Fear vs. Love.

Image credit: Courtesy of the BHE

Right after it happened, I did my best to talk to them about it. Like, to me,  it wasn't okay to be so concerned about their innocence that I didn't tell them about what happened. And to be honest? It was super lumpy.

"He shot 9 people? In a church?"

"He did."

"But why? Like, why would somebody do that?" Isaiah asked incredulously.

"Well. Partly because his mind was sick. But also because his mind and heart had been taught to hate black people."  That was all I could think to say.

"I bet those people were so, so scared." That's all that Zachary said. His eyes were cast downward and he looked somber. "To me, it seems like church is a place where you should feel safe."

"Do you think the devil got in that man when he did that?" Isaiah looked at me without blinking when he asked that. He was serious, too.

"You know what, son? I think the devil got in that man long before yesterday when he walked into that church."

"That's terrible," Isaiah responded.

I paused for a moment and tried to think of what else I could do with that teachable moment and came up with nothing. Outside of the kids knowing what happened, I can't say that I was able to come up with much else.

That is, until now.

This morning, I decided that the kids and I would watch all 37 minutes of President Obama's eulogy of Reverend Clementa Pinckney. You see, this is the kind of thing that my sister Deanna would have insisted upon and probably even have carried out herself. I could hear her in my ear saying, "This will be the perfect way to have the real conversation about race and where things are in this country. And your boys need to know. They do."

And she would be right.

And so. We watched. And I wish I could tell you that they weren't squirmy or balking at the fact that when they touched the mouse it showed them that they would have 37 whole minutes of speech-talking to watch. But yeah, they are 8 and 10 and it is what it is. That said, I made them watch it anyway.

I'm so glad that I did.

When they showed the faces of all nine victims, Zachary said, "Pause it, mom! Pause it!" And so I did. Zachary reached out and pointed to the photograph of Sharonda Singleton, one of the nine. "Did that lady have any kids? She looks so young, mom."

"Yes, she did."

"That's terrible," Isaiah said again. He added in for emphasis, "Just terrible."

"Obama sounds like a preacher," Zachary said.

"Yeah, but I bet that makes people feel good that he does." Isaiah kept watching the screen when he said that.

"I like how he talks," I added.

Finally, we all fell silent and just kept listening. President Obama honored that man's life and theirs, too. He sure did.

When the speech ended, Isaiah looked over at me with a serious expression. "You know what, mom? I think there a lot of people out there that still don't like black people. Like really, really don't." It broke my heart because you could see in his eyes that it was a truly disappointing ah hah moment.

I sighed and twisted my mouth. "I think you're right, son."

"Even though the Martin-Luther-King-days are over."

"Yep."

"I think if your mom and dad tell you some people are bad, then you believe it. That's what I think. Like if that's what everyone says at home."

Damn that Isaiah is wise.

I added on to his thought. "Or any person that has a lot of influence on you. If they tell you something when you're little, it goes into your heart."

"Remember when that boy told me that black people were bad when I was in kindergarten?"

Up until then I'd forgotten. But since I did remember, I nodded. "Yeah. I do. That was bad."

"You and dad said that it was because somebody told him that at his house probably."

I squinted my eyes and sucked in a big drag of air though my nostrils. Thank goodness Zachary broke up the tension.

"Hey! You have to be careful when you're a mom or a dad! I believe a lot of the stuff my mom and dad say to me!" he piped in.

"That's real talk, son."

"Yep! We believe our moms and dads!" His simple idea was as true as it was terrifying.

Yeah man.

Zachary was now smiling and thinking about the video games he'd get to play after his discussion. But Isaiah was quiet, even more pensive. Then he finally spoke. "Mom? Should I be scared?"

I felt my eyes starting to sting as I sifted my mind for an answer to his poignant question. The truth? I mean, open any newspaper and you'll see that it's rhetorical, that question. I mean, a lot of it speaks for itself.

Should you be scared, black child? HELL YEAH. But since fear lives to choke out love, no. We need to fight with all of our might against it. And decide that we won't succumb to it's sticky, slippery grip.

No. We. Won't.

