What had happened.

Warning: Random ramble ahead. Proceed at your own risk.

There was this meme that I saw on social media about Secretary Hillary Clinton. It was shortly after she'd clenched the democratic nod and gave her acceptance speech at the DNC. This person had changed her profile picture to the infamous "H" with the arrow and underneath it said these words:

"Girl, I guess I'm with Her."

I have to be honest and say it made me laugh out loud. And while I can't say that meme spoke to exactly how I felt personally, I'd be dishonest if I didn't say that some piece of that statement didn't resonate with me just a tiny bit.

Yeah.

And let me be clear: I was never really not on board. Like, I had been following Hillary Clinton for some time and was fully aware of her tremendous track record. Her commitment to the "least of these" didn't just pop up out of the blue. This woman has been a champion for others her entire adult life. All it takes is just a few moments of looking over her history and you have to admit it to yourself right away that, when it comes to her resume, Hillary Clinton is one dope lady.

Yup.

Dope, in the urban vernacular, is one of the highest compliments one can give. It suggests more than just "cool" or "really good." It suggests that someone is. . .well. . .the ideal. Yeah. That.

So yeah. As far as doing stuff and showing up is concerned, Secretary Clinton is pretty dope. But still. Regardless of that fact, there was something that held some people back from seeing her as universally dope.

Does this even make sense? Let me try to unpack it.

Okay, so check it. When Barack Obama stepped up on the DNC as a senator in 2004, I felt my heart racing. His voice, his swagger, his intelligence, his essence grabbed me by the chest and pulled me in close. And maybe I was late to it all, but honestly, this was the first time I'd really heard of him.

Yep. I admit it.

But after that, I started following him. I read about him, learned about him and joined the legions of folks who hoped this man would run for President. Yup. And damn, was I among the over-the-moon elated who jumped for joy when he said that indeed he would.

Yep.

Being with him was a no brainer. Not only did I like his policies and plans for our future (and I respect that some reading this did not) the thing I recall the most was liking him. He was cool. His infectious smile made me do the same. He was this biracial man who identified with black culture and navigated it so smoothly that it welcomed others in instead of making them feel like outsiders. And all of it was amazing.

Universally dope, even.

I had an Obama sign on my lawn. I canvassed parts of Atlanta and made some phone calls. I genuinely cried big, fat crocodile tears when I couldn't go with my friends to Washington D.C. for the first Inauguration and cried through the entire swearing in. That was a magical time. We didn't need a sign to tell us that this symbolized hope. We felt it.

And listen--this is not a post designed to polarize. Like, I am aware that some of my friends who read this blog felt true sorrow during this time that stands out as a special piece of my life history. I respect that, too. I do. But really, I'm just trying to understand my emotions about the recent election process and the outcome. Reflecting on the last candidate I supported is a part of that.

I hope that makes sense.

Anyways. So even though I knew for sure that Secretary Clinton was highly qualified, every time she stood up to speak, I felt nondescript. And no. It wasn't like this overwhelming sense of distrust, which does happen sometimes with people I see or encounter. But more just this mourning I felt and longing for the connectivity my heart immediately felt for Barack Obama.

The first time I cast a vote in a presidential election, I was 18 years old. It was an absentee vote for Bill Clinton and I sent that form in with glee. He, too, left me giddy. And at 18, seeing a presidential candidate playing a saxophone on a late night talk show?

Chile please.

I was older when I voted for John Kerry. I honestly liked him, too. It felt good to get behind him. It did. And no. It wasn't Barack Obama good. But good. Big and pregnant, I pushed the button with his name on it. Sure did.

Bernie made me smile a lot. His curmudgeonly passion ignited a lot in me and especially in my husband. And, okay, pound for pound I'd say that as far as the "like" button goes, I found him more likable. Yeah, yeah, I'll admit it. I "felt the Bern." But not in this overwhelming way like I'd felt in 2004 and 2008. So I was sort of left with this in between feeling. Like, "I sure appreciate y'all putting your hat in the circle and riding hard for folks like me and my patients." But that was about it.

Yeah.

So as things reached a fever pitch and Secretary Clinton's campaign rolled forward, I did my duty as a card carrying democrat. I gave money and spoke positively. And though I did feel annoyed by the whole email scandal thing and how distracting it became, I got on board with the pantsuit nation. But as I look back, I think I did it in that way you do something you're supposed to do, you know? Like a middle school kid who washes dishes without being asked.

Awful analogy, I know.

But the thing is, that's why that meme is in my head right now. The "I guess I'm with her" sentiment oozed out of the world of Instagram and Facebook and made its way into hearts and minds. This seething indifference brewed in the very people who metaphorically marched on Washington to get Barack Obama elected not once, but twice. And it was unfortunate.

I was with her. But I realize now that it wasn't in the way that I was with him. Even though I wanted to be.

Does this even remotely make sense?  Sigh. I don't know.

So I guess beyond the stunned feeling, I'm conflicted. I'm not so sure I or even we left it all on the field this time. The lukewarm emotion that some of us felt was probably telling. And the fact that a meme that said "I guess I'm with her" going viral might have been a sign.

Maybe. Maybe not.

Here's what I know for sure. It's not enough to galvanize people to vote against someone. The masses need to feel driven to vote for the party's endorsed candidate. And though qualifications matter, it seems like liking the person matters, too. Not just from the popular vote standpoint but obviously all the way up to the level of the electoral college. I don't know the answer to making all of that happen. I don't.

To those who were truly, deeply with Hillary Clinton from the very start and to the very end, I apologize for letting you down. I eventually got on board but today wish I'd gotten on with all of my heart like I did in 2004. And while I did vote and give to the campaign, I guess I'm just realizing that this isn't enough. It just isn't.

So what happened has happened. It did and it has.

And I get it that someone will find this offensive. Like it's indicative of some self hate I have for myself as a woman or the idea of a woman as Commander in Chief. But I think a lot and in my heart of hearts,  I don't think it was the woman thing. I don't. I guess I'm just thinking that it was this absence of universal dopeness thing that created a gigantic "meh" for the people who needed to be more plugged in.

Yeah. That.

See, when folks like us elect the people we want? It takes moving a few people out of the woodworks. And some part of that is strictly by qualifications. But another part is overcoming the "meh" with a feeling of deep connection.

There was a video I saw the day before the election. It was the first time I saw Hillary Clinton as universally dope. I wish I'd seen it before and felt what I felt when watching that video before Election Day eve. I really, really do. Because today I'm feeling a new kind of burn.

And something tells me I'm not alone.

Yeah.

***
Happy Thursday.

Couldn't figure out how to embed this really dope video. But here's the link.

https://www.facebook.com/hillaryclinton/videos/1318546694868523/

Jeopardy.

my situation on June 23, 2016. Literally.

jeop·ard·y

ˈjepərdē/

noun

1. danger of loss, harm, or failure.

Two weeks ago, I did something that I have never done in my entire medical career. Had I come close to it before? Yes. And is it something I probably should have done a few times in the past? Definitely.

So . . .  what was it that happened, you ask? Well, I'll tell you. Um, yeah. . . I'll tell you even though, after twenty full years of not doing this, it's pretty hard to actually confess. I. . I. . .sigh. Okay. . .I. . .I . . . I .  . whew.

I. Called. In. Sick.

*squeezes eyes closed and turns head so you won't look at me*

Yup.

