Reflections from a Thursday at Grady and Beyond: The Advocate

Three reasons to be a patient advocate. . .Daddy, Zachary and Isaiah
"Camp Pa-Pa" - California Summer 2009

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"I did a 10 mile walk to mark ten years," my dad told me when I asked him how he celebrated the New Year. I knew exactly to what he was referring.

"Wow, Poopdeck," I replied, "It's been ten years already? Dag."

"Yep, ten whole years on December 31. And I've never felt better."

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Cleveland, Ohio ~ December 1999


In December of 1999, I was a senior resident rotating in the Cardiac Intensive Care Unit. Less than a year away from completing a 4 year residency in combined Internal Medicine and Pediatrics, I finally felt like I was coming into my own. Call wasn't so scary any more, my pager no longer made me feel nauseated, and overhead sirens signaling an unstable patient felt as every day as a telephone ringing. December 30, one of my many nights on call, was no different.

My pager went off a few hours after dinner time, and I noticed that it was an operator number. This almost always suggested an outside caller. It had been pretty slow that night, so I was sitting at the nurse's station eating leftover holiday snacks and goofing off with the staff between admissions. I secretly hoped it was a personal call. (Yep, this was back when you kept your cell phone in your locker and used it only for emergencies.)

"Operator. This is Drema. How may I direct your call?" a polite voice said on the other end.

"Good evening, this is Dr. Draper. I was paged?" I gave my most cheerful greeting to the operator while doodling on an index card. Maybe the call was social, but I knew that it was also a very good chance it could be an outside hospital calling for an emergent transfer. Ugggh. I hoped for the former.

"I have Mr. Draper holding, Dr. Draper. I'll connect you if that's okay." I looked at the clock, and it was nearly 9pm where I was in Cleveland, Ohio. 6pm on the west coast meant Dad was home and off work. I loved hearing from him on my call nights--he was interested in anything I told him, no matter how common. ("Sickle Cell Anemia? Wow! That's interesting.")

"Okey dokey," I replied feeling relieved that it wasn't an admission. Then I remembered my manners. "You doing okay tonight, Drema?" (Yes, I still remember the Operator I spoke to that night.)

"Sure am, Dr. Draper, thanks for asking. Here's your dad, hon'."

When Daddy got on the phone, he sounded a little bit funny. He immediately started telling me about a pain that he'd been having in his left shoulder and back. "I played 36 holes yesterday," I recall him explaining, "but it really is hurting pretty bad. I've been taking ibuprofens, but it just doesn't seem like an 'ibuprofen' kind of pain."

"Well, what kind of pain is it then?" I queried while still drawing on the card. Dad called me to ask about minor aches, pains and health-related concerns all the time--his and that of his friends, siblings and acquaintances-- so this was nothing unusual. I yawned and kicked off my clogs under the counter.

"Hmmmm. I don't know how to describe it. It's been going on for several hours now, I know that. I mean. . .it's not like a pain like in your joint.. . .like when I move it, that doesn't change it." I imagined him moving his shoulder, which I am sure he was doing as if I could see him. Dad sighed. "I told you I don't know how to describe it."

"36 holes is a lot, Dad. Did you hit the range first?"

"Yes. . . .but it just seems like it would hurt more when I move it, don't you think?" (I'm pretty sure he was moving it again for me.)

"Yeah . . . . .it really should if it is an overuse injury." I had an idea. "How 'bout you do your best to compare what the pain is like to something you've felt before. Sharp like stepping on a pin? Dull like a toothache? Stabbing like. . .uh. . .a stab? Just describe something that you've felt before to give me an idea." Deciding to multitask, I reached into my lab coat to look over the list of patients on my cross-cover sheet that night and yawned again. So far, everyone was behaving. Maybe I would get a few hours of shut-eye in the call room before morning rounds. I lay my head down with my ear on top of the receiver waiting for Daddy to go on.

"It's like. . . . " I could tell his wheels were turning," . . . it's like. . . .kind of like somebody sprayed something cold inside my shoulder and between my shoulder blades."

I immediately bolted upright. "Like what?" I firmly interrogated. He repeated the statement, but this time he added "kinda like accidentally biting a piece of ice, but in my shoulder and back." Shoot. I jumped up, stuck my feet into my Birkenstocks and started pacing with the phone. Like something cold? Shoot! This sounds visceral, I thought referring to the indescribable pain associated with internal organs. Shoot!

"Daddy! How long has this been going on? When did it start? Are you sweating?" I blasted him with questions feeling my anxiety grow. After spending an entire month taking histories from all kinds of patients experiencing sho nuff and bonified heart attacks, I was very much in tune with the significance of these kinds of subtle complaints. I wanted more information.

"Most of the day," he replied. "I saw my primary doctor earlier and he gave me the ibuprofens. It just kept hurting so I thought I'd see what you thought." I tried not to sound worried, but I was. I really, really was. I could feel my heart beginning to pound in my chest, and place my hand on it in an effort to calm down.

"Listen to me, Daddy. Listen to me, okay? I want you to have JoLai take you straight to the nearest emergency room. When you get there, tell them you have high blood pressure, high cholesterol, and that heart attacks and strokes run in your family. Then tell them you have chest pain and that you're sweating."

"But I don't have chest pain, and I'm not sweating," he countered.

"I know, Daddy, but I'm worried about this pain and I don't want anybody to blow you off." I knew it was a white lie, but I also knew the cold hard facts about black folks being turned away with atypical cardiac complaints. Fortunately, I knew Dad would do whatever I said. I immediately called my younger sister on the three-way who promptly headed over to pick him up. They called me as soon as they reached the ER, and promised to keep me posted.


Several hours later, I learned that my father was found by the ER physicians to have a very abnormal EKG that even a first month first year medical student would recognize as an acute myocardial infarction (heart attack.) They admitted him to the Cardiac Intensive Care Unit at our local community hospital, and early that morning his nurse let me speak to him. I still remember the sounds of beeping IV pumps and monitors in the background.

"My shoulder is a little better but it still hurts in my back some. They have the glass bottle pain medicine at the maximum, but my nice nurse just gave me some morphine and it helped a little." I could tell he was being brave so that I wouldn't worry, but my medical knowledge was sounding alarms in my head. I didn't want to scare him, but I am pretty sure I did with my silence.

What? He is maxed out on nitroglycerin and STILL is in pain? He is STILL in pain twelve hours later???? Shoot! Shoot! Shoot! "Daddy, let me speak to your nurse."

As soon as she got on the phone, I learned that Dad's first cardiac muscle injury/enzyme marker blood test (troponin) was 4.6 in the emergency department. (normal is less than 0.04) His repeat troponin 4 hours later was 22. (Yes, medical students and residents--you read that right: my father had a repeat troponin of TWENTY frickin' TWO!) "Beg pardon?" I gasped, needing her to repeat it as I was sure I'd heard wrong. "Oh, I'm sorry. It's twenty two point one," she read from the computer. Whaaa?

I thought that I would vomit. I hung up the phone and, like a lifeless zombie, I rejoined post call rounds with my team in the unit. My attending, Dr. Biblo, saw that every bit of color had drained from my face, and thoughtfully asked what was wrong. I burst into tears and told him my father was in a CICU in L.A. with a troponin of 22, the highest I had ever heard or seen in my life. I also told my attending that the cardiologist had not reached the hospital to do a cardiac catheterization yet, and that I was terrified. He excused me from rounds to go cry in a call room, which I appreciate to this day.

