My Weekend at a Safeguard Hospital-Part III of III

“Aint no need to worry what the night is gonna bring, it’ll be all over in the mornin’…The soundtrack that is constantly playing in my head decided to soothe me with Anita Baker joining the Winans.  I was able to sleep through the night without the interruption of my ringtone signaling a call from the Transfer Center.  Our own Emergency Department had been equally kind to my sleep hygiene.

As an attending, I do not have to go to morning rounds every day anymore, but when I have patients for whom I am the surgeon, it is the least I can do to show my face and remind them that my care doesn’t end after we close the incisions.  Jamie is somewhat uncomfortable, but doing relatively well.  The overall report of pain, headache, vision, and general well-being is a notable improvement from the status upon arrival.  Max is in the ICU, improved and awaiting transfer.  We often find that transferring a patient out to another institution is decidedly more knotty than receiving someone.  So, we expect a protracted process.

Sunday’s exposure of the fault in our stars began with a phone call, just like Saturday.  Another erstwhile colleague in Emergency Medicine wants to transfer a patient to our institution for a “higher level of care.”  This time, we are actually just a few blocks away, which feels, oddly, like a win.  I try to just focus on the work, but I cannot help but wonder how and why so many Emergency Departments in a 30 mile radius choose us to call first?  I would love to believe it is because the reputations of the physicians at our institution is a significant draw.  I fear that that the reason is less complementary, however.  Empty still does carry the same meaning as available when it comes to open beds in a healthcare facility….

“Pat” has been having trouble swallowing for “a few weeks.”  Whenever there is a foundational story and symptoms really aren’t new, natural inquiry wants to know what happened to create a change that made you go to an Emergency Department.  In this case, the mild trouble in getting liquids to go down captured solid foods in its web of increased work to accomplish once effortless functions.  Daily variations in swallowing had been ignored or denied.  The most significant change, however, was the result of how close the swallowing tube is to the breathing tube.  The problems we won’t face sometimes hunt us down.  The essential function of breathing in air was now a struggle for Pat.  The hunger for air can only be denied as long as one can hold their breath.  So, this symptom carries Pat to the nearest hospital.

The very pleasant physician on the phone tells me that they already decided that Pat needed a CAT scan to try to figure out what was going on.  There a “bump” on the front of the throat and they were rightly concerned about the trouble breathing.  The CT scan shows a mass in the front of the neck that appears to be fluid-filled.  The airway also appears to be pretty narrow.  Can we transfer?  The detailed narrative was a build up to the most important question.  We accept.

The patient arrives in our Emergency Department and is stable, but there is some obvious work to take in each breath.  The nostrils flare a bit, the rise of chest is heavy, not second nature.  The collective powers of observation between me and the two residents on call suggest that the situation is urgent, but not yet emergent.  Let’s get a little more information.  We have a scope, which is sort of like a fat piece of spaghetti with a light at the end, that is small enough and flexible enough to let us peer inside the human body.  We can try to take a look and see why Pat can’t swallow and now can’t breathe.  Our hopes of gaining understanding are quickly dashed.  Nothing looks recognizable.  We don’t see the vocal cords—which are the gateway into the windpipe—and we don’t see much space at all.  In fact, we don’t see much at all that resembles what we’re looking for.  Whatever this mass is, it has encroached upon the expected anatomy in a way that curls lips, raises eyebrows, and adds stress lines to the face.

The “bump” on the front of the neck looks more like a golf ball and seems to be filled with fluid.  I feel like we can move it around some, so I think it is a cyst.  Maybe the fluid is infected and this is an abscess.  I am not sure about the exact nature, but I am positive this is a barrier between me and the windpipe and I have to think about how to get around it.   We plan to go straight to the operating room and establish a surgical airway.  So many of the obstacles that now lay behind me stream into consciousness to build me up and encourage me.  Your 9th grade guidance counselor told you that you weren’t college material.  Look at what happened.  Some of your friends told you that getting into Yale College was a fluke, but you finished Yale School of Medicine.  Anyone who has ever been plagued by imposter syndrome understands this roll call of slain dragons.  I have pushed back that annoying voice fed by the teachings of minority inferiority and I have reclaimed so truths.  The residents working with me are compassionate and capable.  So am I.  We’re ready to do this!

We can tell from the scans that the breathing tube looks pretty normal below the mass.  So, we need to make an incision in the front of the neck, get down to the windpipe and open the airway so we can bypass all the trouble we saw with our scope and on the radiology images.  Having been cheated in our attempts to see the voicebox, we have seen the roadblocks and we know the anesthesiologist won’t be able to put in a breathing tube in the standard way through the mouth.  We have no choice but to keep the patient awake and breathing while we clear a path to let the patient fully inhale and exhale, and not just in the metaphorical sense.  Human beings like oxygen and a person who is awake and breathing will do everything they can to stay that way.  We are going to take full advantage of this natural law planning to make sure Pat won’t keep working to get air in.

One of the great enigmas of practicing medicine is how rapidly the initial encounter with a patient can progress from “hello, what can I do to help?,” to an urgent operation.  “We need to go to the operating room and make a cut on your throat to place a tube in your airway.  We also need to do this with you awake.  We will give you some medicines to take away pain and try to help keep you calm, but you will somewhat aware of what is happening while we do it.”  Those words could be received as paralyzing coming from a most trusted, longtime confidant.  How oddly and clumsily they must fall on one’s ears coming from someone you met 6 minutes ago.  Smoothing the awkwardness, however cannot eclipse the gravity of the situation, nor do we have generous time for pleasantries.  We proceed to the operating room trying to build some manner of trust in the elevator ride, making the most of each second.

We enter the operative theatre once again and it is welcomingly familiar to us.  We are comfortable on this stage, the characters are known and the props rest in our hands with a sense of knowing.  Some of the actors have changes—even on call, there is a first team and a back-up team so there are personnel guarantees. 