It was the week of our interns' orientation in the hospital. Those first few days had gone just fine and at the end of the hustle-bustle of a particularly crazy afternoon, I popped by a casual eatery to grab a late lunch. And that part was fine, too.

Yep.

It wasn't until about an hour and a half later that I began feeling this cramping sensation in my midsection. My tumbly became rumbly and before I knew it, I was in and out of the restroom doing what the Grady elders (and my daddy) refer to as "running off." Somehow I managed to get a long enough window to get over to get the kids from their camps but admit that I sprinted from my car to the front door.

Thank goodness I did.

And you know? The running off part I could mostly deal with. I mean, I was hydrating and such and told myself that if there wasn't anything in my gut, the "running off" would eventually "run out." But then came the nausea. And then came the vomiting.

Uggh.

And so. I pretty much spent the next several hours trying to decide which end of my body to aim at the commode. I tried all those home remedies like ginger ale and the non-home remedies, too, like antiemetics and antidiarrheals. But mostly, this was something that was just going to have to run it's course. Literally.

I didn't catch a wink of sleep until about 4:30 that next morning. My alarm went off at 6am and I just sort of stared at it for a few beats before silencing it. Finally, I sat up on the end of the bed and prepared to treat the day like any other Thursday. I grabbed a t-shirt and a pair of sweats, pulled on some socks and shoes and prepared to walk Willow. And that was fine, too.

Well, I take that back. It actually would have been fine if I wasn't lightheaded from my certain dehydration and on the verge of vomiting the remains of the Canada Dry ginger ale and the electrolyte drink that I'd carefully sipped all night. After only two steps toward the door, I felt my belly churning again. But still, I grabbed the leash (and my tummy at the same time) and took Willow for what I am sure was the least gratifying dog walk ever.

You know? I didn't even think to wake Harry and ask him to take the dog out instead. Even though I knew he would have, I didn't. Then, when I came back inside, I stood staring at the medicine cabinet and trying to decide which concoction would allow me the best chance at not barfing all over a patient. Or passing out on them.

Yeah.

But somewhere in the middle of all of that, I spoke out loud even though no one but me was awake. "I  really, really feel like shit." Which, I am sure, is exactly what I said. Followed by a dry heave.

And right then and there, I had an ah hah moment. I recalled all of the times I've told countless residents that self care is essential. Even though, particularly when it has come to personal illness, I've never given my health priority over going to work.

Nope.

It dawned on me that if I were advising any of my students or residents, I would tell them to immediately contact a supervisor in order to afford that supervisor as much time as possible to cover the clinical duties. And then I'd tell them to drink, drink, drink fluids like crazy and get in bed under the covers and get some legit rest. And/or seek medical attention if it is even more serious.

But for myself? Chile please.

So with my dog at my feet wagging his tail and me hunched over the kitchen sink on one elbow out of fear of projectile vomit, I made up my mind to do the unthinkable. Yes. I decided to call in sick.

Um, because I was. Sick, that is.

Now. I tried as hard as I could to recall a time ever in my career that I'd done that but came up with nothing. And I think I came up with nothing because that adequately represents how many times I've decided to stay in my household infirmary versus crappily do my job while ill. And how many times I acknowledged that I was too unwell to work.

I blame jeopardy. Confused? Okay. Let me explain.

At nearly every residency training program, there is this back up schedule that is designed precisely for moments such as these. And you know? Nearly every residency training program calls it by the same name: JEOPARDY.

Yup.

So when one is sick, they call the chief resident or schedulers or whomever--and that individual refers to the "jeopardy schedule" and notifies some unlucky soul who, up until that moment, was basking in an awesomely easy assignment. Only to be thrust into the firing line of some essential patient care situation such as the intensive care unit, hospital service, or something else even more hellacious. And yeah, it's exactly as sucky as it sounds when you get called.

Yup.

Similar to, say, jury duty, everyone knows that the jeopardy schedule is everybody's necessary civic duty. That is, in the resident community. But, just like jury duty, it isn't one of those things anybody is particularly pumped up about getting notified about. But physician jeopardy is more complicated than that.

Totally.

When I was a resident, we had this longstanding culture of bravado when it came to toughing it out through illness on the job. And I can't say that it was because our program leadership wasn't supportive of our personal needs. It was just this thing that sort of happened, you know? Most of the time they had no idea.

Nope.

Well, I take that back. They were supportive when a person actually endorsed being ill as a reason to call off. But because they came up in the same system, I can't ever remember anyone insisting that someone leave back then. Go lie down for a few moments? Sure. But full on leave and cause another resident to be called in? Never.

Oh, and before I go further, I will say that there is always this teeny, tiny subset of individuals that call jeopardy 200% more than anyone else in their entire program. Most notable was this girl who had taken two benadryl on accident and called in because she was afraid she'd be drowsy. (Me countering her with the half life of benadryl, which she'd consumed 4 hours before, didn't seem to make a difference.)

Anyways. The vast majority of my resident colleagues worked when ill. Furthermore, there was this esprit de corps between us that caused us to rally around the sick guy and fill in the gaps. (Forget the fact that everyone was getting exposed to whatever illness the person had.)

Uhhh, yeah.

A few times stand out in particular. One was my junior year when I was taking call in the cardiac care unit (CCU.) I came down with fever, chills and a terrible headache. My neck was tight and I had some nausea and diarrhea, too. It was the summer and I had just come off of the pediatric inpatient service where kids with aseptic meningitis from enteroviruses was rampant. I even had a tell-tale viral exanthem (rash) to go with my constellation of symptoms. And you know? I was 99.9% sure that viral meningitis was exactly what was going on with me.

Maybe even surer than that.

I called one of my classmates (who was also on call) and asked him to come examine me in the nurses station which he did. "Dude. You probably got viral meninge. You gonna go to the ER and let a second month intern do a spinal tap on you?" He bit into the room temperature honey bun he was eating and laughed at his own joke.

"No way, dude. Did you see my rash?" I asked while pulling up my sleeve.

"Cool," he replied. "So what are you gonna do?"

"I think if I take some Motrin, I can make it through the night."

"Yeah, probably so."

And I am not kidding you. This is what happened. I took the call, fever, stiff neck and all.

Super stupid. Especially since it could have been something far more serious.

That same friend called me the following year (when we were both on call again) to check him out in a call room. He'd developed some shaking chills and a nasty, rattly cough rather suddenly. When I got there, he was breathing super fast. "Dude! Holy shit. You look like you're about to code."

"I feel like I'm about to code."

I listened to his lungs. "Yikes. You've got signs of consolidation. This looks like a bad pneumonia. And that history, man! You might have pneumococcus, I think."

"Hmmm. Cool. Think I can tough it out?"

"You're breathing pretty fast, bud. Let's go to the PICU nurses station and pop a pulse oximiter on you to see if you're hypoxic." Which is exactly what we did.

Guess what his oxygen saturation was? 82% (96-100% is normal.) Craziness.

Let me tell you. This guy? He looked sick-sick. It was NOT a soft call. At all. That said, I am convinced that were it not for the whole needing oxygen thing, he would have slugged it out through that call with his pneumonia.

Yup.

Would you believe that he got admitted to the hospital that very night? And you know? We were so entrenched in that culture that I can remember like yesterday cracking jokes in his room about him spreading TB to the interns and telling him that I was totally going to present him in morning report the next day.

