All fired up

cases for the weekend

2009-04-26T17:21:00.002-05:00

21 y/o morbidly obese female presents to ED with bruising to upper extremities and lower back. Patient looks well though is anxious, PE unremarkable except for eccymosis on upper arms, right wrist and lower back.
Pmhx: suppurativa adenitis. Seen in ED 3 months ago for r/o Meningitis and ED course was pain meds and an LP which was unsuccessful due to body habitus. Labs drawn in previous visit platelet count 75, today her platelet count is 7. What's your ddx? What do you want to do?

67 y/o black female present to ED Friday night (while everyone is in the trauma room working on a GSW to the abd of a 17 y/o who we later determined was DOA) and is c/o itching all over and the feeling that her throat is closing. Seasoned RN gives 50 benedryl and 40 of solumedrol before being able to grab a clinician.
Patient states she had fish for dinner at 7pm and felt fine when around 11pm she gradually started to itch everywhere, took some benedryl with no relief and came to the ED. She states she had hives everywhere, though there is currently no evidence of rash/hives and she states she feels much better. Patient denies any travel, new pets, soaps, foods, etc.
Patient received pepcid, IVF and is observed for anaphylaxis for 5 hours. No changes, patient is d/c home with epipen and follow-up with Immunology on Mon. Patient returns to ED Saturday night, states she itches again and it's worse. Patient states she took some benedryl at home without relief also took the epipen and came in (though she reports never having the sensation of SOB, throat, lips or tongue swelling and obviously wasn't listening when I explained WHEN to use the epipen). Patient has diffuse uritcarial hives all over body surfaces best visualized on her back where she can't reach to scratch. She also has blanchable purpuric rash on her palms and feet. There appears to be no mucosal involvement and she is breathing well without wheezing. Tonight she reports she was recently visiting relatives in North Carolina. Patient is admitted to medicine. WTF? What is your ddx? What do you do?

36 y/o female presents to ED with worst HA of her life. She complains of subjective fever, some associated neck pain, and mild nausea. Initial POC work-up indicates she is pregnant and she elects to keep the pregnancy though not planned. How do you work this patient up? How do address her pain?

weird shit

2009-04-20T18:40:00.004-05:00

There is a lot of weird shit in this world. It's lurking in the neurons and reflexes of our bodies and making many of us scratch our heads. Medicine, the great abyss, teaches and taunts us with these anomalies - or shall we just call them our limitations. Honestly, I think it's amazing we have figured out all we have so far.

My top 3 head scratchers to date are occurring in people i know and love.

Active female in early 30's with onset of ascending leg numbness, difficulty walking and extremity pain, specifically in the limbs that are having sensory deficits. She said it started with a weird constellation of symptoms that included right leg numbness, the sense that she could feel her leg hair growing which proceeded to be leg pain with shaving the hair on her legs and later difficulty climbing stairs (uncoordinated gait and muscle weakness) and some urinary incontinence due to saddle numbness.

Another active female in early 30's with a persistent cough and tickle in her throat lasting > 3 years. She was initially evaluated by her PMD and later several ENT doc's who said she has silent GERD (gastroesophageal reflux disease) - to which end she ceased eating and drinking many offending items that would exacerbate this condition as well as using a PPI. No improvement. She went back to ENT and had an upper endoscopy and they confirmed silent GERD and put her on aciphex which has NOT improved the symptoms but caused her to have terrible bloating and bad headaches. Switched her to Zegerid which also caused terrible bloating and a 5 lb weight gain in 5 days. She was told she should have an esophageal monometry performed but that it would be very unpleasant and she's loath to spend another $50 co-pay for a very unpleasant procedure that she now doubts will yield any new information. Enter family member who had the same symptoms and went through much of the same work-up and treatment and eventually had a smart MD do an upper endoscopy with a dye that highlighted a small patch of gastric mucosa cells lining her throat. What the hell is that? Hard to find any literature on it and my friend is beside herself with who to go to since her family member said she went to a GI guy who was venerated and hadn't thought to do it. Hit or miss, eh?

Lastly, healthy female in her early 40's presents with sudden onset of binocular visual defect: a white spot that is seen in the center of both visual fields and when she closes her eyes. Said white spot is slightly shimmery and gets larger and larger with the center disappearing to have normal vision there now with a O of white-out that eventually ended in a C-shape on the periphery of her vision. This first episode lasted 2 hours and was accompanied by mild nausea and followed by a mild headache that subsided without intervention. The second episode was10 days following the first with the visual changes only lasting 30 minutes and a third episode less than a week later with even shorter duration. Migraines? Occular Migraines? Amorosis Fugax? WTF? Neuro consult? Ophtho consult? Head CT? MRI?

Inquisitive minds continue to ponder and advise.

When to come to the emergency room

2008-11-17T21:34:00.004-05:00

It saddens me to say this, but some people get better medical care than others. I know it's not fair, but I have watched myself and other providers consciously or unconsciously deliver care differently to different patients. It is NOT a simple calculation of the nice vs the obnoxious, the truly sick vs the people we think are full of shit, nor white v black. Prejudice is but a small part in the myriad of choices we must make in a 12 hour shift. That being said, I propose the following syllogism.

If you are: poor, homeless, unintelligent, not-white, have a psychiatric condition, are abusive to the provider, have poor hygiene, or are old and demented without good care - you are less likely to get the same care/work-up/attention that anyone who is any of these things. Why? Because the more of those things you are, the less likely you will follow the plan of care to cure or aid in healing process, and if you won't bother, then more oft than not, the provider won't bother either. You will still get good decent basic care, but no one will go looking beyond the things that will kill you; which is at the core of what we do in the ER. This is multiplied exponentially by the number of those characteristics that pertain to the you and the number of people in the ER at any one time. This is reality.

And I truly don't believe that people understand what we do in the ER. It seems self evident enough, and still I have had plenty of people tell me what my job is - and they are mistaken. We work in the emergency room, so if you have an emergency, then you come in and we make sure nothing is going to KILL YOU. We make our best efforts to change the unstable patient into the stable patient, and if we can do that and send you home, lovely. If not, we admit you and doctors continue to care for you until you ARE well, and can go home. If you want to leave before either of those things can be done, then why did you come in the first place? This ain't McDonald's, or KFC, or Taco Bell. You don't order what you want, it won't be fast and YOU CAN'T DO OUR JOBS.

It is true, you can always sign out AMA (against medical advice), but don't get pissed when you're work-up is in progress and you're tired of waiting. I thought this was an EMERGENCY?

Our job is to make sure nothing KILLS YOU. In order to do this, we "rule out" the things that might kill you. To "rule out" means we have ran tests and diagnostic studies (ultra sounds, cat scans, xrays, etc) and used our big brains to conclude you DON'T have anything that will KILL YOU, and then we tend to what we can, and give you instruction for proper follow-up care WHICH YOU MUST TEND TO, because contrary to what we'd like to believe, we don't cure everyone and can't fix everything. So despite what many people would LIKE us to do, our jobs are not to figure out what's wrong with you (though we do from time to time), but to care for you and rule out that anything might KILL YOU, including yourselves. Capice?

So, if you have a medical problem but not a medical emergency and you walk into an ER, any ER and see the place is packed - go home, see your doctor in the morning. If you don't have a doctor, go to the local clinic, we have many of them. If you don't know they exist or where they are, or it's the weekend, or after 7pm, then either sit patiently and wait your turn or go home, tolerate your discomfort awhile longer and come back at either 4 am when every patient in the ER is asleep or at 8am, just after shift change when everyone is fresh and the ER has been emptied as best is possible.

A do NOT think you are slick by calling an ambulance to bring you in, under the false premise that you will be seen quicker. Everyone, and I mean, EVERYONE get's seen and triaged by a qualified registered nurse and will be placed in the order of the severity of their MEDICAL EMERGENCY. So if you don't have one, and you came by ambulance, don't be shocked to find your ass in a chair in the waiting room. I kid you not.

Let me qualify medical problem vs medical emergency. A medical problem is something anyone can have BUT you are someone with NO ongoing medical diseases, are relatively healthy and you state: 'yo, my eye be hurting for a month and I can't take it no mo', or "I've had this rash on and off for a year", or "I got in a fight with my boyfriend/girlfriend and my heart felt like it was gonna beat out of my chest, so I just want to get checked out" or "Sometimes my feet swell and they hurt." (but they aren't swollen now) or my personal favorite "I have this terrible pain in my back and I was in a car accident...10 years ago". Get the picture?

This is not an emergency. You are a healthy person, you are uncomfortable, the likelihood that your constellation of symptoms amounts to a condition that will KILL YOU is around the order of 1 in a BAZILLION. Use your brain, or someone else's, and seek medical care at an appropriate facility like a doctors office or clinic. Here's a hint - they are open Monday through Friday from 9-5/6/7pm. Generally they like it if you call and let them know you are coming, although some do have walk in appointments, but then you have to WAIT YOUR TURN, because there WERE people who called ahead and they get to go first.

Medical Emergency: You are old and anything is wrong with you. You have chest pain. You suddenly begin to slur when you talk, can't lift one arm or leg, or lose your vision. One of your limbs begins to swell up for no reason and the rest look fine. There is blood coming out of any orifice that is NOT your nose (which you've been picking)...or it is your nose and you haven't been able to stop the bleeding for 4 HOURS, and you have high blood pressure. You've been shot or stabbed (this does not include paper cuts, wounds from plastic knives or welts from paint-gun pellets that didn't break). You fall over when you walk. You have been in any motor vehicle accident where some part of the vehicle was CRUSHED or ROLLED OVER. Scratched bumpers, paint chip off the side and the desire to sue the shit outa someone else who cut you off do not count. You fell on your head, at all. You were hit in the head with something that weighed 10 lbs or more. You can't remember anything and someone else brought you here. You have a cut and see fatty tissue down below (deep enough to merit stitches), or some white thing that looks like a thick string (tendon that allows some muscle to stay attached to the bone and move the joint - like say your finger, or foot, or knee)or the bone is poking out. You can't breath - really. I don't mean you can give a monologue with a hoarse voice or can shout at me for 5 minutes that I'm not helping you and you have asthma/a cold/walking pneumonia. I mean you can't string 3 words together without taking a breath, or you're leaning over with your hands or elbows on your knee's and can't walk because you can't catch your breath, or you truly feel like you throat is closing, or I can hear you wheeze without my stethoscope, or you feel like someone is sitting on your chest and or your windpipe is pushed to one side, or you're lips are BLUE. These are but a few examples of a 'true' medical emergency.

Remember, an 'emergency' to you may not be the same as a 'true medical emergency'. You may just need some xanax or a slap.

patients, patience

2008-11-16T13:13:00.005-05:00

The last two nights at work a few of my patients tried my patience. It is an exercise in control and I can say with confidence that trying to have any type of rational, useful conversation with someone who is intoxicated from alcohol, is a losing proposition. So, what to do? How do we protect the inebriated from themselves, protect ourselves from them and not lose our cool? It ain't easy, although any bartender can tell you that. Of course the bartender has the option of tossing their patron - I do not.

Fortunately in one case, I was in the position to sedate the spittle spewing screaming woman who wanted to: call her barely-teenage-son at 2:30am/leave/call her lawyer/sue my ass for holding her hostage. It began like this: 60-something woman went on a bender, broke her ankle in two places, and appeared in the hospital - son and ex-husband in tow - with her ankle wrapped in a pillow. She couldn't tell me who wrapped her ankle, what happened to her, where she was, or what kind of medical problems she might have - only that she was sobbing because her husband left her for another woman (last year) and would then suddenly stop crying, state casually that she thought she only twisted her ankle and, if I didn't mind, she would just go home. When I tried to explain she couldn't just "walk out" because she broke her leg - not to mention that she was confused and I was concerned about head trauma from her fall, she waved me off saying it wasn't broken, she doesn't remember falling and that I should just tell orthopedics to go away (the doc standing at the foot of the bed who tried to set the break when our patient really started screaming in earnest). Earlier she tried to leave before we realized what an unreasonable joy she would be, so she fell in the hospital once - fortunately I had already examined her and could say for sure she incurred no new injuries. To this end, we placed a restraint vest on her.

I love the "posy" (restraint vest). This device allows a patient to be secured to the bed but still have full use of their arms, it simply keeps them in the seated or supine position. The ironic thing about the "posy" is that any reasonable rational person who was in one and wanted to leave, would simply untie it and take it off - It is designed for the confused patient because it doesn't seem to occur to them to untie themselves, verifying to us that they truly merit it as well as keeping them from falling. It also brings to mind an entertaining visual and new meaning to the phrase: "pocket full of posy's".

My lady screamed at me and in general until I thought the blood vessel in her temple was going to pop. So I gave her something to help her SHUT UP. She slept like a baby after that for the better part of 4 hours, which benefited her for the fracture would surely be painful when she woke, and for the sake off all our other patients.

But screaming lady number 2, she wasn't my patient. She was in the stretcher next to one of my patients who had severe abdominal pain and profuse diarrhea. When he was trying to get back into his stretcher from trip number bazillion to the bathroom, I had unlocked the break on screaming-lady's stretcher and moved her half a foot to allow him to get into bed, and then moved her back. She had been lying with a sheet over her head prior to this and suddenly whipped herself in my direction to accuse me of unnecessarily moving her stretcher. I explained why I had and she told me that I needed to ask her to move her bed, that this would be the "polite" thing to do. I don't know where she learned this word "polite" but I assure you it's not the same word I learned, nor the same one that Miriam-Webster has described in decades of dictionaries. She repeated - ad nausea - and in no uncertain terms, I needed to ask her if I wanted to move HER stretcher. I told her I did not. I didn't say it with any emotion, I did not raise my voice or say it any differently than the way one might say "do you have the time?". This prompted a series of explicatives and a slurring, condescending diatribe on "respect", at an impressive and escalating volume, of which I was the first recipient. My personal favorite was "faggot-ass-bitch".

My father and I recently had a conversation about the use of the term "respect", particularly used in the common vernacular of "you need to respect me" or "she disrespected me" in reference to someone not kissing your ass.

Suddenly I was recalling all the lovely folks I'd encountered as an EMT when I wanted to curse the guys who brought her in. Yes, your tax dollars hard at work. I continued to care for my guy and replied to her spew one or two more times, without anger and a wee bit of sarcasm, until one of the other doc's smiled at me and told me to go take care of another patient. She knew I was just fodder for this - also very drunk - person and that she might settle down if I walked away. It was half true, and I steered clear until she passed out.

Still, I wanted to stick my face in hers and tell her to SHUT THE FUCK UP. That no one in the ER should have to take her abuse, be subject to her vile and ignorant rants, and why the would I ever respect someone who is loaded and lying her own piss?

Yes friends, it is difficult to have patience at times - even when I know I have a significantly better life than those borrachos who come in and push us with their behavior. I know they have problems I would not wish on anyone and I have plenty of pity for them and their situation. Still, I wish we had a special room where all the screaming assholes could be together, where they could take one big TIME OUT, and when they could control their mouths, I would happily take care of them.

marriage for gay people

2008-11-14T10:40:00.002-05:00

I have never dreamed of getting married. I value my relationships deeply, but I've always felt cynical about the "institution" of marriage. Maybe it's because my parents are divorced (though I believe that was the right thing for them), maybe it's because people get married without thought or care, sans "sanctity", it is often not honored as a commitment, and in general made a joke of. I know, there are many happily married people who honor that commitment, and to you I apologize - in fact, it is these kinds of folks who make the "rest of us" ie queers,lesbians, gay men, WANT to get married.

Would we be fighting over it if there weren't legal benefits? And why do married couples get all these legal benefits regarding taxes, healthcare, property rights anyway? What does that have to do with the "sanctity of marriage"? If I take care of a sick family member for years, pay for all their care and tend to them, why shouldn't we be legally allowed financial benefits? Perhaps some history on marriage is appropriate here. "Most ancient societies needed a secure environment for the perpetuation of the species,a system of rules to handle the granting of property rights, and the protection of bloodlines. The institution of marriage handled these needs." Hmm, property rights, bloodlines - sounds pretty economic to me.

Despite all this, my not wanting to get married (and I am a lesbian) doesn't mean I don't think I should BE ABLE to have the option. Everyone else can get married, hell sometimes even more than once at a time! To me, this is an issue of equality, of civil rights. And excuse the tangent, but why do the people who aren't gay CARE? What's it to you? I find that most of these folks don't know anyone gay, don't have any contact with gay people and therefor how can you have issue with, or a problem with someone you don't even have a direct discourse with? I really don't get it - why do you care? I don't care what you do. I'm not out protesting polygamy, even though I disagree with it. I'm not protesting marriage in any way, even though it is abused by non-gays ALL THE TIME. I mean really, just bugger off.

I hear the religious folks proselytizing - it is a sacred bond between man and woman, a right given by God. Oh really? Did God mean for only WHITE people to be allowed to marry, because for most of America's history, those black folks, your neighbors, they couldn't marry - why? Because they were considered PROPERTY. Did your God tell you that shit was ok with him?

But hey, this was a constitutional ban - a government affair - a little too closely bullied by Religious Money and Power - but whatever - let's just ignore that bit about separation between church and state - let's stick to the people who passed the laws, I mean BAN. So marriage is a bond between a man and woman, and we don't have (legal) slavery anymore, so ok, really? Any man and woman? In point of fact, until 1967 - yes, only 40 some odd years ago, a black person could not marry a white person in SIXTEEN STATES in the US, that's 1/3 of the country.

So don't tell me that queers are trying to redefine marriage. Don't tell me the foundation of our society is based on marriage when 50% or more end in divorce (thought that would explain the current SHITHOLE we're in), don't give me any more excuses why the homophobic people of california, arizona, arkansas and florida - say that no, we are not equal, we can't marry - they are just bigots, so BE BIGOTS and TRY and defend that shit because NOW you have pissed off many, many people who love their partners and will defend that love - just as you would, homophobic america, if I passed a ban on you telling you your marriage was NULL and VOID.

Yeah, you can expect me on the steps of city hall, and writing letters, and protesting in every way possible until this gets resolved. Because this is AMERICA, land of the free and home of the brave. So I'm taking my brave free ass out there and telling you NO, I will not sit in the back of the bus.

rules of engagement

2008-11-12T16:27:00.002-05:00

I just returned from the dentist. It was six months since my last cleaning- what a good patient I am. Um, not. I suppose I get credit in the "good self help" category for making a cleaning appointment before having a infected tooth pulled - which I'll do in two weeks. But I should have had that done last winter when it first started. Pain is what usually drives us to the doctor, dentist, emergency room - but I had the luxury of a disgusting little fistula along the gum line of that tooth, where the pus was draining all this time. So there was no pain, and despite being a medical provider myself, I put it off - for a year. The apex of the irony here is that my partner fears the dentist the way small children fear the dark or things that go bump in the night. That there is lurking probability that there will be tooth decay, cavities and perhaps root canals laying in wait. That going to the dentist will result in pain, so while pain-free, why go? And did I say "oh, I know, I don't like going either. Put it off?" No. I encouraged (harassed) her to go get a check up and tend to her teeth; why? because I love her. Does this mean I love myself less? Hardly. So why didn't I go sooner.