For our patient, the experience is entirely new and, as an extension of this fact, somewhat threatening.  The lights are bright!  The room is a little chilly.  More often than not, it bears no resemblance to somewhere you’ve been before.  We maintain an awareness of this dilemma and do all we can to encourage calm and focus in a setting that can feel disjointed and chaotic.  The room is filled with total strangers.  The tender hearts are genuine, but because we have no sustained relationship with Pat, it might feel perfunctory.  Still, we must continue. 

As promised, we start injecting some medicine to make the area numb.  “A little pinch, then some stinging,” we explain as we work.  “Keep taking deep breaths and blow that little sting away.”   Aware that time is not fully on our side, the entire OR team is aware of how scary this must all be for the person on the table.  So, we practice patience.  We give the medicines time to work while we fix our gaze on Pat.  Verbal communication is fill with reassuring words.  Even in a COVID-19 world, human touch brings comfort.

The three surgeons transfer all of our good thoughts and positive vibes to a steel scalpel that divides the skin exposing what lies beneath.  A frequent, if fleeting thought visits any surgeon whose mind is open.  Despite all the importance society can place on the hue of skin, one it is breached, we are the same beneath.  The priority assigned to the peel so often keeps people from enjoying the fruit.  The revelation, of course, calls into question how racism could ever become so prevalent in medicine.

With kindness and concern, we initiate the journey to make a new entryway for life-giving oxygen.  Pat is amazingly cooperative and we are able to maintain some serenity with deep breathing and self-soothing (for everyone in the room).  Like many excursions—including Pat’s day—things often veer off the path and the lump in the neck we saw before shifts our course.  As fluid slowly creeps into our sight, we know the fluid filled sac in the front of the neck is no longer contained.  This is actually a good thing because we can suck out the fluid and the golf ball in our path is now flat.  It is easier to see and easier to feel.  Our senses are how we experience the world and the surgeon’s world relies on the unique information gathered sight, touch and sometimes, olfaction.

When anatomy is distorted, the goal shifts and we aim to make things look like they are supposed to look rather and try to recapitulate normal.  Carefully and methodically, we move structures that were pushed aside by the mass back to the middle.  Then, we can follow them down to the next layer of tissue as we approach our destination.  We move with alacrity and precision all the while imbuing the atmosphere with as much confident serenity as possible.  Pat is awake, and understandably more nervous as we move closer to the airway.  Although our purpose is to be helpful, the body can perceive us as a threat.  Humans have protective reflexes and approaching the windpipe with a scalpel should raise a hair or tow.  We explain our next moves and place a hand on Pat’s should to offer some reassurance.  We then make our cut into the trachea and place a tube in the windpipe that gives Pat significant relief.  We exhale!  Collectively, we ALL exhale!!

We had turned on some music to help keep the room the calm.  Now that Pat’s breathing was stable, I could actually hear a rhythm.  The melodies emerged from the recesses and enhanced a brief celebration.  Then, stark reality forces us to attention.  We need to collect some tissue for a biopsy.  For all intents and purposes, the “thing” interfering with swallowing and breathing is cancer until proven otherwise.  It is always arduous to find proof of the things we already know, but don’t want to believe.  So, we prove that this is cancer to prevent ourselves from accepting all the alternatives we create that are easier to digest.  We retrieve several pieces of tissue for reassurance and to combat any future doubts.  We make sure the plastic tube is secure and tidy things up.  Pat’s situation is better than it was, but we still have a long way to go and many questions to answer (or difficult answers to accept).

We pick up the phone to reach Pat’s family learn more about the sequence of events that lead to our introductions during an emergency operation as well.  Pat’s close relative informs us that Pat has been having trouble swallowing for about a year and it has slowly been getting worse.  People had encouraged Pat to go get it checked out, but Pat doesn’t have insurance.  Pat also works part time without benefits and was/is afraid of missing work and unpaid bills.  Pat actually went to work the day of the ED visit, compelled to protect a paycheck and compelled by the fear of what happens to people who are impoverished in a country of great wealth.  They took a break early in the shift to try to ease the shortness of breath.  Pat actually agonized over making the decision to leave work and seek medical attention and only left the job when the work of breathing became stifling.

We collectively experienced a circumstance in which having trouble breathing was balanced against the need to participate in our modified, crony-, corporate-capitalist economy in order to secure basic goods, services, and shelter.  The need to make money for survival eclipses the basic instinct for survival.  THIS is bad!

When Adam Smith provided a framework for what would later be called capitalism, he valued the worker and the work.  The ability to provide a service was honored and the providers were important, not just cogs in the wheel.  Adam Smith did not envision that one day, when supplied with patients who need service, healthcare facilities would demand that these under-resourced people with illness be transferred elsewhere.  The working poor remain some of the most undervalued, vulnerable people in the experiment that is America.

Caring for these three life forces was complicated.  I am grateful for my training and it readily came to mind that essentially all training hospitals are funded through Medicare/Medicaid coffers.  So, in a very real sense, every trained physician owes some of their clinical acumen, expertise and finesse to the very patients who get displaced and shunned in our modern healthcare system.

In each case, there is a gnawing sense that had something been done with more alacrity, the outcomes could have been improved.  We wonder why Jamie didn’t go back to the doctor a little earlier.  We wonder is Max could have avoided a catastrophe.  We secretly judge Pat for choosing between a rock and a hard place.  We spend far less time questioning the system.

Much of the research about healthcare disparities confuses access with invitation.  There is an assumption that if a clinic is close by, individuals will go there seeking care.  If proximity isn’t reinforced with making people feel like they belong and that their presence is cherished, then the location won’t be enough.  The care is essential in healthcare.  We also talk about health insurance by asking the wrong questions.   Universal coverage is the buzz phrase when we really need universal acceptance.  In 1882, Emma Lazarus penned the ultimate invitation in The New Colossus which concludes, “Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!”  The ‘Mother of Exiles,’ also known at the Statue of Liberty, was not about proximity.  There was deliberate invitation and welcome.