Which he found funny, too. That is, when he wasn't nearly about to code.

Uh, yeah.

I blame this word "jeopardy." The actual definition means "danger of loss, harm or failure." I can't think of anyone who has ever wanted to be the one responsible for putting someone in that situation--that is, one involving jeopardy. Especially another overtired resident who finally, finally, finally is on a lighter work assignment.

But see, that word just underscores the culture. It sounds heinous, punitive even. And to tap into it literally puts another person in peril, if you follow the definition. And I think that's a part of the problem, frankly.

The one time I called jeopardy as a resident was when my father had a massive heart attack requiring emergency surgery. And you know what? I actually took call all night before taking a flight out, now that I think about it. We also have a jeopardy schedule (also called "jeopardy") in my current faculty position and you know what? The one time I called jeopardy with this group then was on November 15, 2012--the night my sister Deanna passed away.

Yup.

So yeah. I am reflecting on all of this and realizing that doctors who neglect themselves really aren't the best physicians at all.  Coming to work while truly ill puts patients in danger, can make things worse and it probably increases the chance of an error happening.

Now. Do I think folks should be calling off for sniffles or allergies? No. Do I think taking two benadryl should allow a rain delay at best but not a full on call off? Damn right. But do I believe that a vomiting, diarrhea-ing, teeth-chattering person should have another able physician working in their place? Definitely.

If you ask me (though no one did) the first step is changing the name. Instead of calling it "JEOPARDY" it might be better to refer to it as "FAMLY EMERGENCY/ILLNESS PATIENT CARE BACK UP." This way, those who need it will understand when it is to be called. And those who get called will feel okay with being called in.

We could even call it "FEIBU" (pronouced FAY-BOO?) for short. As a reminder that this is for FAMILY EMERGENCIES and ILLNESS when back up is needed. And that FAMILY EMERGENCIES and ILLNESS happen and aren't a sign of weakness at all. 

Mmmm hmmmm.

Oh, and the times that folks get pulled in because of human scheduling glitches NOT due to the needs of a colleague dealing with a FAMILY EMERGENCY or ILLNESS? Well. Keep right on calling those times  "jeopardy."

Ha.

So yeah. I acknowledged that I was ill and called off the other day. My colleague Stacie S. was great and made sure I didn't have to feel guilty. And my other colleague Alanna S. was super kind about picking up my slack in the resident clinic that morning. And you know? I think if my patients knew of my decision, they would have appreciated my choice to call off, too.

And so. I drank fluids and rested in my bed all day. That photo is proof that I was exactly where I was supposed to be, too. I went through a whole lot of hand sanitizer and considered going to get a bolus of IV fluids at one point. But the next morning, I felt a thousand percent better which taught me a mighty lesson.

And you know the best part? Not a single patient was harmed or put in jeopardy--thanks to my decision to first put the oxygen on myself.

Yeah.

***
Happy Sunday.

Now playing on my mental iPod. . . .

Repost inspired by Elizabeth and Oliver.

"I'm just saying, you could do better."

~ Drake

Read this beautiful post yesterday by my friend and fellow blogger Elizabeth and felt my toe crunch. I needed that message.  I heard some teenagers and tweens that I know saying that word--"retarded"--repeatedly under my earshot just recently. "OMG, that's so retarded!" and "Dude, stop acting like a retard!" One even mimicked what they thought that looked and sounded like just in case no one was clear on it. I knew them. And all of them, for certain, are great, kind young people. They are. But. They're kids. And to them, it's just simple slang, you know? Sigh. 

Yeah. 

See, what's worse is, I was totally in a position to say something but I shrunk because the mood was light and I talked myself out of it. Those teenagers all respect me and totally would have listened to me, too. Sure, it bothered me the second I heard it but I didn't say anything. And what's funny--or rather not funny--is had they been dropping f-bombs over and over again instead, I am 100% sure that I would have immediately shut that down. Even though the f-bomb is far less hurtful albeit less socially acceptable. 

Yeah.

It was as if she wrote that post for me to read. And then my other friend Angella linked to it just to affirm that YES, I needed that message. To use the word properly, a teachable moment was retarded by my lack of vigilance and resolve to stick to my guns.

Yeah.

Hey. Thanks, Elizabeth, and especially Oliver, for reminding me to refuse to shrink and also to use my influence and power for good. It may seem first world to someone reading this. But I think if any of us still ourselves long enough to feel the sting of whatever word or words hurt us the most, it won't be for long. That's what Elizabeth and Oliver's message has done for me.

Here's a challenge: 

Let's all commit to not using "retarded" or "retard" as a slang word. And even more, to speak up and let those who do use it know that it's not cool (just like Oliver does and Zachary did here.)  That word is hurtful to many people even if it isn't meant that way. We can right this wrong. I know I'm recommitting myself today to doing better.  Who else is in?

Read the post below and make your mark if you want to be down with the movement:   

X______________________________________

Hey Elizabeth? Next time I vow to say, "F-that."

*************************************

Because "love" should be a verb and "retard" should never be a noun. 

The room was filled with people. Seats all forward and facing the hanging screen that displayed the image from the LCD player. A youngish man stood at the front of the room, white coat starched to perfection, a tie that most certainly had the name of some fancy designer on the back, and shoes that appeared to be spit shined. Even though he lacked the grey hair of the endowed professors, he had the look that holds the attention of medical colleagues. Professionalism personified.

But beyond that, he knew what he was talking about, too. His slides were well done and cited all of the resources for the topic of discussion. For the majority of the presentation he wasn't even looking at the screen at all; he knew his stuff that well. And he was cool. No shaking hands or nervous throat clearing. Just one youngish doctor-dude standing at the front of the room with closely clipped nails gripped around a laser pointer. And this doctor-dude? He knew his stuff.

I, being a person who is enamored by excellent public speakers, felt myself wavering between actually listening to what he was teaching and how he was doing it. The clean slides with the clear diagrams. The cadence of his voice and the way he interacted with the audience. And then there was his chosen topic--an area that happened to be his expertise as well as one that is high yield for all of us. Not only was I learning something, I was enjoying it at the same time.

But then something happened. He turned a slide and things weren't configured as he'd expected. Of course, he was still cool as a fan. After trying to talk through the disjointed words and images any way, finally he stopped and knitted his brow in frustration. Then he said this:

"Sorry about that, guys. I prepared this on a Mac and these PCs can be so retarded when it comes to going between PowerPoint for Mac and Windows."

A few people chuckled in acknowledgment. The talk had been so good up until that point that no one seemed bothered.

"I'll move past that slide," he said with a shrug of his shoulders, "Sorry -- I should have checked compatibility before. I'm such a retard sometimes."

A ripple of gentle chuckles went through the room. And that was that.

The rest of his slides were fine, I guess, because I don't remember much else. Everything after that for me was just white noise.

In 2009, I helped lead a writing workshop with a group of colleagues at the Society of General Internal Medicine (SGIM) national meeting. The session was called "Writing and the Art of Medicine: From Personal Reflection to Publication" and included a breakout session where we actually spent time writing narratives. It was really well attended and I remember being pleasantly surprised by the number of people sitting at the round table with me during our breakout.

The task was simple. "I will give you a sheet of paper. You will write -- longhand -- for ten minutes about a pivotal moment or critical incident you've experienced that has taught you, moved you, or simply made you think. We will then share a few of the ones you've written." Straightforward enough, yes?