Dr. Biblo sat beside me when I called the west coast cardiologist after rounds. That absentee cardiologist left me holding for several minutes listening to monotonous recordings with the operator, and once he took my call, he nonchalantly told me that he was in the parking lot and preparing to cath my dad. He also told me that "things in residency aren't the same as real life." I'll never forget the way he trivialized my concern for my father. (I vowed then never to do the same.) After the catheterization, he called me back and, with a snarky tone, informed me matter-of-factly that my dad needed bypass surgery. "There was nothing I could do in the cath lab anyway," he added with a smug chuckle. "See? It isn't always like you see on tv and in residency." In other words, naaa nanny boo boo. Jerk.

By this point I'd managed to secure a plane ticket to leave for L.A. that evening. Ironically, I'd been angry all month that I didn't have plans for the big Millenium New Year's eve that year. Fickle fate--now I did. So much for partying like it was 1999--I needed to be about my father's business. A few hours later, I sat in the airport where my mother called me on my cell phone from the unit after Dad's cardiac catheterization.

"Daddy's groggy, but he's a trooper!" she tried to sound cheerful. At this point, I was 100% business.

"Is he still in pain? Ask him, Mommy," I ordered. I overheard her ask him.

"A little in his back still and between his shoulders, but he says the morphine helps." Still in pain? Still??? Now I was sure I would throw up.

"Mommy, let me speak to his nurse right now. Hurry up, Mommy." She sounded puzzled at the urgency in my voice as she called for the nurse. When the nurse came to the phone, I demanded to know what time he was going to surgery and if his blood pressure was stable. When she told me it was "on the low normal side" and that "I think the surgery was scheduled for tomorrow afternoon as an add-on"-- I completely lost my cool. Even more infuriating than what she said was the patronizing voice she was using. (I promised myself then that I'd make every effort not to do that, either.)

"Are you kidding me, ma'am? You cannot be serious about his blood pressure. What the hell!! He is actively infarcting as we speak! Don't you know that time is muscle? This is crazy! Where is his cardiologist? I need to speak to him right now!" I felt like I was in the twilight zone or on a very bad episode of that show "Punk'd." By this point, all of my etiquette, professionalism and manners were black history. The nurse defensively backpedaled and explained that the cardiologist was gone for the day, but that "the cardiothoracic surgeon, Dr. Z., was aware of the case." The case? The case?!? This was my father. My world. My hero. Not a damn case! I erupted into tears and hung up in her face.

Unsure of what to do, I called my CICU attending Dr. Biblo again, and did my best to explain what had happened. I was crying so hard I could barely speak. All I could think about was that my dad was an active guy, extremely active, and that this delay would leave him likely with disabling heart failure, or worse, death. I could tell that Dr. Biblo knew I was right. "I'm so sorry, Kim," he offered.

"I should overhead page that surgeon in California and talk to him myself. I know his name. They told me." I sniffled to my attending through the phone. I felt so helpless.

"You've nothing to lose by doing that," he responded sounding completely serious. I was actually speaking a bit tongue in cheek, but his vote of confidence was all I needed, no matter how crazy the suggestion. If I didn't at least try, I had something big to lose--my dad. I threw caution to the wind and called the hospital operator where he was admitted. I identified myself cryptically as "Dr. Draper" and nothing else. Before I knew it, I was connected to a man with some kind of Latin sounding accent.

"Hello, this is Dr. Draper. Is this Dr. Z?" I asked anxiously.

"This is," he cheerfully answered. I already liked the sound of his voice. He sounded trustworthy and like he'd at least listen. I launched into my presentation of my father, Mr. William Draper, a 56 year old African-American man with hypertension, hyperlipidemia, and who'd had an ST elevation myocardial infarction the day before. I gave as much detail as I could, down to his last set of vitals and then implored him, "My dad is so active, sir. He cannot wait until tomorrow to have his myocardium (heart muscle) perfused. He cannot. Please." I felt my voice wavering and I tapped my foot, begging myself not to cry. It was the most important patient presentation of my whole life; all over a cheap cell phone in the Cleveland Airport terminal.

"Aaah," he said and then paused. I held my breath until it felt like I was going to faint. "It's your lucky day, Dr. Draper. My scheduled patient had a lunch tray. I will call for your father now if he hasn't eaten." I heard him say a few things to the OR crew.

"He hasn't! He hasn't eaten!" I screamed, "Let me call my mom now to make sure he doesn't! Oh my God. Thank you! Thank you! Thank you!" My voice was quivering and my hands were shaking as I hung up and quickly dialed my mom's phone. As fast as I could, I replayed our conversation and confirmed that Dad hadn't eaten. Divine intervention--they had just brought his tray--but he hadn't touched it. "Thank you, Lord!" I uttered aloud. I hung up, and boarded a plane to Los Angeles. . . . .praying the whole way there.

***

Dad did well in surgery, and recovered in cardiac rehab like a champ. Ten years later to the day, my father briskly walked ten miles in celebration of a decade of health and life--post myocardial infarction and post bypass surgery. To this very day, he gets up at 5 am and walks 5 miles every single morning, and sometimes, if he feels like it, a little bit more. I still get a wave of nausea when I think about that terrifying day, the same day he celebrates.

Many days, I still ask myself:

What if my Dad didn't have a daughter who was a doctor?
What if I hadn't been hearing chest pain/heart disease stories all month long?
What if he'd waited until the next day to get his vessels bypassed?

I shudder at the thought and then thank the Lord that it remains a "what if" and not a reality.

***

Yesterday in the Grady gift shop


"Excuse me, doc, can I ask you a question?" a young woman asked me as I sifted through the granola bars.

"Sure," I replied assuming she was lost in the hospital.

She showed me a bottle. "What is this medicine, doctor?"I leaned forward and read the label. Lisinopril. I wondered why she was on it.

"This your only medication?" I asked. She nodded. "You have sugar?" I added on. She shook her head no. "A weak heart?"

"No, ma'am. Just borderline high blood pressure." I stood up and faced her to give her my full attention.

"How old are you?" I studied her twenty-something year old face. No more than twenty five was my guess.

"Twenty-seven." I squinted my eyes and then noticed a tattoo on her right upper arm with a name that started with a "k."

"Your baby?" I asked with a smile, aware of the practice of many young urban mothers of inking the name of their children on their skin. She quickly looked over at her arm and grinned. She nodded, but I could tell she was wondering what I was getting at. "You had your tubes tied?" Again she shook her head and looked confused.

"This medicine may not be the best choice for you. Women who still can get pregnant should avoid it because if you are on it when you get pregnant it can affect your baby. I suggest you head upstairs and ask your doctor about it, okay?"

"Okay. . . " she replied staring at the bottle. "Wow thanks. . . .thanks. 'Preciate you, doctor."

The clerk behind the counter chimed in. "Oh yeah, that's Dr. Manning. She take care of all of us. Member when my foot was hurting?" I looked over at the friendly shop attendant and chuckled. She helped me diagnose her with plantar fasciitis (a common musculoskeletal foot malady) in that very shop a few years ago. I managed to get her a clinic appointment that same day--all while chomping on a granola bar.

"You know I got your back," I teased. I looked back at the young woman. "Go on and take this up to the clinic and ask to speak to one of the senior doctors. They can help give you something different for your blood pressure. I'm sure they won't mind, okay?"

She repeated her earlier statement--a common one at Grady-- before disappearing through the glass doors. " 'Preciate you." (Grady code for "Thank you.")