Eventually, I spoke. "You could always be scared. But should you? I guess I just don't think that's a way to live, you know?"

"Yeah," he replied.

"You know what, Isaiah? I say just be aware. And pray, too. Yeah. I think we should pray. And love. Even when others don't. Love. And especially remember that no matter how scary things seem, there's a lot of love out there, too. A lot."

"A whole lot!" Zachary exclaimed. He clearly wanted this heavy conversation to end on a warm and fuzzy note.

Isaiah still appeared to be lost in his thoughts for moment before he finally asked one more question. "Mom? Did that man who shot those people have any children?"

"No son. Not that I know of."

He stared into my eyes and then replied firmly,"Good, mom. I'm glad." 

Damn.

***

Now playing on my mental iPod. . . .the song that always puts me in my happiest spiritual place. When I hear Yolanda Adams belting out these words, my eyes immediately well up, my heart pounds and I get goose flesh. I played this for my boys after listening to President Obama and wept the whole time. I couldn't stop thinking about the faith of those individuals and imagine them singing as this choir. That comforted me. 

If I suddenly was blessed with a singing voice? This would be the first song I'd sing. Exactly like this. 

There is no fear in love. But perfect love drives out fear, because fear has to do with punishment. 

The one who fears is not made perfect in love.  ~ 1 John 4:18

Reconcilable differences.

During med reconciliation with a patient recently

"You're taking the pills in this bottle?"

"That bottle there?" The Grady elder picked it up and studied it for a few beats. "Yes, ma'am, so this bottle here. . .I teks one pill with my breakfast and one with my supper. Every day."

"Hmmm. It looks like you have a lot of different pills mixed up in here together. Is that on purpose?" I know that sometimes people do all sorts of things for convenience. I didn't want to assume anything.

"Well. I don't see so good so I jest know which bottle is the one time a day ones and what bottle the two time ones."

"So this one, you just open up and take out one in the morning and one at supper, correct?"

"Yes'm."

"Okay."

And you know?  I have no idea how those pills got mixed up like that. This kind of thing--that is, this exact thing--is not unusual for us to see at all. And you know what else? It's easy to look at this medication mashup and generalize it to his life--and then make a sweeping statement about his need for a nursing home ASAP. Or to, at least, push to make sure he isn't able to live alone. I get that it seems like a no-brainer when you see something as worrisome as this and then try to wrap your brain around someone taking a random assortment of cholesterol, antihypertensive, and memory pills all willy nilly.

But.

Let the record show. This man lived alone. He was dressed and groomed appropriately and had taken public transportation to the hospital (no easy feat in downtown Atlanta.) Every day he cooks for himself, cleans for himself, does for himself and, for the most part, seems to get on just fine. He does. And has. For more years than most of his doctors have been alive.

Yep.

And see, this? This is one of the hard things we navigate in patient care, particularly when it involves our geriatric population. The lumpy bedspread that the patient can't quite smooth out on their own any more. The one that requires a little help to lay flat but that isn't to the point of needing to find new linens altogether.

Does this even make sense? Sigh. 

Okay. So check it: This sweet man, this dear, dear elder needed somebody to--as the southerners say--"see about him." And he didn't have that. He'd outlived or out-healthed a lot of his family members. And a lot of the other ones had lives and families and he didn't want to be a bother.

Nope.

Yeah man. This man needed somebody to see about him. To come by and check in and make sure things like this were okay. He wasn't significantly cognitively impaired or visually disabled that he couldn't get along. He did have a very limited education and admitted to being uncomfortable with most reading. But he'd worked for nearly his whole life and had managed his life quite fine. Taking him out of his home--the one that he built and paid for--is way more than a notion. Way, way more.

Fortunately, at Grady we have a lot of things we can offer someone like this patient. Some of it simple, some less so but all mostly doable and reasonable options to allow him to both remain safe and in his home at the same time.

Yeah.

Do I sometimes facilitate getting people into nursing care facilities? Definitely. But not without stopping what I'm doing and really, truly thinking about it. I reflect on the magnanimity of it and how it will make the patient feel. Will they be sad? Happy? Lonely? Scared? Will they feel robbed of dignity? Betrayed? Relieved? Or will they be none of these things?