I recall that there were many beautifully written pieces. Important topics that we all, as physicians and medical students, could feel resonating in our souls. But there is only one narrative that I remember in full detail. Only one. The story was simple, really. It was written by a young woman who was a resident at the time and she'd spent her ten minutes describing two very clear images.

The first was her interactions with her nephew, to whom she appeared to be very, very close. As it turns out, he was born with an additional copy of chromosome #21 which most people recognize when they see. That's because trisomy 21 is the chromosomal abnormality responsible for Down Syndrome. Yes. Her nephew had some developmental delays and some mild to moderate mental retardation. But that's not what she described. Instead she painted a picture for us of him running recklessly on the front lawn chasing bubbles. Of him tackling her and covering her with his sloppy kisses. And of how much he loved classical music. So much so that whenever he heard it, he'd stop, close his eyes, and wave his fingers like a maestro.

Then she went to another scenario. Her in the hospital working on a ward team. The lab system had gone down for the day and her resident declared the system "retarded." Her co-intern had left his stethoscope on another floor and dubbed himself "a retard" for doing so. And the list went on. According to her, it had become the slang word of the month for that team. Anything imperfect or dysfunctional was referred to as "retarded." And the funny medical student with his perfect comic timing? He was "such a retard." But in the nicest, most endearing way, of course.

So she read her words in her quiet voice and I swear to you that you could have heard a pin drop. And at the end she simply told us that she never got around to saying how much that word stung each time she heard it from their mouths. How awful it made her feel to know that her nephew's life would be just a little bit harder because of that word. I never, ever forgot that.

I will admit that before that fateful moment in 2009, I'd never really "heard" that word. Surely I'd heard it at some point, but it had never created a nails-on-chalkboard effect for me or a visceral response in me either. But her words? They opened my eyes to something that I'd never thought about. An aspect of "the other side" that our patients and their families and their friends experience that even the ones that are supposed to be allies have completely overlooked.

Sigh.

So that man with his perfect PowerPoint presentation and his spectacularly white coat should have been an ally. But he hadn't heard that word either. And from the response he got from everyone in the room, it was business as usual. Which tells me that the majority sitting under his voice hadn't really learned to "hear" the word "retard" like that young resident writer had taught our breakout group to hear it that day.

(photo courtesy of Elizabeth Aquino)

My friend Elizabeth recently posted a photograph of her son, Oliver, speaking at "No Name-Calling Week" in 2010 at his school. I have posted that image above because seeing his young face holding that sign immediately brought me to tears. Just look at him. So brave. . .with that microphone in his face educating what was probably the entire student body. His sister, Sophie, has some special needs and also a severe form of epilepsy. But just like that sweet boy who was chasing bubbles, conducting music with this two index fingers, and freely giving out juicy kisses, there is more to Sophie than her disabilities. So, so much more.

See? Oliver knows that for sure. He lives it and breathes it. So he held that sign and shared his testimony because, for him and Sophie and his brother and his mother and every person who knows and loves Sophie, those words hit like a fist. I am thankful for him and for that picture because now, it hits like a fist for me, too.

Maybe from now on, it will for you, too.

I would make this a jumping point to reference that woman Ann Coulter who sent that tweet during the last presidential debate. You know -- the one that commended Governor Romney for going easy on "the retard." Or being polite or whatever the hell she said. Yeah. I would start unpacking about all of that, but some part of me wants to believe that perhaps she had not yet "heard" this word either.

That or I just don't have the energy to waste on that.

After that lecture, I pulled that colleague aside. I told him about the little boy with the bubbles and paid that story forward on behalf of his aunt. Even though I didn't know Elizabeth and her family back then, I suppose I paid it forward for them, too. In my least judging voice, I shared how that story had opened my eyes. I told him how much I had enjoyed his talk but that his use of the word "retarded" and then "retard" was hurtful and probably not the very best choice.

And you know what? That highly professional physician speaker put his hand on his chest and apologized. He didn't even realize that he'd said that word. And especially felt mortified that he'd said it not once but twice. And I said, "I totally understand because I hadn't really heard that word like that either but now that I do, it hurts to hear." He got it and thanked me. And I thanked him right back for being so understanding.

Today, I say thank you to that young woman whose first name -- Thalia -- I still remember. I have no idea where she is, but she changed me that day. I also say thank you to Oliver and Elizabeth, too. I am grateful to them for helping me to see that if we are going to commit ourselves to making love a verb, then retard should never be a noun.

Or a joke.

From here forward, I hope you'll hear that word differently, too.

That's all I've got for today.

***
Happy Tuesday. (Originally posted on 10/30/2012)

Well. Google is an amazing thing, y'all. I found a piece of Thalia's writing from an essay contest she won as a medical student in 2003. Read it here. It also turns out that Google can also help you find out where someone is now.  This remarkable young woman is now a clinician educator on the Internal Medicine faculty at one of the Harvard hospitals. No surprise to hear that! I hope she's still telling that story. . . 

Bullies and Cool Kids.

*names changed to protect anonymity

"I wish that I could be like the cool kids. 

'Cause all the cool kids they seem to fit in

I wish that I could be like the cool kids

like the cool kids."

~ Echosmith

_____________________________________________

Medicine can be like middle school at times. Much like seventh grade, it's a combination of development, swagger, and perception. The early bloomers ascend to the top while the others settle wherever they can fit. It isn't always fair, actually. 

Someone deems a person "good" which, in the medical field, is like the equivalent of being considered "cool." Sometimes it's a faculty member or a colleague. Other times it's the nursing staff or junior group of admirers. What happens next isn't too far of a cry from junior high. Opportunities come. Shortcomings are quickly forgiven or even not noticed at all. And if a person is in the cool camp, life is good for the most part. 

Now.

In full transparency, I will share that my experience in residency was from the perspective of a person placed squarely in the cool camp. I remember when it happened, too. I was on my very first rotation as an intern and was signing out a late patient to my attending because my co-intern was in clinic. As I reached the end of my oral presentation and marched through the assessment and plan, my attending stopped, cocked his head sideways, and squinted one eye. 

"Remind me of your name again?"

"Kimberly Draper, sir." 

"And Kimberly where did you go to medical school again?"

"I went to Meharry Medical College, sir. In Nashville, Tennessee." 

He jutted out his lower lip and gave me a slow nod. Then gestured for me to carry on with the rest of my plan.  And that was that.

That attending was a key person on the faculty and a program leader. And I could tell that in that little glimmer of a second, he'd sized me up. The rest of our interactions were positive and he always seemed eager to teach me for the remaining time we had together. 

Sure. I worked hard as an intern and took pride in the lessons Meharry had taught me prior to starting residency. But I quickly began to realize that sometimes my lot in trainee life was better because of my position as one of the cool kids. Or rather, the good ones. 

As time marched on, I started to recognize a few other things, too. I started noticing that the cool kids are often privy to some conversations about the not-so-cool kids that aren't so nice. And I guess since I wasn't too cool in middle school, I've always felt a kindred tie to those who haven't been given a golden ticket. For that reason, those mean words always made me uncomfortable. But like any immature person who has found solace in the cool camp, fear of messing up a good thing can be a mighty muzzle. 

