Puppy the Don in disguise. Well, sort of disguise.
Me: "What's with the get up on Puppy?"
Isaiah: "Duhh, he's a bat, Mom. Duh!"
Me: "Hey! He's Bat-Pup!"
Isaiah: "No, Mom. Just a bat."
Me: "Okay, my bad."
Isaiah: *marches off with exasperated sigh*
Hey! I don't appreciate this kid treating me like I'm the lame one. Hello? I'm not the one who dressed up a ratty stuffed puppy for Halloween! And I'm the lame one? Puh-lease.
Is it bad that I marched right after him and told him this? Ha! Isaiah's response:
"It's called being creative, Mom. Not lame."
Followed by another even more exasperated sigh which I think may have been accompanied by the word "hater" under his breath. . . .
Damn.
Hey! What do y'all have going on in your neck of the woods today?
*** Happy Halloween to all of y'all.
*If unfamiliar with the Puppy Mafia, here's a great start. Trust me, it's an absolutely perfect way to waste spend your morning or afternoon if you want to wonder what is wrong with me laugh. Oh, and if you really want to waste enjoy even more of your time, just put "The Puppy Mafia" into the search bar on this blog. Bwaaah haa haaa!
I was making rounds the other day after lunch and was checking in on a patient who'd been awaiting a procedure. The procedure was fairly straightforward and one that I've sent countless patients down to the interventional suites to have done. Not high risk in its nature or even exciting to pique enough interest in a medical student to tag along. But for this patient, it was something that was necessary and frankly, was (at this point) the only reason for his hospitalization.
So my visit that afternoon was intended to be every bit as straightforward as his issue. More than anything, I just wanted to confirm that he'd left the floor and that he wasn't sitting there seething from the hunger of "nothing by mouth after midnight." Simple enough, right? I'd pop in, see the ruffled sheets and empty bed and then check the box on my little list.
As I approached the door, I saw a woman in brown surgical scrubs backing a stretcher out of the room. This was enough to make me check my box as the chocolate uniform is that of our hospital transport people. I was familiar with the woman pulling the rolling bed; she was someone I passed in the hallway nearly every day.
"Hey, Dr. Mannings!" she cheerfully announced.
"Hey there, ladybug!" I responded. I decided in that instant that I liked the way her gold tooth sparkled when she smiled. "Are you coming from bed 2?"
"Yes ma'am!" she answered while rocking the stretcher from side to side to clear the door frame.
Right after that I realized that that question wasn't even necessary. Perched on top of the bed was my patient with his nurse fussing with oxygen tubing and IV lines behind him.
I nodded to his nurse and smiled. Then I took a step back to let them get out of the door while greeting my patient.
"Hello there, sir. I was just coming to make sure that nobody left you up here hungry and waiting!"
He chuckled a bit and rubbed his stomach playfully. This patient had some difficulty with communicating, so I took this gesture for the words that would have been harder for him to say.
"So you didn't eat anything, correct?" I needed to still confirm this. He shook his head emphatically. "Okay, good!"
My resident and intern had already explained the procedure to him at length. His nurse made certain that his oxygen was connected to the portable tank. The transporter had completed a three point turn and had the wheels unlocked and ready to go. Everything was set.
I smiled at my patient and patted his hand. "I will see you when you get back upstairs. It shouldn't take very long, okay?"
He nodded. The sweet woman with the golden tooth dug in her heel and shoved off with my patient. Just as they turned the corner, she stopped rolling and looked back over her shoulder. "Dr. Mannings? He got a question for you."
I briskly walked over to him, taking a shortcut behind the nurses station to meet him face to face. "Yes sir?" I looked carefully at his lips as he mouthed a question to me.
"IS IT *SOMETHING-SOMETHING*?"
I wasn't sure what he was trying to say. "I'm sorry, sir. Repeat that a little bit slower?"
This time I made it out.
"IS IT GOING TO HURT?"
"Is it going to hurt?" I repeated, even though I knew that was exactly what he said. He nodded again, this time with his eyes wide and eyebrows perched upward.
I was just about to fix my mouth to say no when I instead paused to think about his question. Was this going to hurt? Was it? The truth is that I had no idea. I mean, my understanding of it was that he'd be numbed up and subsequently pain-free under such local anesthesia. But the truth is that I didn't exactly know the answer to that. I really didn't.