So today, I guess I am reflecting on what a blessing it is to have someone advocating on your behalf when you are sick or even when you aren't. It's amazing how many folks are out there clawing and fighting just to "get it" and how different the outcomes can be without someone in your corner--especially someone with a medical background.

All of this has made me try just a little bit harder to be an advocate for my family and my Grady patients, now more than ever. When I walk through the hall, I try to look approachable. . . .I smile at people, say "Good Morning" or "You doin' alright?" in the lobby, creating a climate for someone to hand me a bottle or piece of paper or to even show me a rash on their hand. (Crazy, I know.) I am even more careful with the intonation of my voice when taking phonecalls; I want to sound as welcoming as Dr. Z did that day when he answered my overhead page back in 1999. Realizing the awesome responsibility given to me--not just being a doctor, but a Grady doctor--has changed me. It's made me more patient with people's stories and there littlest concerns. It's made me take pause in the hallway when someone stops me instead of feeling annoyed. Now I know-- I might be all they have.

One week ago, I talked to my brother Will--a busy Veterinary surgeon and business owner--about severe wrist pain he was experiencing. A few questions later, we'd quickly reached a diagnosis of DeQuervain's tenosynovitis (a wrist injury from overuse.) Two days ago, I met him in his Decatur office to check on how he was doing. Turns out, it was a super simple diagnosis, but one that could have taken him several steps--a referral, missed work, and hassle-- to get. He was so appreciative.

"You know I have your back!" I told him as he helped me load the kids into the car. He smiled and gave me a big hug.

As I drove off, I felt warm inside. I thought about being afforded the opportunity to be a doctor by my parents, and how good it felt to be able to help out. I stopped at a red light and sighed. I listened to the ambient noise of my kids chattering behind me in their seats. Wow. Glad to have my brother. Glad to have my father ten years later and glad he is alive and well enough to know and enjoy his little grandsons. And glad God saw fit to make me a doctor and lead me to Grady, where I get the chance to walk in my purpose every single day. I looked skyward and sighed again.

" 'Preciate you," I whispered as I pulled off. " 'Preciate you."

". . . .From everyone who has been given much,
much will be demanded;
and from the one who has been entrusted with much,
much more will be asked."

- Luke 12:48

*Written with Dad's permission

The Manning Ten Commandments of Clinical Etiquette: SG Alpha Edition (a.k.a. "The Realness.")

My Class of 2011 Small Group
(Original Keepers and Ambassadors of "The Real-ness")

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"And if ya' don't know, now ya' know. . . ."
~ The Notorious B.I.G.
____________________________________________________

*****

A big part of my job as a clinician educator involves teaching. . . . . but a teeny-tiny portion of my job description includes dropping what my grandmama and the Grady elders call "mother-wit" on my learners. (I know it's in my job description somewhere. . . . ) Anyways, "mother-wit" can't be found in textbooks or journals, and can't even be located on a Google or Wikipedia search engine. Essentially, it involves somebody sitting you down, looking you square in the eye ball, and straight up schooling you on what my advisee Tony C-Q calls "the real-ness."

In addition to being blogworthy in their own rights, all seven of my junior medical student advisees (pictured above) are finishing up their final third year clerkships this week; making this a perfect time to revisit this particular piece of random "real-ness" shared with them at the start of their clerkships last year. . . . . .

*****

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Winter 2009

Alright!

Word on the street is that the seven of you are officially done with the basic sciences. This means that you are officially official. Well, kinda sorta but not really-but let's go with it anyway. Now you can get those crispy, untouched white coats nice and soiled so that you can blend in with the rest of us! Now you can laugh knowingly when folks talk about their war stories on the wards, or you can look at your pager with that exasperated look of someone being paged by nursing for what you believe to be no reason! Yes, my friends, now that you are entering the realm of the "sho-nuff" and "bonified," I would be remiss if I did not provide you with the very top secret, rarely released, extremely limited edition Manning Ten Commandments of Clinical Etiquette. I assure you, they will get you to the promised land (and will keep you out of the Dean's and the Clerkship Director's offices.)

THE MANNING TEN COMMANDMENTS OF CLINICAL ETIQUETTE
FOR MEDICAL STUDENTS AND NEWLY MINTED INTERNS

1. Thou shalt not show up in public places wearing scrubs as if it is cool. (It is not. So not.)

2. Thou shalt not text during rounds. No matter how cool or new the phone is. No matter how many new apps you have.

3. Thou shalt not have any ringtones by Li'l Wayne, Li'l Jon, Li'l Mama, Li'l Kim or anyone else Li'l on your phone in the presence of your attending. Soulja Boy, also a no-no.

4. Thou shalt not drop the "F-bomb" at any time for any reason in the presence of your attending or senior resident. No matter how cool they seem. (Ask a teenager or med student what the "F-bomb" is. Oh, or google it.)

5. Thou shalt not show your mid-drift in the hospital. Ever. No matter how many rips, cuts, six-packs, eight packs, or piercings you have. In fact, I should die never knowing for certain whether or not you even have a belly button. 

Oh--and especially if you have a muffin top, by all means spare us. Worst. Sight. Ever. (Muffin top: see photo on right.)

6. Thou shalt not call your attending by his or her first name. Even if they say it is okay. Trust me on this one. There are still people that I don't call by their first names and I graduated from medical school in 1996. (Also a good idea to avoid calling them the following: "shawty," "playa," or "boo.")
7. Thou shalt purchase bleach and a good iron and use it. This is not a joke.

8. Thou shalt not show up at work with a five, six or seven o'clock shadow. 
Definitely if you are a man and especially if you're a woman.

9. Thou shalt not use ink pens or get highlights in your hair in any of the following colors: Pink, Purple, Green, Orange or Baby blue. Also avoid dotting "i's" with hearts or smiley faces or using text-talk on charts. (i.e. "OMG pt pushed back on O.R. schedule. WTF!")

10. Thou shalt not reveal your cleavage, thigh, thong or decolletage to anyone in the hospital at any time while at work. Chest hair sightings are equally troubling. (Especially shaved chest hair, which completely perplexes, disturbs and distracts me. Eeew.)

Bonus commandment (extremely important, and also ACGME and LCME accepted):

"boo'd up" (n?): The state of being romantically involved with someone to the point of referring to them as your "boo." 
 *Thou shalt never, ever find yourself "boo'd up" or even "quasi-boo'd up" with anyone on your team during the time that you are actually working together as a team. All "boo'd up" status must be declared after the month is over or, if such status precedes the month, avoided altogether.

"And if ya' don't know, now ya' know. . . . . ."

*******

 Yes, my friends,the real-ness often escapes neophyte doctors--and then they look up and it's too late to save face. I hope this prevents somebody from being the recipient of the hairiest of eyeballs in the hospital. . . .and beyond.

I use my powers for good, not evil so please, share this with those who need it, (even if they don't realize it!)

Reflections from a Day in the Life of a Grady Doctor: Joy and Pain. . .are like Sunshine and Rain

"Over and over
You can be sure
There will be sorrow
but you will endure. . .
Where there's the flowers,
There's the sun and the rain
Oh, but it's wonderful. . .

. . .they're both one and the same."

from Frankie Beverly and Maze's "Joy and Pain"

Today I:

• Woke up at 5:35 a.m. to go to Body Pump. I stepped only on the non-creaking parts of the floor so that Zachary wouldn't wake up and ambush me.
  
• Did bonified, bad-ass, military pushups on my toes (and not my knees.) Kept saying "Come on, Manning!" all the while, which kind of helped.
  