We do not live in a culture of preventive care, of healthful living, or self care. Certainly in the current healthcare system that the US has (for some), many people do little or nothing until they have to because they can't afford it. Certainly I delayed my own treatment knowing it would cost me almost two thousand dollars for this one tooth to be completely and well repaired. It's not small thing. In fact I had a family member recently spend two days in the ICU after a bad fall, a five minute bout of unconsciousness and a bleed on his brain. Can you even imagine what that cost? Out of pocket? No small surprise he didn't go for the follow-up head CT, but even when I recommended he see the Neurologist to evaluate his headaches and functional ability, he agreed that would be a good idea. Do you think he went? Nope. Why?

Why do people wait until the last minute? Why do they wait days after an injury, a first sign of illness, a leaking wound, a sure sign that there is a problem, a serious problem, a life threatening problem? Replies to this question I have heard:

1. I am afraid of hospitals/doctors.
- translation: I afraid something might be wrong with me and yet when pain or a sense of impending doom strikes, people find they fear death more than the doctor or hospital and they still end up there when they need to, and perhaps could have been (better) helped sooner.
2. It's inconvenient. I don't have time to go. My doctor never has appointments.
- translation: I can't be bothered to take care of myself. Now, doesn't that sound stupid?
3. I can't afford it.
- ok, this is the only good reason I know. Which is why I feel hopeful with Obama about to take office and why I advocate for affordable healthcare besides just being a clinician.
4. I didn't want to know.
- that doesn't make it go away, though facing ones mortality to even the smallest degree can sneak up on you and freaks out plenty of people. Still doesn't make it go away - deal with it.
5. They'll find something wrong with me.
- um, if you're getting medical attention, you already knew that.
6. My (insert family member here) was killed (insert hospital) here.
- you're family member was probably already on their way out, or maybe they wouldn't have died (yet) if they'd seeked medical attention sooner.
7. I was ok (until I wasn't).
- well duh.
8. I didn't think anything was wrong.
- denial anyone. Oddly, it doesn't stop the illness or injury from getting worse. If you get some care when you need it, maybe you can sleep well at night knowing this is actually true.
9. I don't want to see just anybody, I want someone good. How do I find someone good?
- this one takes effort, maybe some education or at least some sense of entitlement, but it can be done, and if you want to live a healthy life, it just might be worth it, no?
10. I already know there's nothing anyone can do for me.
- ah yes, the know-it-alls. Even you will end up in a doctors office or hospital. Or there really is nothing wrong with you, stay home. Or you don't care of western medicine, ok, don't dial 911 when you have that sense of impending doom. Or get over yourselves, those people that spent 6-10 years in medical school might just know more than you about your health. Really.

Sept 30th; 35 days and counting

2008-09-30T12:57:00.002-05:00

to what? I know you're not asking that? are you registered to vote?
http://www.voteforchange.com/index_obama.php?source=091008emailR

too many people, fought and died for this right, this privilege. get your ass to that website and register, update your address or whatever you need to do to make your voice heard. the money maker giants took a big shit in your back yard with their greedy mess and now they want MORE of your money to fix it - and you can keep paying your own rent, mortgage, whatever. is that ok with you?

V-O-T-E

and educate yourselves on the policies of the candidates, don't just do what someone else says you should. don't just sit by and say you don't count - YOU DO.

one good deed

2008-09-11T20:06:00.003-05:00

Sept 11, 2008

It has been my intention to do some good deed on the anniversary of the 11th every year since the attack. Last night while I worked, a young man with a disturbing problem presented himself.

He was a 25-year-old black male who came in police custody. He smartly got my attention before he was even triaged and began to explain a sad and complex story. He is gay, and he has been beat up for many years for being gay. He has suffered injuries including a fractured zygomatic arch (his cheekbone), a punctured lung, and many smaller though no less painful injuries - all because he's gay.

He currently lives one block from a local high school and he is repeatedly insulted, followed and abused by kids from that school: they have thrown bottles at him, let their pit bull after him, followed him in their cars and threatened him. The recent bait and threats coming from these kids led him to the school to try and address the principle - to see if something could be done.

I have no idea what the whole total story is, but he ended up in police custody because some kids reported to the principle that he threatened them with a weapon (which he did not have); so the principle responded by having the boy arrested on school property for trespassing and accusations of threatening students. The police brought him to the ER when he refused to go into central booking lock-up with so many other men - for fear of possible rape and or beatings.

He received a psychiatric consult in my care, a meal from me and a whole lot of attention. At his request, I called his grandmother who knew he was in police custody, and let her know where he was. She was deeply thankful for the information and we took some time to speak a bit about his situation. I told her I would think about what community resources there might be for her (and him) to address the problem - and give him that information. She agreed that the local police cannot do very much until an assault has occurred and we wanted to avert that if possible. It was 12:30am when we spoke and there was no one I could call so late. I sent him back with police around 1:30am and wished him luck. He looked disappointed but not surprised. He said he was so tired of all this. I felt a little helpless.

Today, after getting some sleep from the overnight shift, I made a few calls to friends/colleagues in the area and someone smartly recommended the NYC Gay and Lesbian Anti-Violence Project (http://www.avp.org/) - which I am so grateful to have as a resource for exactly this kind of thing. I mean really, what else do you tell this kid? Hide? Get some mace? Don't be gay?

I called the grandmother a short while ago this evening and gave her the information, and she invoked on more than one occasion "God is good" and thanked me for the follow-up. She asked if she could have the number in the ER to call and let me know the good progress they would surely make from my help. It was hard not to start crying right there on the phone (or now as I type this).

I will not, as they say here in Brooklyn, "front" and pretend I have any specific faith in a particular God. I have heard this phrase, which has rung so hollow in times before - yet I felt it were true today.

It's so hard to make sense of the violence in the world, be it the memory of the attacks on the twin towers or the attack on one young black man trying to just live in this world.
But if God has anything to do with why I love my job so much, and why I care about so many people I don't personally know - then yes, God is good.

BE the change you wish to see in the world

2008-09-09T15:30:00.002-05:00

BE the change. What does it mean "to BE"? In my mind it means to live. I don't mean to go on about your daily business, to get yours, to succeed, to be happy or anything that one might constitute as 'good' or 'desirable'. I mean the awe and beauty in being alive, which I believe is unparalleled by anything else. Here we are, at the top of the food chain, with so many possibilities and the mental processes to appreciate that. You are a-l-i-v-e and you are living; so live. It is a gift, and these days one that lasts near a century. If you don't remember this every day and engage fully in life - perhaps you should take a moment to consider that one day you won't beanymore. Many people are faced with that every day in sudden and horrible ways. Do not wait to cherish it, to revel in it, to live.

And while you're at it; get off the sidelines. In this country, in an election year, in a time while you have the one time chance to cast your vote and say what and who you want, don't blow it. Read, educate yourself, understand beyond the white noise of political theater, diversionary tactics and name calling - and know who stands for what.

Consider where your information is coming from. Is it a reliable source and how are you determining that?

And if you are a women in these times, consider this: http://womenagainstsarahpalin.blogspot.com/
To me this is a forum, a place for the average person, to say what they think. Does it matter? to you?

BE the change you wish to see in this world.

Medicaid = MasterCard; we need some change!

2008-09-05T10:25:00.003-05:00

Emtala is just the tip of the iceberg, and it's ICEBERG DEAD AHEAD! I work in a new york city emergency room. I love what I do. I love walking into work, casting aside my prejudices, and treating everyone that walks through the door; even if I think they're crazy, even if they're frequent fliers, even if I know their drug-seeking, even if there's nothing wrong with them and they're complaining. This is why I like Emtala.

EMTALA is a law put into place to prevent emergency rooms from dumping patients without insurance to other hospitals or worse, the street. It was a good idea, but it really is only the tip of the iceberg. The hospitals need to get paid too, so the communities can continue to have medical resources that will treat EVERYONE and so those that work at those hospitals can keep having a job. And I assure you that anyone who works a job, pays their taxes, and has or is in need of medical insurance would be ROYALLY PISSED to know that many people abuse the ER with their medicaid cards - waving them about like MasterCard's. Many patients have told me they want a prescription for benadryl, or tylenol, or bandages...or they came by ambulance instead of taxi because medicaid paid for it, why should they pay cash?. Except I know full well that medicaid means me, and you, and everyone else who works and pays taxes. It's a freebie, originally designed to help people who couldn't help themselves.

I understand and have deep sympathy for people who are genuinely disabled, have multiple medical problems, are dirt poor and unable to do anything about it. But I cringe when I think of people who are deciding between paying for their seizure/diabetic/cancer/hiv medications or food...and then there are people who want Rx for over-the-counter medications so they can have their smokes, friday night out, or buy that plasma t.v. I'm not making this up, I've seen in when I worked in EMS and walked into peoples homes, and I see it in the ER. It's not that simple, and yet, it is. People do this, because they can. People use that Medicaid card like a medical MasterCard because they are in a shit place and they should at least have this, right? The laws suck; deep, deep down and from the ground up. We need reform, we need a clearer vision, we don't need another band-aid, more money, or more of the same.

I refuse to become one more cynical emergency medicine clinician against folks who use it because they can; change the system.

RNC (retard national conference)

2008-09-04T03:59:00.001-05:00

Whatever world Rudy, Sarah and John want to live in, I don't - for love of every decent human being in the united states - STOP THE MADNESS. Vote Obama/Biden; if only for common sense.

emt gone pa, can you say ERPA?

2008-08-05T08:19:00.005-05:00

It was a long road from the streets of Harlem to the ER in Brooklyn. You wouldn't think so since they're only 12 miles apart separated by the east river and my favorite, the Brooklyn Bridge. In 1999 I entered the FDNY EMS academy. It would be almost 2 years before I even knew what a PA was (thank you PA Braithwaite) another 2 years before I would be accepted to PA school and another 3 years before I graduated. Tack on two more years before I would be hired as an emergency room physician assistant and you've got 9 years from emergency room to emergency room. A long road indeed, but a damn good one.

Being on the receiving end of emergency medicine is what I dreamed of when I was an EMT. I began plotting how I could practice emergency medicine practically the day after I was assigned to my station. Don't get me wrong. I loved being an EMT and the stories I have from nearly 5 years in the streets could fill a book and make the most cynical person's jaw drop or roll on the floor laughing. Today the stories have changed likely in part to the backdrop (almost anywhere outside the ER vs the ER)and we're tending to their illness and injuries which can be a considerably serious business (though not always).

Still, topping my list of interesting folks and stories, after a mere two months in the ED are:

- The woman who came in with puncture wounds on the top of her head from a hand saw: he was walking down the sidewalk on her way home from church and a man sawing a tree branch on the other side of a fence over-extended on a downward thrust and hit the top of her head with the saw at the end of the motion. He was profusely apologetic and blew it by offering her money not to call the police/ems. When she explained she didn't know the extent of her injury and should be examined, he bolted. Makes you want to move to NY, no?

-The young woman who over-extended her hand while sewing with a sewing machine and the the needle went through her fingernail and finger - I saw her in the ER (quietly in tears) after she was seen in the Ortho clinic the day before for follow-up of the original treatment (which included removing her fingernail because of the swelling). They told to soak her finger and see them in a week. It looked like the top of a tootsie-pop compared to the rest of her finger; red, swollen, nail removed and oozing nasty green stuff (exudate). Warm soaks? Nice guys, nice. We had our lovely Ortho resident come and drain it. The woman almost passed out and since our resident is totally great but not a talker, I held the fingers steady and chatted up the patient to get her through. It worked, and MAN did she have a lot of shit in her finger. We admitted her for pain control eventually. Warm soaks..yeah, right.

-The mystery man - a young built, educated guy who said he had bilateral foot surgery 6 weeks ago without incident or swelling. He'd gone for weekly check-ups revealing good healing and no swelling. In the 5th week he had the flu that laid him out, but then totally recovered and then in the 6th week his feet swelled up and he got this weird looking rash: small deep red flat circles that didn't blanch when pressed - only on the bottoms of his feet and medial malleolus (inner ankle). My first thought? Syphillis. But it wouldn't cause the swelling of the feet. Heart failure? he was healthy without heart problems. DVT? It was bilateral without respiratory symptoms or cramping. Infection to the surgical site? No sign of it, and again, both feet? The MD I was working with was stumped as well (which made me feel good). I ran the short list of symptoms through my epocrates and one dx that jumped out at me was Nephritic Syndrome. So we ordered labs and waited to see. I was thinking with the flu-like symptoms, post-step glomerular nephritis made sense, but he didn't have a sore throat and he wasn't a child. But all the same, the labs came back and nephritic syndrome it was - we called renal and admitted him. Better yet, the MD I worked with that night found me weeks later and said " did you hear about our guy?" (By now I'd seen many "guys") "Which one?" I asked. "The guy with the nephritic syndrome" he replied. "oh, what about him?" - Syphillis :)

So not the same as a guy cutting his chest with a circular saw by accident, nor a shooting or stabbing, nor edp's too numerous to list. But hey, I've only been there 2 months and I love it. Sherlock Holmes in bright green scrubs - seriously, what could be better?

The city of brotherly love

2007-05-24T06:01:00.000-05:00

This time last year I was a 3rd year p.a. student. I was also president of our student society, which among other pro's and con's, bought me a free ticket to our national conference in San Fransisco. Being the big homo that I am, I was pretty thrilled it was in the city by the bay; especially since I had (have) dreams of living there. I went with a few other classmates and it was the first time in my academic life as a budding young p.a. that I was able to sit and listen to people lecture about medical topics without furiously taking notes; second pass. I'd heard all of this before at least once and now larger bits and pieces were starting to sink in as I sat, willingly, lecture after lecture, learning about heart failure, the dental emergency and 10 things you need to know about diarrhea (lol).

It was luxurious. We stayed in a 4 star hotel, ate out breakfast, lunch and dinner, heard all these great lectures, and walked every inch of San Fransisco. In fact my good friend D and I would eat in a new neighborhood every night for dinner, then walk home from it after. It's a wonderful city if you ever get the chance to go, and go again; I would.

This year, I am a nationally certified P.A. and the conference is practically next door to my home in Philly. I have a little pocket CME money from my job that paid for the hefty registration fee. Aside from that, it's piecemeal this year. I have to work fri, sun, mon and I'm going to the conference around that work schedule; sat, tue and wed. I'm borrowing a car to come back and forth and while I thought I'd spoil myself and stay the one night on Tuesday, I had to cancel that for other obligations here in the city that evening. So it will be a bit more like work, than play; but I'm still excited.

I love what I do and I feel as though the folks that make the effort to go to these things also love what they do. I think I will feel more at ease mingling and talking shop with other P.A.'s instead of last year when I felt like an imposter. In fact this year I forked over another 250 myself to take some workshops on reading x-rays and EKG's and my favorite - suturing. I'd like to get back to the ER someday soon, and maybe this will launch me in that endeavor.

I always love a good opportunity to nerd out~

good medicine

2007-05-08T11:12:00.000-05:00

Yesterday I worked on the cardiac unit. Our census was unusually low and I had only 7 patients. I'd had an extremely pleasant evening the night before and sailed into work smiling and energized. I made my way round and saw each of my patients: my new admission with a history of vertigo that suddenly had 2 days of syncope and oddly good BM's with vomiting associated; my lady with the lovely family who had a abdominal bleed as a complication from her cardiac cath when she got too much a/c over the weekend - gratefully being managed medically; my 91 y/o lady who still walks to the store with her 92 y/o sister, who now needs a pacemaker due to dysrhytmias; my 85 y/o spring chicken who had a total knee arthroplasty and was visiting us because she has a little bradycardia with some aberrant pvc's for good measure; my italian lady who's advancing dementia now comes with hallucinations that caused her to leave her house late the other night and her husband found her after a fall which she can't recall (but is ok from) and the room at the top of the hall with my two CHF'ers, one who needs an MVR and I wish they'd do it or let her go home and the other anxious lady who DID go home -novina candles all around for their safe recovery and return home.

I tend to spend a little longer than need be with each of my patients because I hate that we live in a time when clinicians spend so little time with their patients, sacrificing rapport and trust in the name of efficiency. But this morning I went beyond my usual when I came to the room of my 85 y/o spring chicken. I finished my exam quickly and had only two other patients yet to see that were both familiar to me - the day was early and I was inspired to sit. Literally, I did - perched on the foot edge of her bed, I asked a most benign but inviting question: "where are you from originally?" This set my lady off on a story of her life, the love of her husband and some of her favorite memories. I chimed in on occasion, but mostly I listened and watched as she had a willing audience for dusting off some of her favorite places and recalling anew happiness.

Ten minutes time in a hospital is an eternity. When I gently lay my hand atop hers and mentioned I needed to get back to work, she grasped mine and thanked me quite genuinely for the conversation. 'It made my day. Really. It's so nice to have a real conversation and not about medical stuff, ya know?' she said smiling as I departed.

It was a selfish impulse really. She completely reminded me of my grandmother, whom I adore. It made me feel good to open that avenue for other-than-hospital-routine for a women stuck in bed with her knee in a brace. It was selfishly good stuff I walked away with, but it went both ways. I am not saint nor angel as I have been called on occasion by my patients. I just know, with all I've yet to learn, that attention and attentiveness is good medicine.

three days seems so easy

2007-04-26T07:25:00.000-05:00

But really, they're not. It takes the other four days off from work to recover from those three, seemingly innocuous days; at least that's what my brain thinks. No one else seems to find this odd except me. The logic of my brain dictates: fewer days at work, more time off. But life has a way of balancing all things if you pay attention. In fact, I asked for a 24-hour shift, Sunday 7am to Monday 7am, straight through. To me, it's only TWO days work, and only two trips all the way up to the boogie-down, and that means more time for me. One friend argued I'd be in bed all day Monday, and I said "yes, in my bed instead of hauling and hour and a half at 5:30 in the morning - I'll take it."

Still, I've been keeping an eye on myself. I have to or I get a little out of control, lol. Working in medicine is stressful, even if not the harrowing kind, and time to myself is an absolute necessity. So I'm putting the computer down, because today is MY time. Cheers.

internal intimidation

2007-04-18T09:09:00.000-05:00

I just finished a particularly long work stint of 5 days, one of which was a 24 hour shift. It was all a little insane and I won't do it again for a number of reasons - most of all quality patient care (as in, don't kill anyone). But as I made my way through my last day yesterday, I found myself having a little out-of-body experience. I didn't want to see some of my patients. In fact, when I took the seven I had on the floor, I was careful about who I chose. Not all the 'easy' patients, but I did dodge one woman who I knew would talk my ear off and require quite a bit of attention. I already had one seriously sick gentleman with a daughter who was like that, so two seemed too much. Dodge number one.

While I examined each patient, I didn't see everyone at once like I normally do. It was ok since some of the doc's had already seen them, but still, so unlike me. The day picked up speed, as it usually does, more doc's trickling in, patients family members showing up, patients with their own needs, all occurring simultaneously. I watched myself, as if from the outside, walk by certain patients doors. They were all for different reasons, though the common theme seemed to be that each challenge required energy I'd never really considered before.