A lot of folks are completely okay with nursing home placement. Others not so much. And a lot of times the patient doesn't seem to fully grasp what is happening one way or the other.

But I think about them, too.

I guess what I'm saying is that there are so many people who are in, what I believe, is this limbo space. The one where they can live independently just fine if somebody just sees about them regularly. Checks to make sure area rugs aren't heaped up and creating a fall risk or taking a box off of the porch. Runs to the store for them or throws a few old things out from the fridge. Resets whatever got unset when the electricity blinked and puts new batteries in the remote controls. And who asks about the pills and, if they can, does things like arrange them in daily pill containers and throws out the ones that the doctor either discontinued or changed.

And if that person or those people exist, I try to find them. And talk to them. Before jumping to nursing home placement or moving them out of their home to live with someone else. I talk to our pharmacists and social workers and nurses, too. We explore who their support is, like, if they have a church home or some other people out there who really care but who just didn't know. And who would help with something like reconciling medications or pulling the garbage cans to the curb and back if someone asked. Or just slowed them down long enough to think about it.

Moving too fast to notice doesn't mean folks don't care. I mean, not always it doesn't. In fact, many times it doesn't.

Sigh. I'm rambling. I know.

Look. I pray to grow old in this life. There is much that I want to do and see and experience and I think having the wisdom of an elder will make some of those things just that much more awesome. It is my wish to keep my wits about me and my ability to do things on my own indefinitely. But what I know for sure is that, over time, that latter part can hover somewhere between very possible and impossible. I guess what I'm saying is that when that time comes,  I hope someone steps in see about me and advocate for me, too.

Oh, and before someone misunderstands this as me being anti-nursing home, please recognize that nothing could be further from the truth. My point is that function is a spectrum. I'm learning to consider that more. Sometimes there are reasonable work arounds. And sometimes there aren't.

Yeah. Sometimes there just aren't.

But this time? There were some things that we could do. And so we did them. We did. 

Yeah.

***
Happy Saturday. And shout out to the social workers, the family members, the neighbors and the community people out there who see about our elders. You make a difference. You do.

Now playing on my mental iPod. . . .

Peace and permission.

My paternal grandmother was out on the west coast visiting family for the holidays when it all started. She had these abdominal pains and a few other symptoms that eventually nudged her children to take her to a doctor. One hospitalization and a few scans later, they'd found an answer for it.

Cancer.

They offered her treatments, which included chemotherapeutic agents and the like. The particular kind of malignancy that my Mudear had was one that could only lead to meaningful recovery via two ways: a miracle (which can happen sometimes) or a major abdominal surgery. Mudear was in her ninth decade and had already lived through her share of health scares. "Getting cut on" wasn't an option.

Nope.

And so. The doctors offered her palliative chemotherapy which, in my opinion, probably isn't terribly unreasonable for any patient to consider. But sometimes an offer sounds like an endorsement. Patients may not realize that they have a choice and that saying "no, thank you" in some circumstances is perfectly sane to do.

Yeah.

So somewhere in all of this, my Mudear had my auntie and dad call me in Atlanta. I'd just become an attending physician at Grady that year and I had the distinction of being the only human doctor in the family. And so. Mostly I asked my grandmother about her wishes. I asked her what things she loved doing and got an idea of her general philosophy on the time of her death.

"I don't want nobody cutting on me. Nawwww. I don't want that at all," she said in her Alabaman accent.

"Okay. Mudear, you don't have to have surgery. But you also don't have to have chemo. You could just go home to Birmingham and spend the rest of your days doing the things that make you happiest."

"That sound good."

"What do you like doing, Mudear?"

And that's when she told me that, given her way, she'd just like to sit in her chair and watch her "stories," cook a little something in her kitchen, visit with folks on her porch and maybe do a little something in her garden. And all of that sounded wonderful to me and exactly like what my grandmother should go to do.

And so she did.