• Talked on the phone to my mom most of the way to Grady, even though she's been nagging me to fully commit to Oprah's "No Phone Zone" pledge for my car. (Working on it, Mom.)
  
• Waved at Johnny the Parking Security Officer as I pulled into the parking garage.
  
• Had excellent parking lot karma and snagged a ground level parking space (no, not the MD IN/OUT space, either.)
• Accidentally left my badge in the car so had to ask medical students to get me access in the stairwells all day.
• Passed one of my patients in the elevator lobby as she headed downstairs to take a smoke. She has lung cancer.
• Rode the elevator with one of my favorite Grady staff members, Ms. Saadiq from Neurology. I showed her a picture of my sons on my iPhone before getting off.
• Gave a medical student a fist bump for a doing a good job.
  
• Laughed out loud with one of my favorite Grady Social Workers, Myoshi T., who happens to be from New Orleans, LA. I teased her for the way she says "baby" (bebbby) and "today" (t'deey). In return, she gave me and my medical student, Joshua Z., beads from her recent trip to Mardi Gras. (But nobody had to show anything for them.)
• Watched two medical students do physical exams on their patients. (Strong work.)
  
• Asked my patient to show me a picture of her new baby. (Really cute, no really.)
• Talked to a family for 45 minutes about their loved one.
• Talked to my team about talking to a family about their loved one for 45 minutes.
• Saw Gabe W., our chief resident, teaching in a conference room on 7a.
• Told one of my favorite senior faculty members, Dr. Lubin, that he looked handsome today.
  
• Heard my medical student offer to walk down the street to buy his patient a phone card so he could call his family long distance. (That was thoughtful.)
• Introduced one of my favorite residents, Ayushi A., before she gave her Senior Resident Grand Rounds Lecture on "Women in Cardiology." (So proud of her.)
• Gave Ayushi a fist bump, too.
  
• Saw Dr. Wenger, a female pioneer in Cardiology, stand up and speak before all of the residents and medical students as a representation of living, breathing history at the end of Ayushi's lecture. (Awesome.)
• Hugged one of my former medical students who was interviewing for a faculty position in our division. (Wow.)
• Had some girlfriend time with one of my best friends and fellow Grady doctors, Lesley M., after our division lunch. (Love her.)
• Smiled at a man in the elevator who had a gold grill.
  
• Looked up something on the computer and learned something new with one of my medical students.
• Talked to my mentor, Neil W., about a paper he just wrote and submitted for publication.
  
• Saw all of my favorite 12B nurses and called them by name, "Hey Ms. Smith! Ms. Fairley! Ms. Green!"And they all said, "Hey Dr. Manning!" in unison. Love that.
  
• Saw my patient's loved one fall to her knees and hysterically cry in the hallway after hearing bad news.
  
• Hugged my patient's loved one, but really wanted to fall to my knees, too.
• Saw my patient looking worried and pained--not because of bad news, but because I knew he'd heard his loved one fall to her knees and cry in the hallway.
  
• Cried about my patient on my way home from work. And for his loved one.
• Heard my dad getting choked up on the phone because he said was proud of me. I said I was proud of him, too.
  
• Hugged my loved ones as soon as I got home.
• Talked on the phone to one of my other most favorite friends and Grady Doctors, Lisa B., about teaching med students and raising rowdy, screaming sons. Overheard her 4 year-old son Aaron -- apparently clad in a bicycle helmet and goggles--cheering at the TV as he watched that redheaded pro skier zip down half-melted Vancouver slopes. Of note, Aaron is also very much a redhead, which only adds to the fanaticism.
  
• Ordered my kids a pizza online because I was too tired to cook. (Online ordering rocks.)
  
• Read Isaiah three chapters from "Charlotte's Web."
  
• Told my husband about my entire day and thanked him for listening.
• Cried one more time for my patient before I went to bed. And his loved one.
• Prayed for my patient. And his loved one. And my loved ones. And me.
  
• Went to bed. . . but not before kissing my loved ones. . .and even watching them sleep for a few minutes. . . .soft breaths from Zachary, whisper quiet sighs from Isaiah with occasional teeth grinding, and a faint but one-I'm-totally-used-to snore from Harry. . . . .
• Laid my clothes out so I can do it all over again tomorrow.
  
• Felt thankful for more joy than pain and more sunshine than rain.
  

"Oh, but it's wonderful. . .
they're both one and the same. . ."

Grady Seinfeld Episode: Put ya' hands up!

*name and minor identifying details changed

"Uh-uh-oh!"

- Beyonce "Single Ladies/Put a Ring on It"

“You’re gonna love this patient, Dr. Manning,” prefaced Steve V., the third year medical student that was working with me one month on the Grady wards. “No doubt about it. He'll be your F.P. today.”

Anyone who has ever worked with me knows that I always have an “F.P.” (favorite patient) every day. Usually the front runner gets trumped by one of the newly admitted patient (especially if they're a spunky, wisecracking elder.) But don't get it twisted--F.P. status is open to patients of all ages. I loved it that even my medical students were in on the F.P. game.

“Is he up in age?” I asked with a twinkle in my eye.

“No, not really. . . . he's only in his early sixties, but talk about a nice guy, Dr. M. You’d be hard- pressed to find another F.P. today."

“Well, I just can’t wait to meet him,” I replied while rubbing the foam hand sanitizer into my hands.

"I don't know, Dr. Manning. . . .he might even be an F.P. all-star.” This referred to the collection of elite patients I’ve cared for that were so wonderful, so memorable, so much of a joy to care for that they reached perpetual F.P. status. . . . kind of like the Football Hall of Fame, but without the ugly yellow blazer.

Steve launched into his seamless presentation of the man who indeed became my F.P. that day: Mr. Gables. As it turns out, Mr. Gables had relocated to Atlanta from Detroit, and was staying with his son here in Atlanta. Shortly before leaving Detroit, he’d had a series of health problems, including kidney failure which was ultimately complicated by an infection of his dialysis catheter. “Every thing was fine when I was in Detroit, but then it look like-it look-like everything went downhill when I moved here,” he told us on rounds that morning. “Now-now this catheter is all infected-and-stuff, and I-I don’t know what’s gonna happen.” His speech was kind of musical. Was that a stutter or an accent? If it was the latter, I couldn't place it. Is that a Detroit accent? Wait--what is a Detroit accent?

Steve was right. I liked Mr. Gables immediately. His infectious smile was the first thing I noticed when I approached the bedside. For a sixty-something year old man, Mr. Gables looked much younger. His gray hair was cropped close, and he still smelled of the shaving cream he'd used for his clean shaven face. Mr. Gables was one of those extraordinarily cooperative patients who helped you get to his body on exam by quickly untying his hospital gown and who took big, deep, exaggerated breaths each time the stethoscope touched his chest. Definitely an F.P. in every regard.

I looked at the dialysis "permacath" catheter that peeked from beneath a four by four gauze dressing on his chest. After peeling back the tape, a small push of the reddened skin with a gloved finger near the exit site of the tubing yielded creamy pus spilling from its borders. He winced. "N-n-now that. . that hurts right there." I still couldn't tell if he was stuttering, if this was indeed the "Detroit accent," or if he just talked fast. Whatever it was, I liked it.

"My bad, Mr. Gables," I apologized, "I won't mash it anymore." I listened to his heart carefully, and was relieved to hear no additional sounds suspicious for a blood infection attacking the heart valves. Steve and I carefully pulled his covers back over him after completing his exam. I nodded in Steve's direction and quietly allowed him to explain the plan for what would be done for Mr. Gables' infection.