"Sir? I know they numb you up before hand so that should make it not as uncomfortable. I have had the numbing medicine before and personally think it kind of stings going in, but once you get numb it works pretty good."
There. I'd told him the truth about the part that I knew. He seemed to find that acceptable.
Today I'm reflecting on the simplest questions in the hospital to which we, okay I, don't know the answers. We can drop all sorts of science on the mechanisms of diseases and the side effect profiles of medications. We can spit the latest literature on the drop of a dime, including the number needed to treat or harm, for countless medical studies. But funny that something so seemingly simple yet important as whether or not something hurts, we scratch our heads on--mostly because we've never thought about it.
Dang.
When I was a senior resident, I had this really eager medical student on my team. He wanted to go into internal medicine and was as bright-eyed and bushy-tailed as any learner I've ever seen. He was down for trying everything and was glued directly to my side throughout every last call that month. This kid was ride or die when it came to patient care, and sopped up every drop that I had to teach him like some kind of biscuit on a plate of gravy. Anyways. Several times that month, we had patients with respiratory problems who needed arterial blood samples taken. After multiple episodes of watching me do this emergently, the student was ready to move to the next step in the old "see one-do one-teach one" adage. I promised that he could.
Then the next few times we needed an arterial blood gas, it was always an emergency so I was forced to bypass his wobbly novice hands and use the quasi-predictable pair connected to my own arms. I'd look over at him and feel bad each time, but knew that in these instances, it simply wasn't the time. Poor kid. I really wanted him to have the experience, but not at the expense of derailing emergent care. Toward the end of the month, I had an idea.Why not let him do his first arterial blood stick in the most controlled environment imaginable? Why not let him . . . . do one. . .on me? Of course!
Now. If you are shaking your head at the sheer stupidity of this idea, then you have either a.) had your radial artery on your wrist poked with a sharp needle, b.) allowed a medical student to poke your radial artery with a sharp needle, c.) been in or around the block enough to know how assinine this is, or d.) all of the above. Turns out that your radial artery is protected by a whoooole bunch of nerve endings for a reason.
Sigh.
So in a quiet treatment room, I sat in front of my student, smugly talking him through his first art stick on me, his willing and fully cooperative patient. I had him place a rolled towel below the dorsal side of my wrist and even had him tape my finger tips down. In all my infinite wisdom, I repeatedly told him that it was "all about positioning" and that "when done correctly" it really shouldn't be that uncomfortable a procedure.
Now here's a question: How in the hell did I know that? Answer: I didn't. The truth is that it was all my assumption (and everyone knows what happens when you assume.) I neglected to factor in that nearly all of the ABG's I'd done up until then were either on patients so acutely ill that a 22 gauge needle in the wrist was the least of their worries or who'd had such longstanding illness that they'd become a bit immune to procedures lower on the food chain.
So there we sat. Me with my dorsiflexed wrist and taped down finger tips and him earnestly readying his hand with the needle-tipped syringe. I smiled at him all confident-like and even added that the key is to be deliberate with procedures. Careful and deliberate. Mmmm hmmm.
"Okay. Here we go," he nervously said with beads of sweat forming on his brow. "Ready, set, go."
He followed my directions perfectly, deliberately inserting that needle--bevel up, of course--into my bounding and previously marked radial pulse. His hand was steady and he clasped the syringe like some precious inkpen--just like he'd been instructed. He'd checked first to see if his patient was rotated and made certain that the position was perfect.
But none of that mattered. In went that needle . . . . carefully. . .deliberately. . .and---
"AAAAHHHH!!! LORD HAVE MERCY! STOP! STOP! STOP! OO-OO-OOOOOO!!! OH LOOOOORD!!!! GET-IT-OUT! GET-IT-OUT! GET-IT-OUT!!! STOP-STOP-STOP!!!!"
Yes. That is what I said through a blood-curdling scream coupled with a few choice expletives. Because seriously? It hurt EXACTLY like hell. Wait, I take that back--I don't know about that either. But damn, it hurt. I'm not sure that I have ever experienced a more painful thing in my life next to having a nine pound two ounce baby. And to this day, I maintain that getting an arterial blood sampling is right up there with child labor with a nine pound two ounce baby--which is something I sho 'nuff DO know something about.
What the hell? I had no idea before that stupid little scheme of mine that this procedure was so painful! Just thinking about it brings tears to my eyes and makes me shiver. I have never seen the arterial blood draw the same, and never, ever order one unless it is absolutely, positively, irrevocably necessary to patient management.