My daddy got her out of Los Angeles before I could even hang the phone up good. And let me be clear, my Mudear was a smart and elegant woman. She'd made up her mind long before I spoke to her and this was her decision. But I will always appreciate her giving me the honor of weighing in as counsel.

Anyways. By the time Mudear got to Alabama, she was still fine actually. There was no immediate awful that punctuated it all. She wasn't stuporous or on all fours. Nope. Mostly, she was fine. Fine enough to sit in her chair and watch her stories, cook a little something in her kitchen and visit with folks. It was actually January when all of this happened so the garden part and the sitting out on the porch part I can't fully recall happening. But the point is that she decided to forgo the hellacious cancer treatments suggested for her 89 year old body for the things that gave her the most peace.

Yep.

Family came pouring in. And since she had eleven kids and more than twenty five grand babies, that was a lot of kinfolk. And mostly, it was the ones who were closest to her. One of those grandkids was my sister, Deanna.

Deanna had gone to law school in Birmingham. She grew close to Mudear during that time and, at this point, was up in D.C. working for the U.S. Patents Office. She called me in her Deanna way and asked me to "break this shit down" to her. She wanted to know what she needed to expect out of this cancer news with her grandmama.

"You need to book a flight or get in your car and drive to Birmingham--right away," I told her matter-of-factly. And this part I do remember perhaps better than any other part.

"When? Now?" Her voice sounded incredulous. "I thought she was doing okay. That's what daddy and them said."

"Mudear is about to be 90, Deanna. She is at her home and all of her kids are coming to see her. She's at the house she shared with the love of her life doing everything that makes her happy. She is doing well but I've learned that once folks get to a certain point of peace of mind, they will themselves away long before the health part catches up."

"Wait. You think Mudear is going to die really, really soon?"

"I think she sounds peaceful. And I think if she has permission from the family, she will make her transition soon. So yes. I think that."

"Damn."

"Are you coming?"

"Leaving in a few hours."

Which is exactly what Deanna did. She got down there and saw her Mudear. She sure did. She stroked her face and laughed and cried and talked to her. She hugged on my daddy and our aunties and our uncles and cousins, too. And, from what she told me, all of it was magical. It was.

The last person to talk to my grandmother was my father. She'd called all of her living kids in one by one to speak with them and he was last. And my stoic, pragmatic daddy was dutiful and diligent in all of those logistical things that you don't want to think about at times like this. But she also knew that that same spirit of his would permit her to let go.

"I'm counting on you to make sure everything works right," she told him. "I'm tired. And I think I'm ready to go now." And he knew that this wasn't just about her funeral or any thing like that. She meant everything. The family. The harmony. The everything.

"Mudear," daddy told her. "You've lived a good life. It's okay."

And you know what? Mudear looked at her son, took three big breaths and closed her eyes. And that was that.

I just want to be sure that one piece isn't lost here--Mudear wasn't gasping for final breaths or in and out of consciousness. In fact, if someone had just gone by the medical data points available to them, nothing about her condition suggested she'd pass away on that day. But once you live long enough or work in a hospital like Grady long enough, nothing about her transition would come as a shock.

Nope.

When I was an intern, I had this amazing patient who had a non-healing ulcer on his foot and two gangrenous toes. After a significant number of pack-years of smoking, his circulation was pretty much nonexistent. That same tobacco history had left him with advanced emphysema and COPD. The only way to help him would be to amputate his foot above the knee. But there were two problems with that:

1. His circulation was so poor that an amputation would be unlikely to heal.
2. No anesthesiologist would be willing to intubate him for the surgery given his bad lung disease.

And so. Mr. Farrell, my patient (name changed), was essentially left with a dead limb attached to his body. And that? That isn't compatible with life.

Nope.

Mr. Farrell had this little Jack Russell terrier that he absolutely adored that was home during his hospitalization. Though his grandson was caring for him, he worried about his pup incessantly. And mostly, I just listened because there wasn't really much I could do about it.

After several days of wound care, pain control and futile antibiotics, my attending--one of the most senior physicians in that hospital---decided to refocus our goals of care. He sat the team down and laid out his game plan. And then, in true big boss fashion, he left the ward.