This got me thinking about an experience I had in residency. I had a co-intern who'd worked with me in the NICU during our first few months of internship. Sujata (name changed) was this very petite, soft spoken, and nervous young woman of Indian descent. She had a rather thickish accent but mostly it was her apologetic and anxious nature that drew the most attention to her. And that attention wasn't good, either.

Nope.

Sujata and I were on the same team that month and worked shoulder to shoulder on some very sick infants. In our extensive time together, I rapidly discerned that she'd been completely misunderstood. Not only was Suji highly competent, she was also smarter than anyone else working in the unit that month. That said, when the time came for her to defend her management or answer questions, with a tiny shake of her head she'd disappear into soft, mumbling apologies. It was awful.

Suji became my friend that month. Over that year, she looked out for me, too. Whenever I was on call in a unit or a tough rotation, without fail, she'd slide a tupperware dish into the resident lounge refrigerator with "Kim" written on a piece of masking tape stuck on top. Suji knew how much I loved her authentic South Asian cooking and never missed a chance to allow me to try whatever new recipes she whipped up. I appreciated that.  And mostly I appreciated her. 

But.

One day I was hanging out in the resident lounge waiting for sign out. In walks two "cool kid" senior residents, one of whom had already been chosen to serve as a chief resident the following year. Brent, the rising chief, plops down in a chair and groans loudly. 

"What's all that about?" I laughed.

"It's about the painful night I have ahead of me in the PICU." He plunged his hands into his hair and acted as if he was pulling it out. When I wrinkled my nose and looked puzzled, he clarified it for me. "Dude. Did you see who I'm covering tonight? I'm going to be up all frickin' night."

As soon as he said it, I knew who he was speaking about. He was referring to Suji. 

"Maybe she will be sort of helpful, Brent. You never know. . . she's gotten some more experience over these last few months." That's what the other senior resident said which I would have called him defending Sujata but won't since he was cackling the entire time.

Brent squinted his eyes and stared at his co-resident as if he'd just spoken the most asinine words in the world. "Dude. Did you say helpful? Sujata? Phsssssshhh. That chick is like an accessory nipple, man."

That line caused them both to explode in laughter. The other senior. while gasping to catch his breath, howled out loud. "An accessory nipple? What the hell? I don't even . . .bwah ha ha ha ha. . .wait, man. You gotta clarify on that one." He was already doubled over as he probed on this wicked one-liner partly because anyone who knew Brent knew that his quick-witted humor was unmatched--even when he was being mean. 

"Why an accessory nipple?" I asked, trying to look as genuinely perplexed as possible even though I wasn't. I knew that whatever he was getting at wasn't good. So I suppose this was my milquetoast attempt at a quasi-defense.

Brent propped his clogs on the dented up coffee table and leaned back on the chair. He was already chewing a big bite of the apple in one of his hands and nearly spat it all over the room when he added, "It's a perfect description. An accessory nipple is useless and just in the way. And most of the time embarrassing."  

And that? That was all she wrote. The laughing could no longer be contained. Brent literally fell on the floor and his co-senior began running in circles while screaming hysterically. And I just sort of sat there with this weird expression on my face which probably was some bizarre cross between uncomfortable and amused. You know, that way you look when you snicker at something terrible that you see on social media. 

But even worse was the fact that Sujata was my friend. I didn't defend her. I just sat there like someone watching a mugging in the street and feeling too scared to act.

Yeah.

On the way home I thought about the little babies that I'd seen in the newborn nursery with those extra mammary glands or accessory nipples. The parents pointing at the one, sometimes two little brownish peaks and asking if it was some sort of pimple or birth mark and me trying to explain through embryology that it was a "normal variant." Every single time, they'd look at me in horror as I tried unsuccessfully to reassure them about the random satellite teat that their sweet baby hadn't ditched in utero. Yup. Useless and just in the way. And most of the time embarrassing.  Pretty damn accurate description.

And this was the metaphor someone used to describe my friend as I sat by silently and allowed it. I'm still not certain why I didn't speak up, either. I'm ashamed of it even today.

Anyways.

I guess I am thinking about this today because I was talking to Isaiah about bullies yesterday. He asked me if anyone had ever bullied me. Quickly I told him "heck yes!",  reflecting on my awkward middle school years. Then he hit me with another question that got me thinking. "Did you ever stand by and let somebody get bullied without standing up for them?" 

He sort of pulled the wind from my chest on that one because instead of wandering back into high school or 6th grade, my mind squarely landed on Suji and residency. That "accessory nipple" line was one of many very, very mean things I heard about her without defending her. And so. I was honest. "Yeah, actually. I'm not so proud of that either." 

"Were you in 4th grade?" Isaiah pushed.

I twisted my mouth. "Honestly, son? I was a grown up. And some people who thought I was cool decided one of my friends wasn't. I was too scared of not being liked to speak up."

"As a grown up?"

"I know, right? I should have known better."

"Did your friend know that you weren't sticking up for her?"

I hate it when Isaiah's old soul rips the covers off of me. "Um. I sort of don't think so. Which I guess is the part that I've always felt bad about."

"Were you saying mean things about her, too, when she wasn't there?"

"Not so much. But sometimes I laughed."

Isaiah immediately looked disappointed in me when I said that part which sucked. "That's kind of being two-faced, mom." 

"Yeah, you're right. It wasn't cool."

"No, mom. It wasn't." It looked like he felt bad for giving me such a rough time so he added this to make me feel better. "But it's good when you think about something a long time and then realize a better thing to do. Like, now you tell us to always choose kindness."

I smiled. "Yeah. I guess you're right about that. And you know? It's good to let your kids and friends learn from what you did wrong."

"Yup!"

And with that, he ran off to build Legos. 

The part Isaiah isn't seeing is the part of me that now fights for everyone around me to feel like a cool kid--especially my medical students and resident learners. In all these years I've never shaken Brent's stinging words: "Useless and just in the way. And most of the time embarrassing." I don't ever want to feel that way nor do I ever want someone else to feel that way in my presence. Man, I don't.

Yeah.

I've not gotten it all fully figured out. And Lord knows that I still have my days where I don't advocate for folks like I should. But I'm better than I used to be. And what I know for sure is that the real secret to being a cool kid is believing that you don't need to be.

***

Happy Thursday. And hey, Suji? I'm sorry. 

Now playing on my mental iPod. . . . this. . .

and also this. . . . 

Shut up and dance.

Five days you work

One whole day to play

Come on everybody

Wear your rollerskates today

It's Saturday, Saturday

Saturday, it's Saturday

Saturday, it's Saturday

Saturday, it's Saturday

~ from De La Soul

I love being on the inpatient hospital service. The acuity of the patients, the energy of the wards, and just the dynamic of working as a part of a team just does it for me. Seriously, if it weren't for the fact that being on the hospital service also means working weekends, I'd do it year round.

Yup.

One of the best parts for us medical nerds is the fact that we get to do a lot of teaching when on the hospital service. The potential teachable moments are endless, man--especially at a place like Grady. But you know what? One thing I have learned is this: Not every moment is a teachable one. That is, in the literal sense. Sometimes the teachable moment is identifying the moments when it really isn't one.

Yup.

I know that probably didn't make sense, so let me explain. Matter of fact, why not reach back to the source of that lesson--my residency. Since I've been on a bit of a roll with my tales from the residency crypt, I may as well keep it going, right? Ha. Don't mind if I do.