Now I know. That procedure? Um yeah. . . it hurts.
The only way an art stick won't hurt: If you're dismembered.
Later that afternoon, I stopped back by my patient's room to check on him. He was happily eating a reheated tray of food and seemed glad to see me.
"Well? Did it hurt?" I asked him.
He held up his finger and his thumb and mouthed "JUST A LITTLE BIT."
I put that on a post-it note in my head and paused for a moment, remembering his respiratory problems. Pointing at my wrist, I queried, "Sir? Did it hurt as much as getting an artery blood sample?"
He waved his hands and shook his head fast and furious. He squeezed his eyes shut, winced and mouthed in words unmistakable:
"OH HELL NO!"
We both laughed because for once I knew first hand exactly what the patient meant.
***
Happy Sunday.
Check out the lady's expression on the ABG instruction video. She is trying so hard not to cuss the woman out. I am wondering how much they paid her for this and pray to the heavens they got it in one take!
I saw a grown man weeping the other day. Sitting in his hospital bed, face bathed in the late morning sun rays. He had clenched his jaw and remained stoic for several days throughout all of this, but finally the reality was too much.
A paper lay on the tray table before him. We'd spoken about that paper at length over the last several days, but today something clicked. Those words typed clearly across the front of it -- Do Not Rescuscitate and Do Not Intubate -- were only in two dimensions but on this day something about them rose up mightily with gnashing teeth in three dimensions. And despite his prior attempts to avoid it, that 8 x 11 sheet stubbornly awaited his signature. It was the last step before he'd leave for hospice care.
"This means I am leaving to go and die. No matter how I spin it, that's what it means."
And what do you say to that? It was true. With hospice care, all the focus would be on his comfort and his symptoms. The people there have committed their careers to doing just that, but he was right. Hospice is something for people nearing the end of life. Yes, he was right.
"I wish so bad that this disease was not trying so hard to shorten your life. But even if it has its way with the time part, we can win over how that time is spent. We can make that transition easier."
And that's when he did it. He picked up the pen with his hand wobbling and scrawled his signature across the bottom. Done.
The pen fell from between his fingers and his body began to tremble. Like some kind of volcano he vibrated until hot, fresh tears erupted from his eyes like lava. Each burst punctuated by baritone moaning; I grabbed his arm and did my best to be of comfort.
And so. I sat there and he wept. Between his sobs he spoke such simple truths:
"I just have so much I still wanted to do." "I'm going to miss seeing my grandbabies grow up." "I don't want to go home yet."
But this call was not his to make. It wasn't mine either.
So on this day, I just held his hand and patted his cheeks with tissue. I stared out of the window, marveling at the irony of autumn and the metaphor wrapped into watching seemingly perfect leaves softly breaking away from limbs. Still beautiful enough to stay on trees but for whatever reason have come to the end of their time. Just like those multicolored falling leaves, this decision was out of our hands.
I looked back at him and squeezed his hand tight. It was the only thing I had left.
"We're here for you, okay? We are."
And that was the last thing I said to him that day. Because at this point I knew I couldn't stop him from falling to the earth. But I could at least help him find a soft place to land.
Today was great. Just great. Here are my top ten moments from it. Nothing too fancy.
#10 - Urban Outfitters.
Spent ten minutes snuggling with Isaiah this morning which put me behind the eight ball for car pool lane drop off. Had promised Harry I'd take the kids today so ended up jumping into the car wearing my fuzzy Paul Frank pajama pants and Ugg boots--the combination of which Harry describes as a guarantee to not be bothered in ANY WAY by your husband. He also calls the combination "grounds for divorce" but I digress.
Anyways.
Yes. I sure did roll out in that very outfit which wasn't a big deal since it was the car pool lane. Well the funny part came when I realized I'd kiddie-locked the door on Zachary's side. This wouldn't have been an issue if the 5th grade carpool patrol kids had still been out there to open the doors, but since I was running behind, I just missed them by like ten seconds.
So to answer your question, yes. Yes, I had to get out of the car in my pink fleece monkey pajama pants, Ugg ankle booties and college sweatshirt complete with a hoodie on my head in case someone saw me. I pretty much looked exactly like a sociopath. That or some kind of jilted woman coming to get even with someone. Um. . .yeah.
Turns out I was wrong about all the patrols being gone. The one kid who was out there retrieving an orange cone stopped to look at me with this mixture of fear and disgust. Poor kid. (Fortunately, my kids aren't old enough yet to know that they should have been extremely embarrassed.)