Part of the idea of a safeguard healthcare facility is to create a space for those less likely to be accepted.  The idea that healthcare should be a lucrative enterprise pits the entire system against some of the very people who need care the most.  Poverty keeps asking questions and our answers are void of alacrity.  We keep wondering if we can change the outcomes, but we aren’t willing to try to avoid the catastrophe.

Superman and the Wonder Twins will rest.  We will reflect.  We will decompress.  We will critique our actions and we will strive to keep being better, all the while realizing how blessed we are to be in our positions.  Something needs to be fixed.  We know something is wrong.  Three lives hung in the balance and we were able to achieve somewhat favorable outcomes.  Still, Jamie, Max, and Pat haven’t received a hospital bill yet.  There are obstacles in planning for discharge we haven’t even discovered yet.  The acute care results are only as good as the ability to sustain day-to-day health maintenance and appropriate follow-up.  Why do we need to guard against people being denied access to healthcare?  Why isn’t this more of a guarantee?  Why do we spend resources on acute care but neglect preventive measures?  Why do we wait for sickness before acting, but call it HEALTHcare?  We know this is bad.  We know poverty is the underlying condition.  The problems we won’t face sometimes hunt us down.  This is bad.

My Weekend at a Safeguard Hospital-Part II of III

‘Of him to whom much is given, much will be required.”  I do say that, don’t I?  The words come out fairly easily.  Making the phrase an attitude, a way of living, is substantially more arduous.  In the locker room while changing out of my scrubs, there is stillness challenged by a curious mind.  I wonder why the lockers are so small.  I wish we didn’t have such strict rules about wearing scrubs outside of the operating room area because it has been a long day and I would much rather just go home and…Oh wait.  I shouldn’t change yet.  The desire to bring the day to an end shut down some important neurons and I allowed myself to act like I was ready to go home, when I still needed to go upstairs with the patient. 

Jamie was stable, but the Chief Resident, the more junior counterpart (second-year resident) and I were spent, having each served in our roles for the entire day.  For just a little background, the residency training for our specialty is five years long.  Each year brings a mixture of good and bad.  In the beginning, gathering accurate information and learning discernment is much of the goal.  There is a fair amount of observation and stepping from medicine in textbooks into the relationships build between physicians and patients.  The more junior residents are usually the first one to be called, but the back-up is swift and complete.  Passing days build knowledge and confidence and residents gradually assume more responsibilities.  As we are given more, more is required of us.  Chief Residents are close to being certified as independent surgeons and they have knowledge and experience.  In fact, this particular Chief Resident’s fluent conversations in Spanish were invaluable in establishing a relationship with Jamie. 

I was the first Chief Resident in my residency program who looked like me.  They haven’t had one since me, so I am still trying to figure out what that means.  Did I pave the way or permanently close the door?  Did I represented all Black people well or was I the confirmation of long held stereotypes? This line of questioning crept in as I confronted the hovering truth that a majority of the patients transferred to safeguard hospitals DO look like me.  Unfortunately, I did not have the luxury of indulging those thoughts as the minutes marched on.

As we were exiting the intensive care unit, we decided to go check on a patient for whom we were a consulting service.  Max—which could be a diminutive form of Maxwell or Maxine—was brought to our Emergency Department because we were the closest institution.

Despite a relatively young age, a few catastrophic event had befallen Max.  They were suffering from a condition that is recurrent and sometimes progressive, but still considered manageable.  Some people even use the word “cure,” in 2020.  Max had an infection with the Human Papilloma Virus (HPV), but not the kind we hear about in the commercials that affects the private parts.  Max had the kind of HPV that affects the hidden, but essential body part, the airway.

In some patients the growths from the virus, known as papillomas, limit their territory to the vocal cords and mainly cause hoarseness.  There is an unfortunate minority for whom the growths seem unrestrained.  They can pass the vocal cords and go down the windpipe.  They can even encroach upon the lungs and make breathing an exceptionally challenging task.  As Max’s story unfolded, inclusion in the smaller group that bears the greater burden became clear.

When we encountered Max, the effects of not getting enough oxygen were already apparent.  Max no longer had the ability to communicate and no longer controlled limb movements.  A plastic tube, known as a tracheostomy, settled in Max’s airway to help insure that it would stay open.  This was to help prevent the airway from blocking and, God forbid, making the damage even worse.

The three of us reflected upon the way in which life can present massive detours to hopes, dreams, and plans.  As the trio was humbled in gratitude for the blessings of health and mobility, the shared pace quickened as we approached Max’s door.  There was hurried sense as we saw people exiting the room.  “Call respiratory therapy,” wafted through the halls and fell on anxious ears.  Are you kidding me?  This day has already been tense and we were just coming to check in.

As it turns out, the whim was prescient.  We walked into the room precisely suited to watch the numbers on monitors falling.  We took special notice of the pulse oximetry because this is device placed on a finger, toe, or ear to broadcast the amount of oxygen in circulating blood.  We are happiest when that number rises above 95% and stays there.  Once is dips below 90%, there is concern, and falling below 80-85% brings us to the call for respiratory therapy that beckoned us into the room just moments before.

Superman and the Wonder Twins go to work!  We are no delusions that we have superpowers, but we all recognize the moments when we need to dig deep and overcome fatigue to sharpen our minds and our skills for our patients.  We know that papillomas have hindered airflow in the past with a devastating outcome.  One of the Wonder Twins sprints down the hall to grab a scope for us to look into the windpipe and make sure it is clear.  We also think to use a suction straw to make sure phlegm and mucus aren’t building up and blocking the tube.

A collective relief fills the room as we discover that the windpipe is open and air can move through.  Still the numbers on the pulse oximeter make all of us uneasy and we agree that close monitoring in the ICU is probably a good idea.

