded like someone stepping on a sleeping dog's tail. I wasn't sure what to make of that, but he did look miserable.

Just not that miserable. Not yelping-out-loud-at-the-top-of-your-lungs miserable.

I looked over his chart and his chief complaint. And the refills he was requesting? Oxycodone? Dilaudid?

Dilaudid? Seriously?

So I introduced myself and listened to what he had to say. And just like in triage, he had a lot to say. A whole lot. And mostly, it wasn't so bad. He actually seemed to be a pretty nice guy for the most part. But it was weird the way he kept going from very, very miserable to very, very mad to very, very syrupy sweet and cooperative.

Something about it made me tired.

I wonder. Would it be the end of the world to just give him what he's asking for?

The attending

Ugggh. 

That poor intern. He looks so exhausted already. And seriously? I don't blame him. These kinds of interactions suck you bone dry. Dry of any traces of the already limited energy you came to clinic with. It sure does.

Especially when you're an intern.

A lot about this is just like what I've seen many times over. Youngish person comes in. Usually not fitting the more common demographic of our patient population. Why this is? I'm not so sure. What it usually suggests is that a wide net of providers has been cast. At least that's what it seems like.  So yeah, the story is usually predictable--some long and convoluted tale about their journey through chronic pain. A journey over rivers and through woods. Some reference usually to college education and a highly successful career that all folded in like origami after the nidus of this pain began. And somehow, some way that journey always seems to end with words like "oxycodone" or "percocet".

Or in this gentleman's case, "hydromorphone or dilaudid."

I know it's bad to think these things. I know. So I'd never say it out loud. But it is what I'm thinking. And I know it's bad.

Yes, it's bad because I know that every patient is different and that every patient has a story that is uniquely their own. But damn there are some truths or at least semi-truths that always seem to relate to this particular scenario. Always.

Truth #1:  I always feel the same way the moment I walk into the room. Tired. Immediately tired. And like I need to pay attention even closer because the words often feel slippery.

Truth #2:  I always end up scolding myself during the encounter. Telling myself to regroup and individualize this one person in front of me. To acknowledge how this one person is feeling and why they might feel this way. Admonishing myself to let go of the countertransference that I surely have -- and to be "the healer" that I promised I would be with that right hand up in front of Hippocrates and whoever else was listening.

Truth #3:  It usually doesn't end well. Even if, at first, it seems okay. Eventually it isn't. And that sucks because it's like a train wreck that you know is about to happen. At least most train wrecks catch you off guard. These kinds don't.

Wouldn't you act funny, too, if you knew the train you were on was about to crash? But I'm the role model so I can't act how I feel. Or even really say it without some sort of extreme filter.

Because really, I'm aggravated that some irresponsible person somewhere gave a patient this much narcotic. Or better yet, even more aggravated that they gave it to him repeatedly and then kicked him out of their practice because he kept coming back for more.

Duh!

Of course he came back for more. You keep putting heavy cream instead of skim milk on the back porch and what do you think is going to happen? Sigh. I know. I can't say that. Or make analogies like that because that's not cool. I know.

But I'm human, too. Remember?

So yeah. Now I'm standing beside my intern and looking at this man with a twisted snarl on his face sitting in front of me. And yes, I do believe that he is in pain-- I do. Pain of one kind or another. That said, I do not believe that his pain warrants the amount of exaggerated behavior I am seeing.

And that's what always leads to truth #1. That.

Damn. I'm exhausted, too.

Part of me wants to say, "Sir? Let's say all of this pain medicine is appropriate or at least some version of it is. Let's just say that. Can I just give you some advice? Don't do that. Don't do that thing where you behave as if a machete is stuck between your shoulder blades and as if your back is spurting out pulsatile arterial blood. Or make that blood-curdling sound like someone grabbed a pair of pliers and pulled four molars out of your jaw without a drop of anesthetic. Because that's how you're acting--hysterical--and this doesn't call for that. Besides. Real, true hysteria is something I've seen before. And it damn sure wasn't in a clinic talking about chronic pain."

That's what I want to say. But I never do.

Real hysteria? Oh, I've seen it. Once when this little pre-school aged boy got his foot caught under a riding lawn mower when I was a resident. He and his parents were really and truly hysterical. And you know? It was warranted. His foot was all mangled up and he was wide awake. Staring at it. The other time was when this kid was jumping on a bed in his cousin's bedroom. It was a high-rise and he leaped off that bed and crashed into a screened window. Problem was, that screen was loose so he fell. Six stories. So yeah, his family was hysterical, too.

