"I don't come into the hospital a lot." Right after he said that, he pressed down with his hands and scooched his bottom back, trying to get himself comfortable in the hospital bed. I saw an antalgic flash ripple over his face. That fleeting wince told me what I'd come to find out. He was in pain.
Bad pain.
"When was the last time you were here?"
"I don't know. Like maybe six or seven months ago? But it take a lot for me to come up here."
"I hear you."
He was young. Young enough to be my son but old enough to be out of the pediatric setting for his sickle cell anemia. This hospitalization for a vaso-occlusive pain crisis was one of those bread and butter things you see when caring for an urban population. Youngish patients writhing in pain and with high tolerances for pain medications. Ones who've lived so much of their lives in the sick role that it seems to be ground into who they are. That's tough sometimes. And when it comes to any patient needing or wanting or asking for any really, really potent narcotic pain medication, with it comes some skepticism no matter how hard you try.
Yep.
I was back at Grady making rounds late that evening. My resident had asked me to pop in to see him because our pain regimen wasn't quite working. And as soon as I saw him, he quickly notified me that the pain medicine we were giving him was only lasting for about 3 hours.
Yep.
The problem with it was that this was a really strong medication. And giving him even more of a really strong medicine (that is, more frequently) would have put him at greater risk of addiction. And so. I told him just that.
"I worry about giving you this medicine closer together like you're asking. It's habit forming. And one of the most habit forming ones we have."
That's when he just started staring straight ahead, eyes filling up with tears. Nope, not mad. Nope not cursing or yelling expletives either. Just silent and sad appearing.
This was unexpected.
"Sir?" I asked. "I'm sorry. Did I say something wrong?"
He didn't speak back. He just let his eyes rest on the folds of his blanket while blinking back a few more tears. And so. We just sort of sat there for a few moments in this super awkward silence. Him looking down and me watching him.
A nurse walked in and passed a medication. Some kind of pill that looked like tylenol. "How's your pain right now, my friend?" He turned his head toward her and remained quiet. "Okay, sir. I'll let your doctor finish talking to you." And with that she walked on out.
Finally, after what felt like forever, he spoke.
"Doctor?"
"Yes?"
"Do you know what it feel like to be in a sickle cell crisis?"
I swallowed hard, regrouped and thought about his question. But it didn't take long for me to find an answer. "Do I know? No. I couldn't know."
"I'll tell you. It feel like . . . like. . . somebody taking million drills and going in and out of your bones all at the same time. Over and over again. Or like somebody taking the bones in your leg and trying they best to snap 'em in two. Or just putting 'em all in a bag and banging 'em with a hammer until it's nothin' left but dust. And all you can do is just sit there scared it's gon' get worse. And when it finally go away, all you do is pray it don't come back."
I didn't speak. I just listened.
"And you know, Miss Manning? I think that's what have so many people messed up. They don't want that pain coming no where near them. So they ask for more and more medicine 'cause they . . they like. . .traumatized, you know?"
I nodded. "Hmmm."
"But me? I do feel scared of that pain a lot. I do but if you look in my chart, you can see that I don't be up here like that. I try to manage it best I can at home, you know? And when it's real bad, like real, real bad--I come to the hospital."
"I get it."
"But it make you hurt even more to have your doctors looking at you like you some kind of drug fiend. And all I'm telling you is two things: Number one is. . . .I'm me. It ain't nothing in my chart to make somebody think I'm trying to game somebody to get high. But the other thing is that. . .like. . .until you know what if feel like to have somebody break all your bones at once? Cut them folks some slack, man. 'Cause a lot of us be running scared. Scared of that real Boogey Man that's been chasing after us since we was too little to even understand it."
I blinked a few times and let his words sink in. I nodded my head and leaned forward in my chair. "I appreciate you giving me that perspective. I really do. I don't think I'll ever think about sickle cell the same way again.
And I said that because it was true.
I can't imagine what it would be like to have a real, true Boogey Man chasing after me for my whole life. And I especially can't wrap my head around what it must be like to have him catch you repeatedly. In those few moments, that patient gave me a new empathy for those under my care living with sickle cell anemia.
Yeah.
And so. I reviewed his chart. I looked at what he was taking and at all of his numbers. I blended that with his physical examination to guide my clinical decision making. I modified his medication. We talked about his concerns and my concerns and formed a therapeutic alliance. And all of it was good. It was.
A few days later, he was feeling much better and was ready to be discharged from the hospital. He was moving around without pain and felt pretty close to himself again. It made me happy to see him smiling on the way out. Sure did.