My marching orders were pretty simple: He told me to call as many of Mr. Farrell's family members as I could, urging them to come in and see him--today. I admit that I was confused by the urgency because, much like Mudear, he hadn't taken some acute turn for the worse. But I did as told and made those calls.

Family trickled in and out all day. They hugged Mr. Farrell's neck and laughed and spent time with him. Daughters, sons, nieces, nephews. Neighbors, old coworkers, bowling team mates. Grandkids and the kids of those grandkids, too. All had gotten the word that it was time to come see him and all, like me, shocked on arrival to find him looking so great.

Finally, around 4PM or so, my attending physician reappeared on the ward. He was a tall man with great presence, so any time he came into any space, it was noticeable. But this time, it was even more unforgettable. While we made those phone calls to family, he was upstairs flexing his big boss muscle to do something rather unusual.

Yup.

Suddenly, there was the skitter of puppy claws on the slick hospital linoleum and tiny yips interrupting the ambient hospital sounds. Yes. A dog was on the ward. My big boss attending had gotten the green light for Mr. Farrell's grandson to bring his dog in to see him. His dog, y'all!

Maaaan. That sweet little Jack Russell terrier nearly exploded with excitement the moment he heard Mr. Farrell's voice. Oh how happy that man was! He stroked that dog's back and nuzzled his face into his fur. And his grandson promised him that he would care for that dog as long as Mr. Farrell needed and Mr. Farrell wept when he said that because he knew it was true.

Yup.

My attending pulled me aside and told me to not to be too surprised if Mr. Farrell passed away that night. And again, I thought he was sort of overreacting but since he was such a big boss, I nodded and went along with it.

"Peace is a mighty thing. That and permission," he said.

"Permission?"

"Yes. Some people just need permission to die. They need to know that it's okay for them to go."

And that? That made sense to me. It did.

The following morning, I went straight to Mr. Farrell's room. The bed was empty and the sheets were off of the bed. I scurried to find his nurse who quickly notified me of what had happened.

"He went on to glory early this morning. Sure did." And she said that with a warm, knowing smile.

Sure did.

I think of those pivotal moments so often. The one with Mudear and the one with Mr. Farrell. Now when patients are facing some irreversible illness that has brought them near the end of life--or for those blessed near-centurions who've simply stopped thriving--along with the management of symptoms and pain, I focus on those two things as a part of my treatment plan:  Peace and permission.

Yep.

Last week, I told the family of one of my patients about my Mudear and her final days. They'd asked me what else I thought they should do for their loved one who was very advanced in age and now on the way to hospice care.

"Give her your permission," I said. "Let her know that you'll be okay and that it's okay for her to go on home." And that is exactly what they did. She was gone less than 48 hours later.

Yep.

I guess I'm writing about this because it isn't really scientific, you know? But damn is it important. Sick people nearing the end of their days need those things more than we realize. Peace and permission, man. It was important to my Mudear to know that things would work right. And my daddy promising her that they would helped her to have peace. That and seeing those loving faces of all of those special people and being in her home. And Mr. Farrell? Well, my attending was wise enough to recognize that getting that Jack Russell terrier into the hospital was the very best thing that he could do. And wisdom for doctors? It's one of the most important yet impossible-to-find-in-a-book things there is.

You know? I think lack of peace and angst are often mistaken for vitality. Holding out for peace and permission can translate into will to live. And now I know that, even when the monitors aren't wailing impending doom nor are the vital signs circling the drain, just handling those two items--peace and permission--cuts the O2 off on the will part. But in the very best and most beautiful way.

Yeah.

I'm glad for the lessons I received in death with dignity from Mr. Farrell and my Mudear. They've given me a new way to advocate and a different way to fight. So now? I'm thinking. Constantly, constantly thinking. And trying to find whatever it is that will get my patient closer to having peace and permission. Then fighting like hell to help them achieve both.

My Mudear in the center, surrounded by all ELEVEN of her children.  What a lady.

Words my sissy wrote to me before I got married.

***
Happy Tuesday.

Outlast.