See? This is why my next car WILL be a mini-van with automatic doors. (But y'all know that story already.)
#9 - Out-of-body experience.
When I got back from my fuzzy pink pants adventure, I hustle-bustled next to Harry in the bathroom getting ready. There's this thing he does where he talks about me like I'm not there--but in a complimentary way. It's always out of left field and is always after some random act of service like buying him some more deodorant when he ran out or I picking up both Granny Smith and Red Delicious apples at the store. So somewhere between brushing his teeth and spitting out the toothpaste he says:
"Man, I love my wife. I might not be a perfect dude but my wife? Man, she loves me for me."
I just look over at him with my own toothpaste-filled mouth foamy-smiling as he goes on.
"My wife holds me down, man. She gets me. Nobody gets me like my wife, man. We're gonna be ride or die . . . . no matter what." ("Ride or die" = one of Harry's favorite terms for "forever loyal.")
Not sure what prompts this, but I like it. I'm thinking this is what happens when a not-so-mushy-ass-kicking-Army-Ranger dude feels a little sentimental. I think.
Dad, it's okay. Tell me your feelings.
#8 - If my friends could see me know.
I saw Stephanie the med school cafe barista-lady today. She was beaming, y'all! She said, "All the students kept telling me I made it onto your blog and I was famous!" Which really made me feel awesome because I'm consistently touched every single time I learn that someone is reading this thing.
Anyways.
Like usual, we start chatting and we get back on the story about her relationship with Dr. Hurst. She said to me, "When he died, somebody came up here and said, 'Hey, Stephanie, you know your boy passed.' And I was like, 'Who?' And they was like, 'Dr. Hurst!' and you know what, Dr. Manning? I just dropped my head and cried right then and there."
"You did?" I asked. Even though I knew the story of them bonding, I was still a bit surprised that she'd cry at the news. "Was there something in particular that pushed you to tears?"
"Yeah," she answered slowly. Her face grew quiet and serious. "You know. . . .that man. . .he just took a special interest in me. Like he said he don't know why but he just feel like I'm special. He would come up here every day and sit down right over there and have breakfast with me. He even told my supervisor and they used to let me go over there to sit with Dr. Hurst."
"Wow." This was amazing.
"That's when I was real big, you know? Like way over 300 pounds. Then Dr. Hurst lost his wife and he stopped getting around as well. Do you know he never saw me after I lose all that weight? That's why I was crying when I heard. I knew he woulda been so proud of me."
I wanted to cry, too. "I know he would have been proud because I'm proud of you."
"He said, 'I know you can lose that weight. I just know it.' And he was right."
"Wow."
"Yeah, man. He was a good man."
"Hey, Stephanie?"
"Yes, Dr. Manning?"
"Would you be okay with me writing about this, too?"
"Sure, you go right on ahead."
Thought of that for the rest of the morning.
#7 - Any Questions.
"Good afternoon, sir!"
"Look here, Dr. Manning, let me ask you a question."
"Yes sir?"
"Why them folks think that man Murray would want to take Michael Jackson out? That man got a hunned-fiddy thousand dollars from Mike every month!"
"Wait, that's your question?"
"Naw! This my question: What if they gave you a hunned-fiddy thousand bucks a month to take care of me in this hospital. Yo' ass wouldn't never discharge me, now would you?"
"Uuuhhhh. . . ."
"HELL naw you wouldn't!"
"Any other questions for me?"
"Nope, tha's it."
#6 - The Honeymooner.
Went to the resident's teaching conference and watched my friend and fellow Grady doctor Neil W. teaching. He was funny and smart and insightful and memorable. This is why he is my faculty mentor. And my friend.
Afterward, we chatted outside and I told him how much I enjoyed the session. Then I confessed that I secretly hoped it would rain so that I could relax on my couch instead of schlep Zachary to soccer practice after work. That prompted him to start reenacting this:
If you know Neil, you know how funny this was.
#5 - Almost famous.
I walked into the emergency department and a nurse I'd never met before told me she reads my blog faithfully.
"Faithfully?" I asked her.
"OMG, faithfully!" she replied.
OMG.
#4 - Team spirit.
I rounded with my team in the afternoon and had the best time ever. Everybody taught everyone something. It was awesome.