I said a little prayer for him as he disappeared down the hallway. Wished on a star that the real Boogey Man would stay away. And that his doctors would no longer become the new subjects of his worst nightmares.
When my sister passed away, people were so unbelievably kind. They sent notes and text messages and voice mails and letters and flowers and food and probably some things I can't seem to recollect. It came from everywhere, too. From the close, close friends. From the acquaintances. And even from the people that I didn't even realize knew much about my family at all. It was pretty amazing.
All of that kindness will always stand out for me. Like, in the midst of all of that sorrow, it showed me that there is a whole lot of good and compassion in this world. There truly is.
But that's not the point of this post.
The point of this post is something else that I distinctly remember that happened during that time. And it holds such a memorable place because it so sharply detoured from everything I was hearing.
Yeah.
So this friend of mine who knew of my sister and how close we all were heard the news. And when she did, she picked up the phone and called me up. Yup.
"Kim!"
"Hey, lady."
"Is it true? Say it's not true."
"Man. I wish it weren't."
"Deanna died? She passed away?"
"It sounds crazy even saying it. But yes. She did."
"Kim! You are shitting me!
"Nope."
"Fuck!"
*silence*
"Damn. Deanna died. Deanna. Cool ass Deanna. That's fucked up, man!" Then she paused for a moment and repeated herself. "Damn! Deanna? That's SO FUCKED UP!"
And okay. I get it. That's a ton of expletives. But I need you to hear it because that's pretty much verbatim what she said.
Now.
Some might think that was an insensitive thing to say. But not me. Something about her pointing out the obvious -- that thing that no one else had actually said to me yet -- felt good. Cathartic even.
I laughed out loud. "You know what? It IS fucked up."
"She picked your kids up everyday, man. And y'all are a tight knit family. I hate hearing that shit, man. That's so fucked up."
Not "I'm sorry for your loss" or "I'm praying for you." But instead, this raw, true statement. One that described what it felt like to lose Deanna perfectly. It was fucked up.
Yeah.
I can't say the F-bomb is always my go-to expletive, but on this day, it was so soothing for my soul to hear. This unfiltered description of what was right there in front of us. No profession of how it is darkest before the dawn or how the Lord knows what He's doing--all of which may be true. But what was truest of all for me was that having my sister with me on a Wednesday and then not having her on a Thursday was . . .well. . .fucked up.
Yeah. That.
So I remembered that. This person making a choice to simply call it what is was instead of finding the prettiest shiniest words she could find.
I told a patient she needed dialysis today. A young patient, too. Looked her straight in the eye and explained that her kidneys had weakened to a point of needing a machine to do their job. Three days per week.
Yeah.
And she asked me questions and I gave her answers. She wanted to know all of the logistics of going to a dialysis center and the cosmetic appearance of an AV graft. And so. I answered. I told her all those answers and a little more on top of it. And she just took it all in and listened.
But then I remembered. I remembered how good it felt when someone kept it 100% real with me.
"I'm sorry about all this."
"Me too."'
"I won't even lie. This is messed up. Like, being young and having to go to dialysis three times a week is a crappy hand to have been dealt."
She just stared at me for a few beats and then turned her head sideways. One edge of her mouth turned upward and then, for the first time since we'd been talking, she smiled. "You know what, doc? That's real talk right there."
I took a breath and gave a subtle shrug of my shoulders to convey that I agreed. There was no sugar coating it. Being of child bearing age but having kidneys that don't work is. . .well. . .messed up. And fucked up, too.
Now.
Let me be clear. I do believe that people rise out of the ashes of unfortunate situations. In fact, I know they do because I see it every day. And what I do for a living is help them do just that, you know? But I guess what I'm realizing is that sometimes you just have to call something what it is to form your strategy. Like, look it square in the eye and say, "I see you for what you are. And now, I'm gonna fight like hell." Nope. No sucker punches. No pirouettes around it. Just straight up, hand-to-hand combat. But you have to see the target to do that, man.
At least that's what I think.
It's November. And this month will mark four years since one of my favorite people in the whole wide world left for good. The air is crisp and fresh and so is the harsh reality of my sister being gone. And you know? I walk into it eyes wide open, fully recognizing that a life without Deanna in it will always be kind of . . .well, fucked up. And it just is what it is.
But you call it what it is. And when you do, some piece of it feels just a little more manageable. No. You aren't a victim. Or maybe you are. But either way you're aware and not hiding. You give yourself permission to keep going.
