Blackbeard

He came to see me for his annual visit. He had been stable for many years, taking his medication and not having any of the psychotic symptoms that had gotten him to me in the first place two decades ago. This visit was pretty much like all the rest-at first.

Check on his symptoms. Check on his medication, the dose, any side effects, the last time he had routine lab work drawn to check liver functions, blood glucose, lipid levels. All routine.

He was, as usual, quiet, subdued, soft-spoken, looking mostly at his shoes and not making any direct eye contact. No hallucinations, no delusions. No suicidal ideation. Mood good. Sleep and appetite good.

Then, quite abruptly, he looked up, straight at me.

“How long you been seeing me?” he asked.

“Probably twenty years or more, I think,” I said.

“That long? How long you been working here?” he was curious.

“Twenty six years,” I answered. “I started with the mental health center in 1991.”

“That long? ”

“That long.” I said.

“Oh, yeah!” he suddenly sat up straighter, looking right at me, like he was seeing me for the first time in two decades. “I remember you. That, that there (and he pointed in the general direction of my beard) used to be black, dark, black, didn’t it? And that up there (he made general hair mussing gestures over his own short-cropped hair) was dark too. Now, it’s all white. It’s white, ain’t it?”

I smiled. What else could I do?

“Yes, it is a little whiter than it used to be,” I answered.

He looked dead at me again.

“You old.”

There it was. Simple.To the point. True. Sort of.

I smiled bravely again.

“Yes, I guess we’re both getting older, aren’t we?”

 

Time goes by much faster than we realize.

We form relationships, big and small, acquaintances and deep friendships, professional and casual, lasting and fleeting.

Patients age. Customers age. Teachers and mentors age. We age.

We don’t really want to. Not consciously. Not really. But we do, all the same.

We have developed institutional memories of our most cherished places, we have gained expertise, and we have developed confidence.

We think that it will last forever, but deep inside, in those places that we hear late at night as we drift off to sleep or first thing in the morning as we rub the sleep from our eyes at first light, we know that it can’t. It won’t. It shouldn’t.

Eventually, we will find ourselves being cleaned from the grimy window of time so that the generation following us may see clearly into the future. As it should be.

Now, those of you who know me know that I don’t consider myself remotely close to being old yet. I have a whitening goatee and my hair is now visibly salt and pepper when I look at my recent wedding pictures, but I pay that little mind.

I will continue to work because I find it a challenge, travel because it broadens me, and love because it gives me a reason to live another day for someone other than myself.

My work life?

It will end, if all things go according to plan, on April 2, 2032. I will be seventy-four years old. I have made an appointment with myself for that day to start the rest of my life. I have a lovely lady I would like to spend more time with one day, and an insatiable urge to see more of the world.

I’m quite sure that before I do anything else that week  I will be right here, where I am tonight, sitting at my dining room table,  writing something for you to read.

I have no doubt that I will have something to say.

 

 

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Scar Wars: Coming of Age

I hadn’t seen him in some time. I went out to the waiting room, knowing exactly who I was looking for and what he looked like the last time I saw him, many years ago. I called his name. 

He got up, striding toward me on long, skinny jeans with legs inside. His face, his whole body was thinner than at our last meeting. He wore an Arafat stubble which did not hide but accented his angular jawline. He was missing a few teeth. 

He looked twenty five years older. He’s actually a few years younger than me. Chronic psychotic illnesses age their hosts with astonishing and appalling speed. 

“Doc! How ya doin’ man? ”

I smiled. He had the same disarming, boyish grin he’d always had. 

“Fine, fine. Thanks for coming to see me.”

“Dude, it’s been a few years, yeah? A few years. You’re older, Doc!”

(Well, yes, as a matter of fact…)

“Yes, I think we’re both getting older, aren’t we? That’s a good thing, I hope.”

“Man, last time I saw you all that hair was dark. You didn’t have a white goatee then, didja?”

“I guess it’s all a little grayer than the last time I saw you. Come on back.”