Mina, the third year medical student on my team, has such enthusiasm that seeing her immediately makes me smile. She also is one of the only people I've encountered recently who can wear three-inch heels on the wards like me--and still take the stairs like a champ.
Jason is the PA student on my team and my heart leaped a little when I saw him grow in confidence right before my eyes. I was so proud of him.
Kirtesh is one of my interns and for whatever reason this week we have been fist bumping a lot. He's had some complicated patients and has handled them with aplomb. I can tell that he is proud of himself and that's good because he should be.
Wendy is my other intern and I assure you that if you cracked her heart open, gold would ooze right out. The going joke this week has been how Wendy has this tender thing about her that makes patients cry on the spot. She looks over at them all doe-eyed and out of no where the waterworks start. No matter what is going on. Like today she asked somebody if they needed a stool softener and the broke down and cried. (Okay, maybe that's an exaggeration, but for reals she does make people cry for no reason.)
Sandeep is my senior resident this month. I love working with him because he is a medicine nerd like me. He loves patient care and even more than that seems to love people. He knows the names of nearly every nurse, operator, clerk, cafeteria lady, transport person, and environmental services worker in Grady Hospital. With a big ol' smile, he greets them all and it's genuine and kind and wonderful. I am impressed by the what he knows and how he cares for his patients. I am even more impressed by the name thing, though.
# 3 - Who's on first?
One of the clerks was tired of people putting random locks on unassigned lockers. She was ready to get the locks cut off -- but not before offering a fair warning:
Don't say she didn't warn y'all.
#2 - Oh DARN. Rain.
On my way to get the kids from Grady. . . .
Drip. Drip Drop. Dribble Drop Dribble Drop Drop Drop! I kid you not--I rolled down my window, stuck my hand outside and yelled in my best Ralph Kramden:
"Whooooaaaa! It certainly looks like rain tonight!!!"
Rain = No soccer practice = pink fleece fuzzy pants and Ugg ankle booties! Waaahhooooooo!
#1 - Relaxation technique.
Came home with the kids, put on my favorite rainboots (if only for three minutes to walk to the mailbox), stood on my porch in my rainboots watching cars go by. . . thought about my friend Kris R. wearing her happy rain boots this week in Uganda and smiled because in that moment I felt very connected to her even though we are a whole world apart from each other. . . .
Hunter boots in Atlanta
Kris and Bryn(and Hunter boots) in Uganda
. . .came back inside and listened to the kids squeal with delight when I lifted the school-week television and electronics moratorium, made a homemade pizza for dinner that the kids inhaled, allowed them (yes) PopTarts for dessert, sent them to bed after a lit-tle too much television, spoke to Sandeep one more time by phone about our patients, and finally. . . . got cozy on the couch while reading the Hunger Games trilogy on my Nook e-reader. All while wearing my pink fuzzy monkey pants and my Ugg booties.
Oh and ladies? It's true about the fuzzy pants and Ugg boots. No one bothered me for the rest of the night.
(The swagga-docious look that's been on my face for the last 48 hours)
Woo hoo! Upgrade courtesy of Dad's hand-me-down iPhone 4 and the U.S. Postal Service! Let's hear it for tech-savvy fathers!
Ah hem. . .now please excuse me while I send someone an iMessage. . .errr. . .. or facetime someone . . . . . . you know. . .seeing as I have the iPhone 4 and all. . . . .
There's this thing that happens in teaching hospitals everywhere that I'm slightly embarrassed to admit even exists. It's what many have referred to through the ages as the "turf war" -- which is more like a tug-o-war between two different teams of doctors, usually from different disciplines.
Hmmm.
Now that I think of it, in tug-o-war the competitors are pulling toward themselves in an effort to keep the rope or the prize or the flag or whatever it is. In that case, a "turf war" isn't much of a tug-o-war at all. It's more like a "push-o-war" where one service thinks that the other service should be responsible for the care of a particular patient.
Case in point:
A patient is brought to the emergency department after slipping on a patch of ice in her driveway. She unfortunately breaks her hip. That hip needs to be surgically repaired by an orthopedic surgeon.
Simple enough, right?
Well, not so fast. Said patient happens to be a diabetic with a fancy insulin regimen and also happens to have a pretty labile blood pressure. She has smoked nearly all of her seven decades and has quite the case of emphysema to boot. The list of medications in her pocket is equivalent to a grocery store receipt at Thanksgiving. . . .long. The surgeon sees all this medical stuff going on and tells his Emergency Department colleagues at the time of admission, "Admit to Medicine."