Then you shadow box in the corner. And you come out fighting.
There is this lady. This lady that I see every day at a point in my day. Pretty much at the same time. Like, if I walk the direction I need to walk to get where I need to get, I will see her. See her in the path of where I am going. That is, if I take the way that is fastest to get where I need to go. Which is mostly what I do.
Yep.
So every day, there she is. Doing what she does while I go where I go. But then, whenever I get closer she eases in my direction. Comes nearby and says a cheerful hello, like always. Includes some open ended questions that call for me to open it into a conversation. And then, if I don't run any form of interference, she will pause to chat. A little bit about this. A little bit about that. And a little bit about the other, too.
Yeah.
All of it takes no more than 2 minutes, really. And sometimes less than that if all she wants his a hello and a hug. She is a hugger. One who puts her whole body into those hugs, too. Both arms, torso to torso, and pressing into you. Complete with the "mmmmm-mmmm!" sound effects. Yes, she does that.
She does.
But. There are some days. Like, some days where I feel like I'm super busy and feeling harried. Or where I'm late. Like, where I really just want to get to where I am trying to get without stopping to chit or chat or hey or hug. Even for a moment. Telling myself that I am just "focused" today and want to just stay on my task. Whatever that task may be.
And so. On those days, my walk is more brisk. My body language is fast and deliberately standoffish. I typed and deleted that last sentence twice. That word "standoffish" made me cringe. Especially when connected to me. I had to add it back because it is true of what happens. That is what I do. Like, on those days, I do this thing to demonstrate that I don't want to be interrupted. Not even for a hug.
Nope.
So on those days, she will call to me in her singsongy voice as I whisk past going wherever I need to go. She simply calls out a "hello" that floats out into the vacuous hallway then swirls down to the ground like some kind of lonely feather. My salutation in return shoots out and hits it like a fast ball. Quick, pressured. Making it clear that it would be this one pitch. And that's it.
Yeah.
Doing that always feels bad. I mean, because it's not nice really. I'm old enough to know that. So on a lot of days, I just take this really circuitous route to the place I need to go that doesn't take me past the place where I would pass her. But fickle fate somehow always reroutes her path to overlie my own at some point. It does. So then, I'm back to where I was. Either cooling my jets or deciding to turn them on high.
Sigh.
I am not proud of this. I'm writing about this because I am just thinking this morning. I'm thinking about those two minutes (or less) that I so stingily clasp in my hand. My decision to withhold some piece of me, albeit a fleeting piece, because I just sort of don't feel like being bothered. And you know? I am really not sure why I don't want to be bothered by this very sweet individual on some days.
There is this melancholia about her. Like this piece of her that I can tell needs a human interaction as much as she can get it. And I think it's even worse that I am not always forthcoming with it since I know that. Like some sort of middle school mean girl who has decided not to be your friend. On certain days.
Maybe the sadness in her eyes overwhelms me. Makes me feel like what I give needs to be all or none. And like the all isn't necessarily my job since I work a job where I have to give that kind of all all the time.
I don't know.
I know about pieces of her world. Even though I don't have a lot of contact with her, there is the stuff she has told me. And, no, I don't know what her full world is like away from the place where I pass her each day. But what I am processing this morning is this realization that I am a tiny sliver of her world.
I am.
There's probably some complicated piece of my psyche that this underscores. And I don't know what that is since I'm not a psychiatrist. But what I do know is that I love people. And I want to be a good person.
So today, I've made up my mind. To be bothered. And interrupted. By her.
And before you say that, from what you read on this here blog, I seem very good about being bothered, I will say that on some accounts I am. Like, I am very, very good about say, a stranger, in the Grady hallway hitting my pause button because they are lost. Or that wayward medical student who wants to pick my brain. But this? This is different. This interruption is like that movie Groundhog Day. I know what's going to happen. Yet I find myself using some energy to redefine the outcome and order of events.
I'm not really even sure why.
Withholding kindness isn't cool. Even if on other days you give an extra heaping helping of it, it's not. And so. I am going to work on that. With her. With me. Because two minutes is nothing. Except for when it's something.
"Any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.” ~ John Donne
It has now happened to me too many times to count. A person comes into the hospital. Our hands touch at that first meeting and our hearts connect. No, not just in some obligatory way that gets outlined in that first year med school lecture about "BEING EMPATHIC." But more in a natural way. The kind that happens when you strip down the armor of stoicism and reveal a piece of who you truly are.