“Yeah, man, it’s good to see ya, Doc.”

~~~~~~~~~~~~~~~~~~~~~~~~~

I’m standing in the lobby during the intermission of A Christmas Story, a production of my daughter’s new theater company home in Chattanooga. Two of my grandchildren are here, and I’m eager to see them and say hello. 

My four year old grandson comes over to me right away, and he wants me to pick him up for a big hug. I gladly do just that. 

He looks at me, little nose and sparkling eyes inches from my own. 

“I know you’re old.”

I blink. 

“It’s okay, Papa, we know you’re old.”

I give him a big hug, make some small talk, then set him back down on the lobby floor. 

No pains. No pulled muscles in my back. Biceps feeling good. 

Sometimes I even take my own groceries out from the Publix supermarket and load them into the car myself. 

Imagine that. 

Bless the folks with psychosis and the little children, for they have no social filters. 

  

Old Man River

So I’m thinking yesterday about milestones and changes and how life flows like a river.

I’m thinking about how I read on Facebook and Twitter about the lives of all my family, friends, coworkers and acquaintances, how they are always churning and moving and relocating and promoting and transporting and loving and growing and dying and teaching and learning and experiencing.

I’m watching my granddaughter, not quite one year old, her face glowing with the reflection of family and celebration all around her, reaching for the salad and mimicking a smile and watching her big sister, actively coaching her. I watch her clap, clap, clap, smile, smile, smile, by rote at first, but then sensing that this is pleasurable, this is fun, this is something that I can do for myself. I marvel at the way a life starts, helpless, tiny, pink, soft, and then, in less than a year, learning and soaking up the ways of world and actively communicating without yet saying a single word. I revel not just in the birth of another child, but the incarnation of another personality, another change agent in this world that we sometimes think is irretrievably broken, save this.

I’m thinking about how wonderful it is to be young and in love, to see and feel the wonder of the birth of that small child and then a career and then a family. To feel the tug and pull and stretch of life as it grabs you by the throat and says, c’mon now, you got yourself into this now pull yourself up by your bootstraps, by God, and feed these children and finish that degree and put yourself out there and get yourself promoted and make your mark in the world. Work as a team, work as a unit, be a family, because that’s the way the world moves on.

I’m loving the way it feels to teach my oldest granddaughter to play tic tac toe, the little gears in her head turning as she begins to grasp strategy and that this little child’s game, this little exercise played out with green crayon and paper, is a connection, no matter how fleeting, that is learning at its best. A playful assimilation of how things work. A tiny declaration of independence written in colored wax.

I’m thinking that this family gathered around is so very different from that family that was, in so many ways. We laugh, we talk, we remember. We cry, not here of course, but in private. We all know about that, those private struggles and quiet tears shed away from the celebrations and the holiday lights. We all know.

I see aging before my eyes. I see time’s inexorable march in flesh and bone, the weight of decisions made and a life lived sitting on the shoulders and bowing the back so that the vantage point of the eldest among us is both studied and stooped. I wonder what it must feel like to hear these joyous celebrations, as if from the bottom of a well, muffled and distant but close enough to touch.

I see the march of time.

Relentless. Giving. Exacting. Unforgiving. Heartless. Cold. Cruel.

I see the promise of the future.

Smiling. Bright. Energetic. Hopeful. Creative.

I see what all before me have seen.

A river of time that runs deep with the tears of sadness, the eddies of regret, the rapids of anticipation, and the sun-dappled, warm, mossy shallows of joy.

I see life as it runs its course before me, and today I am content.

Señor Citizen

So I’m excited to be in Athens, Georgia, yesterday.

I have just spent the morning with my daughter’s family, watching my granddaughter play soccer with the Purple Crush (how AWESOME a name for a soccer team composed of scurrying three, four, and five year olds) and then making a lunch of a veggie Cuban with everything and enough Diet Coke to put out the ensuing mouth fire. Don’t judge.

Next activity on my Athenian Saturday was to drive over to the UGA campus and take in an afternoon of NCAA Championship Tennis quarterfinal activity at the tennis center. I could not think of a finer way on Memorial Day weekend to get some sunshine, dehydrate myself and have an excuse to wear my summer Tilley hat than a tennis tournament. 

I park Rosie and walk up to the mobile ticket trailer set up outside the tennis complex. The cost of admission is ten bucks. I pull out my wallet, grab a twenty and put my face as close to the ticket window as possible. The white-haired gentleman on the other side of the window does the same. I shove my folded twenty into the little metal tray under the glass. 

Then it happens.

The event that changes my life forever. 

The milestone that I always knew I would reach, some day, somewhere (probably in line at the local CVS or something), but not today. Not one week after my second daughter has just married and is packing to move to Denver, Colorado, which I think is in a whole different country than South Carolina.