As the adrenaline rush subsides, we go into cerebral mode trying to figure out how to make everything better, knowing that we will need to redefine the word to have any hope of being satisfied.  Having worked with patients that have papillomas for decades, I do try to read up and stay current with my knowledge. 

There is a new-ish drug called Avastin that I have read about.  Some people have used the “cure” word when describing it.  I think to myself that this might be a great drug for Max.  Hopeful smiles fall sullen as the three of us admit that Avastin is quite expensive.  It’s a medication that requires a group of physicians to approve its use.  At present, it is mostly used for cancer.  So, the underlying condition of poverty thwarts plans again.

Max’s family has a discussion and though they are sincerely grateful for our care and even the mention of a medication that might be helpful.  Still, there are relationships with providers at the home institution, we just happened to be closer when urgent care was needed.

I know the doctor at the other institution so I call them up for us to chat, and commiserate.  I know that Max will be in caring hands, but we are all navigating relatively languid territory when it comes to how we eliminate poverty as a determinant of health.

This is bad!

I wonder how I will rest tonight, not just because I fear more facilities and colleagues seeking to transfer their patients for a higher level of care, but because healthcare has become a business that, at least by some appearances, is more profitable if there is sickness and streamlined care is a mythical grail.  How do we care for health and profitability simultaneously?  Do we invest in preventive medicine?  Do we address poverty outright?  Do we designate safeguard facilities and hope they can shoulder up as the weights increase? My mind is tired, my body is tired, my spirit is tired.

This is bad!

My Weekend at a Safeguard Hospital (Part I of III)

‘Of him to whom much is given, much will be required.”  This passage from the book of Luke in the Bible was taught to me at an early age.  It has always helped me place things in perspective and realize that my Ivy League education comes with some requirements for what I do with my life.  This worldview is absolutely part of why I chose, and still choose, to work at a healthcare center that provides superior care as the first priority and deals with patient finances as an important, but secondary, issue.

Just a short time ago, I had a particularly busy weekend on call and showed up to work Monday morning completely spent.  The conservation with my colleague went like this.

Them:  “How was your weekend?”

Me:  “Crazy busy!  Disastrous cases…(reflecting on just how dire the situations were)

Them:  “Bad problems?”

Me:   “Yeah, invasive fungal infection and cancer.”

Them:  “What were the underlying conditions?”

As my auditory system received and processed these word, my consciousness aligned the cataclysmic events of the weekend for me and without any hesitation, I emphatically answered, “POVERTY!”

Saturday was the blank page upon which the first tragic story was written.  I received a call from an outside emergency department that wished to transfer a patient to our institution.   The physician sharing the narrative with me was pleasant and, no doubt, committed to securing care for their patient.  I listened as I heard a specific medical risk factor of diabetes and concern about an opportunistic fungal infection involving the sinuses and maybe the maxilla, or the roof of the mouth.

Years of medical training helps the more seasoned physician to both transmit and receive the key words that support a transfer of a patient’s care from on medical facility to another.  The dreaded invasive fungal infection, also known as mucor, is the real deal.  This condition can be rapidly fatal and we are compelled to address it with urgency.  Still, I could not help but wonder why a medical center located over 15 miles away and in a suburb was making a transfer request to us.  I am also aware that this particular hospital is part of one of the large healthcare groups with 900+ doctors.

I have lived in Chicago for what is approaching two decades now.  I am well aware of the surrounding hospitals and their capabilities.  Curiosity and the benefit of calendar flips from one year to the next lead to my education on this matter.  So, while on the phone, I am well aware of the two medical centers with fellowship-trained surgeons an ambulance will have to pass to get to our emergency department.  I naturally wonder why someone is opting to forego the closest option and is seeking us out. 

The gravity of the situation is known by my colleague who is delegating this responsibility to “a higher level of care,” and they request a transfer to an ICU bed for close monitoring.  This, of course, means that another physician at our institution must agree to accept the patient because ICU patients are accepted by ICU, critical care specialist.  My acquiescence only secures surgical management of the deadly infection to remove involved, sometimes dying tissue, and help stop the infection.  These patients also need strong, intravenous pharmaceuticals to kill the fungi and management of the underlying diabetes that weakens a patient’s immune system in the first place.

We cross that first hurdle and the patient arrives in our ICU.  That patient, we can call “Jamie” is calm in a way that feels disproportionate to the extent of disease.  It doesn’t take me long to realize that part of what we are interpreting as calm, is a language barrier.  Jamie does not speak English and we need someone to translate.  It is an unbelievably hard assignment to explain to patient that they have a life-threatening infection that can involve the sinuses, the teeth, the eye and even the brain.  The inability to directly communicate with the patient undermines our ability to establish a relationship and develop trust.  Jamie is displaced, miles from home, alone in an unfamiliar environment and unable to understand what we are saying.   Everyone is patient and we do the best we can to carefully explain our concerns about an invasive, spreading infection and the need to move swiftly.  Jamie is still relatively calm, but does let us know that there is discomfort in the eye and a headache as well.

Based on the history we extract through an interpreter and the chart, we know that we need new CT scans to assess the extent of disease and help with a blueprint for surgery.  We also need to hear from our colleagues in Ophthalmology, Neurosurgery, and Infectious Disease.  Jamie can see out of the left eye, but it looks swollen and it doesn’t match the right one when we have them follow our fingers to check how the eyeball moves.  This looks bad!

In Jamie’s nose, we see the spores that are telltale signs of an invasive fungal infection.  Even more ominous is the fact that tissues that are pink and plump when healthy look gray and shriveled on our examination.  The other pathognomonic (Latin and Greek for telltale) sign is that this tissue doesn’t bleed when you scratch it.  This looks bad!