Yes. So this happened to me this week. It did.
From our first encounter, I knew. I knew this patient, this person would leave me forever changed. I inwardly chuckled, knowing that it would be one of those weeks of late departures--not because of neediness on her part but my own selfish desire for more. More while I could have it. More because my patient was preparing to leave. She was.
It wasn't obvious at first. So mostly, it was just her quick wit and wisdom that created this giant magnet to which I attracted. Between laughs and reflections, I'd coordinate her care with the residents and speak to consult teams. And for every single day that she was there, I would round on her twice. First, for logistical things like pain control and management. Then, to simply close out my day. I'd drag a chair to her right side, hold her hand, and soak it in. I would and I did.
On Friday she was slowing down. Together we'd agreed upon a master plan for an intervention the following week aimed at making her feel better. But some piece of me was conflicted. "Is this what you want?" I asked her.
"What do you think?" she said.
"I think I don't want you to be uncomfortable."
"Okay. Let's play it by ear, okay? If I'm not up to it, I think you will know. And I will trust your judgement."
"I will pay attention, okay?"
"You always do, Dr. Manning."
And that was the end of that discussion.
When I stepped into her room yesterday, the lights were off. It wasn't pitch dark, but more filled with shadows and only the morning sunlight. The family was at the bedside and another consultant was there, too. My team walked in and the family, with whom I'd also developed a connection, notified us that she wasn't talking. The pain in their faces grabbed me by the neck and punched me in the chest. And that, coupled with those shadows, was telling. It was.
I went to her. Usually, I offer a subtle hello and fall back when a consulting colleague has come first, but on this day I broke the rules. She was my patient. An urgency was swelling inside of me. Something was telling me, screaming to me--"You will not get a 'two-a-day' today. You will not."
She was looking straight ahead, not speaking but appeared totally lucid. Like all of this silence was voluntary, representative of elevated thoughts and reflections. The first thing I did was touch her hand like always and move close to her face. "Hello sunshine," I murmured.
And just like that, her face erupted into an enormous smile. Relief washed over the family and even the consultant. She was still there. She was. But still. I could feel it. Her hand on this day was ice cold. Yes, her spirit was still warm, but nothing else.
Nope.
I asked her questions about her pain and nausea. She nodded yes and no appropriately and told me how she was. All nonverbal but still fully present. And so. I kept talking to her. And to the family. Fielding questions from them and all the while holding her cold, cold hand.
The consultant slipped out and all that remained was the family, my team, my patient and those shadows. More questions from the family came. Concrete queries that you ask when you love somebody. Love's myopic view doesn't allow for big picture objectivity. Not that kind of love. But what I've learned is that some piece of this love category, that is, the doctor-patient love category, leaves the sliver of insight that gets lost in other kinds of love. And now that I know this, I have to use it. I must.
So, I try. I try to talk but my face. It starts to get boiling hot and those tears. Those pesky tears they pour from my eyes. My voice cracks and I feel her icy hand tighten around mine like a vice grip. She knows. Her clasp stabilizes me. She gives me courage to be honest and transparent. And so I do.
I give her hand an affirming squeeze to let her know I got the marching orders. Then I turn to her daughter. "Tell the family to get here. Get them here. Today. Now. To love on her. Love hard on her like she loved on all of you." And then I started weeping outright. And because she was holding my hand, I couldn't even wipe the tears fast enough since that would have been a two-hand job.
"Love on her," her daughter repeated while holding my gaze. "Love on her."
"Yes. It's all we have. Love is the what."
There wasn't much more to say after that. Our rapport was good and my patient's response was obvious. I leaned in to tell her good bye and asked once more if she needed anything. She nodded yes to pain medicine and no to nausea medicine. "Okay," I told her. "I got you."
And then, just like that, she spoke. "You look so beautiful." Her voice was clear. Nothing garbled or suggesting confusion. Sure, direct, clear. And those words? They were a gift. Not just to me, but to her family. They needed to know that she was there.
Shortly after that, my team left. Sujin, the third year medical student broke down crying and I consoled her in the hall. And my intern Sonali did the same. "Let it hurt. You want to be affected," I told them. "And don't let anyone tell you otherwise." Then, all of us just stood there in quiet awe of the amazing privilege we'd been given as the caregivers to this soul. We sure did.
A nurse saw us walking up the hall afterward. She asked me, "What happened? Did your patient expire?"
I smiled with my red face and snot-filled nose and replied. "No. We are just feeling fortunate to be her doctors. That's what you see." That is exactly what I said. Because it was true.