Mrs. C is a 97-year-old woman with severe heart failure; completely edematous, breathing with her mouth open so that she has severe xerostoma (dry mouth) and couldn't really swallow (she was being fed through a PEG in her belly).She'd had a piece of tape on her nose that no one bothered to remove for some time. When some outside observer inquired about it, we were all forced to address this small innocuous detail which was so totally demonstrative of how we all avoided Mrs C in some way. After removing it and treating the wound under it, I finally deduced the wound was because of the bandage, not being protected by it; fer fucks sake! It had been left, I believe, from when she'd had her NG tube, to hold it in place. When the NG tube was removed, the tape was neglected, as was Mrs C.

She is both so old and so sick, that she doesn't communicate much with us, if at all. She couldn't tell us. I found that this sad little story speaks to a much larger issue that I saw in myself on this day. I didn't want to go see her because she was SO sick, that I could do nothing for her really, and that I wanted to discharge her back to the nursing home (as planned). When I did finally go in, I felt so much for her. I thought, "I NEVER want to be so sick and plugged into so much medical intervention, to prolong, what???? It seems as if she has ZERO quality of life left, and who cares? Or rather, HOW did they care. Likely they, if "they" existed at all, they wanted to pass her along as well for as long as she would live. Still, I felt like our interventions prolonged nothing but time she had to endure. I held her swollen hand and ran my hand through her hair in a loving gesture, all the while feeling guilty for having avoided her all day. argh.

Mrs G is a 36-year-old woman walking around the halls and seemingly not in need of medical attention. She's super easy to care for, and she was dodge number two: why? because she abuses alcohol and cocaine, and as a result she has acute pancreatitis. Now it's not my job to play social worker, though I do tread that ground a wee bit in what I do. But that aside, I needed to go discuss her medical care, which is intimately intermingled with her abuse history and at this point we are placing her in an inpatient substance abuse rehab center; she is willingly going. So why do I avoid her all morning? Because it takes energy to tactfully talk about this subject, to confront my own experiences, and prejudices around substance abuse. So many things take energy that we overlook when we have it.

Mr A is a 63-year-old male who's been having difficulty with his NG tube (like i'd blame him for yanking the thing, um, no.) He has a partial small bowel obstruction and he wants to be able to eat. When he last "sneezed" his tube out (some sneeze to blow out roughly 40 cm of tubing; um, yeah.) he asked if we could wait to see the results of the most recent test in case he could eat and wouldn't need it. That seemed a no-brainer to me; I avoided him for awhile so I might be lucky enough to follow his logic and not have to put the tube back in. The man has colon cancer, and I'm avoiding him because of a little tube. Jesus, this was getting pathetic.

I mean, what it all came down to was, this job takes energy; loads and loads of it. Likely most medical jobs do and it begs us to pay attention to all those folks who want to make folks in medicine work insane hours. That reduction of house staff to 80 hours per week isn't just about residents not killing people, the BIG error, but the thousands of tiny errors or even poor attention that matters in a million little ways.

To all the folks out there in the medical field; be kind to yourselves first, or you'll have nothing left for your patients. And after all, why do the job if you can't do it right, eh?

Peace out~

the swing of sunday

2007-03-04T15:42:00.000-05:00

i love sunday. i mean that i love sundays at home, but every so often, i love them at work. it's a good thing too since this is were i spend sundays now. it's not like i don't get a sunday, except that everyone else's thursday is my sunday. not quite the same, especially when it comes to social gatherings and such.

sunday on the unit is a coverage day which means i don't have to examine every patient, but i read the sign-outs and the charts, check labs and results and change care accordingly. it's pretty chill, until something happens. that something came early on this morning when mr p. was signed out to me. 'his breathing: you can hear the gurgling from the door' said the pa who was handing him over to me. i examined him before starting the day and thought 'this man is not long for this world' then proceeded to look over this chart. Prostate cancer, renal failure, heart failure, end-stage parkinsons and then the anecdotal bit about him being psychotically depressed and nasty to his family when coherent. he was pasty white, sweaty, erratic breathing that came with a gurgling sound, fluid in the tissue of his arms and legs and really, not there. The family signed a DNR/DNI just the day before (do not resuscitate, do not intubate - basically, no extreme measures to prolong life) and I thought that wise. After all, what kind of life did this man have now? I know it's not mine to say, but quality of life is what i advocate for most in this gig of mine, so whatever you may think of me, i thought him better off dead. Harsh? maybe. real? i think so. As i read through his chart the RN kept notifying me of his plummeting blood pressure. 'He's crapping out' was all I could think and then challenged my own attitude about aggressive treatment vs what? baseline treatment and let the man die if that's what he's doing? Seems a little counter to what we do right? we heal, we save lives. but neither of those phrases really applied. his cancer was killing him slowly and through circuitous routes, like sepsis, and falling blood pressure. was i being aggressive enough with the treatment within the boundaries of the DNR/DNI? I thought long and hard about it as i read his chart and discussed IV fluid with the hospitalist.

not long after the renal attending showed up and we began discussing the case. the main doc had written a note that morning with the first line headed "PT DNR/DNI", which says pretty loud and clear, 'he's dying, no extreme measures, don't forget'.
we both agreed that his life was nearly without any quality and how sad that was for the family who was both loving and supportive despite his year-long aggressive verbally abusive behavior. we looked over his labs and went in to see him together. while the renal guy was checking his oxygen saturation, i noticed the patient looked very still. very, very still. dead in fact. we both shrugged our shoulders in gallows agreement that this wasn't unexpected and casually he walked away while i got an EKG on the patient to confirm death. 10:27 am, i called it, time of death. it's one of the more intense things we do as pa's, even if it feels rote; it's not. not ever really. i didn't feel sad for him, didn't freak or feel nervous. i began the paperwork for 'notification of death' and before i could call the wife, she shuffled down the hall into his room without anyone noticing. that's when the shit hit the fan.

a long wailing sound echoed down the hall. while it only hit my subconscious, as i was going through the steps, it all clicked into place when someone said 'ms p just went into her husbands room'. shit. not like she wouldn't have been just as torn or heartbroken, or in shock, but finding him dead, well shit. the Rn staff took good care of her and i notified the son at her request. the rest went as expected and i went on about tending to the other 20 patients.

but when i did have a quiet moment to myself, the waters calm for the time being, i went to find an vacant on-call room. i needed a moment to myself. i needed time to feel whatever i was going to before i could move on; this much i've learned about myself and what kind of impact my job has on me. as i lay in the dark in that room, i thought about mrs p for a moment, and then my mind raced, mumbo-jumbo through random and personal places. my mother, hospital work, death, how many hours i had left, how tired i was, my sister and her current incapacitation, my hunger, my dirty laundry, my own internal wailing in darker moments past...i found it difficult to just lie still, to quiet my gerbil brain. in a moment of recall, tripping through memories, i recalled being with the engineer in recent days past, the feel of her arms around me and the comfort, the safety, the peace it brought me. like quieting a crying child after a skinned knee, i lie there still, calm and resting. i stayed there a good 15 minutes or so and felt sad, loss even maybe, but ever calm. my pager went off and another question, another need called and i slid my feet back into my clogs, put on my white coat and with a deep breath, entered the unit and tended to the query.

----

2 more hours. the sun is setting. how does that happen? how does 10 hours disappear like that?

----

the afternoon landslide: where am i? lol. 6:46pm, no matter, i'm OUTA here in t-minus 13? oh shit. where is wingnut? crap. time to unbury the burried.

never say it's quiet

2007-02-27T15:07:00.000-05:00

i know better. i swear i do. i worked ems for almost 5 years and you never, NEVER utter any phrase remotely resembling "gosh it's quiet today". It's asking for work, plain and simple. i'm on the overnight tonight and it was a very smooth start. i split the floor with another PA, took back some patients i'd had earlier in the week and a few new ones. the requests of nurses have been very simple: BP's high - hold the med? patient needs sleep med, patient needs order for the posey. simple shit. i even took almost an hour to have a little food and make a phone call. i said it on the phone "yea, it's pretty quiet on nights and tonight especially".

it could still go well. it's early really. one just came up, mine is on her way, and there's one more. after that there are only two more beds. if everyone sleeps once these folks are tucked in, i could catch a little shut-eye as well. we'll see....

-----
11:15 pm
my admission is missing. well not really. she's just not here yet and i have nothing to do. everyone else is sleeping. i want to be sleeping. my brain is already starting to nod off. i need to make some friends in japan so i have someone to keep me company on these insane shifts. lol.

-----
1:55am
no rest for the weary, or those with big mouths. i've seen my two admissions but still have to write them up and now another one is coming. my counterpart will get this one, but i've ditched the notion of sleeping anytime soon and bought some peanut m&m's and fresh bottle of water. that's one thing for nights, at least we can dress down (scrubs and a t') and eat candy and drink at the nurses station. nights are for rebels and insomniacs. if only i could wear my MP3 player, then i'd be set!

------
2:10 am
i HATE loud nurses, loud people really. this RN has some serious volume control problems. does she want the patients awake???? seriously. And fer fucks sake, NO SPIRITUALS. jeeze.

------
2:50 am
testing, testing, 123, testing, testing
no one knows that's funny except wingnut, but she's home sleeping. bugger.

-------
3:53 am
nothing doin. brain says lie down. maybe that's not a half bad idea. where is the one call room???

------

7:01 am
a disrupted 2 hour and change nap with wierd dreams of patients needing odd things i don't know how to order. i dreampt i was asleep in a road in manhattan and glad it was early in the morning so i had less of a chance of getting run over and feeling guilty that the cheap ass blanket i have might, I might have lifted off some homeless dude. then i thought the homeless dude was telling me about a patient that might need me and i should go back to the hospital and give him his blanket, also i might miss my flight. rolled off the top bunk and had a moment where i thought my knee's would buckle, 2 min later shuffling down onto the unit to assess a patient, order another unit of blood, call a doc to tell him his patient ruled in NSTEMI and watched the sun rising blazing through the east side windows. the mind numbing receptionist is here, i gotta GO.

happy birthday to liv, happy birthday to liv, happy birthday and i'm gonna sneak attack, happy birthday to liv
...and lael. march should be good :)

wicked curve

2007-02-26T22:21:00.000-05:00

my day today, is a blur. in fact, most days are like subway trains, blasting by, catching clear glimpses of things that make me reflect; mirror in and out, though that vision is gone and replaced by another, whooosh, just like that. i have moments of hilarity, moments of being buried by work and demands, moments of profound sadness, longing, anger, reverence. i want to sit and write about them when they happen, but this is a roller coaster and you can't just get out at the top or deep in some wicked curve.

yeah, i'm not a fan of reality t.v., or much t.v. and i think this is why. i am living. i am alive an living the intensity of life that leaves me wasted at days end. i like that feeling, being wasted and as if my knee's just might buckle and leave me in a heap on the ground, on the subway platform, the street corner, just inside my own door. i wish it in fact, to just collapse. why is that? what is that push? draw? dark curious place?

i had soda at lunch today. we three, wingnut, me and no-no-i'm-good; we were frustrated by the sheer stupidity of numa-numa. she is all power and no good sense. she's is hardly different from most folks in this, but wingnut and no-no-i'm-good let her draw them in with her stupid ways and they can't make sense of it. i keep trying to tell them that 'sense' is what she lacks, so going to look for it is like the needle in the haystack, except there is no needle and it's hardly fun to flail through hay - pokey, pokey stuff that it is. so before i let their frustrations trigger my own, i announce we will NOT be dining in the PA office today. it's a hot lunch day for us and the cafeteria beckons. I lead us off the floor and even stick my face is ms O's (our dimwitted secretary) and tell her in a maniacal whisper "we're ALL leaving the floor to eat, no PA's for you" and like most of the ridiculous stunts i pull, it is within bounds but outside the expected, and she laughs despite herself in the wake of my departure. Wingnut and no-no-i'm-good are venting, venting like big steam smoke stacks, billowing frustration into the air. i chime in to make smart remarks at numa-numa's expense, but mostly i'm just hungry now. it's almost 2 and we three are starving.

we get food and find a table in the back. i pop the top on my soda-pop and dr pepper trips the sugar switch in my brain; jeckle-work-serious, to hide-imitation-delirious-joke-cracking crack-up. i imitate co-workers, doc's, unit secretaries and random other phrases and voices that just trip them from laughing to crying, beat red faces and tears in the corners of their eyes. it feeds me, that laughter, and i swallow it whole - on and on until we're all laughing, gasping for air.

laughter is good for the soul. it's good for the frustration, it's good for the lungs, the lacrimal ducts, the pent up fear of things we don't say masked as other complaints. it's the pressure release valve and i have cracked it wide open for each of us. we each have a need for this release, and i'm prostrate and pleased to be a source of healing.

sunday evolves

2007-02-25T09:13:00.000-05:00

friday i got blasted; nurses calling my name every other minute, doc's coming by and demanding my undivided attention, and me sitting amongst the chaos wondering if i'm missing something that will ultimately kill someone.

this morning there is calm (for now), and i find myself slowly, methodically sifting through the information on each patient, with the occasional low key interruption from sleepy sunday morning voices of doctors covering, only 2 or 3 of us at the nurses station. there is no shouting, no cursing, no air of frustration or urgency and it feels good for once. it feels like there's room to pay attention and really focus.

i can feel the events of my life over the last week and week to come rolling around in my brain and my emotions are unfolding inside me like some origami piece that wasn't folded quite right.

my compadre is cranky and has been consistently agitated by this job, while i quietly struggle to understand basic concepts; our frustration comes from the same place though we deal in very different ways; me always internally processing, processing, trying to pay attention and make small important changes. she's trying to discharge a patient, but there are no formal orders from the doc; lazy and lame. so she's frustratingly trying to decide what to give, how much and doesn't really know how to figure it out. i don't know the answer any better than she does, so i tell her to call the hospitalist, he can advise, but she refuses with the complaint that it should have been done. maybe. but it wasn't. isn't the point to do it right, rather than be frustrated and vent at me? this is how things get neglected, left undone or done poorly.

i feel her growing frustration like a noose around my neck, tightening with every additional question. why keep asking me, if my answer is always "call the hospitalist"? my own frustration is growing like a slow burn on an otherwise mellow sunday.

tick, tick, tick

a few hours later wingnut asks me if i want to take a walk. i called it this morning. still, all quiet on the cardiac home front. i predict the whole day like this. it's ballsy, but what have i got to lose. i tell her no, i'm trying to sort through a patients chart and let her wander on her own. maybe she will take stock, find a some peace, find some perspective... and as for me, i can take the time to myself. the chattering of the philipino nurses in their native tongue is the white noise of the cardiac unit. i'm feeling calm and centered, and am enjoying my job this morning.

------

five hours out of twelve. stepping onto the unit is like stepping into a time warp, and the outside world doesn't exist. i have no idea if it's sunny, cloudy, snowing, day or night. the overhead lights glow the same all hours and very little changes in the beeping, patients calling out in frustration, boredom or pain. it's some netheregion that seems like a dream when i'm here. i feel like my own doppleganger with the hint of recollection that time is passing and i don't only exist here. i'm unconvinced.

mr t is having chest pain. he's not my patient. but house staff isn't answering the call. i watch everyone pass the buck in trying to track down blue team doc. after listening to 4 different people discuss who's job it is, while mr T's nurse becomes more flustered about his chest pain and possible weird EKG changes - i pick up the phone and page blue team. suddenly none of the nurses want to get upstaged and they start paging blue team. when the doc finally calls back, the stupid effin nurse starts telling her how they've been paging her for 20 minutes and where has she been, blah, blah, wasting precious time on mr T's possible heart attack - and i am grateful i'm not mr T.

----

"leads off room 852a, leads off"...i hear this voice every so often and i think to myself, "hmm, god is a woman, yeah, i knew it"

-----

"he's gone" says the nurses aid laughing
"who?" says the nurse
"mr d" says the nurses aid "he yelled at me and just walk down the back stairs"
"call security" says the nurse, followed by jocular conversation about mr d, who has been medically cleared (and the doc told him) but is homeless, so he has nowhere to go. he doesn't want to stay anymore, but he hasn't been discharged. security calls up and says they have him. someone is calling the doc.
"no he's not confused" says his nurse. the conversation continues. here comes the patient with security, calm but confused looking.
"I thought i was discharged?" says the patient, he wanders back into his room, and order is restored. ha.

----

wingnut is looking over her patients charts. she's been pretty chill since her mid-morning walk break. yeahbuddy. she calls me over to show me the I/O's (ins and outs, what goes in and what comes out, literally - food, fluids, you get the idea). Listed on her "in" list is 300 mL for her 87 y/o lady. not so wierd, except it's listed as 'breast feeds'...oh yeah. i wanna know the genius who pushed 300 mL of ANY fluid into that womans breasts. lol.

-----

her arms were swollen with fluid her vessels could no longer hold. he head was cocked at a painful angle. her lips longed to meet, but the stale hospital air kept them apart as she inhaled, exhaled, inhaled almost imperceptibly. every organ system played tricks, marco, polo; who was responsible for the ailing, failing of this woman. one, who had lifetimes ago, survived a concentration camp, the ink on her left forearm, clearly etched 5 numbers balanced on a triangle, palpable beneath my tender fingertips.
i cradled that arm as my colleague attempted to draw blood from veins that hid deep below the surface. the two pinpricks were likely insignificant in the scheme of her history - necessary in the elucidation of her complex picture of poor health - and still, we focused with the intensity reserved for heart surgery or some such feat. i held her arm as if it were the most precious thing i had ever touched; the cure to hate, the beginning of time. When she failed twice, I pushed fear and shame aside, and did what should have been my job to begin with - my patient.
One gloved hand on the needle, the other never letting her arm use it's own strength, her head ever so slightly turned to glance at me. Reposition, with the vision of sense in my fingertip, the flash and I was in. Watching the lifeblood of this woman, stronger than i could ever, ever know - one of too many - I nearly wept on her, at her bedside. All tenderness, calm and gentle voice, I humbly offered my thanks; hoping for an answer in this bottle.

wisdom in the wake of the beatdown

2007-02-13T20:03:00.000-05:00

the last two nights at work were brutal. someone called in sick sunday, and i got saddled with 19 or more patients on the cardiac unit, followed by monday where 2 people called in sick and one was late and we just got creamed, every last one of us; it was just brutal.

medicine is hard in ways that nothing else is. one - you need to understand complicated medical information; two - you need to negotiate with patients who are sick, afraid, angry, stubborn, sometimes demented and they have family that have a whole other agenda and range of emotions about the situation; three - the doctors don't tell the patients ANYTHING, and if they do? well it' not in english (or spanish, or russion, or hatian...) it's in medicaleese; four - whatever you may need, whatever your emotional state is in that 12 hours, it takes a back seat to caring for everyone else; and lastly - even with shift work, when you get to turn off your pager, walk out the door without work to take home - you take it home, if only in the exhaustion of having cared all 12 hours long, for a multitude of people.

things happen in a medical setting that don't happen anywhere else, for the most part. bleeding, vomiting, excruciating pain, wound care, intubation, tube feeds, cardiac arrest, reaction to medications - seizures, respiratory arrest, skin rashes...oh and the infections of all shapes and sizes and infectious paths. how this manifests in our minds, on our emotions - both in and out of work, yield gallows humor, misplaced anger, the desperate need to talk about anything else, the desperate need to talk about it, the desperate need for silence.

there was a poster around EMS after 9/11 that said "you take care of them, who's going to take care of you?" i thought about it a lot. i thought it was brilliant.