The Unteachable Teachable Moment

My residency training took place before there was duty hour reform. In other words, how many hours we worked in a week or consecutively never seemed to be fully factored into anything we did. In some ways, it afforded us great experiences as learners. But a whole lot of other times all it meant was that  you were guaranteed to be in an exhausted stupor at some point. And how that stupor looked depended upon the person, the call and the location in the hospital.

Yup.

I will never forget this one morning on rounds in the Pediatric Intensive Care Unit (PICU).  I'd been up all night long without even a few moments to catch my breath. The kids on the unit were sick-sick--I'm talking tenuous and teetering on codes well into the wee hours of the morning. It didn't help that the PICU was, hands down, the most terrifying place in the entire hospital to me. Sure, I learned a lot but the intensity coupled with the nausea-inducing fear that I'd assassinate somebody's child was a lot. Yeah, man.

Well. What I remember the most was that this particular morning on rounds upon which I'm reflecting fell on a Thursday. That's significant for two reasons: The first is that my weekly continuity clinic was every Thursday afternoon. The second was that, because of the fact that this was during the pre-duty hours reform era, I was expected to go to clinic despite having been up all night long with critically ill children.

Yeah.

One of the kids I cared for that night had severe, persistent asthma. A fun afternoon with his family turned into a nightmare when he started having a refractory asthma attack. "Status asthmaticus" they call it; an ambulance whisked him straight to our emergency department who quickly shunted him upstairs to us. His lungs were so tight that he received the entire kitchen sink from the moment he arrived; he even had to have his blood oxygen levels monitored with an arterial line--which isn't an every day thing with kids. Arterial sticks hurt like hell which made my hands super shaky and nervous while attempting to stick him. On top of that, he was only eight or nine years old. God, he was just terrified. With every air hungry inhalation he took the skin over his ribs pulled tightly over his bones like some kind of relief sculpture. I also remember him crying as I stuck his wrist. All of that was right before he got intubated. It sucked, man.

For him more than me, of course, but still it sucked.

That same night, there was another child I cared for that we all knew very well in the hospital. Man, was she cute. Her cheeks always looked like that had a perfect application of blush and the strawberry blond ringlets she'd been born with looked like they'd cost her parents thousands to achieve. But beyond her natural beauty, she also had severe epilepsy. I'd admitted her before for complications of her frequent seizures--usually to the regular pediatric ward. On this night, she was down in the emergency department and the on-call pediatric resident was preparing to admit her for the same. I was called down from the PICU after she suddenly went into something called "status epilepticus"-- a condition where a seizure persists for a substantial amount of time and, in this case, doesn't respond to initial treatment.

We pushed med after med and nothing was working. The pediatric neurologist was en route and the PICU fellow was right there in the trenches, too. The nurses who weren't caring for her comforted her mother, a woman who, by now, was a friend to us all. Finally she had to be put into a medically induced coma. And let me just say that this was some shit I'd only read about on test questions--not actually participated in making happen. By morning, I was metaphorically down on all fours begging the sun to rise into a new day--which would mean a new resident on call.

Yeah.

So the way it worked was that we rounded with the ICU attending the following morning to discuss every single nitty-gritty detail of the overnight events. My attending that month was this really, really nice man who loved to teach in a Socratic style which, usually, I responded to as a resident. But on this particular morning, I wasn't really up for Dr. Quizbowl or any of what would surely be his standard litany of questions.

Now. Let me also just remind you that at 1PM, I was still expected to go and see a panel of seven patients in the clinic. Whenever this was the case, the goal always was to knock every single drop of work out so that you wouldn't have to return after clinic.

Yes. You read that right. RETURN. AFTER. CLINIC. POST. CALL.

The only way this could happen--and I do mean the ONLIEST way on this morning in particular--would be for my attending physician to focus more on the care of the patients than the quiz bowl soliloquy. And NO, I'm not saying that it's cool for things in residency to be all service related and not education related. But what I am saying is that the ground was fallow and not EVEN fertile for a whole bunch of extraneous teaching seeds to be planted. I needed this dude to get down to business. And focus on just the damn facts.

Capisce?

But he didn't. Not one bit. Dr. Quizbowl started first with a bunch of questions about the AV mismatch in asthma and I swear I don't know how, but from there he jumped off into a tangent about fetal hemoglobin and oxygen carrying capacity. Even though this child with asthma was not a doggone fetus or anyone with something warranting that as a discussion at the moment. (No, he didn't have sickle cell anemia, you medical nerds.) I did my best to answer his questions which escalated in difficulty.

Uggh.

Dr. Quizbowl liked to grill only the post call resident. Again, that was usually fine for me but this night was so bad that today it wasn't. I also couldn't keep my eyes off of the clock. I wanted nothing more than to get the plans locked in by 11:30 so that I could tie up loose ends and scoot to clinic.

But then we went to see our sweet curlyhaired girl.

First, he waxed poetic about the mechanism of status epilepticus and what happens on a physiologic and pharmacokinetic level with the anti epileptic drugs. From there he began quizzing me about the mechanism of action of some of the newer agents and then, after studying the vitals overnight, decided he'd start asking me a bunch of pathophysiology questions that I hadn't really thought of in such detail since my second year of medical school. And you know what? I didn't effing know the answers.

I didn't.

Well, I take that back. It was past 11:30 and I was already feeling nauseous from being so tired. While maybe, just maybe, with some thought I could have found some piece of the answers to his questions to at least prime his teaching, at that moment? I had nothin'. The more his mouth moved the faster the clock seemed to tick. Before I knew it, it was already 11:45.

"Why a pentobarbitol coma, Kim?" he finally asked me.

"What?" That is literally what I said in response. Because that was too vanilla a question for it to be almost lunch and too nebulous for me to even hold on to the tiniest chance of me getting any more work done.

"Pentobarbitol. Why do we use that in status epilepticus?"

"Um, to stop the seizures, sir. To quiet brain activity."

"Be more specific. Talk me through what is actually happening in a noisy brain that sees pentobarb. Why is this something we do in this situation?"

And just as he said that, the clock struck twelve noon. I promise you it seemed like it happened in Dolby stereo, too. Honestly, the whole team was shifting between their feet, but lucky for them, they weren't on the hot seat like me. Noon and he was still teaching with no end in sight. It was official. I would have to return to the PICU at 5:30 that evening to finish my work. Even though I'd been up for more than 24 hours at this point.

"Kim?"

"Sir?"

"What say you?"

My eyes began to throb with tears. As soon as my chest started heaving, I knew it was a wrap. My mouth hinged open to talk but only a squeak came out. "Status Postcall-icus," they should have called it.

"Dr. Draper?"

I wiped my hand over my face hard to try to mask the tears that were now falling straight from my eyes to the linoleum floor in big splashes. Shaking my head in embarrassment I responded. "I don't know, sir. I don't. I just. . ."

"Are you okay, honey?" The nurse on rounds with us rubbed my back and tried to console me. She looked over at Quizbowl and added, "On sign out the night nurses told me she didn't sleep a wink."

"Welcome to the PICU," my attending responded with a heartless chuckle.

And I swear to you, that was that. No further acknowledgement of my brief outburst or any such thing. We just kept it moving. Yep. That dude talked and taught for another half hour or so and finally let us go. All I ended up with was enough time to change into my clinic clothes, eat some leftover stromboli from the night before, and hoof it to clinic. And yes, at 6PM I was BACK in the PICU finishing up some notes and trying to stay awake for sign out rounds. While Dr. Quizbowl took it upon himself to make a few more teaching points to boot.