My patient passed away yesterday. Only a few hours after that encounter. That family got to her and they were all glad they did. Sonali, the intern caring for her, loved her, too, so returned to the hospital. That sweet intern sure did. And all of it was good. It was.
I'm so glad my boundary issues allow me to feel this way. My chest is heaving as I write this, but in the very best way. We are all connected, I think. Being aware of it and surrendering to it is the issue. That's what I think.
Yeah.
During one of our late afternoon handholding sessions, my patient asked me to write about her when she transitioned. I promised her I would. And so today, I honor that promise and also present a piece of her love to you. Because love? Love doesn't expire. And love, my friends, is the what.
***
Happy Sunday. And thank you for Angella for that beautiful mantra that I say or write somewhere nearly every day.
My patient took off her glasses and said, "I can't keep looking through these rose-colored glasses. I just can't."
I was holding her hand and both of us had tears in our eyes. Her body was sick and she knew it. I felt sad because there wasn't any other treatment to offer.
Then, all of a sudden, she looked at me and smirked. "You know what? I just noticed that these ol' glasses of mine really are rose-colored!" She threw her head back and laughed so hard that I did, too.
After that, we just sat in silence. Holding hands, looking out the window, and wishing on invisible stars.
Today I received an email from a former Emory student/resident that was, quite possibly, the single, most moving thing I've ever had written to me or about me in my entire career. I'm busy right now. Just got back on the hospital service. Have been mad at myself about missing personal deadlines on completing a manuscript I need to finish. And dreading the over 15 "strong" letters of recommendation that students are depending upon me to write for their residency applications. This work can be so grueling sometimes. And sometimes thankless, too.
I started out this day feeling frazzled. I rushed the kids all around the house this morning and still got both of them to school just after the bell. (Fail.) After that, I drove to work coaching myself like a good girlfriend, saying things like, "Girl, stop tripping! You are a great mom" and "Oh, come on. You're an awesome doctor." Because, you know? It was just one of those days. I was so turned around at one point that I thought it was Friday. Except it was Thursday.
But then I checked my email. While sitting in my minivan waiting for my son to come out of ultimate frisbee practice and feeling flustered about the things I still had to do once I got home. A simple tap of my thumb and there it was. Waiting on my iPhone like a balm for my soul. On a day that I truly needed it.
As a clinician educator, I have won some really great awards--I'm talking career-defining ones that parents and family fly in to witness. I've also done some cool stuff--from talking to Anderson Cooper on CNN to publishing in JAMA and Annals of Internal Medicine in the same month to even getting a medical blog nod in the doggone Oprah Magazine. But nothing--and I do mean nothing--compares to one individual learner's affirmation that you've had a real, true impact on his or her life and career. It supersedes any trophy, plaque or media attention. My fellow clinician educators (and educators in general) know what I mean.
"Believe half of what you see and none of what you hear."
~ Anonymous
A few years back, I was in clinic and went into a room to listen to a patient's heart sounds. A resident physician working with me that day had already seen the patient first. Before I entered the room, he'd described everything about the past medical history including a "easily audible" heart murmur. Even though it was pretty straight forward, I still wanted to listen. And so I did.
"It is an early peaking, systolic murmur," he said as we walked up the hall, "radiating to the carotids. But super loud." That description was suggestive of a narrow aortic valve. I figured that a murmur this loud had been assessed with imaging in the past.
"Did she get an echocardiogram?" I asked. The two dimensional ultrasound of the heart, or echocardiogram, visualizes the blood flow and the heart valves. Though the physical findings lead us to where we are going in heart disease, actual images tear the roof off of the sucker to confirm things. The clinic was busy. And this was an upper level resident. So I cut to the chase. I wanted the echo results.
"She did," he replied. "I need to double check the final read but I'm pretty sure it confirmed aortic stenosis."
"Do you know how severe?"
"No. I'll have to look again when we go back into the room. But I know she doesn't have any symptoms which is good."
"Yeah."
So he went on to tell me a few other things about her before we reached the room. After a quick knock, we entered the clinic room together. Nothing about it was unusual.
"Hi there, ma'am. My name is Dr. Manning and I'm one of the senior doctors in the clinic working with your doctor. We always put our heads together about your health and figure two brains is better than one." She smiled and I smiled back. After a quick review of her concerns and the plan of care, I reached into my pocket to pull out my stethoscope. "Mind if I listen to your heart?"
"Not at all," the patient replied. "Guess four ears is better than two, huh?"