You walk every single day and you tend to your garden. You do for yourself and keep your mind sharp by doing crossword puzzles in the Atlanta Journal Constitution and by balancing you own checkbook. And these are the things that, in your opinion, helped you to live this long. That's what your granddaughter told me before you went silent.

These last years were hard for you. Not from a health perspective. No, not that at all. You'd been independent until just a few weeks ago. Things were tough just from a life perspective.

Yes. That.

Some piece of us hopes to live as long as you, to be a part of that rare and coveted centurion club. I guess no one really thinks about what comes with that membership. I know I hadn't.

"She became lonely," your granddaughter said. "No one was left. No one. She'd outlived them all."

I squinted my eyes and thought about that for a moment. Before I could speak, she spoke again.

"Her kids were all elderly when they passed. I mean, I'm 57 and I'm her grand baby. When my daddy died, people said he had a full life at his funeral. And that's because he did."

"Man." I paused before speaking and then went on. "But she lived longer."

"She lived longer than everyone. Her brothers and sisters. Her kids. And even a few of her grandchildren. Then her friends, too. They're all gone. I felt so bad for her sometimes. She didn't have nobody left, you know? Not that could relate to stuff she saw in her life."

The other "elders" in your senior high rise were the same age as your children.  Your children.

And so. Here you are now. After outliving them all, here you are.

And you know? I could see how it was lonely. I could.

I want to live long. But until today, I guess I hadn't thought much about how long.

Hmmm.

***

The hold over.

The first thing I saw when I entered that clinic room was a worn and tattered Air Jordan sneaker hanging off of the edge of the examining table. It was the only thing peeking out from under the mound of sheets and blankets that he'd piled on top of him before curling up into a fetal position. He'd purposely turned his body to face the wall; that blanket tucked tightly between his chin and shoulder like some kind of angry spouse determined to prove that this wasn't an "in the mood" kind of evening.

And see, all of this was super awkward-appearing considering we were in a regular clinic room and not on the inpatient service.  I hadn't snuck up on him in the wee hours of the morning for some quick post op assessment on rounds. No. This man wasn't in a bed so this was weirdly indulgent and a bit odd, particularly since that short little table was no match for a six foot four inch man. I paused with my hand on the door knob the moment I stepped into the room and squinted my eyes, a gesture I knew he couldn't see. Instinctively I began to coach myself to be patient.

Instead of perking up or turning to face the door when I came in with the resident, he didn't flinch. "Good morning, Mr. Ashby," I said to his back. "My name is Dr. Manning and I'm one of the senior doctors working in the clinic today. I've been putting my head together with your primary doctor and wanted to come by to see you, too." He didn't move.

Nope.

Now. I'd already been briefed on the details of his clinical concern. He had some very treatable medical problems that warranted taking medications and keeping appointments. They were the kind of medical problems that could become life threatening over time without specific interventions and lifestyle modifications. But, in addition to missing appointments, he never wanted to talk about any of that.

Nope.

Mr. Ashby wanted to talk about the fact that his back hurt. He'd been in a fender bender two or three years before and had complained of back pain ever since. MRI films, orthopedics consults, and visits to physical therapy were arranged for him which never came to much. No acute findings on those magnetic images, not even a slipped disk or so much as a degenerative change. He missed the ortho appointments and PT discharged him after he skipped the first three sessions and then cursed out the therapist on the other one.

Yup.

See, Mr. Ashby had a fairly clear agenda on each visit. And that was to get some kind of narcotic pain medication. He was pretty much about as uninterested as anyone could get when it came to discussing anything else.

I'd looked through his chart already. I'd spoken to the resident doctor and we truly looked to see if there was any indication for narcotics or high level pain management. There wasn't. That said, he'd been to several emergency departments and clinics and somehow got narcotics every single time. That is, enough to "hold him over" until he saw the next provider.

This. This is what I'm thinking about this morning. The easy wrong versus the hard right. And "hold over" prescriptions for patients who try your. . well. . patience? That's one of the world's easiest wrongs.

Ugggh.