This is the point where the (Internal) Medicine team (us) gets the phone call from the ED telling us of our surely lovely patient and her (surgical) cause for admission.
"Yeah, so she has a bunch of medical problems so they said that they'll consult and you all can be the primary team."
"But she has a hip fracture. A hip fracture. This is what got her admitted, no?"
"I mean, yeah. But . . .look. . . I . . .honestly? Dude, I thought it was for Ortho but they refused. I guess they balked at all those medical issues."
"Balked at her medical issues? She is almost eighty years old. And her medical problems aren't warranting her hospitalization. I'm balking at that broken hip."
"You're preaching to the choir, dude."
"Tell them that MEDICINE will consult and they can be primary -- considering her primary issue is a surgical one."
"They refused."
"What do you mean 'they refused?'"
"Just what I said. They refused."
"Okay, well then we refuse, too."
"You do? Wait--can Medicine even refuse anything?"
Damn.
Turns out that Medicine rarely refuses to care for patients under most circumstances. We are the ultimate nerdy destination for all issues requiring major head scratching and prophetic waxing. Okay, I take that back--the Neurologists can be equally nerdy, but that isn't the point. The point is that the Emergency guy was right--Medicine rarely refuses and other services know that. For this reason, we lose a lot of of these battles.
Anyways. This is exactly what a "turf war" looks like. Which now that I type it, makes me feel kind of like I should delete the whole thing. It sounds really terrible when I reread it. . . . . this thought of tossing someone's loved one back and forth like some searing hot potato. Not cool.
The whole term "turf war" was made popular by this book called "House of God" that nearly all medical students, residents and faculty have either read or heard of at some point. The book was written back in the seventies and blew the cover off of so many aspects of residency training (back then) that the author published it under a pseudonym to keep from getting jumped in a dark alley by somebody's mama. In this story he spoke of "turfing" between services and even "bounce backs" -- the patient that gets discharged and has to quickly return for readmission. The "turf" became this term used to describe one service getting their patient's care to be assumed by another service which isn't always done willingly--hence the term "turf war."
As you might guess, referring to these situations as "turf wars" is probably not exactly p.c. So I don't walk around describing them as such. In this instance, however, I'm simply admitting that this is probably the best way to tell you what most people are thinking of when they hear of such a thing. At least, people who work in teaching hospitals.
Anyhoo.
I guess I'm reflecting on this today because of a bit of a disagreement we found ourselves in yesterday with a surgical service. Without going into too much detail, I'll simply say that one of our patients was waiting for a surgical procedure after all of the medical problems had been dealt with. In fact, had there not been a surgery planned, the patient would have been long gone. Well, the patient has this complex surgery and usually afterward the team of surgeons assumes the care of the patient until discharge. But not this time.
I hear of this and prepare my mouth to say, "Oh hell naw!" Okay, maybe not actually say it, but surely, surely some very diplomatic version of the same thing. My resident explains the whole thing to me and tells me that the person speaking to him was both rude and unprofessional about it all. Alright, alright. . .I'll admit that maybe I wasn't exactly diplomatic because seriously? This sounded like an inappropriate load of horse manure to me and I'm pretty sure I made that fairly clear. That's when this happened:
"Dr. Manning, I didn't see the point in arguing. I really didn't. If someone doesn't want to take care of our patient then they won't do the best job. I don't want our patient in the middle of that."
And I just sat there silent because really? My resident was so right. This was about a human being not a . . .well. . turf war. He had decided to simply take the high road. . . . spending his energy on coordinating care for this human being and not fussing with someone who didn't have time for dealing with any of it.
Let me be clear--I have had countless encounters with my surgical and non-Internal medicine colleagues at all levels who have taken the exact same position as my current resident. The position of focusing first on what the patient needs and ultimately on what is best to meet them. Yesterday I was tired and I felt myself forgetting that. I was ready to put up my dukes, tie up my boots and march on Washington. I was two beats away from calling that surgeon's attending physician to tell him or her exactly what was on my mind. . . . but was I really just trying to win? Win a . . .turf war? And like any war does anyone really win?
My resident had it on the money. Who wants to be cared for by a person who does so begrudgingly? Not me. He clearly decided that there would be no war. A discussion, perhaps, but no war. Imagine that. Well, I thought of this a lot yesterday evening. And you know? Thinking is a funny thing. You actually realize other perspectives when you do it which is why I highly recommend thinking to my kids and my learners. After my thinking, I decided that maybe the surgeon wasn't as wrong as I initially thought. In that surgeon's defense, once I looked at things more closely the active issues post-operatively were arguably medical problems instead of surgical ones. But it took me sleeping on it all night to see it this way.