"You were right, Mr. Gables," Steve started, "That catheter is definitely infected. The first order of business is removing it. We sent off the blood to the lab to see if it would grow bacteria or germs, and then we're also going to do an ultrasound or what they call an 'echo' of your heart. This will make sure that you don't have any infection on your heart valves." Steve looked at me, and I smiled reassuringly, nudging him to go on. "Are you following this so far, sir?" he asked.

"Yeah, I'm-I'm, yeah I'm with you," Mr. Gables responded, "but how y'all gon' do the, you know, do-the-dialysis if you take out the catheter?" I glanced downward, signaling to my student that he still had the floor.

"Umm, well, they're going to put in a temporary catheter and then we will replace it with the more permanent one. Eventually, we need to get you a one of those grafts." I liked the way Steve was learning to speak with authority, and how deliberate he was about avoiding medical jargon.

"You mean like the one they bury up under your skin in your arm?" he asked Steve before he could say anything further.

"Exactly," Steve affirmed, "but until the infection is cleared up, it isn't a good idea to put anything like that in just yet." I looked at Steve and raised my eyebrows; the closest thing I could offer to a fistbump.

"O-0-oh yeah, doc. I-I-I get what you sayin'. I tell you, doc. It seem like-like a brotha just can't-get-a-break." He shook head and sighed. Even though his words conveyed trepidation, his actions didn’t. Mr. Gables was as cool as a fan. He smiled easy and often, kind of like somebody relaxing in hammock in the middle of July. He asked good questions, and I could tell that he had good understanding of what was going on.

I decided to chime in. "Mr. Gables, the good news is that you are here where we can get to the bottom of all of this. We're all over this infection, and if there's anything you need or that isn't clear, just say the word. This guy will be taking excellent care of you." I smiled and gestured to Steve. "Steve's your man, okay?"

Mr. Gables chuckled and extended his hand to Steve. "Yeah-yeah. . . . .that's my-man-right there. . . that's my-my-man-hundred-grand," he said in my direction, and then redirected his attention to his young caregiver. "I-I- sho' 'preciate-you, Steve. You alright-with-me." A pink flush quickly spread over Steve's face. We answered Mr. Gables' additional questions, confirmed that he wasn't in pain, and then bid him adieu for the morning. My-man-hundred-grand? How could he not be my F.P. after a line like that?

And so, for several days our team cared for this wonderfully pleasant and musically fast-talking man from Detroit, or "the D" as he described it. Coming to examine him was like visiting a nice neighbor that minds their own business and doesn't get bent out of shape if your kids step on their lawn. His catheter was removed, his blood cultures were now free of bacteria, and one afternoon I stopped by to check on him after he'd just had the new permanent catheter placed. I decided to review his chart for a few moments before stepping in to see him. From the chartbox I could hear two men talking fairly loudly.

"Man, that Beyonce fine as a m@%&-f#%*r! And man! You seen her mama? Her mama fine, too!" I overheard someone say. The older male voice wasn't familiar--I assumed it belonged to Mr. Gables roommate, likely chatting with a visitor. I didn't even flinch when I heard the statement considering the myriad of similar comments I hear flying out of rooms and landing in the hallways every single day. I could faintly hear Beyonce's hit tune "Single Ladies" playing from both of their televisions.

"Yeah-yeah, man. . . . . you-you-ain't bullsh@$%in'!" a familiar voice responded. Wait- what? "Yeah-yeah-man. . . she might-might-not want no old cat like me, but-but-now-her mothaf$%@ mama? That's-that's a different story." Both voices erupted in laughter. What? Is that Mr. Gables?? Not my sweet, musical/stuttering/maybe-Detroit-accented F.P! Say it ain't so!

"Got dayum!" I heard my F.P. say to his roommate a moment later. "This-this-this is some bullsh@$%t! They-they-they didn't let me eat 'fore my procedure and I'm hungry-hungry-as-a-motha-f@$%cka! Shiiiiiii. . . they didn't leave a brotha-a-brotha-a-tray or nothin'!" I covered my mouth and gasped. Mr. Gables! I couldn't believe that was Mr. Gables with that potty mouth!


"Oh, man, they made you N.P.O.s? Yeah, thas some bullsh@$%!" his roomie responded using our shorthand term for "nothing by mouth."

"N.P. what? Man, somebody betta N.P.O. my moth-f@#kin' tray fo' I stick my foot up they ass!" They both exploded again in laughter with Beyonce repeatedly saying "Uh-uh-ohhh-uh-uh-oh-uh-uh-oh!" in the background. Uh oh, was right. How apropos.

I slid into the doorway like James Brown just as Mr. G. had finished his last colorful comment. He was sitting on the edge of his bed with his back to me, facing his roommate."Mr. Gables!!" I exclaimed. He quickly swung around, clearly startled by my voice. Once I saw his face, I decided I'd repeat it for emphasis. "Mr. Gables!"

He truly looked mortified. (His toothless roommate, on the other hand, didn't even flinch.) As a matter of fact, Roomie just poked out his lips and quietly nodded while surveying Mrs. Z (aka Beyonce) jaunting around on the music video still playing on television. (Like "Dude, you're on your own with this.") I didn't know what to say, so I said the same thing again. "Mr. Gables!" He could tell by the look on my face that I had heard him.

"Aww-aww-doc, you know I was just in here having fun," Mr. Gables said sheepishly. Then he suddenly looked worried and glanced over my shoulder. "Steve is with you?"

"Who? Your man-hundred-grand? Uh, no, thank goodness."

"Aww-aww-doc, I wouldn'ta said all that if-if-if I knew you was standing there."

I chuckled and said, "I bet!" I slipped on my gloves, looked at his permacath site and smiled. "Looks really good, Mr. Gables. I'll see if I can get you a tray, okay?"

He looked embarrassed and nodded. I couldn't resist poking fun at him before leaving. "That is. . . before you stick your foot in someone's you-know-what." He and his roommate looked at each other for a moment and then both doubled over in laughter. Beyonce's video seemed to go on forever. I could still hear her bleating "Uh-uh-oh!" Equally perfect timing.

Mr. Gables and his roommated could barely catch their breaths. They were having way too much fun for hospitalized dudes, but I must admit that seeing patients get along well with one another is one of my favorite Grady sightings. "That guy-that-that-guy-right-there is a bad influence, Miss Mannings. Switch-switch my room," he joked. We all laughed once more as I shook my head and waved goodbye.

Here is what I learned from Mr. Gables:

1. Don't sneak up on anybody or eavesdrop on their conversation. You just might find something you weren't looking for.
2. Nice people may secretly have potty mouths.
3. You can't judge an F.P. by how they look under the hospital cover--they just might cuss you out.
4. People from Detroit have interesting accents (or they stutter.)
5. More thought should be put into what we show on the televisions at Grady and how we arrange the roommate situation. (I'm just sayin')
6. Beyonce's mother is apparently really good looking.


Can't you see why I love this job? Uh-uh-oh!

Reflections from a reformed Valentine's Day hater: Happy dia de San Valentin!

Don't hate, celebrate!

"Valentine's Day sucks!"

"Valentine's Day is totally commercial and is so WHACK!"

"I don't do Valentine's Day, dude."

These are all versions of what you might have heard me say in the past. I was pretty much "anti" when it came to Valentine's Day--the day that I had branded, with a surly snarl, a "Hallmark holiday." That was before I met Harry.