I have walked a long, long road to learn to recognize the value in self-care, that there was such a thing as self-care. I learned early on that i sucked at it. So it was quite a big deal that although I'd signed up for overtime for tonight a few weeks back, that when it came in the wake of these two brutal shifts; that i thought well enough to cancel it. It took a conversation with a wise woman in my life - we spoke not directly of it, but eventually. She asked me pay attention to the joy in having the choice to make regardless of what i decided to do. She would never suggest a course for me, it's why she's so great.

I stayed home and now i'm trying to decide, chinese of indian? the snow is falling and i'm in love with it. Self-care, how fantastic.

whoever revered medicine wasn't paying attention

2007-02-05T13:53:00.000-05:00

or at least, they were either a surgeon, often bathed in myopic view of their own greatness or they were in research and discovering new ways to improve health. For whom?, is a great question, since most of the newest anything is expensive and near 50 million americans are without healthcare. In fact these folks, the under- and un-insured, are often the sickest, most in need of surgeons and the latest and greatest medicine has to offer - but it's a bit like caviar at the russian tea room; they'll never see it, taste it nor enjoy it.

but my rant today has nothing to do with the gross injustices against low income, under/un-insured folks -but about my days with them and what they're really like. Today, there is considerably less mystery behind what 'we' in medicine do. With the likes of ER, Greys Anatomy, Scrubs and my personal favorite, House -the doors of the hospital are wide open like some reality t.v. show, with the exception that much of it is sensationalized for your viewing pleasure.

when i entered PA school, I imagined I would be living "ER" when it was all done. I was going to get everyone and anyone coming through the door. I would diagnose heart attacks, stroke, stitch up lac's, correct acute metabolic disturbances, and respectfully turn away the drug seekers.

yea, not exactly.

mrs p was an elderly overweight hispanic woman with a host of medical problems. she had heart problems, she was diabetic, she was completely blind in her right eye and could only see blurry figures from her left, she'd had 2 strokes and we were worried her third might have landed her here in the hospital as she's passed out and fell one night in her home. She was a fiercely independent woman, who lived alone and had a home attendant to help with not being able to see things, but she still controlled her own life. I admired her and related very well. I admitted her that sunday evening a week ago and one of the things i first realized was how her previous stroke had affected her.

there is the part of your brain that is in charge of speech, and then there is the part of your brain that is in charge of language. The connection between the two for her had become somewhat faulty and though she knew the word she needed, she often "couldn't find her words" so it took her a long time to tell you something. it wasn't a big deal so long as you're patient - which i was. i really felt for her (see overnight, overtime 7:29pm) and made sure to tend to her.
I saw her the next day and followed up on her making sure everything was being evaluate properly.

well i was off for 3 days and it seems it just takes one doctor to fuck things up and maybe not even in the way you imagine. the bitch of it was that the doctor taking care of her is this incredibly intelligent and capable doc, except she is stereotypical in that she spends more time on learning and teaching other doc's than listening to her patients and teaching them. she has a shite bedside manner and i walked back into the wake of it on friday morning. mrs p had been
medically cleared - no stroke, no bleed, no heart attack, no broken bones. now she'd been in bed all week and was deconditioned, but nothing some physical therapy wouldn't fix.

the ambulette folks came to the front desk asking for mrs p and i was caught off guard. who cleared her and why didn't anyone tell me? ah, the life of a hospitalist pa. a few moments later, the nurse came to tell me that she was refusing to go. "what?" who refuses to leave and what was going on.

i walked down to her room expecting to find the kindly woman i had admitted. what i found was mrs p, sitting in the chair clutching her sweatpants and she was furious. i tried to ask questions and got interrupted by her several times trying to tell me about pills she wasn't supposed to get, and who would answer her questions, not the doctor, no, what doctor? she was furious and stuttering and frustrated and i was one of them. The nurse, the nurse manager, the social worker and both ems guys were in the room or door and crowding her, cajoling her, telling her in no uncertain terms, she was cleared, she couldn't stay. I one, by one, removed them from the room, either by instruction or patience or request.

when it was just us, i tried to apologize, but she couldn't hear me through her anger. and anyway, i was just another white coat trying to coax her out of the room, right? it was clear what was going on pretty quickly. i sat there for 20 minutes - an eternity in hospital time - and i asked her to tell me what was wrong, and what did she want. it was heartbreaking when in the midst of all this she stated in her stop-start speech pattern, that what - she - wanted was to - be - treated - like a decent - human - being.

the players in healthcare. so much is demanded of them. compassion gets crushed by time and the weight of so much, so often, so fast, so easy to forget about oneself until there you are, rushing through exams, notes and deaf to patients pleas for explanation, instruction, compassion.

i stayed until she was done. i kept everyone at bay. i waited until she had no more to say and set at once to her one demand - to get her sister on the phone. after about 10 minutes alone, i came back to see how she was. she'd put her sweatpants on in so far as she could, mid-thigh and was working the clasps of her bra with limited sight and arthritic dexterity. my heart made a sharp cracking sound. i walked into the room and knelt at her feet. I asked "can i help you with that". She paused, almost imperceptibly, her lips parted as if to speak, but did not. "honey, let me help you with that" i said softly resting one hand on hers and she let go of her bra.

I unfastened the clasps and wondered how she ever manages on her own. I handed it to her, to let her lead, and I fixed the back. I then helped her stand, pulled her sweats up quickly and helped her sit back down. I found her shirt, put it on her then helped, one shoe at a time, gingerly with the painful foot. She sat there, dressed, calm and grateful, though still not diffused. I asked nothing of her and except to inquire if she needed anything else. When she said "no, thank you" i left quietly and returned only when her sister called.

I told her sister what had transpired, and we agreed how to best get her to the place she needed to be; making her OWN choices. When the call ended, i returned to her room and asked if she spoke with her sister. She said yes and i then asked her what she had decided to do. She reluctantly said "well, i guess i have to go to that place" and rather than try and convince her it was best for her, i simply said this: "I think you made a good choice. I think you'll do really well and will be home in a weeks time, able to have your life back without worry of a fall that could land you permanently here or there". She shrugged, not entirely convinced, but still listening. "may i call the ambulance back for you?" i asked, and she agreed.

she looked none to please when she left, but i hope that somewhere she felt heard and not tricked into going.

my co-workers thanked and high-fived me for 'getting her to go' and while there was some good natured joking about it; i hope her dignity was restored before she left and she remembers that someone gave a shit, even if some did not.

overtime, overnight, let it just be over...

2007-01-31T02:47:00.000-05:00

wingnut says she has no life. "let's do some overtime"
"why?" i asked
"because i have no life and i'm broke" she replied laughing
"i have a life and i don't feel broke. but wtf, ok, when?" i said , confering once more that we might as well be conjoined twins.
"tuesday, the 30th" she said looking at the overtime spots on the schedule.
"word. hook us up." i said. famous last words.

7:03 pm

i take signout from one of the three that had been on telemetry, where i would be tonight. i went downstairs where the other two PA's were still finishing with patients. I should have seen it for the bad sign that it was. But i was too busy whistling "bringing sexy back" and greeting the daytime RN's as they were leaving to notice.

7:10 pm
my first admission, a post-cath patient. piece o cake. one of my patients is the lady who will not stop whining but there she is smiling away as she walks her family to the door. "how you doing ms r" i ask as i smile and say my hello's to the family. "ah you know, i'm feeling betta but my stomach, it still hurts me" she says never pausing. i wish she'd just keep walking out with her family. alas, she is due for a bypass on friday and so we are graced with her presence a few more days - but worse, all night for me.

7:29pm
new admission on the other pa's side of the board. no problem i tell the internist, if he's doing two post-cath's on the southside, i can manage this and he can do mrs L when she comes up. i got it. so this lol (little old lady) roles up and ask her to tell me what brought her into the hospital. i am gently smiling, touching her arm in a gentle manner and leaning in to listen. she takes quite a long time to respond and i wonder what her mental status is when she apologizes, and says she had a stoke and sometimes she can't find her words. this is when i know it's possible to fall in love instantly. i want to do everything possible for her and i tell her the nurse will bring her to her room and i'll be right down to take a full history from her and take care of her.

7:45 pm
i try three times to down and do my admission, but another one has arrived, the whiney lady wants pain medication and attention, one of the patients is missing a bunch of his meds in the chart so the nurse needs me to put it in so she can give it, another patient has low blood pressure and the nurse wants to know if i should hold one of this meds (which requires me finding out who the hell he is), and one more patient needs something for sleep. i need something too. DINNER.

8:11pm
I finally get down to mrs P room and she's in pain. she tells me how she syncopized or "fell out" as we say in the city and we talk, and i take her history. it a slow process since her stroke left the part of her brain that can find the words and the part that speaks are not talking to one another very much, so everything is slow to come and i stand patiently, helping her when i know which words come next. she looks all the kindly grandmother, la abuelita, and i take a very long time with her without any complaint or rushing her. her history is complicated: hypertension, diabetes with complications, peripheral vascular disease with bipasses, corinary artery disease and an MI, possible sarcoidosis, asthma/COPD, blind in her left eye and mostly blind in her right, stroke, chronic UTI's and stress incontinence...gettin old is harder for some than others. the SA comes in to take her weight and we help her stand and then get back in bed. her left leg is very painful and i order x-rays for hips, and her whole left leg. she fell and this is different pain for her. we finish after a long time but it was worth the patience.

9:33pm
still hungry. want food. next admission is here and 3 other patients want my attention. One pt family needs to talk to me because their 35 year old son who was in a car accident and the trauma called a heart attack where he was without oxygen for long enough to make him brain damage; well he has wounds on both his ears from lying on them all the time and their not healing. i apologize for making them wait when security is trying to throw them out and tell them i will tend to it. another patient who had a catheter snaked up his femoral artery wants to sit up, but he can't for another 4 hours. he is none to happy, but grumbles he will try. 1 am i tell him, and another has belly pain but falls alseep before i can see him. just as well.
I finally make it into see Ms J and i pull up a chair and we chat liken we're old friends. i use a few local euphamisms and my own local flava, and we're both laughing pretty good. I take a little longer than necessary, but she is smiling as the RN finished with her and resting comfortably.

10:02 pm
really effin hungry now, but i need to enter labs and finish the electronic charts for both my admits and remind myself i still need to see my post-cath lady who came in when i did. who's idea was this anyway to come in and do overtime. wingnut. she calls me and says "what the hell man. seriously. are you getting slammed?" to wit i reply "and whoooooo's idea was the overtime?" and she giggles on the phone. "i'm hungry dammit" i grumble. "me too, but i just got a new admission" she says. "ok, go do your admission, i have to enter all this shite anyway, call me when you're done and we'll eat" i say. "ok bye" "ok bye". All our conversations sound like this. we scream in whispers, we laugh all the time and we talk in low covert tone, always ending with some smartass remark followed by "call me later, ok bye"

10:59pm
i call the other medicine floor "is jenn the pa there?" i'm put on hold. She picks up and says in the unhappiest voice "this is jenn". I pause for effect then say in a low long word with the O drawn out "Foooooooooood" and she giggles. "I need help" she says "I need food" i say. "I have don't know enough spanish to do an admission with mrs L"
"ok, if i come up and translate, can we then eat????" i plea
"it's not my fault i can't understand her, i'm hungry too" she blurts
"ok, ok, yo hablo para ti and then we eat" i appease "why's she here?"
"dka" she replies
"crap, maybe she's hungry too" i say smartly. she giggles. "I'll be up in 2 minutes"
"15 minutes, got it" she replies smart-assly
"ooooh. ok bye"
"ok bye"

11:16
i finally feel like no one needs me for two seconds and i leave my floor. i arrive on the other medicine floor and wingnut and i go into Mr L's room. It's dark and the light from outside flows in a glow and the sky is hazy with snow, snow, snow. Apprently it's been snowing for hours, but we've been a little busy. I stare like a tiny child with the prospect of a snow day. I ask wingnut what she wants me to ask, when i know damn well what to ask, my brain is already begining to fry. we go into this hilarious bad spanish inquisition but i start by telling the lady, i am a gringo and my spanish in only slightly better than jenn's as i thumb at her. she laughs and we're off. when i'm done and jenn is about to do her exam, i get paged from my floor. bugger.

11:54pm
i come back downstairs and my post-cath man says he cannot lie flat anymore. i try and explain to him that if he moves before the very large vein in his groin has healed well than maybe a clot can break off and lodge in his heart or worse, his brain and he could have a big heart attack or stroke. he says he understands, but still wants to get up. i don't think he understands what understand means. I convince him, one more out of his life maybe uncomfortable, but won't kill him, whereas moving might. he agrees not to get up until 1 am. christ.

12:34am
i have both my admissions done but there are holes in the paperwork, in my brain and now i'm about to go into dka - so i put everything down and go to the office and heat up my watery chicken soup. it's delicious. not really, but i'm so hungry, i don't care. i send some emials to unplug my brain for a bit, because i know the night is just getting started. i manage 15 minutes - an eternity. wingnut comes in finally and has a sandwhich. she is blathering at me about all her admissions and madness - it's like background music, like a waterfall, like the beeping monitors. i hear it, but i don't. then she says "let me see if i have any cheese". She's been seeing this guy from match.com who originally seemed anal and stuttering at best, and now after an evening with him, quirky though he is, he is also totally nice, if not cheesy. super cheesy in fact. bad emails like "i'm gonna have to call the irs to levy a distraction tax against you, i can't get anything done" and at worst, a percy shelly poem. drip, drip the big fat stinky cheddar cheese. so now i call him cheezy or the big cheese. she laughs and complains, but secretly, or not so secretly loves it. who doesn't love attention. she has mini-cheese. he is staying up to hear her voice. cute.

12:55 am
next admission, and not even on my floor. we are FULL. i go upstairs for my 3rd admission for the shift. he's a big gruff looking old guy, another dka (diabetic ketoacidosis - body not getting sugar, breaks down shit to shift things and toxins build up and make you wig out or fall out) he's pretty tired and at first i can't tell if he's sleepy from the acidosis or because it's 1 am and i'm waking him up to ask him his whole lifes story. i decide its the latter and proceed slowly. my partner, wingnut, is trying to draw blood without being able to see any veins. oy. it takes the doc to come after we stick em twice. poor dude.

1:45 am
admission number 3 done and I am NOT calling his doc to wake him now, i'll call in the morning. i enter labs, check other labs, put out a few other fires, a nurse calls my name every 5 minutes. there will be no rest tonight.

2:43am
a patient wakes up to use the loo. she suddenly feels chest pain, sweaty and dizzy. shit. her blood pressure is in the shitter and so is her heart rate. the rn smartly starts fluids. i kick myself for even having to think about it, and check on her. she's like my grandmother, just had a stent put into one of her major arteries and she didn't want to bother anyone, but...

3:30am
sleep is slowly and clearly not becoming an option. meds for this one, that one can't sleep, someone has chest pain, follow up on the labs post-cath, none are done...arghghghghghh...

4:30am
another admission. where??? the floors are full. down in the ER. cripes. fortunatley for me, thought not for her, my lol is non-verbal and has a positive O sign (her mouth is gaping open and in the shape of an O, she's demented). The history is short and sweet from the paperwork, the exam is quick and no conversation. I'm done by 5am. Phew

5:10am
i threaten wingnut, we NEED a break. let's make hot chocolate and go out in the snow. she agrees. as we're standing in the ER bay with out mugs of hot coco and the look of wild animals, but official looking: long white lab coats, pda's and books stuffed in pockets, pens and name tags, blood draw kits and turnaquites, we look and feel a little like an ER episode. i laugh like mad. i love that show, and now we ARE that show. i laugh and say we need to go inside, my pants are cold and when they touch my leg i shreik. um, i don't shriek.

6:03am
wow, it's tomorrow. i update my signout when a patient starts to have runs of quad and trigeminy. i don't even know what that means except that it might precipitate a heart attack. for the love of pete, NOT BEFORE 7 AM!!!

6:54am
wingnut needs me to help draw labs on our abuelita since the lab failed to. WHY ARE WE PAYING THEM???? it will be my last act. then out into the snow and ESCAPE...i hope.....

where did all these stupid people come from???

2007-01-29T22:59:00.000-05:00

Mondays are hard enough. doc's coming in the beginning of the week after a weekend full of events for their patients that they need to attend to, and subsequently, meaning i have to tend to their needs; their being the doctors, the patients and everyone in between. It's cool though, that's why i chose to be a PA; to be that spoke in the wheel where the coordination of care occurs and the patient ultimately gets some fine fuckin care. yep, there we are, physician assistants, the center of patient care. Funny thing about being in the middle of it all, everyone wants a piece of you.

It started with a bang when i walked into the Medicine Department PA Office. Oh yeah, we are so special we have our own office. Yeah baby. It is the size of a bathroom, with 16 or so lockers in there the width of a shoe, and it's two to a locker and they're on top of one another. There's this table in the middle of the box that's something out of my niece's tea party set with 4 whole chairs around it. A desk with a computer on it that the administrators constantly pull the solitaire game off of and one smarty pa keeps reinstalling it. A instant coffee maker takes up half the desk that has this sludge in it on fridays, saturdays and sundays when alex works, the only person who makes it and i am always suspicious of it's close resemblance to a code brown (use yer imagination). Next to that is this folding t.v. dinner tray with the microwave precariously balanced on it, with plastic utensils, napkins and sundry condiments piles atop that; just one good hip check would make quite the yard sale in our little sandbox.

The chief PA is always complaining about how close the microwave is to the desk where she does most of her scheduling and that she's getting irradiated. Makes me think she can be a spice now. Next to the house of cards microwave stand is the worlds tiniest trash can. And if it's not small enough, let's mention that there are there cardboard boxes everyone uses from the cafeteria - they're a simple design, fold open, put your food in them so that you don't have to carry "open food" through the cootie-filled halls. Except they don't have a top and once yo shit is upstairs, people throw them away! ACK. They don't get recycled and most folks don't even break em down before throwing them into thumbalina's trash can, so in about 5 boxes, the can is inefficiently full and the chick who empties the trash rarely comes around. Do you think folks stop stuffin stuff in there when the trash reaches the top. No siree. We have masters degree's and can care for critically ill patients, but we're still human beings by god and we will NOT be the ones to take out the trash. I digress.

So I come into the office with my partner in crime, Wingnut, and we're late. Normally this isn't a big deal, but one guy called out sick, one terminally lazy drama queen is late because her car broke down and even though we're going to simply put our names on the board on the ward then have breakfast, we aren't there when she wants to dole out the census and she's irritated (and irradiated).