Yeah.

I know that the only thing that allowed me to drive home without face planting on my steering wheel was how resentful I felt of my attending and his irresponsible use of our time that morning. Not only did he not recognize a dangerously exhausted learner in front of him, he also ignored the fact that we needed to transfer patients out, care for new admissions and just get some damn work done. And I wasn't a lazy resident by any stretch either. I loved being taught and guided--and still do. But this day? It just wasn't a teachable moment, man. I mean, not in the way he forced it to be.

I bet you a million dollars that from eleven o'clock on, nobody heard a damn word of what he said. That I know for sure.

Let me quickly contrast this by saying that just a few months later, I was rounding on a Saturday with the chairman of the Department of Pediatrics. The service was busy and he was even busier. That said, he was an outstanding teacher and champion for children's health. And so. I remember him starting rounds that morning by simply saying this:

"It's Saturday. It's busy. And it's Saturday. A Saturday where our team isn't admitting new patients and where the ones we have are primarily stable. The teachable moment this morning is on focus and efficiency so that we can take excellent care of our patients and then leave. Y'all got that?"

And yes, he said "y'all" which he often did. That didn't mean be cursory or rush things. It meant to focus on the essential tasks at hand. It meant that this wouldn't be the day to draw algorithms on the chalk boards or sit the whole group down to review a new article. There were teams assigned to the hospital for the full day on Saturday and his point was that we needed to do our work and then allow them to take over so that we could achieve some semblance of work-life balance.

Oh. That.

Now that? That was pivotal for me. The thing I remember the most was that he was SO right about THAT being the teachable moment. The fact that this wasn't the time for him to review every study he has ever published or to recount all that is in his memory about every subject he can think about. It wasn't.

You know what else? Midway through rounds he looked at one of my post call interns and then interrupted rounds. He pointed straight at him and said, "You. Go ahead and sign out so that you can go home. You look like you're about fall under the nurses' station. Go get rest." The intern just stared at him. He looked from side to side and then repeated himself. "I mean NOW. Leave. Now. Get rest. Your work here is done today."

And yes--we, too looked conflicted when he said that, but nobody questioned the dang-on Chair. See, he was right. That intern was about to collapse on his face from exhaustion and that man had the sense to know it. Then he said to me, "Kim, the teachable moment here is knowing when somebody is on fumes.  Getting him out now means he'll be better tomorrow. Trust me. We can pitch in and finish what needs to be done."

And yes, he said "we." I loved the way he often said "the teachable moment is. . ." That put us all in the right state of mind for whatever it is we were doing. And helped us to see the teachable moment as just that.

I have never, ever forgotten those two experiences. Every single time I am attending on the wards I remember both Dr. Quizbowl and Dr. Chairman--and apply their mighty lessons to the way I manage my own teaching and team management. Yes, in medical education, we walk a fine line between balancing service and education. And, of course, our learners are there for supervised instruction, not just scut work--I get that. I do.

But.

As awesome as the music of medicine can be and as fascinating as the melodies often are, sometimes? Man, sometimes the very best thing that we can do as teaching maestros of this symphony called medicine is simply shut up and dance. . . . .

That, my friends, is sometimes one of the most powerful teachable moments of them all.

Yeah.

***
Happy Humpday. This post made me think of this post on Saturdays, balance, and why it's so important.


____________________________

Every time I round on Saturdays when my team isn't admitting, I think of Dr. Chairman and hear this song in my head. Then I say to my team, "It's Saturday." (Even though I am hearing this song in my head the whole time and feel like I have on roller-skates. Ha!)

But first, here's some proof--I sent this text to my ward team last weekend--complete with a witty emoticon. Heh heh.

Next time I'm just gonna text them this. . . . 

The secret weapon.

The thing about residency is that your growth isn't just related to clinical acumen. A huge portion of it is dealing with people and their personalities. And you have to do all of that while learning to keep human beings alive. As I look back on it, that was one of the most challenging aspects. But you know? Some of my best lessons came from that aspect. Lumpy interactions that helped me learn how to navigate this high stakes job in the midst of not only my own crazy--but the crazy of a bunch of other people.

I've been reflecting on a few of my experiences--and how they helped me to grow. Here is one of them. More will follow.

The One-Upper

There was this woman I trained with who was really smart and highly competent. She had an answer for damn near everything and a lot of the times she was right. And all of that was cool.

But.

She also liked to be the person who'd been to the mountain top before everyone else. She seemed to take enormous pride in superseding whatever it is you saw on call or did on your rotation with some far more sexy experience that she'd already had to trump it. And you know? It was annoying. Annoying as hell.

I've always loved medicine since starting my training. I like to think about it, talk about it, revisit things and hash them out. I like to sort out aspects of a clinical story and try to piece them together. And back then with my learning trajectory going skyward, there was always much to debrief on. The highs, the lows, the wows and the OMGs. Mostly I'd do this with my friends, which this particular woman was not. But what many folks will tell you is that residency is kind of like boot camp. Ward teams are like the folks in the barracks with you and often out of necessity you share when your lives overlap for whatever time that is.

And so. One month in my second year of residency, I was placed on the same team as the One-Upper. And I will just give you a spoiler alert and tell you that it didn't end too well.

Ugggh.

We were in the Medical Intensive Care Unit that month. That's a place where the sickest of the sick come for care and the call nights have the most action. Well, the way our schedule was set up, our call days were like two days apart--that is the One-Upper and myself. So whenever I was post call and trying to sort out my patients and their problems, she loved to position herself next to the attending and fellow like she was my boss, too. She'd stand there with folded arms, feeling all super rested from being home the night before-- in contrast to my up-all-night hotmessness and scatterbrain to boot.

One night, I'd gotten this patient who was profoundly anemic for multiple reasons. Due to her hemodynamic instability, she'd been placed in an ICU step-down bed which, at our hospital, was managed by the ICU team. For us, step-down patients were like a breath of easy, fresh air. I figured I'd tank this patient up with the blood that she needed and would have her ready for transfer out of the unit in no time.

So check it--I'd given her a blood transfusion and, much to my horror, like two hours after she received it, she developed severe respiratory distress. Like severe, severe respiratory distress. This was not a woman with a ton of medical problems before hand either. It was terrifying.

Her respiratory status was so awful that she required intubation. And her blood pressure fell even lower than it had been before. And so. We supported her breathing with the ventilator and lots of oxygen and also pumped her with some fluids. Given the time frame of the symptoms, I decided that this might be something called TRALI--transfusion related acute lung injury.

Well.

I'd only read about TRALI. This was all academic as far as I was concerned, so I simply did the best I could given the circumstances. And fortunately, by the time the morning came, my patient had taken a turn for the better.

My attending studied the nursing notes and vitals for a moment as I presented the overnight events. "Wow. So that was pretty sudden. These MAPs (mean arterial pressures) are in the basement," he said.

"Yes, sir," I replied. "We started the pressors fairly early since we didn't have much reserve. She was already on the low side to begin with."

I saw the One-Upper shifting from side to side. I knew she was about to say something so I braced myself. "What about steroids?"

I just sort of looked at her and paused for a moment. "Um. Well, mostly what I read said you start out with supportive care."