“Hi!” says the Silver Fox. “You’re in luck. Senior citizen tickets are just six bucks today.”

My hand freezes, the twenty still between my thumb and forefinger, halfway in, halfway out of the little silver channel, sort of like I am in relationship to MY GRAVE, I think almost reflexively after hearing this pronouncement from the man behind the glass who MUST be at least sixty years older than me. Hell, maybe eighty years older. 

I swear, I think I turned around to look over my shoulder to see who he was talking to.

There was nobody in line behind me.

“Excuse me?” I said.

“Senior citizen tickets,” Silver Fox repeats, like he thinks I am not only old enough to purchase one of these decade markers but I’m also DEAF.

“They’re six dollars today.”

He looks at me, then down at my hand with the death grip on the twenty, then back at my face again. I know that if I release my hold on this piece of currency, that if I complete this transaction and take him up on his offer to buy an OLD MAN’S ticket, that, like a bad relationship, I will have consummated something that will haunt me for the rest of my natural life.

Something that I now know, just by buying this ticket, is much shorter than it was thirty five seconds ago. 

“Oh, wow.” I say lamely. “Well, yeah, okay. Six bucks. Cool.”

I think I am probably drooling now. I’m not sure, but I may have just had a stroke or developed urinary incontinence or caught toenail fungus. 

He asks if I also have a dollar so that he can give me a ten and a five back instead of using all of his singles making change for me. I secretly think that he is giving me the cognitive portion of a mental status examination. 

“No, I’m sorry, I don’t,” I say, truthfully.

The lady next to me flips a rumpled greenback my way. 

“Here you go. Don’t make the man use all his singles.”

So now I’m OLD and I am receiving charity from a lady I have never met who feels sorry for me because I have incontinence and toe fungus (she could tell, I’m sure she could). This has got to be a nightmare. I’m going to wake up, young and alive and in bed with a George Clooney castoff. I can feel it. Come on, come on, come on.

“Thanks,” Silver Fox says, handing me back a ten and his last four singles. I flip the dollar back to the lady and thank her just the same. He gives me my ticket, which looks yellowed and nicotine stained in my hand. (I made that part up)

I take my ticket, my first ever Senior Citizen Ticket, turn around, and walk toward the entrance to the complex. 

The grandstand is steep. The day is hot. The sun is blazing.

I hope they have an ambulance on standby.

Dehydration and falls are two of the most common things that get us old guys, you know.

Well, at least I know I can ask for a discount on my next veggie Cuban. 

 

 

Talking ‘Bout My Generation

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I had had a long day yesterday, starting with a trip up the interstate to Columbia to meet with other Medical Chiefs from around the state of South Carolina to discuss the issues that affect the practice of psychiatry in the mental health system today. We had struggled with the electronic medical record, Medicare paybacks, e-prescribing, CPT coding, content of notes, billing time, and motivating our medical staffs to accept the changes that were coming, inevitably, down the tracks towards us like a governmental bullet train, sleek and fast and unstoppable. We had come up with a plan to educate ourselves as a group, to better understand the issues so that we could pass them on, a major part of the jobs we are tasked to do in our respective mental health centers. We set goals, timelines for implementation of new procedures, discussed training sessions, and then took our leave, feeling reasonably sure that things, by sometime this spring, would go without a major hitch. The session was recorded, and information was presented by the state’s wonderful IT professionals in real time with projector and laptop and other wizardry.

I got back to the office and reviewed file folders, processed emails, looked at applications for the jobs I’m advertising to supplement the present medical staff, aggregated policies from other centers that I would use to write one for my own center today, as requested by one of the powers-that-be in the capital. I organized the information of the day in a format that would allow me to present it cogently and succinctly to the Board of Directors of the mental health center that night at the regular conclave of the group. I reviewed an order I had made online on Amazon.com for a new pico projector and associated connection cable that I wanted to use with my latest generation MacBook Air to present a four hour training session on psychopharmacology to about a hundred people at the end of this month. I checked a program on my iPhone 5s to monitor the process of the flight of a friend who was returning to Atlanta from Munich later in the day. Things clicked along pretty smoothly until six PM, the appointed hour for the Board meeting.

My place on the agenda assigned, I sat and listened patiently to others present their reports about services rendered, budgets and community issues until it was my time to speak. I them went over the main issues of my first medical staff meeting last week, since coming back on board as the Chief of Psychiatric Services at the center. I supplemented that with the information gleaned at the Chiefs’ meeting earlier in the day.