Today was my first day off this whole month on wards. Our census has been at maximum capacity with a steady collection of sick, ever-evolving, more often than not mind-boggling patients. I was tired. . . real tired. Harry, who works every day as well, had every right to say, "Everybody is tired--suck it up!" But he didn't. He could have even told me stories about his days as an Army Ranger in Ranger School. But, again, he didn't. Instead, he handed me a lovely gift in the form of a delightful afternoon of peace and quiet. Yes, I said it. Peace y quiet! Pura vida! My good friend Tracey H. is the queen of randomly mixing English with Spanish--a habit I picked up from her (although did I fail to mention that she is actually fluent in Espanol?) Either way, I have adopted this practice which I find particularly helpful when something needs emphasis. And so. . back to the story. . . . Peace y silencio! Woo hoooo! Good ol' San Valentin!

The start of my afternoon of peace y quiet!

Quiet. No, not a new designer purse (which Harry is quite wonderful about springing on a sista), not a piece of jewelry (also not too shabby about), and no, not even the ever-generic spa day gift certificate (which, for the record, is a "generic" that I whole-heartedly welcome.) None of that. Instead, he gathered up our two rowdy boys, and took them out all day while I faceplanted like a ragdoll on our sunroom couch, entering and exiting all four stages of sleep repeatedly. Talk about romantic. For a full-time working mama slash Grady doctor, it gets no romantic-er. It was un-believable. Maravilloso, even!

Chicken soup for the soul

When Harry got home, he and the kids prepared (homemade!)chicken and dumplings for dinner, gave me a beautiful bouquet of flowers, and even chocolate-covered strawberries (totally my favorite.) Delicioso! I kind of started feeling bad, and so I asked Harry how did this day suddenly just become all about me? His answer? (Brace yourselves, ladies)

"It's always about you, baby. If you're happy, then I'm happy." Aaaah. Excellente!

It is officially official. I have turned in my Valentine hater card, thanks to my sweet, yet stoic husband. Even in my coke-bottle glasses, no makeup, in a post-Grady Hospital haze and with my ratty Nike sweatjacket, he manages to makes me feel like all of the Disney princesses rolled into one. And what's better? He's teaching our boys exactly how to do the same.

I know it's sappy, but I'm gonna say it again. . . .I'm just wild about Harry. He is the "sho" to my "nuff", the "holla" to my "back", and yes, the "bien" to my "gracias." Claro que si! :)

My funny valentines: Thing 1 and Thing 2- who says snotty noses aren't romantic?

Reflections from the Grady wards: Don't cry over spilled milk (at least no more than two tears)

*patient name and minor identifying details changed (although written with patient's permission.)

____________________________________________________________

One of our patients on the inpatient service at Grady has multiple organs failing secondary to a hard life of drug use and alcohol dependence. Even with the most aggressive management, his overall prognosis is not good. Let me not sugar-coat it--he is dying. Not necessarily in the next few hours or days, but the problems he has are severe and they aren't reversible. The little picture of his hospitalization focused on daily fights against kidney malfunction and fluid filled lungs and shortness of breath. We talked about it on rounds until we were blue in the face--

"Do you think increasing the diuretic will help with the fluid? Or will it make his kidneys worse?"

"Well, yesterday it helped. Today it seems to have made his kidneys worse."

"Sigh."

The big picture we didn't discuss so much. It involved uncomfortable words like "refractory" and "hospice" and "death." On this particular day, I knew it was time for us to go there. I said to the team on rounds: "As much as we don't want to, we have to address the big picture." Nick, the intern caring for him, nodded in agreement--he knew this statement was code for "you have to address the big picture."

Mr. Miller was a middle-aged, self proclaimed "old playa the streets." He had no problem admitting to his abuse of illicit substances in the past, and, I think, took pleasure in telling us about his lessons he'd learned along he way. Mr. Miller had pretty decent insight about the little picture of his hospitalization--heart failure and kidney failure leading to fluid overload--but the big picture, I wasn't so sure about. When we finished examining him and discussing the day's plans, the time had come for us to talk about his overall prognosis (a.k.a. "big picture.") Nick knelt down and rested his elbows on his knees. He softened his voice and gently explained to Mr. Miller that the combination of weak kidneys with a weak heart wasn't good. "It's like a vicious cycle . . . .the treatment for the fluid buildup hurts your kidneys, and letting the fluid buildup can be life threatening. We're trying to avoid dialysis, but even with that, your organs are still very sick."

Mr. Miller just looked at him calmly without speaking. In fact, let me be even more specific: He was in the bed leaned on one elbow comfortably while reaching over the top of his head scratching his scalp with the other. He seemed to be concentrating far more on trying to suck some trapped food from between his teeth and the nagging itch atop his head than anything his young doctor was saying. Hmm, maybe that insight isn't so decent after all.

"Sir. . . .I want to talk to you about your feelings about. . . well. . . what you might want if your heart was to stop beating or you were to stop breathing." Nick swallowed hard and looked at Mr. Miller earnestly. Awww, shoot. What will he say? Will he be upset? Accuse us of giving up on him? Challenge us to trust in God, just as he was doing? It was hard to tell; I knew the best plan was to just wait and see.

Mr. Miller yawned wide like a lion on the Savannah. He reached over his head to do the signature scratch one more time and then rested his eyes directly on Nick. The whole team stood quietly around his bed casting glances between kneeling Nick, each other, and of course, Mr. Miller. I found my mind wandering. . . .despite my efforts not to, I eventually starting trying to predict what would come next. I imagined something like:

"Y'all doctors sometimes thank y'all have all the answers, but I know that y'all don't have the final word. Only my God does."

I could handle that statement, and even knew what I might say in response: "You're right, sir. In no way are we suggesting that our explanations go beyond what is divine. It is just our responsibility to share with you the medical information that we have available to us based upon what we often see under these circumstances."

Or maybe his approach would be slightly different, and instead he might say with a twinkle in his eye:

"I'm fine--I don't know what y'all talking about! If my heart stop, bring me back, man. I got a lotta years aheada me."

To that, someone on the team might launch into a soliloquy about how subjecting him to an aggressive resuscitation could create unnecessary hardship for him as well as his loved ones. If the intern grew uncomfortable, I might step in and add that one of our goals is to always try to help our patients with conditions that bring them near the end-of-life achieve a pain-free death with dignity. But from looking at Mr. Miller, it wasn't clear what he'd say next.

Nick shifted his weight on his toes as he continued peering up at Mr. Miller from his stooped down bedside position. My knees hurt for Nick the moment he assumed that pose--these conversations are usually not quick ones. Mr. Miller snorted loudly, gathering something his throat and gestured for someone to hand him the emesis (vomit) basin. Nick gave his knees mercy, quickly stood, and obliged his request. We continued to wait respectfully as Mr. Miller hocked up a few more mouthfuls of phlegm and, without the least hint of embarrassment, expectorated into the plastic half moon in his hand. After placing it to the side, he propped himself back up on that elbow, sucked his teeth a few more times, and yawned once more. Oh lawd. What is he about to say? Did he hear Nick? Is he bored and ignoring us? What?

If I haven't learned anything at Grady, I have learned this--you cannot, I repeat, cannot predict what will come from somebody's mouth at any given time (that includes both words and bodily fluids.) Finally, Mr. Miller cleared his throat, and gave a small shrug. He spread his fingers apart for emphasis before he spoke.