I chuckled and nodded while placing the rubber tips of the stethoscope into my ears. And honestly? I wasn't even thinking too hard when I did that. I reached over to her chest and searched the classic listening areas--aortic, pulmonic, tricuspid and mitral--with the cold diaphragm.
Sure did.
The whole "not thinking too hard" thing wasn't because she didn't matter. It was just that I'd heard the story and exam already including the echo results. This was mostly a formality, honestly. I even made comment about the pretty necklace she was wearing as I slid it out of the way to reach her chest. The patient began sharing that she'd splurged on it during on a vacation once and how she hasn't removed it since. I raised my eyebrows and nodded, then lifted one finger to let her know we'd need to hit the pause button for a few moments.
You know. So I could hear the murmur that already had a diagnosis.
And so. I lean in and quickly listen. And just like that, I recognize that what I was hearing isn't at all what had been described to me. I raised my eyebrows. "What did you say this murmur was from?"
"Aortic stenosis."
I squinted my eye and listened again. "Hmmm. This murmur sounds diastolic to me. Hmmm."
"She definitely has aortic stenosis. I heard a crescendo-decrescendo murmur. And it was during systole."
"Okay." I carefully listened again. I then felt the patient's pulse and listened some more while timing it out with the rhythm of the heart. And still what I heard sounded like the flow of turbulent blood during the relaxation phase of the heart cycle. I listened some more. And then once more. "Aortic stenosis, huh? Okay. I guess my hearing is off today." And that was that.
I conceded since I knew that the imaging supported his assessment. But honestly? That murmur sounded nothing like what he was saying to me. The whole thing made me uncomfortable, especially feeling so off on something like this--a bread and butter physical finding.
"Yup. Stenosis. But let me just confirm how severe, okay?" He pecked into the computer and clicked a few screens. And while he did, the patient asked a few questions.
"Is my heart okay?"
"Have you been told about your heart murmur?"
"Yes'm."
"We're just talking about your heart murmur. That's just the flow of blood rushing over your heart valves. Have you been lightheaded or dizzy?"
"Naw. Never that."
"Okay. We're just checking to see how narrow your heart valve is but it sounds like this is an old issue, okay?"
"Oh alright then."
She asked a few questions about aortic stenosis and what that meant while he moved through screens to confirm for me the final reading on the echocardiogram images. Since I was less occupied, I pitched in and explained. Even though my ears were telling me of a different diagnosis.
Yeah.
So as we discussed all of that, suddenly I notice a funny look on the resident's face. "Oh must've misread that," he mumbled to himself. "Um, Dr. M? It's actually moderate to severe aortic regurgitation."
He said that right after I'd finished my soliloquy on aortic STENOSIS and right after I'd finally talked myself out of what I knew to be true based upon what I'd heard with my own ears.
Shit.
And no. It didn't turn into a big thing with the patient at all. I apologized and told her that I'd misspoken and that her heart murmur was more of the kind you get form a leaky heart valve instead of a narrow one. My face felt like it was a million degrees. She laughed and said, "I was wondering. I been told before my valve was leaky. I ain't never heard of it being stiff and narrow before so that was news to me."
Sigh.
So here's my point of telling you all of this:
The things that happen to me at Grady are simply metaphors for life. Trust your gut and what you know. Listen with your own ears and then listen again. Believe your ears, especially when they've heard a lot of things. Same goes for your eyes. But especially believe yourself even when odds stack against what you think. That is, when you feel sure.
I doubted myself. And honestly? It wasn't even a soft call. I felt embarrassed for my initial instinct to doubt the echo report when I shouldn't have. I shouldn't have at all. Plus, I hadn't seen that echo result with my own eyes. That's a lesson, too.
And no. I am not always sure. But this time I was. And I'm still mad at myself for not laying down my nickel and betting on me. I recognize it's okay to be wrong. But I think my "ah hah" moment is in that I need to be just as okay with being right.
Does this even make sense?
As for my resident, I gave him some feedback. I'm pretty sure he, too, convinced himself of what he heard based on what he thought the images showed or could have just been so junior that he misjudged what he heard altogether. So yeah, I gave him feedback right away. But as I did, I showed my own clay feet and revealed what I'd done wrong as well. I'm senior to him yet I needed him to understand that even after 20 years of being a doctor, we are still works in progress. I let him know that being scared of looking silly isn't a good reason to not push when you feel pretty sure. And mostly, I was sure, even though I was being told otherwise. I was just two seconds away from saying, "Well, I don't know what that echo is saying, but this murmur isn't consistent with aortic stenosis at all." But I didn't. After all, the echo said it was aortic stenosis.