We obtain our new scans and have our consultants weigh in.  The neurosurgeons essentially say, “Call us if you need us.”  The ophthalmologist want to protect Jamie’s eye—remember part of the treatment is removing tissues and are infected—so they opt to inject strong medicine into the muscle around the eye so that we can try to save it.

I am a vocal cord surgeon, so I need to brush up on the anatomy of the sinuses.  It is true that my name is recorded at the attending Otolaryngologist on call, but this really isn’t my area of weekly work.  Notwithstanding, I am committed to being thoughtful and careful with the initial management of this patient.  The plan, going in, is to remove the obviously disease tissue and flush the area out with some antifungal medicine.

Healthy tissue likes being part of the body, so it isn’t easily separated.  This is not our experience in the operative theatre.  The gentle grasp of tissue initiates its total detachment.  The “normal” anatomy inside the nose just falls away as the chasm we have entered seems to enlarge with our every move.  I begin to fear that the sinus cavity won’t be salvaged.  I worry that brain is right behind us and that left eye that didn’t look so good, is right above us.  We are on a rapid slide from bad to worse.

We open all the sinuses and find that mainly the maxillary sinus (the one near the cheekbones) is really involved.  We see a lot of fungus in there and wash it out with antifungals.  We get the bad tissue we see and make a plan to come back later to take more tissue.  It looks like we will need to take some of the bone that forms the roof of the mouth and some of the bone for the sinuses.  There are definitely more surgeries ahead, but things look a little less bad.

Jamie has been living in the great melting pot for years, but she has not been able to complete citizenship requirements for a variety of reasons.  Still, she went to see her primary care doctor when she first developed headaches and tingling in her face.  From the initial visit, there was a concern about a possible tooth abscess so they started antibiotics.  Jamie got them took them and did everything she was asked to do.  When the symptoms didn’t really resolve and, in fact progress to include new complaints, there was a timely return to the doctor’s office.

The doctor sent Jamie to the closest emergency department and they completed a work-up that lead to the telephone call that connected me to this patient.  I asked if we were the closest institution and I was informed that no one else had an available bed.  The desire to communicate well taught me to listen carefully and interpret the actual word choices people make.  When someone says, “there are no available beds,” it doesn’t always mean that there are no EMPTY beds.  Sometimes, it means that the open slots are not available to all patients irrespective of financial circumstances.  This is how poverty can dictate which hospital beds are “available.”  This is BAD!

By law, a physician cannot inquire about insurance status, but others involved in telephone conversations can.  Many steps are involved in moving a sick patient from one facility to another.  It is also true that the reputation of being a “safeguard” facility means that people will preferentially call us when they are confronted with unfunded or underfunded patients.  This is why in a 30 mile radius, we top the list of hospitals to call if a patient needs to be transferred. 

There appears to be collapsing concern for displacing a patient or having them travel far from their families.  Whether or not the family has the means to travel to our facility and provide the critical support and familiar voices and surroundings that are also essential to recovery feels like a fourth or fifth level question as a plan provide care is developed.  

One of the signal phrases is “a higher level of care.”  The careful listener has a curiosity that is piqued by the liberal use of this phrase as well.  The person seeking to send a patient UI Health often requests a “higher level of care,” but I now find myself wrestling to extract true meaning.  Are they calling me because they believe the physicians at our institution are more experienced?  Do they think we have more extensive training?  Do they find us nobler in our commitment to providing care regardless of the ability to pay?  Or do they think an underfunded patient is going to generate a higher bill and they would like to pass that on to another facility? This still feels bad.

Many questions flood my mind as I ponder why there are no available beds all along Lake Shore Drive—or maybe they will take the Kennedy Expressway.  Either way, it will take approximately 50 minutes or more for them to make it to the Illinois Medical District.  I am confident that once the patient arrives at our door, the dedicated physicians here will provide a high level of care and will fight exhaustion and cynicism to help the patient and family feel like they were sent to us because we are the BEST, and not because we were the only ones willing to take them.

Our hospital slogan reflects our desire to make healthcare delivery personal.  I like that.  I am not as fond of the marketing idea that we are a well-kept secret.  I actually want people to know that we give our very best even with limited resources, even in challenging times, even when it doesn’t seem logical, even when we wonder if you had a similar patient with better insurance, would you still have called us?

For now, Jamie is stable, but we have not yet reached the half-way mark for this weekend…

The Celebrity

My father poured into my life and his efforts left eternal imprints.  Daily, I recognize more of him in me.  Some of his gifts to me were attributes and temperament.  Some of them were more concrete.  The 1988 Chevrolet Celebrity was one of the last tangible gifts, so the memories are indelibly etched on my temporal lobes.

My first car [or the first car I had been allowed to use] was a white, Chevrolet Chevette.  My sojourn through college held many lessons and the Chevette taught me one of the most enduring.  Checking and changing the oil in your car can protect your engine from burning up, requiring an expensive replacement.  My folly resulted in a car that was unreliable.  So, I started medical school as a pedestrian and a part-time patron of public transportation.  After the first two, non-clinical, years, I needed transportation to start my clerkships in varying hospital settings. 

I had the perfect plan.  I found a Ford Probe that was perfect for me.  All my parents had to do was cosign for the car loan and help me make payments. They, of course, had not forgotten how well I had cared for my last vehicle. The “compromise” went like this:  The city of Bluefield had leased dad a vehicle because he was the Director of Parks and Recreation.  That lease was fulfilled and dad was given the option to purchase the vehicle at his own expense.  He bought the burgundy Celebrity and gave it to me.  At twenty-six, I naturally preferred the sleek, sporty Probe to the 4-door sedan that screamed, “my father’s car,” but over those two decades, I honed my skills to anticipate the logic that dictated my mother’s interrogations.  “You got Probe money?”  That was pretty much all she had to say to open and close her argument…So, in the summer of 1991, I left home escorted by Bessie, my “new” vehicle.  I would not see my father upright and healthy again, but that is not the focus of this story.