It starts with the body language. Strange contortions that aren't commensurate with the problem or situation. A lady lying on her back on the floor in the waiting area with her feet up on the wall moaning out loud and saying that this is the only comfortable position. A gentleman crying and pacing the moment you get close to him. And on this day? Mr. Ashby--tucked under a pile of blankets that he'd likely dug from one of the supply drawers coupled with the very definition of making oneself at home. All of it off putting and usually the first thing that pops the valve on the patience reserve.

Now. I'm sure this reads like a lack of empathy but I swear I don't mean for it to sound that way. I don't. In these situations, I coach myself to find the indication for, say, hydromorphone or oxycodone. I mean, I really do. And sometimes there is a patient who has truly been misunderstood and who absolutely has been getting their pain undertreated. But then there are the others who've regrettably encountered enough irresponsible or burnt out providers and received such liberal amounts of habit forming medications that now they feel sick without them.

Yup.

And so. A while ago I made up my mind not to participate in the "hold over." I made this decision after repeatedly feeling the pain of seeing the patient who'd been held over. Being unable to arrange some follow up with the treatem-and-streetem provider they'd seen before and tired of feeling bullied into doing something that didn't make me feel good.

So now? I look at the chart and the patient. Then I make an assessment. If, in my medical opinion, Percocet or Dilaudid or Vicodin or whatever isn't indicated? It's a no. A firm, unwavering no. But in the kindest way.

Here's what that means, though: sticky, prickly encounters sometimes. That's what makes hard rights hard, you know? That feeling like you're rubbing a dog's fur in the wrong direction. Nothing about it is ever smooth. And since it is human nature to not like such a feeling, the most natural thing to do is to avoid it at all costs.

Yup.

So. A man treating a clinic exam table like a California King bed and who is trying to negotiate with me on how "if I give him something for pain, he'll let me treat his high blood" might wear a lot of folks down. But not me.

No, sir. No, ma'am.

See, it isn't a pride thing with me either. It's just that giving someone things that they don't need--especially medications that have consequences to health--isn't okay. And I'm thankful that I've been at Grady long enough to see how awesome it is when people get providers who are willing to fight for them. Even when it is uncomfortable to do so.

So yeah. I guess this is just a way to fight for the patient. Though I doubt Mr. Ashby saw it that way.

He told me to go to hell and walked out of the room without even being discharged. His blood pressure was too high and his cholesterol was, too. The cigarettes in his front shirt pocket rattled as he pointed at us and called us names. Mean names. And all of that happened after he'd been lying like Eeyore on that table barely moving.

I'd asked him to sit up and he said he couldn't. I told him I thought that he could and that I couldn't talk to him that way. So when he finally was upright, he pulled the covers over his shoulders and hunched down like Yoda. And yeah, I'm sorry for all of the comparisons but I need you to see what I was seeing. So amidst all of his psychomotor hypo-activity somewhere in there a light switched on to "now I'm going to try to scare you" mode. I cracked the door open and positioned myself in front of my resident.

Yup.

And he yelled and cussed and paced all around. Calling Grady names and me names and all sorts of things. And yes, I listen to my spirit and respond when my fight or flight instinct button gets pushed but most of these times--the ones like this one, it doesn't. I wasn't afraid. Instead I was just sad. For my patient.

He wasn't going to wear me down into a hold over. And I know for certain that this was exactly the way it had happened before.

"I really want to take good care of you, Mr. Ashby. These medications aren't good for you. I can't prescribe you Percocet, sir. But please, let's talk about another way we can address your pain, okay? I think we can come up with something. It won't work exactly like Percocet but you'll start to feel better when your body isn't used to Percocet."

"None of that shit works! Can't you understand? NONE OF THAT SHIT TOUCHES ME!"

"I understand, sir. And part of the problem is that you've been getting Percocet. We have to get you off of it. Away from it. It's habit forming."

"Not for me it ain't. It ain't! I need something that WORK. Can I at least get like a seven day supply until I see my doctor?"

And that's where it happens. The hold over. The chart told it all. Nearly 17 encounters in the last 4 months. Most ending in just that. A few more. To hold him over.