You didn't quit smoking. Nope. Not even after that big, long, drawn out discussion we'd had about you setting the perfect quit day. "Juneteenth!" you announced with a big, loud laugh. You banged your hand on the desk and clapped your hands after. I typed it right into the chart when you did:
QUIT DATE: JUNE 19, 2016
Then you added, "Perfect, ain't it? The day of emancipation, right?" And I nodded my head in acknowledgement, loving the idea of you being freed of the nicotine stronghold on the very day that our people came up from under the dark cloud of slavery.
"That day sounds perfect," I replied. And I said that because it was true.
But sadly that day came and went. And you didn't quit. Nope.
Your blood pressure was high today, too. You promised that you'd take your blood pressure pills but when I looked into the pharmacy history, you hadn't picked up a refill for two full months.
Nope.
342. That was your blood sugar reading on the finger stick today. Which meant that you probably weren't taking you insulin either. (Even though you'd promised you would.)
And last was your weight. Your chief concern at the last visit was losing weight and quitting smoking. We'd talked and talked and talked all about it and you sounded so ready. So ready. Together we identified some simple tweaks that could be made to help you shed pounds and, I have to admit, I was just as excited as you.
Sure was.
But that didn't work out either. Instead of dropping a few pounds, you gained nearly ten. 9.73 to be exact. Which didn't fit the gameplan we'd discussed. At all.
So yeah. Essentially none of what was supposed to happen happened. And honestly, I'd be lying if I said that some piece of it wasn't frustrating because it was.
Yeah, it was.
And so. I creaked open the clinic room door to come see you. The undeniable scent of cigarette smoke wafted into my nostrils the very moment I stepped inside; it had found a crevice of every part of that room. I coached myself to not be disappointed in you. To not feel like you'd hoodwinked and bamboozled me into believing that this visit would be some celebratory party where I fist bumped you for your big emancipation from cigarettes and unhealthy foods. Yeah.
"Good morning," I started. I took the seat across from you and smiled. Trying my best to not sound condescending, I added, "It's good to see you."
I was kind of tired that morning. Isaiah had forgotten to tell me about a homework assignment he had until the very last minute which forced a late night/early morning kitchen table science combination. Zachary couldn't find his shoe and seemed hell bent on wearing only the pair that had the missing mate. Our dog decided he'd tear up a throw pillow overnight. And I'd run out of creamer that morning so had to drink black coffee which I did but did not enjoy one bit.
So yeah. I'd hoped for some good news from you.
"I didn't quit, you know."
I sighed and leaned my face into my hand. "Yeah. I know."
"I gained some weight, too. Even though I ain't had much of a appetite. I just ain't been doing so good." Your mouth twisted when you said that and I could have sworn I saw tears glistening in the corners of your eyes.
"What do you mean by that? By 'ain't doing so good?'"
That's when those tears became undeniable, spilling over your lashes and onto your cheeks. You offered a lopsided shrug in response. And this? This was different for you. Normally you were chipper and full of happy spunk. And even though I was not so thrilled about your failure to clear the hurdles we'd pinky sworn upon, at minimum, I'd expected some funny one-liner about why it didn't happen. But not this. Not tears.
And so. I just waited. I touched your forearm and waited.
"Remember my grandson? The one who was staying with me?"
I thought for a moment and then remembered him from a visit once. He'd driven his grandmother to the clinic one day and seemed rather unhappy about having to sit in on a discussion of antihypertensives and insulin. "I do."
"Well. . he. . he. . " You couldn't finish. Instead you just dropped you head into your hands and wept hard. Your ample bosom shook rhythmically along with your fleshy arms.
"Oh my goodness. . .did he get hurt? Is he . . is he alive?" My hands covered my mouth immediately after I said that. I hated to be so direct but I'd worked at Grady Hospital long enough to know that it was a fair question. Your home address was in a rough part of town and that grandson was in your custody after drugs left his mother unfindable and incapable of raising him. The same streets that took his mama, though, preyed upon him, too. And you knew that. You'd lamented about your concerns of him selling drugs on corners and getting mixed up with the wrong crowds. So yeah. That question wasn't unreasonable.
"He got locked up. Caught a murder charge. He gone, Miss Manning. He might as well be dead. He gone for his whole life. And he ain't but nineteen."