And rightfully so.

Okay, and perhaps I did get a wee bit hysterical when I was having that nine pound two ounce baby, but that was before the epidural. Or the dilaudid.

But this? This is a dude walking around with pain of one kind of another, but not one that calls for all of this. Because real, true hysteria has to be short-lived because it is too exhausting to keep up with.

So yeah. These truths (or rather semi-truths) makes it harder to individualize care. Knowing that the train wreck is coming whether I like it or not. Because it is. It always is.

The interaction

"Hi, sir. I'm the senior doctor in the clinic today and your doctor and I have put our heads together about your health problems and the plan of care for today."

"Thank you, doctors. Thank you so mu--AAAAGGGGGHHHHHHH!!!!" The patient started taking deep, exaggerated breaths. Then he added through panting breaths, "Th-th-thank you."

"Mr. Fields? I have spoken to my attending about you. We went over all of the history together and I talked to her about your physical exam. Thank you for bringing in the records from the other hospitals. Do you have anything more recent than four years ago?"

"Arrrrrrrrgggggghhhhhh. . . .do you mind if I lay down on the examining table? I just can't take this pain. It's so---GRRRRRRRRRRR--I'm sorry. It's awful. Now what were you saying doctor?"

"I was saying that the records you gave us are from emergency visits but they appear to be pretty outdated. I want to be sure we aren't missing anything. I know you've had this pain in your neck and back since 2000. Did you have a primary doctor caring for you?"

"Listen, doctors. I had a doctor but eventually he told me I needed to come here to see you guys. He said he couldn't take care of my pain any more. Well, actually, not him. His partner raised some crazy concerns about me like I was some kind of addict. And like I told you, I have a Master's degree. I am not some kind of addict."

The attending interjected. "We want to be honest with you. Our goal is to have the same conversation with you in this room that we just had outside this room. We are concerned about these medicines and no, we aren't calling you an addict. But we do want you to know that we are concerned that there could be some dependency that you've developed on these medications."

"That's some fancy BULLSHIT WAY of just saying the same thing. I'M NOT AN ADDICT. YOU GOT THAT? " His eyes were wild and agitated. The intern backed up and the attending remained between the door and the patient.

"Sir, I never said that."

"The HELL you didn't. I don't know what you expect me to -- AAAAARRRRRGGGGHHHHH!!!!! I'm in PAIN! Don't you see?" The patient dropped his head into his lap and began crying. Hard, loud and exaggerated. Then it tapered off to a whimper. "You have to help me. . . .please."

The attending reached out and touched his hand. "We want to help you. We do. We want to do right by you. We think at some point you may have been given more than you needed. We want to be responsible in caring for you. Even if that means it's a little uncomfortable at first."

"I am happy to cooperate in whatever way you ask, doctor. I just want to not be in pain. I really do."

"First, I want you to know that we do believe that you have pain. I don't want you to feel like we don't believe you." The attending looked like she was willing herself to be patient with him. She was still holding his hand. The intern sat on a nearby chair watching.

"Thank you for helping me. I knew when I saw you that you wouldn't treat me like I was a junkie or something. I went to ivy league schools and have terminal degrees. I'm not the kind of person who would try to just get narcotics just for the sake of getting narcotics. I wish something other than Dilaudid worked for me. But that's what works."

The attending pressed her lips together instead of instantly responding. After an almost uncomfortable pause, she went on. "Words like 'junkie' and 'addict' are hurtful. I wouldn't call you or any of my patients those words."  The patient let out another hysterical yelp in the interim. She pressed her lips together even harder--this time with a deep inhalation.

"I'm sorry, doctor. I'm just so, so much in . . . aaaagghhh. . .pain." This time his voice was a tiny whisper. Almost cartoon-like in it's quality.

"We need to start a process to treating your pain differently. Something that doesn't involve all of these habit forming medications like hyromorphone and oxycodone.  I reviewed your records and also saw that you had a CT scan and an MRI here at our hospital. Fortunately, they were mostly normal with the exception of a little bit of degenerative changes from aging."