Not only that but one of the shit-stirrers is telling her about this most egregious act yesterday when an overwhelmed house attending was overburdened with patients and wanted me to take one of his since the private doc agreed to move him to the PA service. I had discharged 3 patients already, had a decently light load and liked this doc and simply said "sure, no problem, happy to help". But when Mr Stick-up-his-ass found out I'd been so helpful, he began to vomit volumes of reasons why this kind of behavior would only lead the the landslide of attendings ignoring the protocol for patient admitting and management. That we would be the lackey's for these house officers and schlep their shit instead of the honorable service we were. Oh fer FUCKS SAKE. So the hospitalist that day saw no issue with it, and said, we'll take em - meaning i will take em. Good. But Mr personality can't let it go. And there he was a full 24 hours later winding the chief up - which was all to easy since everyone was late and she loves to be her control-freak self and protect the PA service from these, undoubted evil-doers. IN fact, I'm willing to bet he can make a case for them having weapons of mass destruction.

So she spins her double wide butt in her chair and accusingly asks me "What happened???" as if I'd set her house on fire and left her family naked in the streets. I calmly replied "Well, Doc M said he had a PA case he's been taking care of but that Dr R was taking him now, and Dr Z had already seen him today, and then gave me the lowdown and thanked me profusely for helping him out." She continued to stare at me and then asked "Why did he do that?" Now, I thought this an incredibly stupid question. How am I to know the thoughts and desires of another human being, much less one that I am so tenuously connected to? I could guess, but that's not what she's asking me. In fact, what she's asking me is 'how dare he, when he knows the rules'; a rhetorical question in fact. But I couldn't and had no desire to make that leap and simply said (a bit too smartly i think) "How can I know what he was thinking? I don't know why, I can only tell you how or what he said/did" to which her peanut sized brain rejected this information and simply gave me her version of 'does not compute' which sounded like this: "I don't understand what you're telling me" in a volume slightly inappropriate for our proximity and emotion. I wanted to say "what part of that English phrasing didn't you understand? Am i speaking in tongues? I can't read the mans mind and anyway you want to know why someone would, in your opinion, take advantage of the PA staff, to wit i would reply, they didn't, i did him a favor and so fucking what?????

The whole thing was quick, tense and not so pretty. I felt I had been dragged into overstepping my role as newbie PA. Great way to start a Monday. But it gets better....

bits and pieces

2007-01-23T00:55:00.000-05:00

my first 24...
which is to say, my first 24 hour shift at work. yes. 24 consecutive hours at work, taking care of patients. i know, i know, all you non-medical people are thinking (with a great big HARUMPH) that this is negligence, stupid and downright dangerous. perhaps even a few of you primary care folks are thinking it's a little crazy. well, it may be, but if it works for me, this may ultimately mean that i work 2 days a week instead of my current 3. Imagine it, 2 days a week of work and full pay. What would you do to work 2 days a week???? probably 24 hours.

I had to get up insanely early to get to work this morning, so i've been up for 21 hours already. My day shift was pretty decent, 8 patients, no emergencies, plenty of work, but status quo really. Highlights from my day:

The 83 year old lady who insists that she 'sneezed' her NG tube out. Yes, 16 cm of naso gastric tube, taped to her nose. she cannot walk, cannot get up herself or barely lift her own head, but wanted me to believe she sneezed so fiercly that it blew her tube out. 3 times. UH-huh. I loved that one. Mind you I have a heart, I didn't put it back in. we'll figure out another way to feed her.
the woman who went into cardiac arrest, only to suddenly sit up, tell is she felt much better now and no, she didn't need anything for pain. really. Oh and could i adjust her donut so it's right under her? she gets terrible sores if it's not positioned just right.
colleague (and i use that term loosely) who during a break announced that some people should just die, i mean, it's like darwin said, natural selection. all jaws dropped...except hers of course. i still can't figure out how she escaped darwins well explained observation.

I thought it was all a stupid idea, the other 12 hours when 7 pm rolled around
and i wanted to lie down. yes, lie down and never get up. i thought 'maybe this IS dumb. maybe no one should work more than 12 hours at a time." Then i had a burrito and an orange and was a new woman. sadly, my recent GI distress had not entirely resolved and i had to sequester myself in the bathroom and corners to save my co-workers from myself. Good thing the hospital is such a stinky place and most things can be blamed on patients.

No sooner did i finish eating than an admission was on her way up, another patient was threatening to die and a third needed a central line that a critical care fellow was pleased as punch to do when i had a minute. yeah. i got a minute. ready, set, GO. I kept trying to write the orders for my new lady, while the RN let me know that the minute the other ladies family left, so did she, literally and permanently. I did the usual EKG, check vitals and pronounce her dead then paperwork, paperwork. The critical care fellow was pestering me and I loved the small talk he made while jabbing this lady on a hunting expedition for her femoral vein chatting about how low her platelet count was (the little buggers that allow us to clot and STOP bleeding, which he was making her do). After explaining the procedure to her (since he never bothered) and talking her through it (despite getting looks from him) I nearly grabbed the huge needle and stabbed him with it. When I finally got to the lol (little old lady) who was my new admission, she patted me on the hand and said she was in no rush, like the kindly grandmother she surely was.

It's 1:10 am now and I need a GD nap. I am now silently but very purposefully making a mental deal with my patients. I'll let them sleep, if they'll let me sleep. We'll see.

4:24 am

i was dreaming of my bed; my big, comfy, waiting to swallow me up bed. i dreamt i was out in a field somewhere lying down. i was so tired, and the ground was hard, but i didn]t care because of how tired i was. every time i rolled to one side my pistols dug into my hips. i kept readjusting them, knowing i couldn't take them off, knowing i might need them any second. i felt far from home and wondered if the sun was going to come up soon. it seemed oddly warm for winter, but i didn't care, because if i couldn't be in my bed, i could at least be warm.
"How many?" i heard her say, "two, oh, one and two more coming"
I reached for my pistol and it was vibrating. Odd, i thought, until i opened my eyes, not to see the dawning sky, but the call room cieling and my pager going off. We had another admission and I had to get up. The luminous face on my watch read 4:20. Ah well, at least i got a small nap, and would soon be in the bed i was dreaming of.

off to see the wizard...

2:18 am

2007-01-10T02:18:00.000-05:00

The nurse is hoping like hell she doesn't die tonight. She's never done a post-mortem work-up and by the sound of it i'm guessing she doesn't want to start tonight. Mrs G never should have been intubated in the first place. She's 87, she's been bedbound for 3 years, she hasn't said a word for over 2 years and she's contracted in all her limbs and neck. By the look of the earwax blocking up both ears, and the dry skin that covers her tiny head that has fallen and made a pile in the crook of her neck - no one is caring for this woman. This is her end; or at least the end of this.

The only reason they put the breathing tube in is beaurocracy. Her health proxy died, and the doctor able to renew her DNR (do not resuscitate) was late coming from another hospital - and when her oxygen saturation dropped to 77, they tubed her. I had her that night she was admitted. I felt sorry for her that the paper pushers failed her, that some home health aide and their agency was collecting money for what they weren't doing, and that she was trapped in that crooked shell for awhile longer.

The paper pushers have been satisfied a week later, and palliative care made sense to the pushers, so today they took the tube out and she's breathing on her own. Who know's for how long. I went into her room earlier to see her, place a warm hand on her, silently wish her well, and to sit with her for a bit. There was no reason to, no medical need, but a little company is always nice - perhaps even now.

We're all waiting for her to die now. I'd just like to see her get to leave of her own volition.

Escape from fatasia

2007-01-01T14:53:00.000-05:00

I am not a runner, not by any stretch of the imagination. While i did up and run 20 miles one day - it was the the energy of the park in all it's splendor and my crazy friends that enabled me to do it. The days of me up and doing whatever physical thing I might get into my head seem to be numbered; but I still push it a bit.

My housemate and I are tired. Which is to say we have tires of fat around our middles. We do not care for our tires and when we joined a local gym, he declared this was to be our "escape from fatasia". He's not much on will power but he does like a challenge and when I told him I could drop 15 lbs before he could, I believe his response was "fuck you, you cannot" - and it was on. Today was the beginning. We walked in the rainy lovely portland-like day 4 city blocks to the gym and in the locker we doffed our shoes for the 'weigh in'. The scale appeared to be a relic from the 1970's and the post seemed to be about ready to abandon the base sometime soon. He freaked a little after weighing himself and then I noticed the scale wasn't zero'd. THAT was a project.

In the end, J weighed in at 121.50 lbs at a 5'3" and I plunked in at 162 at 5'8". Neither of us is fat, and we aren't looking to pick a fight with folks who think we're freaks for engaging in this little challenge - but the point is that through our own lenses we think we'll be happier with this small change that is much larger and heavier than 15 lbs. I will be curious to see if this is true. All I know is that as I age the pear phenomena is hitting me and I don't much care for that; as nutrition, yes, as a body shape, no thank you. Eek.

We don't know what the bet should be, what is worth winning and will sustain our determination besides bragging rights - so we're taking all suggestions. In the end he decided, quite responsibly I might add, that 10 lbs is about all he could/should spare. I upped the ante and said I could drop 15 before he could drop 10. Ha! I've never tried to lose weight before, not with any real effort (or success, except for that time I was REALLY sick) so this should be interesting.

When we walked out of the gym I handed him my sweatshirt and keys and asked him to take them home and buzz me in when I got back. When he asked where I was going, I simply replied that if I was gonna win this bet, I needed to take my trunk for a run around the park, and off I trotted up toward the park in the misty brooklyn afternoon. No, I'm not a runner, not by any stretch of the imagination, but I am one stubborn and determined bugger.

The new year and the beginning of time

2007-01-01T10:40:00.000-05:00

Every year begins on day one, January 1st to be exact. Each society marks it with some kind of celebration, cultural custom and we vow to begin anew. I like this idea even if my society has made this much like a bad 30 second pop music video to be forgotten once something sneezes and gains their microscopic attention. This is a gross generalization, as all generalizations are, with some blade of truth surrounded by the crap that I elude to in the first place.

What must that first day have looked like? Time itself being such an assumed and confusing concept. I've occasionally try and grasp the primordial ooze, big bang theory, but surely before that meteor (if you believe it, maybe you like some other story) things were existing and time existed and when all did it begin? How did it begin? My little cerebrum barely able to process smaller complex concepts. I shake my head like an etch-o-sketch and clear it.

I didn't make any new years resolutions and hardly "celebrated", save to spend the waning hours of 2006 with good friends in a Brooklyn apartment with rice pudding, chocolate cake (home made, yeah baby) funny stories, and a quiet and warm love; one of the ways I do love to spend my time. We raised tiny glasses of champagne and counted down our own last 10 seconds and then one irreverent friend quietly sang 'Auld Lang Syne', (interestingly enough a song whose roots lay in a Scottish song written in 1796). While she is know for her bartending skills and fantastic delivery of dry and sharp wit and forwarding the best online nonsense - singing is not something any one of us expected from her. While she shy'd a little, she did recite all the lyrics for us; we were none surprised. Is was the small evolving moments like this that made those last few hours and the first few of 2007 worth smiling over.

I fell asleep not long after driving some fellow party-goers back to their brooklyn abodes and tossing myself in my beloved bed. I was thinking about this delineation, the this year and that year, how some use it as a demarcation to reset, refresh, start anew. However we may have slaughtered this idea by smearing it all over the t.v., radio, other media ad nauseum, it is the kernel, the seed that I love. The idea that people believe that in some place, they could do more that aspire to be and live how they want to be/live. They can too and I hope more of them succeed in realizing this, then living it. I think the world would be a better place if they did.

As for me, I am happily letting go of socialized habits and recreating my life into the shape that fits me, as I fit into everything else. I laugh when I think of how concrete my life used to be, definitions, declaratives, my comfort zone protecting me from...from what? lol. So I stretch, and create, and learn, and love, and sing, and dance, and laugh alot. And if that sounds a little too hippie, touchy-feely, etc - get over it ya buggers.

peace out

he got his last prayer. he got his last meal.

2006-12-30T11:07:00.000-05:00

I think justice was served...
It's closure for a lot of people...
I think it was a very generous death for him...

Saddam Hussein is dead. He was hanged yesterday by verdict of an Iraq court. Folks here in the US have many comments about what this means to them, what they think it means to the world.

Justice. An eye for an eye. Punishment for torture and cruelty. Is it that simple? This makes me think of 911 - even though they are not related the way the media brainwashed us into thinking. I mean that a group of men hijacked some planes and crashed them into two tall buildings killing 3000 + people and our reaction was - who did, go kill them. What was our part in it? Why would someone want to fly two planes into the buildings in the first place? How did Saddam get in power? Someone must have liked him. Hell, 51% of America liked Bush, for awhile. I guess I just hate the knee jerk reactions that happen. I'm not sad Hussein is dead, I'm sad he ever lived the way he did. I'm sad for all the Afghani people we killed in hunting Bin Laden, if he was even the master mind as the spin told us. I am sad for the 51% of America who thought Bush would take care of us, lead us, give a shit about anyone except his friends and pocket. I'm sad that someone thinks hanging is generous.

Death is what it is and it will happen to us all. For all the folks who don't get their last prayer, last meal, what does this mean for them in their death. I know what it means for those of us left behind to sort it out, each in our own way. It is true, Hussein can no longer torture people, rule badly, cause any more harm... at least not directly; and that is good. What we do with his memory is another story.

Whatever he did, whatever he stood for - let those of us left behind be anything but that, and put something healing out there for the world. It's all we can do, ja?

the balancing act

2006-12-30T08:23:00.000-05:00

Context is key. This might be an excuse or it might just be that 'it is what it is'. I'll let you be the judge. Because that is what people do; hell I do it myself to myself and this post comes from that place. Last night I found myself laughing like mad with my co-worker, wingnut, about a few of our patients. Already that sounds awful - but it's true and I refuse to regret it. I will likely always twist this one around in my brain. It's like watching someone slip and fall on ice, or get their tongue stuck to an ice cold pole - that shit can be incredible funny at someones expense. There is humor in a great many things and we of the medical underworld laugh at people's illness. We laugh at vomit, at diarrhea, at jaundice, at screaming and gorked out patients. It is appalling the things we find funny and what does that say about our compassion? I think you can take it on a person by person case - because surely there are some callous assholes among us - but they tend to stand out by being genuinely annoyed by the patients - the people they dedicated their lives to caring for. Oh the irony in THAT one. I digress.

So who does my humor hurt? Well, I can tell you it makes my co-workers laugh until their sides hurt and I'm cool with that. Laughter is the best medicine and really, we need something to balance out the pain and suffering we see, we care for, we make decisions about how to lessen, lighten. I love what I do. I listen to my patients. It is the connection to these folks and the lessons they repeatedly teach me that I respect. I fight for them, for their care, for the nurses to give them respect, for their doctors to tell them what they need to know, for their family members to understand their situation, for the fucking bloodsucking insurance companies to cover them fer fucks sake. I'm no saint, and not even that unique really,after all, it's not about me - it's about them.

And they make me laugh and that little gift keeps me open, makes it possible for me to sit in their suffering and illness and frustration and give them whatever I can. I understand the rules of politeness, of respect for not saying stupid shit that taken out of this context can be very, very offensive. I try and never say anything I'm not willing to have anyone overhear and I'll stand by my words. Say what you mean and mean what you say, says I.

Wanna hear a funny story?

letting go

2006-12-29T23:25:00.000-05:00

Responsive only to pain, she barely opened her eyes when i ran my knuckles on her sternum. Anyone else would have punched my lights out; if only she could. But she's way past that now. Her blood pressure is dropping, her white cell count is climbing, fever is only a matter of time. The antibiotics aren't touching whatever is causing the infection. Her kidneys are shut down and we haven't been able to drain the toxic waste from her abdomen because it might drop her blood pressure in the toilet and cause a heart attack. Her tube feed backed up to the top of the tube this morning and we suctioned tube feed from here lungs. Sepsis, the nemesis of healing, the hospital ward welcoming committee if you stay long enough.

She's been here for 22 days; it started when she passed out at home. She's only 63, and she's trying like mad to leave us. Is she even in there? I wonder when I go in to draw blood cultures to see what's growing in her bloodstream, making her sicker. The stream of doctors and consults have come like a river of advice that the family watched flow by, unabided. Her prognosis is so poor, and everyone has laid it out for the husband, the children. The merciful thing would be to sign a DNR/DNI (do not resuscitate, do not intubate), give her pain medication and let her rest. She lays there with her mouth slightly gaping, lines and tubes sticking out everywhere. Where is the love in this, keeping her plugged in and turned off - who is this about?

The last sentence in the note from the attending reads: "....have explained prognosis in detail to family, answered all questions requested DNR/DNI for patient. Family members fully expect a miracle. Full code."

Why?

defervescence

2006-12-27T23:48:00.000-05:00

He was walking toward her, bare-chested, a Japanese black wrap covering his lower body only slightly darker than he; the hilt of the sword gleaming in the sun, swinging alongside as he strode toward her. His face looked peaceful and she began to think this was a merciful end as he gracefully drew the sword, towering over her. "You need to sleep, but first you need this" she heard him say, knowing only a friend, as old as he was to her, would she let get this close. She was sure she heard the long steel blade sliding out of the sheath, almost like the sound of water over rocks. The vision of him blurred as he approached her and she could feel her head being lifted. Soon it would be over and she couldn't find regret it in her anywhere, she let her eyes close. Swallowing hard, she thought there were pebbles in her throat. She tried to swallow once more then tried to speak, but the river was flowing and she decided drowning was just as good. She seemed to cool from the inside out with each breath, the water in. Her head felt light and she began to hum. She heard his laughter as if in another life and then she was floating, her legs and arms bobbing like paper things, soon wafting down into a heap.

Standing atop a mountain the sun shone brightly on her, the swaths of farmland on the near vertical slopes created a patchwork, as if a giant quilt had been draped over each peak. Looking around she could see the small town below here and the Amazon River winding off to the South. A small dark-skinned barefoot boy in brightly colored clothes walked up to her and smiled. She smiled back and tried to speak, but could not find her voice.
"Tienes sed?" he asked in a small and steady voice. She nodded yes and he disappeared like a breath into a stone doorframe, the scent of sweet plantains as if air, and reappeared moments later with a small cup of dark liquid. She bowed toward him taking the cup and let her eyes close as she did this, falling into the liquid.

She felt warm, all over, and only when the breeze began to make her dry again did she open them to find herself looking down a soft wooded path at a person in a distance, a woman.

She was still so thirsty and found it hard to swallow. Maybe the woman would have some water to share. Hum staggered forward and when the breeze blew again she felt an ice cold chill. Her clothes were soaked through and she began to tremble trying to warm herself. The light was taking its leave and she tried to call out to the woman to slow down; she would never be able to catch up. A small cough escaped her tired throat and the woman stopped, but didn't turn. Hum's vision began to swim and her lids dropped like small stones.