Now I'm not saying I excuse the rudeness of the way he did it. But I am woman enough to say that having this patient cared for by internists isn't exactly as far off in left field as I initially made it out to be.
So, yeah. That whole thinking thing? I highly recommend it.
Next time? I think I'll try to channel my resident:
"Okay. Let's just try to focus together on what the patient needs instead of ourselves."
Standing at the elevator this morning in my white coat looking all official-like. These Grady elders walk up and see me and then give me the proud-grandmama/proud-granddaddy twinkle in their eye. The one that says, "Look at her, she's a doctor!" And I smile and stand all tall-like because I know that look, especially when it comes from people who look like me.
So there we all are. Them twinkling and me smiling. Then my phone beeps so I reach into my pocket to get it. In that moment, the elders noticed my cracked-face iPhone 3G and seem to deduct every last one of the cool points they'd given me earlier. Yes, I'm cheap, okay? And yes, I know the new iPhone just came out, but this one still works. . . .
Verdict:
You can only have so much swagger with a cracked phone. Just saying.
P.S. Don't worry--my dad just got the new iPhone 4S and is sending me his old one to replace this one.
Another year, but the same song is looping in my head 365 days later. I guess it's because I look for the words to describe what it's like to be your mother and I become a weepy mess. That's when I stop and sing that song instead. . . .
Baby boy, know this--you are cherished and were conceived in love. Fortunately, that love is still intact and working together to build you up into a man who recognizes his worth and feels proud of who he is. Yes. Because who you are is wonderful. . .something like a miracle.
Sigh. . . .I wish I had words to tell. . . .but I don't. I love you, son. I so, so do. That's all that I can say (without crying.)
*If you want a chuckle, read the story of my labor with Zachary here.
*some details changed to protect anonymity and all that stuff. . .you know the deal, people.
"See one. Do one. Teach one."
~ Anonymous
Hands shaking inside of tight sterile gloves. Eyes with laser focus on the landmarks. All but a tiny square of skin on the small of the patient's back is blanketed in blue sheets. That exposed area, now rubbed sterile with surgical-grade antiseptic, awaits those hands.
"Your position is perfect. This is exactly correct."
The upper level resident is coaching; he is using those words of encouragement that surely were used for him. Though technically a novice at being a supervising physician, he is obviously a natural. I smiled as I observed the entire thing--his back straight and confident and his words commensurate with his posture. I liked the way he glided between giving attention to the medical student whilst offering continuous concern to the patient. Of course. The patient.
"How are you doing, ma'am? Are you okay? Just let us know if you are feeling pain, okay?"
And gently she'd respond, "I'm fine."
Like clockwork the student mimicked this, checking on her patient's well-being despite her trembling hands. This was the first lumbar puncture she would perform. And perhaps, for her supervising resident not even six months out of internship, this was one of his first experiences guiding someone junior to him through it.
"Make a wheal under the skin," she spoke aloud. She wanted to be sure she followed the proper steps.
"Exactly," he affirmed. She continued anesthetizing the narrow space that awaited the spinal needle as he nodded in confirmation.
Then, as if planned and blocked by a director, they peered over the sterile field and spoke in unison:
"You doin' okay over there?"
She paused for her patient's answer before she continued--just as she'd been taught.
"Okay, so now you may feel some pressure. I'm about to insert the spinal needle, okay?"
"Okay," the patient nonchalantly replied. She looked cherubic all curled into a fetal position. Mostly because she seemed content with all of this poking and prodding. Words like "T-cells" and "viral load" and "spinal tap" weren't foreign at all to this patient. She'd been there and done that, and didn't seem to mind at all when, with full disclosure, the student admitted that this would be her first time doing this procedure.
"That's okay with me," the patient said with a genuine smile. "You have to learn at some point."
And despite the fact that no person ever really wants to sign up for a lumbar puncture, let alone one performed for the first time by a medical student, there was a peacefulness about it all that immediately told me it would go just fine.
"Bevel up." She continued to narrate her actions as her supervisor stood close; this time she was referring to the mouth of the spinal needle. I liked the way he nudged her along, peppering in relevant questions along the way.