In the summer of 1992, I was driving home to see about my mother.  Dad hadn’t been gone for a full year, but everything was different.  Life moved on, but it was forever changed.  I had finished rotations, but my short white coat was almost always in the front passenger seat just in case I got called to the hospital or needed to present my professional self.

I had purchased a cool device that would let me attach a CD player to the car’s sound system.  The Celebrity came with a cassette player, but I had 5 CD’s.  Being able to play them in the car—skips, bounces and all—felt like a bridge to my fantasy Ford Probe that had an amazing sound system I enjoyed during my test drive.  I was listening to Chante Moore’s Precious rolling down the highway.  “Ba da dah, ba dat dat dat da”….While the fingers are popping and the neck is rolling, the music can make one’s foot grow heavy.  I was also on a decline and gravitational pull of a downhill stretch along Interstate 78 added speed.  Before I knew it, I saw flashing lights in my rear view mirror.  $%@*!!!!

I am a struggling, under-resourced medical student, the LAST thing I need is a speeding ticket.  You should have paid more attention.  This is money for meals you’re about to spend.  My self-flagellation was about to kick into full swing when the arrival of second patrol car snatched my attention.  Next came the third patrol car.  The racing thoughts in my mind were collimated by a single name:  Rodney King.  I started to feel short of breath and being to sweat.  Stop it!, I told myself.  They will think you are nervous and that will make you look suspicious.  The mental tug-of-war is so often unseen by the audience while the main actors perform the story of being a Black man in America.  Still, internally is where micro and macroaggressions elicit the full sequelae of traumatic injuries. 

I steel myself and calm down remembering everything I have been taught about interacting with the police.  “Keep your hands visible!  Be polite!  Don’t make any sudden moves!” Two officers approach, but there are six in my rear view mirror.

 One of the realities of existing in a world where you are judged on site is that you learn to see the lightning quick assessments displayed on the faces of the people you encounter.  You are trained to notice that slight change of the lips and mid-face when someone greets you in person after speaking with you over the phone.  As a defense, you learn to size up the people who are sizing you up.  Often, their higher-level function neurons override their more primitive urges and they fix their faces with great alacrity.  Still, the trained eye sees it.  We have to.

Time was already standing still for me in an ethos of constrained anxiety, but I was still able to notice the officer’s eyebrows raise as he peered through my front passenger seat window.  He was scanning my car, no doubt for evidence of my criminal deeds when his eyes crossed my white coat.  I witnessed the pause as his gaze fixed on my beveled, blue and white acrylic name tag.  More important than my name was the institution beneath it.  Yale Medical Student.  As his faced morphed, so did I in his mind.  As the muscles in his face relaxed, I became a human being, not just a Black body.  I would like to thank that is was happened, but it may also be true that the coat and the name plate informed him that it would be likely that people would ask questions if I wound up dead.

I will not pretend that I could read his mind, but I am fully confident that I was able to read his face and his body language.  In an instant, I was transported from being a natural born killer threat to being someone worthy of inquiry.  My humanity began to matter.  He asked, “are you studying to be a doctor?”  [‘Well, that is what most people do in medical school’…Steve!  Don’t be snarky, you aren’t safe yet!]  Yes sir.  I am.  “And at Yale?”  Yes sir.  I am in my third year.  One more to go.  [Please let me live to see it!  Please don’t beat me like Rodney King!  Also, I think it is a safe assumption that since my name tag says, ‘Yale Medical Student’ that I am a student studying medicine at Yale, but that’s just me.  Steve!  Shut!!  Up!!!]

While I feel like I am winning one of the officers over, I remain aware that there are five others on the scene.  I am still in the middle of Pennsylvania and I am far from the safety of home.  Be vigilant!  Be polite!!  “May I ask what is going on?”  My tone is measured, I make sure to let my voice lift at the end so that I sound like I am asking a nice question, not making ANY demands.  “We clocked you at 72 in a 65 mph zone.”   Okay, I admit I was speeding, but it doesn’t typically require 6 officers to write a ticket.  SHUT!  UP!! STEVE!!!  “There seem to be quite a few officers here, sir.”  See how I cleaned that up?

“Well, there’s a little problem with your registration.  It doesn’t match,” he explained.  “Oh, my dad gave me this car for my medical school rotations.  It is registered in West Virginia even though I am currently in New Haven…”  Give some details.  Remind him about Yale and mention your family so that he knows people care about you.  “I am really sorry officer, I don’t know what could have happened.  I have had a busy schedule, but I am pretty sure I sent the registration in.”  More Yale!  More medical school!  “It says this car is registered to someone in Fairmont, WV,” he continues.  “Oh!  I am from Bluefield.  That’s at the southern tip of the state.  Fairmont isn’t even close.  Bluefield is in the coal mining region.” I say with a smile.  Keep making yourself human to him.  Time continues to move at a glacial pace, but my heart rate is normalizing.  The second officer who approached the car has disappeared now.  Three squad cars are still on the scene.  The conversant officer says, “we’ll try to get this cleared up.”  I see a glimmer of hope.  He said, “we.”  Perhaps he is now my ally and working towards getting me home safely.  This is actually my baseline expectation from law enforcement, but life has taught me that people who bear my resemblance are often feared rather than protected and more frequently brutalized than served.

Ultimately, I graciously accept my speeding ticket and drive off with no music.  A cacophony of voices in my head filled the silence.  I could not stop replaying what just happened.  Did they draw guns or did you just see them?  Did the other four officers ever exit their cars?

I would like to think that the encounter left at least one of the 6 officers with a fresh template for assessing young Black men.  Perhaps he required no such thing because he met me as an individual from the outset.  But no!  I saw it.  I SAW his face change when he looked at my nameplate.  So, I was left to wonder if Yale University had separated me from Blackness and made me acceptable.  If it had, what might have happened to me if I hadn’t had that name tag.  I was unsettled for the remainder of the drive home and for many, many days to come.