"We won't be prescribing you any form of narcotic pain medication today. We won't administer it here and we can't give you a prescription for it. Do you want to talk about some other options we've thought of?"

And that was the end of it. Him telling us to go to hell. Which is a much nicer way of describing what he really said which involved an F-bomb and a recommendation that I do just that to myself.

Yup.

But you know what? I looked myself in the mirror that afternoon and felt fine with my decision. I did and do think of him but not in the way I think of those I've done wrong.  I hope in my heart he someday realizes that we were trying to care and do right by him. So that's what I think about. Just as much, I think of those other providers he'll see and hope that he doesn't push them into easy wrongs that will hurt his body more.

My job is hard sometimes. It is. Loving people and trying to do right by them is tough. . . . but especially so if it isn't something a person is used to experiencing.

Yeah.

***
Happy Saturday.

Mindfulness exercise: Hands.

Wanted to slow down and be mindful. So I sat still and just looked at my hands. Then I wrote about it.

Hands.


What do I say about my hands when first looking at them. Hmmm.  “Baggy at the knuckles and appearing older than their stated age.” Yes. That. I know. It sounds like an awful way to describe these hands that have been a part of me for forty-four years and counting but it’s true. When I hold them flat, those redundant folds over my fingers become more pronounced. The hand sanitizer I use repeatedly has left them dry which doesn’t help. Lord knows I won’t be on the Jergens commercials or any such thing with these suckers. That said, I love them. Instead of feeling fretful and running to the nearest beauty counter for creamy anti-aging concoctions, I look at my hands and  feel connected, empowered, and affirmed.

Yes. That.

That part, the baggy knuckle part, comes from my mother. The joke in my head has always been that we have the faces of a brand-new mamas and the hands of great-grandmamas. “Old lady hands” my mom has said with a laugh of the veiny lattice strongly handed down from her side of the family. Deanna didn't get those hands. Once, as I lamented about them at the kitchen table, she shook her head over her crochet needle and chuckled,“You get that from your mama.”

That I did.

Weathered hands that look like they’ve been working harder and longer than they had.  They do work hard, but not hard like they look. I’ve milked no cows, tended to zero fields. These hands have no excuse. But still. I love them because they tell the story of my lineage. The similarity shared between my mother’s hands and my own has always made me weirdly happy. My hands give me a way to see  her every single day. Which means as long as I’m alive, I always will.

Yeah.

A few years ago, Miss Hanna in the nail shop says my nail beds are “nice and long.” When I told her I had old-person hands, that was her response. Then she explained. “You have beautiful nail bed. Even when you break nail and have short nail it look good.” And she smiled and said that while clipping down my other eight nails to match the two broken ones that she’d been tasked to manicure that day. Ever since that time, I’ve looked at my nails differently. Like they are something lovely.

Yeah.

My wrists are tiny. Dainty, actually. I use that instead of tiny because it sounds more endearing. My sister Deanna used to say that she had the wrists designed for kicking somebody’s ass at 3 o’clock after the school bell rang and that my younger sister JoLai and I had wrists meant for dialing a payphone with her on the other line at 3 o’clock after the school bell rang. That is, if an ass needed to get kicked.

Yup.

Interesting fact about me: I think I’ve removed my wedding bands less than ten times in the eleven years I’ve been married. I almost never take them off. Three times were when I had them buffed and shined up at a jeweler. Another was when they were being appraised for our insurance. Right before I delivered Isaiah in 2005, the obstetrician considered a cesarean section. Harry carefully pulled my ring off then and quickly slid it back on once it became clear that our son was coming the good old fashioned way. The other few times I can’t remember but what I do know is far more frequent is Miss Hanna asking me to remove them for her to apply lotion to my hands. “No thanks,” I always say. “I’m good.” And like always she just shakes her head and tells me how I’m going to mess up my pretty rings and make them look old.

And you know what? She’s probably right. But what she doesn’t know that old and pretty rings would fit in just right with my hands. Which just happen to be both of those things already.

Yeah.

That's all I've got.

***
Happy Monday. On wards so hoping my writing block will unblock.