The scent of sweat and something familiar made her lift her head and she felt an arm around her waist, helping her walk. "C'mon babe, just a little farther" was the voice soft, warm and familiar. Hum began to weep from a place deep inside. She was not alone, the woman who once showed her all the possibility in the world held her securely now, sitting her down on a nurse log. Hum felt a deep sense of longing rise up in her, making her weak, and without turning her head at all, she knew it was Daria.

"Why did you go?" she heard her own voice croak, barely a whisper.
"You didn't need me anymore, you know that" Daria said matter-of-factly as she wiped the sweat from Hum's brow and set her pack behind Hum to prop her comfortably so she could pull some water.
"I wasn't done, we weren't done; you showed me so much and..." Hum trailed off, knowing this was the weak part of her, off-center and small.
"You are so much stronger now and that strength came in the wake of my departure. You know that. You wanted, and I wanted, but our paths diverged and you didn't want to accept that. I understand. Hell, I didn't want to leave you either, but it was written in the wind. I still love you, but I don't need to tell you that." she said sweetly as she held the water to Hums dry cracked lips. Hum knew it was true, but the ache inside her from the excision of that connection was like a wound that never quite healed. She wanted to protest, but deep down she knew it was futile, false and instead she reached out and placed her hand on Daria's chest, resting gently over her beating heart.
"Is that why you're still out here? Are you trying to find him?" she asked. Daria smiled and kissed her gently on her forehead, like a splash of water to a fire.
"I know where he is. I'm trying to find my own way now. Have you found the beautiful princess yet?" she smiled radiantly. The question was serious but still silly sounding from such a strong, bold woman.
"She doesn't exist. I've stopped looking" Hum stated quite plainly.
"Good, you'll put out your own light looking and then how will she know it's you?" Daria retorted. Hum laughed, a deep sound vibrating through her ribs, it hurt her chest and her throat, but she laughed all the same. "I miss that laugh" Daria said wistfully as it filled her. Hum wanted to say that she didn't need to, but she knew better and their time was short now. Hum took her face in both hands and uttered 'a mountain keeps an echo deep inside itself, that's how i hold your voice'. She said it with a certainty Daria has never heard in her voice before. She kissed Daria lightly on the lips and as she pulled back Daria whispered "I knew you would find yourself. I saw it in you. And she's out there, closer than you know".
"Maybe" Hum whispered back and then let go of Daria and turned away. The sky went black and the rain began to fall. Hum walked for what felt like a very long time. The wooded path became an open field which fell to concrete. The buildings sprouted up around her and the noise filtered in slowly; a garbage truck, a fire engine siren, people talking loudly over the din. She was shivering and her head began to ache when she realized she was lost. How could she be lost? This was her home, wasn't it? As she shuffled down a street looking for a subway, she felt the hair on the back of her neck rise up. She stopped and looked around. Everything felt familiar, but still she knew she hadn't been here before... not yet. The wind kicked up and the chill ripped through her.

"Hum. Hum girl. Shit" he mumbled to himself watching her shiver in her bed.
"How's she doing?" Szu asked peering over his enormous shoulder.
"Not much better. I'm beginning to wonder if we shouldn't just take her to the..."
"no" she whispered through parched lips.
"damn girl, you were starting to scare me" he said turning back to her and smiling.
"thirsty" she mumbled, never opening her eyes. He wrapped one large arm around her as if she were a small child and not a woman at all, and sat her up. She sipped from a warm glass of water that had been by the bedside. "What time is is?" she asked.
"About 1 am. how you feelin?" he asked sitting back and relaxing a bit.
"I think I need some new pj's" she said pulling a soaked t-shirt off her chest, "but I think my fever broke" she said. He pulled out a thermometer and a minute later said "98.9, close enough”.

“Close enough” she whispered back still washed in the memory of where she’d been.

i CANNOT believe they left us alone

2006-12-26T01:15:00.000-05:00

1:01 am
I graduated as a physician assistant 4 months ago. I was hired by a prominent private inner city hospital 7 weeks ago here in the city that never sleeps and that's exactly what I'm doing right now; not sleeping. It's my first overnight shift, 7pm to 7am and my partner in crime is 3 weeks senior to me. We are like tweedle dee and tweedle dum, except I call her wingnut and she calls me window licker -yes, out loud. Our chief PA watched over us until midnight, everyone on the unit seemed to be "in for the night" and we had finished 2 admissions each. When the chief left, I looked over at my partner in crime and said "I CANNOT believe they left us alone" and we both started laughing like madhatters.
We are currently the medical professionals in charge -effectively the "docs" on the cardiac telemetry unit. Telemetry = heart problem . All I can think is, seriously, what the hell were they thinking; 'they' being the powers that be, our bosses. I can hardly believe they deem us capable of handling any dilemma which could consist of elevated blood pressure, maybe some unexpected vomiting, or maybe a BIG FAT HEART ATTACK. Really, what would I do if one of the lovely nurses came to me and said "Mrs D is having chest pain and she feels like she's GOING TO DIE! What would you like me to do?". At that point, I might start by taking my own pulse. I mean really, we're just sitting here waiting for something to happen. It's a bit like holding your breath, except that you're not allowed to pass out. You're in charge. So here we are....waiting for 7 am.

2:11 am
I can't effin believe James Brown is dead!! What the hell am i talkin about? the last time i saw him on some awards ceremony he could barely walk to the podium, and he looked like an old leather baseball mit. But he did say some smart thing about the young people need to stop using such eff'd up language in their lyrics and we need to share the love. Right on brotha, right on. Me and wingnut are chowing down on pb & j's and carrot cake. I am currently wiggling vigorously to 'get up offa that thing'. Go on James, say it like it is. UH, Uh, OOwwwwww, Uh, yeah, get up offa that thing. The chief just called to check in on us. When I told her everything was fine, she didn't really believe me. I wonder if she'll sleep at all. We have two more admissions coming on. Poor bastards. Damn this pb&j is good. I wonder how many neurons are actually firing in my brain right now.

4:46 am
know what happens at 3 a.m? well most people are sleeping, even here in the hospital they are sleeping, but not if I ordered labs on them to be drawn at 3am. Then they come wake the patients, stab them and take blood from them. What did my chief say earlier "this is the hospital, don't expect to get rest here. you want to rest, go to the hilton." nice, right? it seems at times, like they're trying to beat the patient care attitude out of me. I told her that won't work; they tried to do it in EMS for 4 years and were unsuccessful - i still care.
Orrrrr, they don't come; even though we tell them to. We order the labs for 3am and the lab people don't answer the phone, and then when they do they tell you they don't know where the phlebotimist is and you can't page them. The phlebotomist is mysteriously walking the halls, diligently doing his or her duty, or napping somewhere, or who knows. But the labs don't get drawn. It's making wingnut very unhappy. she's actually trying to track the phlebotomist right now. Poor bastard.

I have a patient, a frequent flyer, come up from the ER where they did emergency dialysis on her because she had SOB (that's shortness of breath, not that other thing you're thinking) so after being dialyzed for 4 hours from 11am to 3am they brought her here and paged me to admit her. But I'm upstairs having carrot cake and listening to james brown and my labcoat is hanging on a hook where my pager (which is on vibrate) is trying to tell me this. So i miss the page by 10 minutes - no big deal right? WRONG. The patient is dead asleep now and I have to wake her from her exhausted state to ask her a mess of questions. nevermind that she's 82 and mildly demented. When I can't wake her I have to write that she is unable to answer my questions. I ask the nurses if she had been coherent. They say yes. Is that good enough. I stress it, I wonder, I delay calling her doc - after all she's sleeping.
And now she's not. It's now 4:58 am and she has just been wheeled in a humongous chair in front of the nurses station because she's AWAKE and they don't want her to wander. She said her holiday was lousy and she won't let anyone touch her and she's yelling she wants to go home. She won't let the nurse check her sugar and she hates everyone except wingnut who offered her a sandwhich instead of a discharge. She poo-poo'd the sandwhich idea, but wingnut is persistent because she can't find the phlebotomist and needs something to distract her - plus she is a well meaning PA. Well who can blame her. At least I know my screaming lady is stable and she likes corn flakes. Why did I take this job???? (I can't believe I'm still awake)

6:50 am
T minus 10 and counting. We survived and all I feel is lucky, tired and hungry. Oddly, it inspires me to so and extra shift maybe twice a month for some extra dough, to tack on another 12 on 12 for a 24 shift as my last. Am i insane or what? Clearly. I chose medicine.
peace out~

Steel Peaks

2006-12-19T10:08:00.000-05:00

Glide wanted to crawl out of her own skin, go deaf, grab the butter knife and take it to her own throat; make a bloody mess to mirror the image of what she felt was happening. Slate had asked her here on purpose, the giant wooden slab between them, the metaphorical wall, maw, eternity that she intended to use to bolster her weak explanation of why it was over. The waitress set down two pints and then asked if they were ready to order. Slate said she wasn’t eating and then gestured toward Glide as if to say “did you want anything?” as calm as could be, as if they were just another two people out for dinner and drinks. Glide felt a red hot fury that couldn’t unfurl through the panic and fear, the confusion. Her thoughts attacked her like a mob: ‘Was she really doing this here? She has no plan on staying to finish that beer. This is an execution and my head is on the block. No, this doesn’t make any sense. This is not what’s between us, this is a mistake.’ The words were like rocks falling on her head. “Glide, did you want anything to eat?” she asked, just short of sweetly, oh so normal appearing. Glide looked up at the waitress whose image seemed to waver like the horizon over a hot distance, almost a mirage. Glide felt as if she was going to hurl. She shook her head no and the waitress gratefully disappeared.

When the wave of nausea passed, hope tenuously clung to Glide. She looked up across the table at Slate as she swallowed ale, put her pint down and was about to speak. She loved her, she wanted to reach across right into her chest and show her what was possible, awaken her from her own nightmare. Instead she saw the words gathering like an army in formation, prepared to march, to slay, to defeat and never look back. She knew this about Slate; her decisiveness, her mathematical calculation of emotions. She had been warned long ago and refused to believe this would ever mean anything directly to her. She gripped the edge of the booth she sat in, as if to hang on, to brace herself for the onslaught.

They began - the words, hollow, spilling first from Slate, explanations, simple, reduced, deduced and empty of the meaning used to describe her regret, her sorrow, her need. Glide refused to read the script and rebuffed, gently at first, strength gathering in her with the love she carried in her heart, but all Slate saw were the tears, which she read as weakness, desperate, clinging, and much too much emotion for her taste. Her own emotions were enslaved, locked away somewhere inside her she’d completely forgotten about when the world came crashing around her some 5 years ago. It was her talisman, her shield, her excuse.

As Slate watched the tears fall silently on the beer stained wood, she was vindicated in her decision and her resolve solidified into the sharp edged misshapen shape that it was. It should have been like a thousand year old steel blade being reclaimed by the kiln of Glides love, to be forged once more, folding the two of them 400 hundred times over until the new blade was the love between them; unbreakable and able to cut through all the difficulty life would deal them. But something fundamental was broken in Slate. Glide had seen it from the very beginning and she felt like an astronaut who’d been pushed off into the cold vacuous uninhabitable deep space with a momentum that has no opposition, the sense of Slate fading.

As she slumped to the ground at the edge of the Hudson River, she could not remember how she got here. She desperately tried to remember what had happened. All she could retrieve was the image of Slate as she rose from the table and calmly walked out the door; never looking back. She remembered the tearing sensation inside her, still there, relentless, despite how every other emotion seemed deadened. How long had she sat there? Who paid the bill? What was the point now? The wind rose up and tugged at Glides clothes that were soaked with sweat. She closed her eyes and wept with such force she was sure every vessel would rupture; she wished it would.

She stood suddenly and began running toward the water, tearing through the last wooded section before the precipice. She purposely grabbed branches as she ran, snapping them when she could, the skin on her hands being ripped from her when she couldn't; blood leaving a trail of her intention. The wind rose up again as she neared the edge and with gale force it pushed against her slight frame until she could no longer move forward. It made no sense, this cool summer eve, this wind, but what did make sense at this point. She waited for it to abate without ceasing her attempt to get to the water. It was as if she had walked into some giant web that held her there, tilted 45 degree’s off the earth’s surface, suspended. So focused on the pain and her destination, she didn't realize she'd been there longer than any northeasterly wind has right to blow. Only when she felt the wind inside her did she cease, slumped to the ground and abandoned consciousness, she surrendered; to what she did not yet know.

commercial commerce coersion

2006-12-12T18:23:00.000-05:00

christmas is christian, or at the very least catholic. which i suppose i am by confirmation, but not by choice - so not really. i don't believe their stories. but this isn't the day of kings on camelback, these are the times of camelback for hydration by the trendy, the traveled and those who won't slow down enough to really enjoy anything. the television tells me what my loved ones need and where to get it - which i suppose is why i watch so little t.v; rather weild it with dvd's and things that move me. but i cannot escape the ad's on the train, the bus, the paper in the hands of the man sitting across from me - the smatter of chatter of mothers i work with, so far from who i am.

but i love quite a few deeply and the charlie brown christmas, the stories of chris kringle, the humble giving to those in need, to those we love, to remind them of this, still resonate in me. the presents piled under a tree illuminated in the pre-dawn hours, our eyes big a saucers that such booty could be ours, lavished love as toys. this is what i remember when i sift through sellers; picking and choosing the thing that will say what i mean. yes, i still believe in santa, because he's like the buddha, living in all of us who choose to love generously and mindful of our actions.

but i'm still not shopping til next week.

hum

2006-12-09T10:35:00.000-05:00

Hum was beside herself, the warm breeze from the water seemed to ripple her emotions, the caps of excitement, fear, arousal, and curiosity folding over and smoothing back on the surface of her only to rise and fall, as if she were all nerve endings, live current. The reeds of the marsh at the lakes edge bent to the will of the wind and as her gaze settled there for a moment, calm claimed her, if only temporarily. The bruised sky was still full of light although the rods would defeat the cones soon enough and shades of grey would announce the night. She still had plenty of time to hike back to the yurt, but couldn’t be bothered to move just yet.

She pulled her legs under her, stretched her spine toward the sky and let her gaze settle in the distance. The din of mental coffee shop chatter began to fade. The sensation of each blade of grass, bent under her weight, pushed against her; each mass settling into one another, equal but opposite forces. As if handling puppies, she let each thought softly wiggle, lapping at her, then gently put them down. Her edges ached and she had a moment of impatience, always at this point before passing through where her body seemed to disappear from her minds eye.

She was the fickle breeze, she was the generous reeds, she was the deep still water of the lake, she was the metal of the sky, she was clear and clean when she felt the electrons jump, all flipping to polarize, vibration subtle but true. ‘What was this? Let it go’ As if some obstacle dressed as desire, she wanted to reach out and grab it, but didn’t want to leave this place it was so hard to get to. She pulled the reigns on her mind taught. It felt like the deepest string plucked, the wooden box pushing it back out into the world through her. As if a butterfly landing in her open palms, fluttering, soft and about to take flight any second. She wanted to open her eyes, the base desires rising up in her; want, impatience, possession, longing. She could feel her hips, as if bone grinding on bone. No she commanded, not so much in her mind as her center. She let it go, stopped trying to wrap herself around it and that’s when a hot liquid spilled, beginning on her shoulders, as if atlas. It soaked her, gliding down her back, around her sides, through her spine, pooling in a place that she could never describe. It was like sex, like fire, like shouting, like drowning, like nothing she could name.

She blinked as she felt her face cupped by a soft warm hand. She was alone. The sky melting into the mountain peaks, the air pulled from the north and a shiver ran through her. She looked around her, sure that someone had been there; pulled her rudely from her meditation. But there was no where to hide for a mile in any direction and the call of the loon brought her fully back. She rolled her shoulders and pulled herself up to her full 5’10’’ frame, as if unpacked from a box come cross country over weeks. She began to hum a tune she’s never hum before, born of the lush green hills where her grandmother’s grandmother was born a yesterday too far to touch.

from the rubble

2006-12-08T20:33:00.000-05:00

“It all depends on how you look at it”, She said.

“That’s bullshit” he replied, “You’re just justifying your actions”.

“No I’m not. Think about it. You have a guy who ties a bomb to his body, runs into a crowded public area and blows himself and everyone else up” she started. He stared at her blankly, almost as if he'd just been slapped, failing to make the connection. She continued, “He did it because all those people in that square support a government that say its o.k. for their armed forces to rape and kill his people because of who they are and where they live, when they’ve been living there all their lives. Is this guys a terrorist or a freedom fighter?” she queried. He raised his eyebrows knowing what was coming.

“You’re kidding right?” he stated.

“No, I’m not. To his people he’s…” she trailed off.

“Yeah, yeah, yeah” he cut her off, “I know where you’re going with this. But it’s not the same” he said rolling his eyes at her.

“You only say that because that’s not how you look at it”, she said smirking satisfactorily.

“I shoulda seen that one coming”, he said smiling.

“All done” said the tattoo artist.

“Nice” Siobhan breathes in a whisper. “What do ya think?” she asks Ryan.

“Very nice. Ready?” he asks.

Siobhan paid for the fresh artwork on her right upper arm. She gripped Jo’s hand and pulled her chest to chest in a familiar embrace. “Thanks Grrrl. Beautiful as usual” she said shoving an obscene amount of money in her hand. Macha, drawing her sword, eyes glaring out at the world, much in the same manner Siobhan was prone to doing, beautifully replicated onto her skin. Jo tried to object to the ridiculouly generous tip, but Siobahan wouldn't have it. "Can you put a price on art?" she said to Jo and backed out of the shop smiling, with Joann smiling back at her, palms pressed against each other and bowing slightly. She and Ryan made their way back to her loft in DUMBO. As Ryan climbed off the back of her bike he fiend fixing his hair and batting his eyelashes at Siobhan. She just giggled at his hulking 240 lb sculptured body acting like a 15-year-old girl.

Once upstairs, Siobhan drew open the long white curtains framing the huge picture windows facing the East River as it pours into the bay. The apartment lit up as if unvieled, light spilling in despite the gray clouds looming over the city. Ryan turned on the stereo to find Stevie RayVaughn wailing away his Texas style blues that immediately put a smile on Siobhan’s face. After a little air guitar solo, she brought him some water and collapsed on the sofa across from Ryan with a satisfying 'flump'.

“So” he said leaving an opening for her.

“Uhg…can’t we talk about something else” she requested.

“No. I want to know what you intend to do. You know Mari’s birthday is nearly here. You’ve already bought a ridiculous amount of presents, as usual, and yet you’re sketching images of this other lass. Where is your head?” Ryan asked.

Siobhan grabbed her face and threw her head back with a groan of frustration. “Ryan, I just don’t know,” she mumbled into her hands.

“You talking to me or yourself” he asked sarcastically.

Sitting up and glaring only to receive a big smirk in return from him, she defended, “I love Mari. I have loved Mari for years. Of course I bought lots of presents.”

“And the sketches…” his words left hanging in the air.