Dad had been one of those men who got a new car every three years.  I strayed painfully far from this example and Bessie finally gave out on I-65 when I was in Nashville finishing up my fellowship in vocal cord surgery.  Dad gave me the Celebrity before he died.  I was in Music City meeting and treating celebrities.  The earthly presence of Dad had given me direction and drive and I believe he saw what I would achieve long before I did.  The spiritual presence of my father sat with me in the Celebrity when fear could have overtaken me.  I wish the world had seen the promise my father and my family saw so I didn’t have to work so hard or wear a moniker to matter…

First Blood

Phlebotomy (Fluh-bot-o-mee)

I actually didn’t find the pronunciation of that word to be particularly difficult, but the thought of taking what seemed like a silver mini-rocket and putting it into someone’s body to get blood out was, well, terrifying.  I was a second year medical student in the chrysalis that would carry me from the classroom into the hospital wards.  I was also an African-American and fully aware that the class before me had 4% African-Americans and my class had 12%.  If you’ve never been in that proportion, you may not fully grasp the experience, but it has weight.  Minority status inevitably couples with a burden of being seen as representative of ALL people like you.  Any wrong answer or any performance that is less than stellar is significantly magnified while successes are often minimized with dismissive quips like, “well, you guys are naturally good at…”

So, with the overhead bin of my thought fully packed with the baggage of being marginalized and having a shot few others would get, I walked into the hospital with my short white coat ready for my phlebotomy training, or at least ready to fake it until I could make it.

The hospital was not new to me because I had worked there the summer after my Junior year in college.  The old folks would have probably said I was “smellin’ myself,” but at 19 I thought I was grown—there were many ages at which I thought I was grown until I was actually grown and truly appreciated the depth of my ignorance.  I decided that I should stay in New Haven rather than going home where my family just didn’t understand the new person I had become in college [remember, I now appreciate how lost I was then]. 

I began the summer at Robert Henry’s.  RH was, by most accounts, the finest restaurant in town and I secured a position as a bus boy.  My recommended—read forced—attire was black plants, a white button down shirt and a cotton apron supplied—read available for purchase—to me by the restaurant.  The hostess was a pleasant woman named Bella.  She instructed me to work with Tony and assured me that I would learn the trade.

Being the Yale undergraduate I was, I was determined to master each task.  I learned to crumb the table.  I became an even greater expert on the distinction between a butter knife, a dinner knife, a steak knife, and a fish knife.  To this day, I doubt Bella completely understood that my mother lived by Emily Post and I knew how to set a table before I started college.  After two weeks, I decided the position was good, but the tips weren’t great and I sincerely believed I could advance my ultimate career goals by getting a job in the hospital.

Bella was astonished when I gave my notice.  I still remember her saying, “if you master service, you can always get a job.”  Those words seared my temporal lobes and I still hear them today.  The unmitigated gall of this woman to suggest that I had been in any way unemployable when we met or that I needed her tutelage to develop marketable skills.  I have wondered many times if she understood that I was Pre-Med at an Ivy League institution when she first laid eyes on me.  More than that, I wanted to know if she could fathom that I was the grandson of two coal miners from West Virginia who had ALWAYS held a job?  Did she know my grandmothers both worked?  Did she know my father and my mother both worked full time and my dad always had a side hustle?  Could she even comprehend the industry, dedication, ingenuity, prescience, innovation and grit that defines the African-American community in these United States?

I felt the mix of anger and steely resolve you achieve when you take an insult as a challenge steroid to propel you forward, and I walked into the hospital rebuking the spirit of Robert Henry’s on my first day to learn to draw blood.  Bella had pierced me with her words and she had tried to take some of my life force.  Her instruments were blunt and her execution was clumsy.  I committed to being better and seeking to help more than harm.

Brenda greeted me with a big smile that gave me some much-needed reassurance.  She was an African-American and we both embraced the silent exchange of knowing.  She knew I was relieved and comforted by her presence. I knew she was happy to see a brown medical student.  We both knew we needed to shine.

Brenda taught me to look at an arm and see the vessels, BUT, she taught me to rely on touching the arm and feeling the “bounce.”  She shared the secrets of a master that guided me to a place where I could let the vessel “call me” and guide the needle in.  Long before I heard, “I believe I Can Fly,” Brenda had me testifying that if I see it/feel it, then I can do it!”  There was nothing to it with Brenda as my muse and phlebotomy Sensei.

Recently, I had to have some blood drawn so I viewed this exchange from the other side.  I missed Brenda terribly as I politely comforted and reassured my patient care associate as she readied herself for the third attempt to start an IV and draw some blood.  Turns out, 4 was the magic number.  I wondered if anyone had ever implied to her that she should stay in the service industry to make sure she could be employed.  My compassion for her was sincere and I really wanted to comfort her, but I couldn’t help but wonder if her path into healthcare resembled mine at all.

I should be clear that I have worked many service jobs and I actually think being a physician requires a servant’s heart.  My very first job was working for my father.  In addition to supervising kids at the Hardy Street Recreation Center, I also mopped the floors.  I worked as a nurse aid and I am familiar with bedpans.  When I changed linens and gowns for sick patients, I took pride in that work  I guess there is a sphere in which Bella was correct, but I am also crystal clear that her prediction for my future was not that I would be in academic medicine and a tenured Associate Professor on his way to Full Professorship.

Even in my current position, I often give my own infusions and I am still pretty good with a butterfly needle and when I dine at an establishment like Robert Henry’s, I am mindful of the common thread of humanity and the promise that might be held in my servers.  I would rather encourage than deflate.