"Look hear, doc," he started while gazing into Nick's sincerely concerned eyes, "I done had a hard life, knowwhatumsayin? But it's been a good life, though. I done some thangs that's been hard on my body, and I know that, knowwhatumsayin'?" I was mesmerized by the way he placed his own special punctuation to every few syllables. "Look here, I understand that the damage is done, and I'm okay with that. I done made peace with my God, knowwhatumsayin', and I ain't gon' sit here pretending like all the sh#% I've done to my body ain't take a toll on it."

"Yes, sir," Nick replied softly. I hung onto every word of Mr. Miller's monologue.

He went on. "We got a little saying that we use around the way, doc. 'Two tears in a bucket, motha f$%k it!' That mean, no needa you cryin' over somethin' that's already done, knowwhatumsayin? Look here, I know what's up. I do. Don't be comin' to me every day with all that slow sangin' and flower brangin'. Man, if my time comes or my number is up, man, let me go. Don't do all that stuff to me if it ain't gon' help matters."

Wow. Mr. Miller broke it all the way down in less than thirty seconds. Nick could have kept kneeling for that. Though quite colorful, Mr. Miller's explanation of his situation revealed that his insight was not just "pretty decent", but excellent--and not just on the little picture, either. He knew "what was up" with the big picture, too. I subconsciously offered him an apology for thinking otherwise.

I have to say, I particularly liked his delivery of the "tears in a bucket" statement, although (should I be telling you this?) it wasn't the first time I'd heard it (or even the second time. . . .should I be telling you that?) That said, it's still fair to say, even though I've already admittedly been exposed to the language of a few other "old playas", it was indeed my first time hearing that in a hospital, which gave it a whole new meaning.

Here's what I learned from Mr. Miller that day:

1. Never underestimate your patient's ability to understand what is going on. Never.
2. Wait long enough for your patient to hock up loogeys before interrupting them--you just might learn something.
3. Be okay with your patient expressing things in their own words, even if they aren't ones you'd choose. Again, you just might learn something.
4. Remember their words--they can be pretty profound sometimes. ("Slow sangin' and flower brangin?" come on, man!)
5. Worrying over spilled milk gets you no where, or as Mr. Miller and "playas" like him would say, "Two tears in a bucket. . ."

***

Turns out that Mr. Miller is doing a lot better right now. Hmmm. Perhaps his philosophy on spilled milk is one that we should all consider adopting. It might help us all avoid any negative self-fulfilled prophecies . . . .or at least enjoy ourselves while waiting for whatever our futures may hold. :)

Verbatim at Grady: Respect Thy Elders

HEARD VERBATIM AT GRADY:

*****

In the clinic. . . . .

Me: What's the key to living this long?

Grady Elder: It's simple, baby. . . you listenin'?

Me: Yes, ma'am

Grady Elder:

• MIND YO' OWN BUSINESS
  
• GET YO' OWN MAN
• AND PRAY!

*****

On the wards. . . . . .

Me: Good morning. . . .Just wanted to come by and see about you this morning. . .

Grady elder: Damn, yo' hands is cold!

*****

In the lobby. . . . . .

Grady elder: 'Xcuse me, baby, can you do me a favor?

Me: Yes ma'am

Grady elder: Can you please reach around here and scratch my back?

Me: Beg pardon?

Grady elder: Can you scratch my back?

Me: Uh. . .sure why not. . . .(scratching through her shirt). . .how is that?

Grady elder: Up some

Me: (still scratching, still standing in the middle of the atrium and late for clinic)

Grady elder: Over some. . .

Me: How is that?

Grady elder: A little bit harder. . . .yeah. . .there you go. . .

Me (in my head): Seriously? Seriously.


*****

In the clinic. . . .

Me: Hey there. . .come on back. . . thanks for keeping your follow up appointment. I know a week is a short time.

Grady elder: No problem, Miss Manning! I feel much, much better!

Me: Oh, that's great! So the medication helped with your hip pain?

Grady elder: Did it help!? Chiiiiiiile. . . . I'll show you, Miss Manning! (jumps out of her chair, I PROMISE, and commences to do "the stanky leg" dance.)

Me: Wow, you DO feel better.

******

On the wards. . . . .

Me: What's the key to staying married so long?

Grady elder: If you gon' stay true to your vows you got to remember one thang.

Me: What's that?

Grady elder: You gets married based 'pon your feelings, you stays married based 'pon your willing.

Me: That's what's up.


******

On rounds. . . .

Grady elder: Why you wear your hair so short?

Me: Beg pardon?

Grady elder: Your hair. Why you cut if all off like a little boy?

Me: Uh, I don't think it looks like a little boy.

Grady elder: I do.

Me: Well, fortunately, I generally choose my hairstyles based upon what I think.

Grady elder: Well you need to worry about what a man think. And a man don't like when a woman cut her hair off like a little boy.

Me: Is that right?

Grady elder: Yes. (not even flinching or the least bit apologetic.)

Me: Actually, my man likes my hair, and I think I'm going to go with what he thinks on this one instead of you, okay?

Grady elder: You got a smart ass mouth.

******

At the hospital entrance. . . .

Me: Good morning!

Grady elder: All riiiiigggggghhht. (Note: I never asked the question "How are you?")

*******

In a hospital bed. . . . .

Grady elder: I was born at Gradys, I had all my babies at Gradys and I don't go no where BUT Gradys when I'm sick. This is MY hospital. And y'all is MY doctors.

Me: That we are. :)

Reflections from a "Role Model" at Grady: The Accomplice

*names changed, minor identifying details changed




Grady Inpatient Service, early 2007

“11:41 a.m.!” I announced to my ward team while walking backwards. I spun on my heel and turned into the corridor leading to the emergency department. My long, brisk strides signaled urgency to all around. The team—made up of one senior resident, two interns and three medical students shuffled quickly to keep up. 

It had been a long morning of rounds, and we were finally approaching the bedside of the last of ten new patients admitted to our team on call the evening before. On our “post call” days, it was a struggle to get everything done. As the attending, it was my responsibility to see every patient with the team, seize teachable moments along the way, and finish in a manner timely enough to dismiss the house staff to the lunchtime teaching conference.

We were nearly three weeks into the month, and by now our team dynamic was relaxed and familiar. The learning environment was good—safe, collegial, and interactive. I worked hard to keep the group engaged, and to avoid the stagnant, endless rounds that I occasionally experienced as a trainee. I slowed my pace just long enough to scan the patient board in the ED for our patient’s initials and room number. 

“She’s in 208,” I spoke while pointing down the hall. The pack swiftly marched ahead; all of our eyes locked on room 208. As soon as we reached the room, like a well-oiled machine, everyone did their part. One intern stepped into the doorway and quickly murmured to the patient that we would be in shortly. Another industriously flitted about the nurses’ station searching for the hospital chart. 

Closing the door carefully, I pulled out a billing card and positioned my pen. Like clockwork, the team formed an arc around me as Evan, the third year medical student, stepped forward to begin his patient presentation.

I scanned the faces and body language of the group; the shifting feet, shoulder rolls, and quick glances at the clock made it clear to me that we needed to soon wrap up. I smiled and nodded in Evan's direction. He began speaking in a HIPAA-sensitive voice. 

“So last but not least, Ms. Harris is a thirty six year old African-American female who presented with a two hour history of chest pain after using crack cocaine.” 

He looked over at Mitchell, the senior resident, who let out an exasperated sigh. “She’s had two admissions this year for similar symptoms, and also has a history of hypertension and tobacco use. She’s nonadherant to her medications. Her chest pain started retrosternally and then radiated to her right arm. There was no associated. . . .”