In short, I was feeling pretty good about how everything was coming together and my own ability to handle it and do my job.

When I had finished, a board member, probably ten to fifteen years my senior (I am fifty-six years old), asked to speak.

“I for one really appreciate your being back in this capacity, and presenting all of this information to us tonight. I didn’t really understand about half of what you just said, but I do appreciate your trying to give it to us in a way that we can understand it.”

“Thank you, ma’am.”

“Yes, of course. I want to say one more thing. I’m not sure if this is the right way to say this, or even if I should say it, but I will.”

Hmm.

“I especially appreciate your efforts in all these areas since, you know, you are not of the younger generation anymore. I know all this is hard to grasp. I applaud your efforts to learn how to use all of this new technology.”

I looked to my left at the young woman who had just taken over the position of head of the child-adolescent-family unit. I looked to my right at the slightly-older-than-that young woman who is the heir-apparent to the Executive Director job at the center in the next three to five years. I realized that I was, indeed, not the oldest person in the room by a long shot, but that I was most certainly no longer the youngest gun.

I also realized that this woman, trying to compliment me in the best way she knew how, knew nothing of my history of using a Radio Shack TRS-80, every generation of Palm Pilot made, several Treos, one of almost every IPhone and iPad offered for sale, multiple MacBooks and PCs along the way, and having a home office complete with wireless connectivity, a scanner, two printers, two 4TB hard drives, and a cloud-based backup system just in case everything else goes up in smoke after a freak lightning bolt hits my apartment building.

One day, I hope to be really, really old.

They’ll be talking about my generation.

I’m not there yet.

Aging Gracefully

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Many of my notes begin something like this:

Forty-five year old white female, who looks older than her stated age, presents with symptoms of depression, hopelessness, and suicidal ideation.

I was discussing with a fellow worker in the mental  health field yesterday the fact that we are all well-trained in observation. We must be, to do our jobs properly. I have written posts in the past, and have even taught medical students, about how to do a fairly complete or at least serviceable mental status examination on a patient who never says a single word to you. It is not optimal, but it can be done. 

We notice what our patients look like the moment they walk in the door. How is their hair done? Are they wearing makeup? Is it tasteful? What kind of clothing are they wearing? Is it appropriate for the season? Do they have jewelry on? As they walk down the hall toward the office, we can see if there is any disturbance of gait or balance. When they sit down, body language, abnormal movements, and eye contact are all readily available markers of what might be going on that brings them to see us. All this before we have said much more than good afternoon to each other. 

What we forget to remember sometimes (for we knew it all along; we just don’t want to acknowledge that it is true) is that our patients also notice us. They notice how tired we look one day, or the bags under our eyes if we have not been sleeping enough. They notice if we wear new clothes or have new glasses or a new wristwatch. They may have a mental illness, but that does not mean that they are not concerned about the welfare of the person who is treating them. 

Most of the time this is harmless, but sometimes it can be telling in a very important way that impacts good patient care. Like the time that I hired a temporary doctor to help with coverage in a rural clinic. Shortly after she had met some of my longtime patients at the office, I received a message that one of them wanted me to call him about something important. Now, this patient never called me and left a message like that unless it was truly important to call him back. I did so, promptly. (As background, please know that I had already heard grumblings from the staff at the main mental health center office where this doctor was also spending some time.)

“Dr. Smith?” my patient began on the other end of the line, his southern drawl so thick it took him days to tell a story.

“Yes, Bill?” I answered, wondering now what was up. He sounded good, calm, together. 

“You know that lady doctor you sent down heah to see us until you can git sumbody else hired to help you out?”

“Yes, I do. What about her, Bill?”

“Well,” he hesitated.

“It’s okay. You can tell me whatever you need to tell me. It’s all right.”

“Well,” he began again, “Dr. Smith, you’ve known me a long time. I may have a bad mental illness, but Dr. Smith, that lady is one of the craziest doctors I think I’ve evah met.”

He went on to tell me details of some inappropriate behaviors that impacted care in the center, consistent with the feedback I had already been getting from others. 

I fired the doctor the next day.

I saw a young patient in clinic recently. He had not been in to see me in well over a year, maybe two. He greeted me this way:

“Well, I guess we both got older, Doc. A little gray there since I last saw you.”

Just a few years ago, this might have bothered me. No more.