She stopped talking to me and sort of shifted toward our attending. "I don't know, boss, what do you say? I've seen some good results out of these guys when you hit 'em with a little SoluMedrol."

Oh have you?

"Eeeeehhhh, you can." He studied the chart a little more. "Mostly it's all supportive but yeah, steroids are often given."

"I'm a fan of the steroids," the One-Upper chuckled. Then she turns to the medical student rounding with us and says, "So the patient has acute respiratory distress right after you've given a blood transfusion. We already talked about transfusion related acute lung injury. What else could this be?"

The student floundered a bit and threw out a few options. I felt my face getting hot. Partly because I was tired but secondly because I was tired and this woman was irking the heck out of me.

"Taco," she said with a smarty pants grin.

"Excuse me?" the student said. I could tell that student was wondering whether or not she was speaking of Tex-Mex for lunch.

"TACO," she repeated. "As in Transfusion Associated Cardiac Overload." She looked toward me and asked another question. "Dr. Draper, did you consider a touch of Lasix just in case?"

Let me be clear on something: The One-Upper woman was my PEER. We were at the same level and in the same residency class. And today, she was pissing me all the way off. While my attending allowed it.

"In case of what?" I responded flatly. I hated that she addressed me as "Dr. Draper" like that. A lot of attending physicians would do that. But fellow residents never used such formality unless they were standing in front of a patient.

"In case it's not TRALI and it's volume overload like TACO." I could have sworn that she twisted her neck when she said that part. I glanced to my attending hoping he'd get my cue for him to shut her up. But he kept studying all the overnight event recordings and didn't say anything. When he didn't, she launched into another spiel on TACO and how this could have been that and how it is actually indistinguishable from TRALI. She even sort of nodded to me when she said that as if I was also her medical student. She started to say more and I cut her off.

"She was hypotensive." My voice was flat. Irritated.

The One-Upper paused for a moment. Then went on, "Well, Kim, you've not actually seen both conditions clinically but I have and--" she turned back to the student--"they both present with respiratory distress so they're indistinguishable." Her tone was so condescending. I tried my best to be subtle as a took  drag of air through my nostrils.

"Hypotension," I repeated, this time with what I know was an attitude.

"Mmmmm. . . . .Well, actually the blood pressure in--"

I cut her right off. "They are distinguishable. One gives you really high blood pressure and one bottoms you out."

She squinted her eyes and tapped her lip with her index finger.  "I'm trying to remember what my last patient with TACO looked like blood pressure wise."

"Hypertensive," I shot back. Then I took a clear swipe which was immature, I know. "That's how she looked. And if she didn't, your diagnosis was wrong."

"Somebody sure is post call snarky!" the One-Upper replied with a snort. Then she turned back to our student and put a hand on her shoulder. "When you really see a patient with transfusion related respiratory distress, you'll be just trying to keep them alive in anyway you can."

My face was hot. Thank goodness for melanin because I know it would have been beet red otherwise. This had been going on all month and I had been up all night. I decided to clench my jaw and just shut up. Finally my attending decided to climb from under the chart and chime in.

"Well, that's true. . . but Kim is right about the blood pressure being the hinge that swings you from one diagnosis to the other. TACO occurs because of a massive upswing in the blood pressure." He yawned and swirled the tepid coffee he'd been nursing all morning and took a little sip of it. "Looks like things are  going in the right direction for this patient. Who do we have next?"

And that was it. That is for that patient, it was. That same thing happened four or five more times on rounds. And each time, my blood boiled just a little more. By the end of rounds I immediately walked off the ward to get away from her.

Yeah.

But everyone knows that when you really, really need to escape this kind of person they somehow keep popping up in your personal space. I was writing the last of my notes in the corner of the physician team room when the One-Upper came strutting in with the medical student behind her.

"Heard you ran two codes last night. Pretty busy," she opened up in my direction.

"Yuh." I kept myself busy, nose down in the chart and hand writing feverishly. My fuse was short and I knew I needed to get away from her before I lost it. I was also totally exhausted.

"I had a guy with a horrible pulmonary hemorrhage a few calls ago. Thank goodness I was able to position him to keep him stable until the Pulm team arrived."

"Yuh."

"Did both patients make it?"

I looked up and rested my eyes on her. I knew she knew that one had expired and one hadn't. But she asked anyway. I'd had enough.

I laid my pen down in an exaggerated slap. "Why are you asking me that? Like, why?"

"I was just wondering. Sheesh."

Her pseudo-innocence was making my head hurt. "No, you weren't. You heard me debrief with the fellow and you knew that one passed away and one didn't. So what I want to know is why are you asking me this?"

She put her hand on her chest and acted like she was surprised. "I-I-I I didn't know that--"

"YES. YOU. DID." I turned to medical student. "I'm sorry for this. I'm just really tired."

She awkwardly mumbled that it was okay and then excused herself, which was probably smart. Now it was just me and the One-Upper. Before she could speak,  I just shook my head and asked that she leave me alone. But she just couldn't respect that request.

"I just don't understand why you have to be so hostile. All I asked was a question."

I closed the chart and stood up. Against my better judgement, I spoke. "Did you just say hostile?"

"I mean, yeah. I asked one thing in small talk and you got all hostile."

"No. You didn't just ask a question. In fact, you never do. You just. . . " I wiped my face with my hand, sat back down, and sighed. "You know what? Just leave me alone. Please. Just go away."

She just stood there staring at me. Like someone had frozen her or something. "This has happened to me before in med school. People feel intimidated when someone smart comes along. Usually it's men who have the issue. But I guess this time it's a fellow sister."

"What?" I whipped my head over at her and crinkled up my face. That's when I knew I needed to remove myself. Which is exactly what I did.

Yup.

I called my dad and lamented to him about her. He listened and then said, "Why is she able to take over so easily when you have the floor? You need to think about that." That was pretty much the gist of what he said. I thought about it all night and throughout the following day.

That was enough inspire a new strategy. For the rest of the month, I spent at least one hour reading on every one of my call nights. I showered, changed into clean clothes instead of scrubs and arrived as ready as I could for rounds after those overnights. Instead of looking haggard and beat down, I coached myself to be the exact opposite. I countered her one-upmanship with excellence. And man was it an awesome weapon.

Yup.

What I learned from that experience was that it didn't even matter whether or not she was being an asshole. I'd given her space to step on my toes by not being excellent. In my head, I'd convinced myself that looking broken down would translate to how hard I'd worked and gain me some kind of badge of honor. But what it did was give someone room to usurp my presence as a competent clinician and teacher.

So I guess that's what I'm reflecting on. Excellence as a secret weapon. Instead of getting angry, I bleached and starched my white coat, shined my shoes, and prepared. I looked my attending in his eye, tried to anticipate his requests, and covered my bases. It was much more empowering than all that huffing and puffing I did before.

Yup.

Eventually, she stopped trying me on on rounds. The fun of it was gone. My buttons weren't pushable thanks to the perspective my dad had given me. And look---I have no idea what's going on with any of you in your lives or on your jobs. But let me just say this: When plotting your attack, consider just focusing on being more excellent. I can't say I always get it right, but trying at it makes a huge difference. Excellence is the pièce de résistance that shuts the haters down every time.

And even when it doesn't, trying to be excellent takes up so much energy that you won't even have time to care.

Yeah.

***
Happy Saturday.