Siobhan was silent for a few moments, thoughts of Alex running through her head. Her beautiful smile, her unabashed laughter, her bullshit free conversations, the way Siobhan felt when Alex would casually touch her somehow flirtatious without towing her into betrayal …well not by the letter anyway. Alex at the beach, Alex on her Harley, Alex in uniform, Siobhan was gone. “Hellooooooo, there was a question there?” Ryan jarred Siobhan from her reverie.

“Oh Ryan. I cannot stop thinking about her. I know I don’t know her, but I know her. She makes me feel…on fire, alive, free.” Siobhan blurted.

“Didn’t Mari do the same for you when you met?” he countered.

“It’s not the same. New is new and all things new burn fresh, but... I mean, Mari was new once and then more, and I love her now; but I promise you, this is something entirely different and has tilted my world just enough that everything seems to be sliding. This isn’t just new, and yet I feel new. There’s this…I don't know....connection between us that there just aren’t any words for. It’s as if I’ve known her, which I obviously haven’t or like I’ve found someone I knew I was about to meet, but couldn't have known, some kind of deja vu but less hokey...” She said groping for the right words.

“So you lie to Mari, cheat on her and if what you say is true, eventually leave her. Nice.” He said sounding disappointed.

“No. I don’t want to leave Mari. I don’t feel I’ve lost anything, I mean not that wasn't already missing. I mean I know we have our own shit today to deal with, but it’s not related. You know I’d tell Mari if I could but I’ll end up in the street. She wouldn’t get it.” Siobhan said exasperated.

“Maybe there’s nothing to get. Maybe you’re just romanticizing this for your own benefit and you’re simply a cheat who wants her cake and eat it too.” He offered.

“Some friend. Do you ever listen to anything I tell you? The time I spend with Alex is free from expectation. I’m not thinking about how to swoon her, how to get with her, what comes next. I’m simply there, present, enjoying the moment. She doesn’t want me for herself; she just wants time with me to share whatever connection it is we’ve got. The only want in tomorrow is for more time with each other.” She explained, but as she trailed off her brow furrowed thinking there was no way to find this in her life with Mari. Mari was filled with expectation, and shouldn't she be? It 's how Siobhan has always been with her, filling her expectations. And how do you change midstream, how do you explain that something in you feels as if it's been free'd, made anew, by someone else?

“Look. I don’t always understand this free spirit rubbish you spout, but I can appreciate it. Still, how can it work when Mari believes you are hers alone. No one wants you to be happy more than I and it would be different if Mari knew and agreed with your life’s philosophy or even knew things have changed for you. But can you really love Mari and spend time with Alex, having to lie to Mari? I don’t know Siobhan. I’m just worried about you…and Mari. I’ve grown to love her you know.” Ryan finished. Siobhan stood staring out the giant windows the gray clouds turning darker. The conflict between Mari not knowing how she felt about this aspect of life and trying to live the way she thought her life should be. She growled at the sky and turned staring at Ryan.

“What?” he asked feeling cornered suddenly.

“I appreciate your honesty. I’m not trying to be a dick. I don’t know what to do. You know me, you know I’m not just trying to get one over one Mari” she started.

“I know, I know. I didn’t mean that. I just want to you to try and think clearly about this one. Be good to Mari. “ he was saying when the intercom buzzed and Mari’s smiling face came up on the screen. “Speak of the devil,” he said.

Siobhan buzzed her in and moments later sat listening to Mari tell her about her day, with Ryan gone and promising to finish the conversation later. Mari’s words were clear, but Siobhan’s thoughts were not. A flash of brilliant lightening lit the sky and appeared to be a premonition to the coming days.

seconds slipping

2006-12-06T18:58:00.000-05:00

always this wretched conundrum about the seconds bound, in a day
and now i'm too damn tired to write
fresh this morning, gazing on sleeping figures, in a row rocking gently as if basinets in a nursery, gentle faces
the sun threatening the horizon as my ride rattles onward north,
two young men, never quite meeting gaze, palms graze smoothly in greeting that is allowed
the rasping gasping breath of mrs m, her brow furrowed like sand dunes just before the gust that flattens them, giving way to a smile for taking the time to explain what the herd of big brains would not, they never see them though they claim them as purpose
mi amore, mrs q at 99 years young, a light too bright to be extinguished
asking only and simply to go home
the gentle vibration in my pocket, a whisper distraction that makes me smile
in the hustle of my juggling act with lives, deft hands, near total focus, dropping nothing
the wonder at how i always seem to surface, just as the bustle to home carries me with it,
how easy it would be to drop into a deep sleep and end up in marine park, much as i love the ocean
i'm glad to be crawling in my own bed, the last chord still humming in the air
as she hangs on the wall,
me alma

blurred lines

2006-12-04T00:28:00.000-05:00

which is more important: to have people fulfill some equivalent criteria for what we value as important and right, or to be able to see what is beautiful in them and love them flawed and all? surely there are lines we draw, rightly so. there are things in my life i value and won't compromise, but it's a damn short list because i prefer possibility and i think room for growth only comes with an open heart and a good sense of humor.

during one of the most challenging times of my life, i was thrashed about in a sea of brutal wave after wave after wave of not water, but information. some people are better swimmers than others and i freely admit that it's dog paddle or drown for me - except i can tread water for a damn long time, and anyhow, i love the water.

she stood apart from the get go, and some folks bristled at her demeanor. she knew it, but sometimes it's this simple; we are who we are. i think she said something sharp one day, and i laughed. maybe we knew we'd be friends then, maybe it happened when i placed a clementine orange at her seat, a gesture that maybe surprised her. the smile that is proprietary to small children who have no use for defenses or facade is what blossomed on her face as she looked over her shoulder at me. things are not as they seem.

when i think back to that crazy time, it seems truly a lifetime ago. but i can still see her smiling, a scarf wrapped around her face, earplugs in, ignoring the lecturer and studying something else - the occasional smart ass text message popping up on my screen one row behind her. we'd try hard not to giggle out loud. i can remember as well the pained look on her face, when she couldn't look me in the eye for fear of expressing her thought of betrayal and that i could be on the other end of it - confused, she didn't want to believe it and i didn't understand and was hurt that she might think it of me. but i knew to give her room, let the dust settle and wait it out, because we were friends and things like this don't break friendships - not real ones, and not this one.

so why did i walk away without an explanation? a comment, text on a screen, rife for misinterpretation. an inappropriate remark that seemed so selfish, so harsh, so fucking wrong. I couldn't let it go, I refused to reply, I backed away - it was easy(er) from 3000 miles. who would say such a thing? did i want to be friends with someone who would say this? there are some lines we draw and rightly so, i thought.

the problem, i see now, was the sharp lines i inked; the rigid, unforgiving lines i stood on the other side of. if it meant that much, if i was to truly tow the line, i would have faced her and opened the door to explanation. i was offended, i shut the door on her. flawed, we are all flawed and all that's left to mend these bit and pieces is the very thing that's been the ground under foot the whole time; love.

from this quiet late night brooklyn apartment i am kept awake by the realization, clear and softly tapping on my chest, that it takes much more than a fucked up comment to crush love and that i can either toss it to the wind and continue to look east, or open that door. caught quite unaware with nothing to lose, i am pulling the pins out of the hinges. all you need to now my friend is walk through it.

309.81

2006-12-03T13:53:00.000-05:00

I am a health care provider.
I am a human being.
These two things are not mutually exclusive, gratefully.

Medicine is often described as having 3 different facets; it is an art, a science and (disgustingly, but true) a business. As with all businesses, there is always the bottom line; profit. Tracking how to bill for pills, procedures, exams and evaluations is a complicated task. The billing of medicine is tracked through a somewhat organized system between illness/disease and procedures. The codes for the first are called ICD codes, the later CPT codes. I forget what that stands for, as I do try and remain as far from the business aspect of my profession as possible. I am especially irritated by the connection between healing and profit, but this is a rant for another day.

This morning as I was responsibly and routinely paying my bills, i came across a handwritten invoice from my therapist. My internal reaction upon seeing it was the antithesis of spying any other bill. The handwritten notice itself reminded me of how much I appreciate, adore and respect this woman. She has given me language for emotions I could barely name and showed me how I could navigate myself out of the most difficult times of my life, both past and present. When I flipped it over I noted the ICD9 code at the bottom of the letter; 309.81 because of course the insurance company would need it to pay it. With the curiousity of both a small child and a medical nerd, I wondered how I was being depicted via this numerical code, so I looked it up and found this:

309.81 Posttraumatic stress disorder
Chronic posttraumatic stress disorder
Concentration camp syndrome
Posttraumatic stress disorder NOS
Excludes:
acute stress disorder (308.3)
posttraumatic brain syndrome:
nonpsychotic (310.2)
psychotic (293.0-293.9)

The definitiveness, the concrete boundry in this code, let alone the pairing with 'concentration camp' pulled at a thread in my steady morning and unraveled me. Was the other end of this thread tied to some ghost of steel and dust laying in the landscape of my memory? Or did it go farther back to a place and time I still winced at? The origins hardly mattered, because I knew this was not a descriptor of convenience, it was not simply for the insurance company- it was part of me, it is part of me. I forget most days in the way we forget what our feet look like, though we can always look down and there they are.

I do this the same thing, every time I am faced with this. I compare, I diminish, I try and squash it into an impossibly small box. I am not being shot at in the gaza strip daily, I am not being raped in darfur, I am not drowned in a tsunami, I am not in a refugee camp or guantanimo bay for that matter. There are so many other trauma's worse than mine - and no matter how many times I think this, strangely, my shit is still there. I laugh a little at this exercise in futility. How many times do we fall in the same hole before something in our synapses fire and tell us as we approach the gap that it is there; WALK AROUND IT FER FUCKS SAKE!

But I'm describing rather than addressing my reaction to this metaphorical slap in the back of the head, and maybe it's because I still lack the language for it. Maybe that's a total cop out and I still turn away from it just because it's like wool underwear and I need to go underwear shopping.

friday afternoons...

2006-12-01T20:29:00.000-05:00

They told us in school that friday at 4:30 the shit would hit the fan. It's when all the patients wanted/needed something and the clinicians would be trying to go home, go to their weekends, to no avail. We all laughed at the stories, after all they were just stories.

This morning was a smooth morning, 5 patients in all and it seemed that only 2 were new and pretty low maintenance. At a morning break I jawed with another new PA and we talked about things felt calm and we would be leaving on time today, yeah baby. Yeah well, it was friday, and around 3 or so, things started to stir. It felt ok at first, after all, I'd seen all my patients and now it was just a matter of follow-up and management until 4:30 rolled around. And as the minutes ticked by, and 4:30 loomed larger, the winds of fortune were gathering speed and about to whip my ass. The woman who was supposed to be discharged yesterday, but sweet talked her way into one more night away from her job and bustling house, was constantly asking her nurse for a letter stating her hospital stay - a small task. The woman who were worried had a PE was itching to go home and with the negative V/Q scan, that seemed just fine, except her coumadin level was still subtheraputic, she has a history of PE's and she still wants to go home and shower and change, not stay and let us bring up her levels - she was threatening to leave. Hell, I would too, cuz the shit was starting to stir. The man who had been ready to be discharged for days and days, sitting in our bed instead of his bed, was baseline bewildered beside his wife who had lied about her insurance coverage and now cried innocence when the care he would require cost near $700 a month (from a company she continuously failed to pay and now wanted more services) and passively blamed everyone for her inability to take her poor husband home. "Put him in hospice???? That's how he got the bedsores that brought him here!!!" They were deep and ugly and even I winced upon seeing them today. How can they pay for him to be in a hospice, but not some simple care in his own home with me??? She chewed the ear off anyone who would listen, and I was her husbands PA. The gentleman I had seen very early this morning, who probably had some aspiration pnuemonia required some consults and getting consults on a friday is tough business. But I'd started early, I knew better, even as green as I am. Still, the doc showed up right aroun 4:30 while I was trying to put out the biggest fire yet, and she had a whole slew of orders. Who cares that I'm done now, I'm still here and I'm his PA. All new orders, changes to others, customs orders, things I'd yet to do. And the creme de la creme, poor Mr C who's son was getting married tomorrow. He lives in Puerto Rico but he used to live here. He went for a check up while in the states, after all he had his heart valve replaced here. The doc found him anemic and decided to work him up as an inpatient. Don't worry, we'll have you out by friday - the wedding saturday, the flight home monday. We assured him once he was back from his colonoscopy, if all went well, he'd eat one meal and then be discharged. But here was one of the cardiologists on the phone, incredulously in disbelief that we would even consider sending him home today without anticoagulating him for 4 or 5 more days - after all, he has a mechanical valve and has been off heparin all day! What were we thinking???? I go to break the news to Mr C after explaining and advocating for him to the cardiologist. His jaw hits the floor and then sets tight in anger. He's been here all week and we're gonna tell him this now??? Even I was with him yesterday and told him all about how he'd be going home afer his scope - it's what the senior PA told me. Fuck, fuckity, fuck and fer fucks sake. We got the cardiologist on the phone directly with Mr C, his wife shows, they both do their best to be cool, but the floors been taken out from under them. It's now 5:15 and I'm not going anywhere soon. It's friday.

romeo is crying

2006-11-28T19:19:00.000-05:00

In fact there is little else Romeo does besides cry and sleep. The other one thinks he's deaf and it's why he howls so loudly, and I have decided something else altogether. I think he is narcoleptic. One moment he will be howling so long and loud and mere minutes later he is sound asleep, right where he lay. It could be anywhere, and when i realize this is the cause for his silence, I am reminded of ambulances, city streets bustling with cars, people, shouting, shooting and all the while i could sleep save for the three words "one, six, charlie". My face pressed against the glass; my cheek like a smudge against the pane, my neck at some geometrically challenged angle, my shoulder driven into the seats edge to keep me from slumping completely to the floor. Dreams of Joy as she lay in her own life's blood, pooling ever wider and me unable to find the source, quizzically looking around for something to stop it, sop it up. If only my partner would stop fussing about his hair, his clothes, we might save her. Because that's what we do, we save people, all kinds of people, even people he says he hates and complains about all day. I know it's his own life that he won't face, so he comes here every day to lay blame at the feet of people who have enough to worry about without some white boys angst. I could care less because I'm sleeping and anyway, we're only trying to save ourselves, and if only I could finish this dream I could figure out from what. But those three words come out, as if from the other end of tube out in space 'whuuuuuuuun, sssssiiiixxxxx, chhhhaaarrrrlieeeeee" and I refuse to be pulled from my revere, so close to the answer I can feel it like the strings of a guitar being pulled just right. He doesn't wait for me to wake and i cling to sleep like a sapling to the ground eroding away underneath me because the oil rigs and the corporate fucks have wrecked the soil from 50 miles out and it's all crumbling away when I hear the wailing of the siren, my head hits the window that is now the desk, drool on my shoulder and shirtsleeve and I yell to Romeo - 'fer fucks sake cat, shut it' - but he can't hear me because he probably is deaf.

50 bullets

2006-11-27T12:01:00.000-05:00

My friend asked me if I heard about the shooting in Queens. I did not, I told her. I suppose I tune out what I think is often sensationalized news, if it is news at all. People are shot all the time, you'd be horrified if every shooting was in print, every rape, every domestic violence occurrence, child abuse -we'd all explode from the overload. People are being extinguished in Darfur but it's too far for the average joe to care? What we think about the world is shaped by those folks who have the power to write about events in print - do you know how many people think if it's printed, it's true? I contended. She challenged me. She said it was important because it raised her awareness of police violence, unwarranted brutality and wielding of power with the badge and the gun. She was concerned about the response from the the bloomberg administration vs the way guiliani used to do or not do things. She was mystified about how some group could unload 50 bullets into a person. Having dated a cop and knowing a little more about guns, gunfire and police protocol than I cared to know - I asked her if she knew how long it took to unload a clip of 16 bullets. If even 4 guys do it, it can take less than 10-15 seconds. None of it was the point of course.
I don't really think it takes 50 bullets to stop a person with a gun (which i guess he didn't have) and I bet there could be some underlining racism involved, overuse of power or even scared cops firing because the others were and they were covering for them. Who knows, I wasn't there and I will never believe I'm getting the truth from the paper. This is going to make it hard for the good cops, the ones who get lost amongst the mix of the fuckers who do wield the power of the shield. In the end, that guy is dead and while it should be an investigation, thorough and done by the book, bringing things into alignment - it will likely fall prey to politicization and leave everyone feeling angry and unsatisfied. Just what the city needs, dammit.
So what do we do? Here is this horrifying event that will polarize communities and be talked about, like ripples in a pond. Perhaps it is the chatter that pisses me off. Sure, we can't do something every time a horrible thing happens, but stirring the pot seems dumb too. I hope that the people who want to have direct impact on this, will become involved. I hope rest of the folks who give a rip make it a point to bring something good into this world, because I don't care who you are, while we may not be able to personally eradicate all the violence and hate, we can at least be good, decent and generous human beings to try and balance all this shit out. Ja?

know when to hold em, know when to fold em

2006-11-26T00:09:00.000-05:00

I've seen love go by my door
it's never been this close before
it's never been so easy or so slow

I've been shooting in the dark too long
somethings not right, it's wrong
and you're gonna make lonesome when you go

purple clover, queen anne's lace,
the crimson hair across your face
you could make me cry but you don't know

I don't know what I was thinking of
you might be spoiling me with too much love
you're gonna make me lonesome when you go

there are dragon clouds, so high above
i have only know careless love
it always hit me from below

but this time around it's more correct
right on target, so direct
you're gonna make me lonesome when you go

flowers on the hillside blowing crazy
crickets talking back and forth in a rhyme
the blue river running slow and lazy
i could stay with you forever and never realize the time

but it's situations have ended sad
relationships have all gone bad
honey it's like verlains and ramboughs
but there's no way, i can compare
all those scenes with this affair
you're gonna make me lonesome when you go

you're gonna make me wonder what i'm doing
staying far behind without you
you're gonna make me wonder what i'm saying
you're gonna make me give myself a good talking to

but i will look for you in honalulu
san fransisco, astabula
you're gonna have to leave me now, i know
but i'll see you in the sky's above
the tall grass and the ones i love
you're gonna make me lonesome when you go

you're gonna make me lonesome when you go
you're gonna make me lonesome

shawn colvin

yog-urht

2006-11-25T13:41:00.000-05:00

When I first heard, years ago, that friends of mine were going to yoga, i giggled a little. I've thought of myself as a tomboy-jock for as long as i can remember. I've worn baseball caps since I could walk, was the first girl in my hometown to play little league baseball, 3-sport jock in high school and went to college on scholarship to throw a little white ball across a plate. I even kept playing after college in a work league filled with macho puerto-ricanos who would scream to the ump about everything i was doing wrong because they couldn't simply admit i threw too hard for them. So in my base jock brain, yoga made me giggle. Yoga is what girls did in their little tights - I used to think. In fact I teased a friend of mine and called it yogurt for all it's lack of strength, competitiveness and grrrrrrrr.

Oh the things we think when we're young, dumb and full of shite.