I’ve come to like my rapidly whitening goatee, the touch of gray-white at my temples. Badges of experience. Signs of (hopefully) wisdom gained in the struggle? I’m not as skinny as I was in the ninth grade in high school. My hairline has receded a bit, but at least I still have hair! Some days, I’m sure my patients notice me sitting down with an audible groan or struggling for a half-second to get up when my polymyalgia has flared. I’m sure they notice that I forget things, parts of their history that I know and have known for years, but that get swept away downstream in a modern-day torrent of electronic medical records, red tape and sheer volume of information coming at me from a dozen different pipelines. 

I think my patients give me the benefit of the doubt, because they know I care. 

We grow old together, my patients and I.

I am treating the fourth generation in some families now, seeing first hand the living textbook of mental health genetics that is a family plagued with substance abuse, depression, or schizophrenia. I have always said that I am privileged beyond words to be let into a patient’s life and circumstances on such an intimate level as this. I mean it. It is an honor. 

Aging gracefully is a skill. An art.

In this age when we value beauty and youth, we sometimes forget how important it is to revere and respect our elders. They hold priceless memories. They have seen things we have not had to see. They have picked us up when we have fallen and protected us from untimely hurt. They have known that they could not forestall the inevitable painful education that life bestows on us all, long before the first gray whisker or arthritic joint visit us and take up permanent residence. 

Yes, my patient pointed out the gray. He reminded me that, like my patients, I grow older with each passing year. Not a bad thing, given the alternative. 

I work.

I play.

I love.

I lose.

I learn.

I share.

I live. 

Rage, Rage Against the Dying of the Light (Dylan Thomas)

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They come into the ED after they have fallen down and can’t get up. They don’t eat or drink for a few days, a week, then get dehydrated and can’t take care of themselves.

They forget to turn off the stove. They leave the keys in the lock to to the outside door. It becomes too hard for them to bathe, so they simply stop bathing. They run out of food, but they don’t remember that one must go to the grocery store to buy more.

Email, their lifeline to the outside world and the family members that live in it, suddenly becomes stange and difficult to understand. Hitting the keyboard and yelling at the beige box become the only way they know how to express their frustration.

One glass of wine becomes two mixed drinks a night becomes half a bottle of wine becomes a fifth of liquor. The overt withdrawal symptoms seen in the emergency department are unexpected in a woman in her late seventies whose substance abuse history is “Not Applicable”.

The elderly account for a large number of visits to the emergency department each year. They come for falls, trips, slips, bruises, congestive heart failure, accidental poisonings, depression, confusion, and urinary tract infections. They have heart attacks, strokes, trouble breathing, headaches, visual hallucinations and chronic constipation.

They can be delightful people who bring a smile to the faces of their caregivers in the ED, or they can be someone’s worst nightmare (family or staff). They can command instant mobilization of resources, by virtue of the frightening acuity of their presenting symptoms. On the other hand, they can easily get lost in the shuffle and be pushed, literally, into a corner while squeakier wheels get the grease. 

Seeing elderly patients in the ED brings forth many emotions in me. I have pictures in my mind of family members, friends and patients from the past who inform my responses to the person in front of me. I won’t belabor the fine points of evaluating an elderly person with changes in mental status here, but I will share some insights with you that I have gleaned over the years. 

Old people have a lot to share. Youngsters, and even us middle-agers, sometimes tend to treat our elders as if they have given their best years and brightest ideas up and are just coasting through the rest of their lives. Not so. They are often very bright, very attentive to their surroundings and have much to say about the world around them. 

Old people tell great stories. No, they don’t do it in 140 characters or less. No, they don’t do it by embedding YouTube video clips in the conversation. They do it the old fashioned way. They paint delightful word pictures filled with satin and lace and fragrant hay fields and fishing ponds on a summer afternoon and tales of “the one that got away”. Be prepared to stay awhile. You can’t tweet a masterpiece. 

Old people remind us of where we’ve been. My own relatives, as they aged and faded out of my life, would often let me know that I shouldn’t forget where I came from. It was good advice then, and it’s especially good advice now, as many of us struggle for meaning in a cacophonous world.

Old people remind us of where we’re going. We will all age. None of us will get out of this alive. We can choose to ignore the wisdom that our elders have to impart, but at our peril. One day, we will be the one in the wheelchair or softly restrained to the gurney, trying to get someone’s attention. 

You are one day older today then when you read my post from yesterday. How will you age gracefully today? What will you learn? What will you give back?

 

“It`s not how old you are, it`s how you are old.” 

Jules Renard