I felt my eyes throbbing with tears. I puckered my lips outward and swallowed hard to try to keep myself from crying, too. It didn't work. "I'm sorry," I whispered. The tears splashed disappeared under my chin before I could wipe them away.
"Me, too," you murmured back.
And that was it. We didn't utter another word about you blood pressure or your smoking or your blood sugars or your weight. We just sort of sat there and felt the enormity of how hard this life can be sometimes and pushed all of the rest of it to the back burner. And yes. Your blood pressure and weight and blood sugar are important. But your emotional well being is, too. You'd lost your baby boy after losing the baby girl who made him. Your aging soul didn't deserve this pain. The streets were winning 2 - 0 which meant you were 0 for 2.
Later that day I thought of you. Thought of your grandson and the significance of his age--19--and that date you'd so cheerfully chosen for your quit date--June 19 or, as you said it, "Juneteenth." That number was supposed to be a happy one, representing freedom and a brand new day. Instead, it turned out to be symbolic of pain.
I hated that.
Here's what you taught me, though. That sometimes even when there is some pressing shit to discuss, something else more pressing should take precedent. And that sometimes the reasons that people don't follow through on things is because they physically and emotionally cannot. That slowing down and paying attention to souls matters more than slapping wrists for missing marks.
This lesson is one I need in all aspects of my life. So thank you, my friend. And know that this morning I am quietly weeping into my coffee and holding your hand. Feeling sad that nineteen hurts for you and wishing there was something I could do to fix it all. Like offer you some kind of Juneteenth to rescue you, your baby boy and his mama from the shackles of your reality.
"Let's talk about all of that other stuff next time, okay?"
Like many of you, my social media timelines have been flooded with frustrated, hurt, angry posts in reaction to the senseless death of yet another black man at the hands of police. This time, it was Mr. Alton Sterling of Baton Rouge, Louisiana. It was captured on a grainy cell phone camera. Two cops took him down and shot him multiple times at close range ending his life. His kids saw that video. I saw it, too.
Here's what I'm thinking about:
Just maybe, you are my friend and your world hasn't been flooded at all with bitter one liners and battle cries from your peers about this. Just maybe, you have checked your social media threads of choice several times but, because this doesn't hit quite as close to home for you or those whose posts fill your screen, you had no idea about this incident until just now. If that is the case, consider this an invitation. First, to Google #altonsterling to understand what happened (if you weren't aware already.) Then, I invite you--my nonblack friend---to be as sickened, appalled and bothered by those hashtags as me.
That is, if you weren't already.
I want you to imagine talking to your sons about police and feeling your heart turn a tiny relieved flip when your husband comes home from a regular day--alive. Talk to your kids, make this a big deal in your house, and please, join us in being pissed off--because everything depends upon that. Nothing changes when we don't provide anybody space to empathize. But now that you have the space to stand with me, I want you to know that any indifference here forward will be hurtful--whether I am telling you or not.
I think we are all super guilty of polarizing others when upset about the things that affect our own communities. Our soapboxes are so tall that they make people shrink, hide and peep through their blinds like voyeurs. Black, white, straight, gay--we build these walls that won't let good people be allies--or at least let them ask enough questions to feel something. And no, I don't think it's intentional. Pain just makes us all impulsive.
At least that's what I think.
For my friends who don't know what it's like to worry in this way about your father, your brother, your husband and your sons. . .I want you to read this post (if you haven't already.) If you feel so inclined, you can also read or re-read this one, too. It will give you more perspective of what it's like raising black boys in America.
Yeah.
Then my hope is that you will accept my invitation. To ask questions. To comment. To say something. To feel something. But especially to be pissed the eff off. Because no movement ever really gets moving until more than just the oppressed get mad. My prayer is that we can all be a little more aware of each other's joy, pain, sunshine and rain.
This is our reality. Thank your God if it isn't yours.
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.
Honestly? I write this blog to share the human aspects of medicine + teaching + work/life balance with others and myself -- and to honor the public hospital and her patients--but never at the expense of patient privacy or dignity.
Thanks for stopping by! :)
"One writes out of one thing only--one's own experience. Everything depends of how relentlessly one forces from this experience the last drop, sweet or bitter, it can possibly give."
~ James Baldwin (1924 - 1987)
"Do it for the story." ~ Antoinette Nguyen, MD, MPH
Details, names, time frames, etc. are always changed to protect anonymity. This may or may not be an amalgamation of true,quasi-true, or completely fictional events. But the lessons? They are always real and never, ever fictional. Got that?