This morning, after a long absence from it, I dragged myself out of my Saturday morning laziness and rode down to the local bikram yoga studio. They had a cheap deal to get people like me off my ass - so I went. Bikram, among other things - is done in over 100 degree heat. I love this part, not because sweating makes me feel like a jock, but because it feels like I'm wringing all the weight and crap in my life out with each drop of sweat that hits the mat below me as I stretch and breath and think about n-o-t-h-i-n-g. In fact it's one of the few places my mind will, quite all on it's own, shut off...or rather, be still.

As I stood in front of the mirror (in the back row, of course), I found myself judging. My belly, white as snow, rippled just enough to piss me off, to hang ever so slightly over the edge of my snug yoga pants. I easily gained this while sitting and sitting and studying that first year of PA school as i crept into my late thirties - an though I've run and biked and joined a gym again...there it was, still staring back at me, dammit. All legs, my hips are just a little wider than I care for. I thought it made my head look tiny. And at this I started to laugh (inside) and shook my head, literally. Why do we do this to ourselves? Who gives a rip if I don't look 20 anymore? This isn't why I went, and I just smiled as let the judgement go, if not a little disgruntled that I had to go through that exercise at all.

As we began with breathing exercises and moved gently into the 26 poses, stretching this way and that, I could feel my body uncoil from the discomfort I've been feeling with all the new changes of my job and settling back into new york. Although I wasn't really thinking it, I know one of the reasons I go, is because I also believe that it just might keep me from turning into a 'C' in my old age. My shoulders already round forward and by the way I find it hard to sit up so long on the train each day, I know that my spine probably looks a little like a pea vine. I push and pull as each pose demands and the instructor explains in her rapid fire english curved beautifully with her native japanese accent.

A women in front of me is at least 20 years my senior and she is so immersed in the movements, it enhances the humility I feel while moving through this. Another, much younger and very petite woman is to her left and she has clearly been practicing bikram for some time now as she bends in ways I didn't think a person could, and with such fluidity. It was impressive to watch and at the same time, a great model for what the pose I was attempting, was supposed to look like. I spent a bit of time imagining that if I made this part of my life, I just might manage some of that myself.

And then with that thought floating in my center somewhere, as we were lying flat on our bellies, we were instructed to put our arms underneath us, completely save for our shoulders, palms facing down to the floor and then lift our legs. As I watched many other people do this pose, I felt the weight of my butt pressing down through my hips which then dug painfully into my forearms and for a moment thought "if i keep pushing like this, i'm gonna snap both my forearms and how fucking ridiculous will that be, bilateral arm fractures from yoga, seriously, i must be doing this wrong" and realized i was far from enlightenment. All the same, when i left the studio and stepped out into the warm winter sun I felt happy. yoga is good.

DNR

2006-11-23T21:35:00.000-05:00

Mr P has diffusely metastatic prostate cancer. It's eating away his bones, literally. The medications fail to work anymore and he is curled around like a little 'C' of an old man. His tattoo's on his arms can nearly be mistaken for the hematoma's where blood has been drawn and destroyed his fragile old veins. His head is tiny with sparse snow white hair on it and he has bony sharp features. His voice is raspy and he has a speech impediment where his L's don't quite come out, which remind me of a cousin I love. I've been caring for him for 2 days and I will see him again tomorrow after a comfortable day at home. I think of him and remember the conversation I had with his daughter yesterday.

She doesn't want her mother involved in the discussion regarding end of life care. She, herself, can barely manage. She thinks she's protecting her mother from harm, fatal, heartbreaking, irreparable harm. Maybe she thinks her mother will quit living too if she knows her love will leave her soon. I think the woman who loved the man for so many years has a right to know - but I am not her daughter and don't know how strong nor fragile she is. It is enough for me to tell the daughter the stark reality of his condition and that she needs to consider a DNR for future hospitalizations. She must think about his suffering, his quality of life, his end. She cries harder and softer through most of our conversation, my hand rarely leaves her shoulder.

I weep openly now as I write this, because I could not yesterday. That was the time and day for me to speak clearly, make myself heard. It was not about me - this was my opportunity to help her, and him by pointing her in the direction of life as it faces death. I cannot even consider the death of my own parents, and won't until I'm forced to, like her. I told her that their decision about whether he goes to hospice or home is a matter of where he will live best, where he will be most comfortable. His days are numbered, who can care for him - and this has little to do with medicine, and all to do with love. I said, if he is to come home, what he will need is his family. And not to help him sit or eat or walk, although that may be true. They should not treat him like the sickly man that he has become, for although is this quite obviously true and hurtful to all of them - he is still, and always, will be here father. If she loves him so, then she should simply be with him the way she always has. Could he ask for anything more, if a cure is not possible.

It's true, he is dying. But for as long as he continues to die - he is alive. I hope she heard me.

i am a selfish m.f.

2006-11-23T16:48:00.000-05:00

I met Al Bolden on a subway platform. Amongst the people coming and going, there he was bobbing and weaving as he shuffled forward. I recognized he was drunk almost instantly. He must have weighed a good 275 or so, and with little momentum gravity took him straight down with an ungraceful collapse. Being a fairly rotund man, it looked as if he cushioned his own fall and was soon trying to get up, with little success. A small group of people stopped and stared, at a safe distance; non-committal, maybe wanting to help but staying safe inside their own perimeter of intention, unperturbed and not willing to veer off their path. It was both interesting and sad to watch them, watch him struggle, shuffle on his knees toward a cement post and use it to try and stand. His legs would not push his atomic belly upward and the alcohol made it near impossible as he collapsed under his own weight again and again. I could hear him talking softly to himself, "c'mon man, c'mon, damn, c'mon"; both frustrated and encouraging.

I watched him with the detached professionalism of a seasoned new york city EMT. Hardened by years of taking drunk folk off the street, them fighting with me, spitting on me, puking on me, and in general, a sad lot. I always felt bad for them, but had a job to do. I felt myself in that mode as I watched him, knowing if I went to help him I was initiating care and would be obligated to some end. I was like everyone else, not wanting to interupt my evening, thinking of calling an MTA person to help -not willing to just do it myself. Why?

When I watched a couple of strapping young dudes walk by him and he was calling out to them for help, that was it. That was the moment when simply being a damn decent human being was the point. Fuck where I was going, or what this meant for the trajectory of my evening.

I walked up to him as he held onto the concrete post, as if his life depended on it.

"hey man, let me help you" I said
"huh, whu..." his inebriated head bobbed in my direction and with it, the weight of him.
The moment I stepped up, another young man asked if I needed help. I said yes right off, I knew with one arm in mine, I'd never be able to manage him myself. This young guy grabbed his other arm and I asked Al to push up with his legs.

"Hold on" he said as I could feel him try and center himself and push. He was standing. Wobbly and reeking of alcohol, but standing with us on either side.

"where you going?" I asked him
"i just want to sit on that bench" he said nodding to the bench some 20 feet from us. And we walked him, shuffle, wobble, listing.
"you got any medical problems or are you just drunk" i asked point blank as we walked.
"both. i had a stroke and been drinking" he sputtered.
"any chest pain now?" i asked
"what, you some kind of medical genius?" he asked
"hardly" i laughed

With a great thud, his ass hit the bench. He was breathing heavily and before I could look up, the other guy was gone. I yelled thanks after him. I looked down at Al and he at me. A standard 'thanks man' was what he offered up. I said 'your welcome' and looked him straight in the eye. I didn't walk away, but stood still right there, waiting for the train. He looked me over and must have been thinking about his getting from the place he fell to the bench, now able to breath easy.

"seriously" he slurred "thank you very much"
I looked dead back at him and asked him "what's your name?"
"Al, Al Bolden" he said. I held out my hand toward him, told him my name and shook his big paw of a hand.
"I used to be a marine you know. But now I'm all used up"
"You ought be kinder to yourself Al" i offered
"yeah, i knows. I beat me up more than anyone. I used to put the smackdown on folks. Now look at me" he said.
I stood there waiting for my train and he sat quietly catching his breath, his self.

My train pulled in and I turned back to him as I boarded. I nodded toward him, and he back at me.
And that's how I met Al Bolden.

crush

2006-11-23T10:47:00.000-05:00

crush

The act of pining
Bite in and get that cool sensation
Emosio-hormonal takeover
Mental processes disrupted
Creation of scenarios
Made for television specials
Running through a field of grass
Slo-mo arms outstretched
Crackling fireplace
Urban impossibility
Emotional idealism
Mathematical improbability
Kazilion factorial
Non-functionality
Zero causality
Carcinogenic physical phenomenon
Eyes locked on
Hypersensitive sensory organs
Butterflies immune to digestive enzymes
Solitude keeps them company
Clock hand restores normality

drowning

2006-11-21T21:16:00.000-05:00

it's not so bad really, the water splashing all around my head, into my mouth, mixed with air, my arms flailing...

i love the water actually. it must be how i got here. the sound of the waves breaking over me echo monitors, call bells, overhead pages and nurses calling my name. when did they learn my name, i just fell in the ocean and it's so huge, don't i just look like all the other fish.

i wish for once the waters were Caribbean, but not near those fat gringo vacationers, flaunting their money and ignorance de la lengua. i think this when i'm asked to flail my way over to los personas regresa sus casa. how can I be the one they call for this? I tred water for hours and it's no wonder i find myself confused, exhausted, soaked to the bone on the 2 train back to brooklyn in the oily black dark of evening.

how did i get here???

el beso debajo el tren

2006-11-20T21:22:00.000-05:00

peels of laughter, arm in arm - such good friends we'd be...
she pulled me to her and i realized the winds had changed on me again
not that fast hurried 'must have' that drives 20-somethings into teeth gnashing and lip smashing,
but the slow approach of letting each moment linger
burn an image in your brain for the multitude of minutes to follow
soft, so very soft were her lips on mine and i could feel the breath catch
in my chest, right before my knee's buckled as her tongue touched mine
which i think is when the world fell away

few things in this world can make you forget everything, and i mean everything, the way a perfect kiss can
what was i saying?

unspent love

2006-11-19T21:52:00.000-05:00

with the sounds of debussy's 'claire de lune' playing softly in my room, i sit alone and wonder, what do we do with unspent love. it was a thought forced upon me this summer when i got my heart broken in a way that seemed more painful than any other loss of love. it seemed odd, that after 4 months i could feel so powerfully. someone suggested that it was a catalyst of sorts that tore open every other painful memory, every unhealed wound and every insult was fresh again in one moment. someone close to me is going through a very similar place in his life right now, agonizing over a lost love that has been leaving him for some time now and when we spoke this evening, his sadness was overwhelming. it was hard to feel so helpless with him and when i later returned to my own space, i picked my guitar up and sang the song i wrote, only for the first time i realized that it was a true for him as it has been for me. likely it is the same for many others - and so for anyone who understands this...

unspent love

sing me a lullabye she said
as she lay her head down on my chest
in her bed

was it really just last week
that she called to say, i miss you
one more flight and i'll be home
with you
hold, on, tight

what do we do with unspent love
what do I do with this unspent love
cuz' i just can't give it away
can't save it for a rainy day
i can't keep it for myself
it doesn't belong to anyone else
but her

what do we do with unspent love
what do i do with this unspent love
how do i look to tomorrow
through all this sorrow

what do we do with unspent love
what do i do with this unspent love
cuz' i just can't give it away
can't save it for a rainy day
i can't keep it for myself
it doesn't belong anyone else
but her

what do we do with unspent love
what do i do with unspent love
won't someone tell me

my new gig

2006-11-19T16:00:00.000-05:00

i wanted to write about this, my new job, although the word 'job' makes me cringe a little since this is much more than just that. i've invested roughly 9 years of my life to get here, and the last 2 1/2 being the most intense - grad school. having had the experience of being a rookie before, i wanted to be sure to record it from the beginning because i know things are going to change soon and fast.

i'm a pa, a physician assistant and I started my first job at a large inner city hospital just a week ago. i work in inpatient medicine and predominantly very sick and commonly older people. i chose this hospital because it's roughly in the same neck o' the woods as my previous incarnation as a FDNY EMT. These folks are a great many things, except rich isn't one of them - at least not financially. I didn't go into medicine to provide for people who had the means to do well for themselves, and I certainly didn't choose it for the money - though I have to say, it pays a helluva lot more than riding around in an ambulance all day (even if i do miss it).

my first day last week was a lesson in the way things worked. late in the afternoon, the day before, i had heard nothing from anyone at the hospital and only knew that tomorrow was my start date. That's it, that's all i knew. Not where to go, what to bring, who to meet or what i'd be doing. I didn't freak, but with one eyebrow raised after a few phone calls, I wondered what i was getting myself into.

I showed up, dressed neatly, ready for anything. Uh, well, almost. I'd left my stethoscope at home. A little like showing up for work without pants. They gave me a long white coat, and a shiny new name badge with the department 'medicine' and the title "PA" tagged at the end of my name. It was a surreal moment, whisked quickly away and replaced by total terror. I filled out a form for computer access and then was matched with a PA on the floor. I put my things in someone else's locker and then we were off.

The 3 floors had 2 units each on them, and I would be in the 'telemetry' unit. This means that for some reason, whether the primary reason they were there or simply a co-morbidity, each patient needed their heart monitored. So we put a little box in their nightie pocket with EKG leads attached to the stickers on their skin and they were wirelessly monitored for abnormal rhythm's or arrest - read: they're SICK, and I don't mean the flu.

My PA was a bright funny woman who talked at Mach 4. I don't know if she mainlines caffeine or this was her biological baseline, but it scared the shit outa me and I was already doing my best to choke back the panic, like a big ball of crap in my throat. I nodded, smiling and 'uh-huh-ing' as she zipped through the different computer screens, options, ways to gain information, the charts, the people, where things were. At lunch another PA said she's been there 7 years and listening to my PA made her wanna quit.

All in all, the lot of them were a good bunch and that made me feel like I wouldn't run out the door just yet. I kept hearing that song from 'saving nemo' play in my head like a little soundtrack...'just keep swimming, just, keep, swi-ming...es-ca-pe...hey that's spelled like escape. ESCAPE!' The day did not get any slower or less overwhelming, and at one point I thought, "I'm just gonna walk on outa here. I'll just say, no thanks, I was mistaken." I'll go take some cush little family practice gig were I look at sore throats and itchy vagina's all day - and that was enough to keep me swallowing down the panic and trying to retain all that was being thrown my way. When I walked out the door at 5, I gulped the evening air boarded the bus and allowed myself a small smile. I'd done it, I'd survived my first day, hadn't quit (or passed out) and it was all real. I was a PA. I had no freakin idea what i was doing, but I was a PA and we all have to start somewhere.

Funny how something as small as a place to hang your shite makes you feel easier, and I did the next morning, my things in my locker and listening to morning report. I hauled off with the same PA and found I really liked her. Sure, she was a fucking whirlwind, but I didn't at all bother with notes since i knew a) i couldn't keep up with her, b) half of what i was learning would be second hand shortly and c) the rest i would learn by doing. There was no 'way' of learning and everything was as it came - sink or swim. Where the hell were my water wings????

I had my first patient this day and since my PA was a right good woman, she let me pick. I had only laid eyes on one patient the day before (in a sad attempt to put in a line) and so I picked her - why not right? I'll tell you why not. Because that lady was a 65-year-old hypertensive, high cholesterol, diabetic, polysubstance abusing, anemic train without breaks. She was admitted for bradycardia (low heartbeat) and hypothermia (cold core temp) and on PCP! I already knew there was no chapter for such a patient and all the things I'd learned suddenly seemed stupid and useless. I tried to review her chart before going to see her, but couldn't read half the doc's notes (scribbly bastards) and i drew a blank on the most basic physical exams and it was my FIRST PATIENT. What I failed to take into account was she didn't know anything, was barely awake (even sober) and I could have done anything and she wouldn't know. It should have brought me comfort but I was too overwhelmed by her medical state. It wasn't until the end of my first week, after the millionth conversation with her drunk and loud husband, did my street smarts kick back in. I remembered where I was, how I needed to translate medicine to something understandable, and how to give every person, even my drugged up lady - respect. I was her liaison between what the 'medical establishment' thought of her and wanted to do for her - and her; how to best serve her. This is what i love about my job.

Every day I eased more into my role, talked to more patients, did more exams, made a millions tiny mistakes that were easily corrected though they felt like someone attacking me with spitballs; harmless but a little bothersome and unpleasant. The panic sunk a bit lower each day until i realized I had much too much support in the other PA's to need that useless emotion. I still had no idea what I was doing, but it all seemed possible. By the end of the week, I'd seen several patients in addition to my first. Mrs R who cried when we discharged her back to the SNF (skilled nursing facility) because they made her pee one their schedule and we'd been so nice; Mr L who was a one legged, diabetic, heart failing, gasping for air talker who had some very creative hallucinations; Mr R who had emphysema, lung cancer, one lung left, diabetic, high cholesterol, a small bleed in his brain, and new onset AFib (heart arrhythmia) who only spoke Spanish and kindly entertained my version of it; Mrs L who was a demented , schizophrenic, diabetic, hypertensive, multi-infarct (in her brain) sweet LOL in NAD (Little Old Lady in No Apparent Distress) that also only spoke Spanish, couldn't remember what you just told her and wandered, a lot; and Mrs M who never should have been there...yet.

When I would walk out of the building each night to watch the color of the night sky fade to black while I caught the bus back to the train for my hour plus commute, I smiled, every time. I was so exhausted those last few nights that while caught in the rain, I failed to cover myself. It felt good though, because while I love this new gig - it is already clear that it will be heartbreaking on a daily basis. The question of 'what does it mean to practice medicine' or 'what's the point?' all in relation to quality of life, is already burning bright in my chest.

I've been reading "house of god' on my commute, a book written in the 70's about an interns first year of medicine and the shattering of the illusions of what it meant to become a doctor. Not so different. It is dark, cynical, real and dead on. It makes me nod my head in affirmation, laugh out loud and not feel so alone. A fantastic read which I recommend, if ya like that sort of thing.

so here I am, in the beginning. and as always, i say, bring it on.

writing, writing, all the time writing

2006-11-19T09:18:00.000-05:00

This last year of my life i had a website through my university, a rare perk. From there I was able to set up a little home that existed in all places there was wifi. When i graduated, it disappeared, like i did from the west coast and now i find that i miss writing out loud - and the scootking has kept me entertained all this time with her thoughts and music and videos, I feel it's time to rejoin this place.

I woke with thoughts of disappointment; from the war in iraq, to the physical distance of some good friends, to a women i don't know, to the upcoming 'holiday' (my ass), to this new position in medicine that has me really twisting my brain around 'what the hell are we doing for these folks anyway?' Basically I couldn't quiet my brain. And yet I recognize this as pretty common for me, all these thoughts like riptides and alternate currents, as if my brain were the east river. I want to dive down, to take one idea and be able to think it through without all the white noise. I wonder if it's the lack of physically moving my body. I'm a bit like a little kid in this respect -simple. If i get out and ride my bike, or run or in some other world, go for a hike...it might give me some room to let things settle.

But really, the problem, sometimes, is i can't tear myself away from my own sedentary spot. It's like a puzzle I want to figure out before i can move on, yet I can't move on until I move. I know this, so why am I still sitting here?