Mitchell groaned and then interrupted. “Can I please just give you the Cliff Notes version? Basically, Dr. M, it’s just another crack-chest-pain. Totally not typical for cardiac causes, EKG was negative, enzymes negative, exam unremarkable, totally non-compliant and 100% uninterested in taking any of her meds other than crack.” Mitchell reached out and gave Evan a half-hearted pat on the shoulder. “Sorry, buddy, it’s getting really close to noon, and I’m sure Dr. M has reached her crack-chest-pain-limit for the day.” The group collectively released a nervous chuckle.

Wait. . what? 

A fine ripple of discontent ran through me—not the kind that mobilizes you to march on Washington, but just enough to make you take pause. I wasn’t sure what was worse—referring to this patient, this person as “just another crack-chest-pain” or the fact that I had created this climate that allowed my resident to do so. I searched myself for some poignant but quick statement that I could make as the attending to point out this faux pas to my learners, but came up with nothing.

“So do you want to pop in there together or would it be okay if you saw her alone?” Mitch made an exaggerated lean backward stretching out his back after a late evening on call and a long morning on rounds. I was still processing the “crack chest pain” statement. “Dr. Manning? Dr. M, you with me?” Startled, I sheepishly acknowledged that my mind had drifted, and agreed to reconvene with them later.

I began looking through Ms. Harris’ chart as the group prepared to leave, and overheard the team chatting amongst themselves. “Dude! What the heck is up with all of these crack-chest-pain admissions?” someone asked. Mitchell shook his head and snickered. “I know, right? It’s the blue plate special. Chest pain with a side of crack.” 

Again, the coalescent eruption of nervous giggles, and again my ripple of discontent.

“Hey, Dr. Manning,” Mitchell said with a mischievous grin,“I have an important suggestion for you to bring to the powers that be.” I braced myself for what I knew would be anything but. He playfully stood up and straightened the lapels on his lab coat whimsically. “We need a crack-team at this hospital.” 

The entire team exploded in laughter, some leaning over the nurses’ station, others slapping their legs. This only egged him on. “There could be a crack-pager, and somebody could be on crack-call in a crack-unit. Oh, and when they leave the hospital, they can all just follow up in the crack-clinic.” 

By this time, tears were rolling down his face, and others on the team could barely catch their breath. Their boisterous mirth continued down the hall as they waved goodbye and disappeared around the corner.

I stood there with the same nondescript expression that I had from the moment the first “crack comment” was made. It felt like I had just made a wrong turn down a dark alley and witnessed a mugging. Instead of leaping to the defense of the victim, I was paralyzed with uncertainty on how best to proceed. And by doing nothing, I felt like an accomplice.

When I entered the patient’s tiny room in the emergency department, she was leaned over the tray-table drawing a picture. The nasal cannulae initially given to her in triage was now perched atop her hair like clear rubber headband. She looked up at me and smiled. I returned the gesture, pulled up a chair, and sat beside her bed.

I learned that she was thirty-six, just like me, and that her family was originally from the south, just like my own. She told me about her 4 children, two sons and two daughters, none of which were in her custody. 

“Do you have kids?” she asked me earnestly. I responded by showing her a picture of my two sons on my cell phone, and again we shared a smile. A boyfriend had suggested she try crack cocaine when she was only twenty one years old, and she “got hooked from the jump.” I eventually came to the history of present illness, followed by a physical examination, which yielded very little. 

Methodically, I explained that she didn’t have a heart attack, and she could probably be discharged from the hospital today with plans to follow up in our primary care clinic. “That sounds good, doc,” she said, again flashing the same dingy grin.

My eyes rested on the sketch that sat before her. “Do you mind if I look at this?” I asked. She nodded in acknowledgment, as I inspected the carefully penciled drawing of a mother holding a baby. The intense love between mother and child was captured beautifully; from the glistening eyes to the details of the mother’s embrace. “Wow. This is awesome,” I uttered aloud, completely sincere. 

“Yeah,” she spoke softly, “I always loved drawing pictures.” 

I reflected on my own interests, and quietly replied, “Me, too.” Yet another thing we had in common. I enveloped her right hand in both my hands, encouraged her to keep drawing and to keep her appointments, and told her it was wonderful meeting her. I meant that.


Later that afternoon, I met up with my team to solidify the plans on our patients. 

“Anything earth-shattering when you saw Harris?” Mitch asked lightly. I stared at her name on the billing card, as the team waited respectfully in the pregnant pause.

I looked up from the card and gave the team a half-smile. An unexplained tension mounted in the room; I chose my words carefully. “Miss Darlene Harris is originally from Demopolis, Alabama. She has four kids—two boys and two girls—Dwayne, DeRon, Denise, and DeShon. ‘D’ is for her grandmother’s name, Dorinda. Her grandma raised her since both her parents struggled with health problems and alcohol." I looked up for a moment at the group, some shifted nervously in their chairs while others just sat-- mummified and quiet. I cleared my throat and went on. "She loves to draw, and wow, y'all . . .she’s really good. She was only twenty-one when she got addicted to crack, and she wishes she wasn't. Oh yeah, and I also learned she’s the same age as me, thirty-six.” 

I could see her smiling face, warm and genuine. I felt an unexpected wave of emotion pushing against the backs of my eyes. I swallowed hard and willed myself to keep my composure. 

“So yeah. . .I guess what I learned was kind of earth-shattering for me. I guess I learned that she isn’t just another crack chest pain.” I scanned the faces of my learners, earnest and thoughtful. I suddenly felt my face grow warm with shame and dropped my head, identical to that of my children when they’ve knowingly done something wrong.  

Had I? Had I done something wrong?

In this moment, I had the undivided attention of my team, just as I had many, many times that month. That told me my answer. As the attending, it was I who had set the tone for that team. The foundation for what was acceptable and what wasn’t had been laid by me, and brick by brick, whatever I did or didn’t do, or any indifference I'd shown had sent a mighty message. 

It wasn't like I had this egregiously unprofessional resident that month. He was a good resident, really, but somehow, some way as their role model, I'd dropped my guard and allowed things to go awry. . . . as was clearly evident in his comfort in delivering that stand up "crack" routine. 

I studied my chicken scratch notes on her billing card again, shook my head and sighed. “We’re taking care of real people, y’all. I’m sorry for not slowing down more to help us remember that. I promise to do better. . . .yeah. . .I really do. . . let’s just all try to do better, okay?” When I looked up, the first thing I noticed was one of the medical students, silently crying.  

Yeah, man. . . .you've got to do better.

*****

Medical school and residency training is an exhausting, confusing, and curious existence. I still remember those days of admitting ten sick patients all with self-induced medical emergencies, and participating in those unflattering resident conversations over Chinese takeout in the middle of the night. As trainees, we'd find ourselves looking to those huddled beside us in the trenches to join in the co-misery. . . .and to help offset the heaviness of it all. Let's laugh about it, you tell yourself. It's funny, man, admit it, you say. And maybe when you're still a learner. . . . perhaps it is. . . .and just maybe you can convince yourself that this is one of the only ways to cope. Right? 

But what I've learned over time is that at some point, that stops working. . . .and it starts with that first time you see someone junior to you do or say something exactly like you. . . .just because they learned it from you. That's when it hits you-- Oh sh@%! I'm a role model! And each time, it's like a bucket of cold water in the face, and it's up to you to decide if and how you'll respond to the jolt.


When I saw that student crying at the end of our discussion that day, it affirmed my response to that morning's "jolt": I promised myself that I would never be an accomplice to another Grady "patient mugging" again.