"My disks are herniated, though. You knew that right? One doctor wanted to operate. I couldn't afford it. My nerves are pinched from my disks being herniated." He winced again and began audibly gritting his teeth in pain.

"The images they took of you three months ago were much better. That happens sometimes. This doesn't mean you don't have pain, but it also doesn't sound like you need a surgery, so that's good. I noticed from your urine screen that the medicines aren't in your system. This way we don't have to worry as much about your body withdrawing from not having these medicines. It will take your mind some time to readjust, though."

The patient yanked his hand away and stood up. "So you're NOT giving me anything for pain? NOTHING for this pain?"

"We plan to have you go to our cognitive behavioral program for chronic pain. We also want you to see our mental health specialists, too."

"WHAT MEDICINES THOUGH? WHAT ARE YOU GOING TO GIVE ME?" Now he was up and pacing. His hands were shaky and everyone in that room looked nervous. The attending instinctively cracked the door open.

"The plan is to give you a combination of naproxen and also something for nerve-related pain called gabapentin."

"I've TRIED all that and that DOESN'T WORK!!! So you are just going to let me go home in PAIN? Do you even CARE?"

And that attending started trying to explain the best she could. All while coaching herself to stay calm and like something close to a role model. Something close.

The patient turned and looked at the intern. He saw that fear and confusion in his eyes. "Do YOU even care? I could tell that you did. Follow your OWN heart. Don't let what someone else says make you let someone go home in pain. That's the kind of doctor I KNOW you can be." And somehow in all of this he forgot to wince. Or yelp.

"Sir, I'm sorry you are in pain like this. I truly am. We want to help you," the intern offered. And he meant that. His eyes kept darting back over to his attending.

The patient crumbled to the floor and began crying again. On all fours in a way that startled even that attending who had been at this for several years. "Then help me with my pain. Even if you just give me a few to help me make it to another doctor. Please. . . .just. . .please."  And really and truly he curled up into a fetal position right there in the middle of that floor.

The attending gently closed the door again. "Sir? We will help you. But it will be a process. Today we cannot prescribe you any narcotics. It's important that you hear me say that because I want to be clear on that part. We don't think this is in your best interest. We will be ---"

And just like that the patient cut her off. He quickly got to his feet and snatched all of the papers off of the desk. "All of you doctors are FULL OF SHIT." He glared over at that doe-eyed intern. "And that includes YOU, TOO."

The attending opened the door all the way again and the patient marched past her. "I'm going to somewhere that actually HELPS people."

Both doctors stood by watching. Their eyes were on him and speaking words like "sorry that you feel that way" but this time only with eyes and expressions. Not mouths and sounds.

The patient made a ruckus as he walked away from them. Yelling expletives and saying really unflattering things about the doctors. At the end of the hall way he looked back at that attending and that intern and said this:

"I would have liked it better if you had the guts to just call me a JUNKIE or an ADDICT to my face. Cowards."

And with that he disappeared between the double doors. You could tell those words stung that attending like the unexpected snap of a rubber band.

Interestingly, a senior resident walked by and looked toward her with an amused expression. The kind that comes from being desensitized to such interactions. Unfazed by the sight of a train wreck.

The intern was not amused. He just stood there in that corridor looking like he'd witnessed a mugging. And the attending leaned against a wall wishing that truth #3 wasn't true.

Too bad it was.

So again, this was a train wreck. But one that they pretty much saw coming. And just like all train wrecks it didn't end well.

Sigh.

This? This is what complicates medicine and caring and healing so much. The patterns. We all fall into patterns because it's human nature to respond to what we can predict. You avoid Peachtree Road because you know the traffic is heavy. So you take Juniper instead. And you know that because you've seen that over and over again.

See, things in medicine have patterns -- but with these patterns there are people involved. And people are not as simple as patterns. They aren't statues just frozen in time and fixed into one position. They aren't traffic patterns or cell phone signals. They aren't. Not the patients or the providers.

No, they are not.

So the key, I guess, is to fight against becoming a statue. That's what made me write about this today. I need to flesh out these ideas and the perspectives of those involved. I want to fight myself to make certain that I never get so complacent with the sight of a train wreck that I look at it with amusement. Or freeze like I'm made of stone.

So I fight. We fight.

Fight to see the perspectives. Try not to take Juniper because of the train wrecks we see coming on Peachtree.

But most of all? To still be bothered enough to care when they do.


***
Happy Tuesday.