"You alright, ma'am?"
"Fantastic."
She inched the long spinal needle through her man-made welt while carefully sliding the stylus out periodically to inspect for a flash of spinal fluid.
Advance. Look. Advance. Look.
"Watch your hand, don't lose your position."
"I'm meeting some resistance. Do you think it's bone?"
"The intervertebral space is narrow. You just need to reposition you hand and make sure she's not rotating forward or backward."
"Okay." She took a deep breath. I loved the determination in her face.
"We're almost done with the hard part, okay, ma'am? How are you doing?" her supervisor asked.
"Just fine. I'm okay."
"Pain?" she asked earnestly. The student really wanted to know and seemed to deeply care about her patient's comfort.
"No, I can barely feel anything," the patient replied.
"Okay, let me know if you do, okay?"
"I will."
Advance. Look. Advance. Look. Advance.
She swung her head in the resident's direction, eyes widening behind the clear plastic eyeshield. First a few drops of blood and then. . .
Drip. Drip. Drip. Drip.
Eureka.
"Now we're just going to take the samples of the spinal fluid, okay? We're in with the needle and the spinal fluid is coming on out now." I could hear the tremble in her voice; part relief and part elation. Her first time doing a lumbar puncture. And she'd succeeded. On the first time she succeeded. (Which is more than I can say about my first L.P.)
Next they collected the specimens; the resident downshifting his gears and morphing into her trusty assistant. Diligently he handed her the numbered bottles and methodically cleaned up the sharps.
Throughout all of this, I sat quietly on a nearby chair; close enough to see everything, to chime in if necessary, and to assist if required. . . . but still far enough to let my resident lead. The residents call it "micro-managing" when attendings breathe down their throats and cramp their leadership style. I didn't want to be that person, so I crossed my legs and watched; I even answered my resident's pages for him. Sure, at one point I felt myself itching to gown up and snap on a pair of size 6 1/2 sterile gloves just for old times' sake. . .but I fought the urge staying glued to that seat and resisting that temptation.
"See one. Do one. Teach one."
That's a common saying in medical education. Classically, that's been the order of things, particularly procedures, in everyone's medical upbringing. You stand by passively those first few times. Then at some point you get the chutzpah to try it yourself, but only if the planets align and you have a supervisory resident that feels ready to both relinquish the operator position and guide you through it. Finally, you become that person who's done this enough to remove someone else' training wheels and walk behind their bicycle.
But on this day, I recognized a shift in this unspoken law of learning in the clinical setting. I have already seen one, done one, and taught one many times over. This time, I watched this with different eyes. I had the golden opportunity as a clinician educator to see one . . . one who finally had the chance to do one while having her tremulous hands held by a newly minted resident. . . . ready and able to confidently teach one. Gives a whole new meaning to that old adage--it had now gone full circle.
They dismantled the giant blue force field separating them from outside germs and also eye contact with their patient. At this point, I'd stepped out of the room, but I didn't need to be there to know what would happen next. They would ensure the patient was comfortable and provide some anticipatory guidance about laying supine to avoid a spinal headache. They'd ask if the patient wanted her window shades opened or closed, her room light on or off, and her television muted or with sound. And then they'd promise to share the results as soon as they were available. And as soon as they did appear on the computer screen a few hours later, without question, they'd be standing at her bedside going into the nitty-gritty of each and every detail.
Or rather she, the medical student, would go back and do all of these things alone. Why? Because, at some point, this is what she'd seen someone else do. At least, this is what I've chosen to believe. . . .
"See one. Do one. Teach one."
Medicine and learning . . .all in a continuous cycle. . . .simultaneously wonderful and terrifying. . . . . yeah.
"But you young! Why you not gon' try for the girl?"
"I like having boys!"
"But you know that boys grow up an' they get a wife and leave. When you old it's your daughters that see about you and take care of you."
"Really? My dad always saw about his parents."
"Naww. I bet he had some sisters helping, too. It's always the girl children that see about the elders. Never the boys. Tha's why you need least one girl for when you get old. They'll see 'bout you and cook for you."
"Hmmm. Good to know."
"Wait. How old you is?"
"How old am I?"
"Yeah, doc. You in your thirties yet?"
"I'm forty-one."
"Forty-one!"
"Forty-one."
"You forty-one!?"
"Yes, ma'am. Forty-one just this past September."
*Big goofy smile on my face, expecting her to tell me how good I look.*
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?