Chicken in a Shoebox

I grew up in a small town.  Though I absolutely needed to leave to fulfill some of the hopes and dreams of my ancestors, I have never forgotten the unique ways in which Bluefield, WV is the foundation upon which I stand.  The cornerstone for me was being born into a supportive, closely connected family.  Both parents were in my home and both worked.  Still, my siblings and I were completely unfamiliar with the concept of a nanny because my maternal grandparents lived next door and paternal set were up the hill and around the corner.

I grew up in a Black neighborhood.  My childhood reality was that multi-racial cohabitation other than the Black people who had non-Black spouses, did not exist.   ALL of the “mixed” couples lived in our neighborhood and my town preserved the idea of a “White” neighborhood.  As I listened to Ja’net Dubois’ lyrical storytelling to introduce “The Jeffersons,” I was so captivated by the song that it took most of the first season for me comprehend that Tom and Helen Willis, George and Weezy Jefferson AND Mr. Bentley all lived in the same building.  I had no concept of a White neighbor then.  I was indoctrinated into a belief that we should live with our kind.

Still, I never felt deficient because I had the gift of a glorious community.  I knew everyone in my Black neighborhood and my parents knew them as well.  When we went to school, nearly everyone on our bus was Black until just a few stops before we reached the school building.  All of my teachers were White until I entered Junior High School except for the two African-American student teachers I had in Fourth grade.  I suppose this is the womb that births code switching and the sense of always wearing a mask.  At least internally, the ride from the East End neighborhood to Wade Elementary was a cultural journey as well.  The school would not keep our secrets and didn’t always look for the best in us.   There, we needed to be different; we needed to excel to be considered normal.  The benefit from this arrangement, however, is that the respite of a home and neighbors was intensified.   The trip home brought relief rather than anxiety.

There were ways in which the “outside” world would challenge and even pummel me daily, but my neighborhood would receive me when I exited the bus.  I would be reminded that I was loved and all the things the metaphorical locusts had taken from me during the day would be restored.  Our bus stop was at Thelma’s hotel.  Even on the days I didn’t have many pennies to secure candy—back in the day a quarter was more than enough to bring satiety—walking around the store brought peace and belonging back to my consciousness.

Ms. Thelma’s hotel had been a place where “Negro” sojourners could stay and find safety.  Part of the amenities was the shoebox lunch.  Fried chicken fit nicely into a shoe box which made the meal portable.  Pound cake, sweet potato pie, boiled eggs and other foods that didn’t require refrigeration or packaging often found their way into the shoebox as well.  The cornbread would fit in the shoe box, but you might need a mason jar to carry the collard greens that paired so nicely.

All of the components of the meal were prepared with love and kindness and nourishment for body, the mind, and the soul was boxed up and sent along with the traveler.  So each day that I caught the bus in front of the hotel, I imagined that the love, support and nurturing of my community went with me.

As our family grew, the vicissitudes that come with just living out a life shifted us from the East End to South Bluefield.  We moved to a predominantly White neighborhood, two doors down from the town’s only synagogue.

There were initial fears, but I think we all came to understand that the power of community rests in getting to know your neighbors and finding commonality.  Conversations replaced trepidation and we grew in knowledge, understanding, and empathy.  Even my new shoeboxes always had fried chicken, but now I might find pasta from the Italian family across the street or Ms. Hazel Caldwell’s  deviled eggs!  It wouldn’t be unheard of to get some latkes to go.

My mother had always taught us to respect the neighborhood elders.  I bristled when she compelled us to carry groceries for Ms. Alexander and Ms. Martin in our Black neighborhood.  I was no less enthralled when she suggested that my brother and I cut Ms. Templeton’s grass.  I was nearly apoplectic when she insisted that we return the $5.00 Ms. Templeton had paid us and tell her we were glad to help.

As an older and wiser person, I recognize my mother’s brilliance.  She was tireless in teaching our family how to be good citizens and how to care about other people.  Individuals respond to love and kindness!  Sometimes acts of random kindness elicit rejection or fear, but there is always a response.

As I graduated high school and prepared to leave for college, many of the thousand points of light along my journey coalesced into some formidable beacons that would guide me.  Each time I came home, folks from the East End would tell me to make sure I stopped by before I left.  I would invariably leave with a shoebox full of love—and pound cake, fried chicken, sweet potato cake, mac and cheese, you name it.  Equally as important, I would be reminded by people were proud of me and wanted the best for me.  I could stand on the shoulders of community and glimpse a future.  Though I could only see the base of the mountain, I was never climbing solo or without provision.

Buddy Caldwell, who lived across the street from our home in South Bluefield would also call me over before I went back to school.  He would slip me a $50.00 bill and give me some life-changing advice. 

“Don’t spend this on something you need.  I know you’ll need a lot of stuff up there in college, but this is money for you to tuck away and spend it on yourself.  One of those days when things get tough, use this money to do something for yourself.”

Buddy Caldwell (Haze’s husband) reminded me that I mattered and that self-care is essential.  He helped me appreciate that we must honor commitments, but it is okay to put a little money aside to reward yourself when you need it.  There is motivation in this practice.

I grew up in a small town and everything I needed to survive in our vastly populated world came from that hamlet.  I still carry the shoebox full of love and nurturing.  I still marvel at how people, some of whom had limited means, shared what they had with me and blessed me.  I reflect on the wisdom of my elders who all shared pearls so generously.

It is true that my current life includes dining in fine establishments and exquisite meals, but this is only possible because I had chicken in a shoe box and collard greens in a mason jar.

Family Fruitcakes

Last weekend I baked a fruitcake.  A perfectly ordinary task that may not seem like much became much more.  As I worked, I felt the spiritual presence of the multitude of shoulders upon which I have always stood and still stand.  There was some trepidation because this was maiden voyage for the kitchen that came with our new home.  Ovens cook differently and it takes time to get to know one’s appliances.  Therefore, I was glad to feel the elders with me.

As I gathered my dried fruits and placed them in the mixing bowls, I imagined my grandmother’s hands.  She had bequeathed the bowl to me as her mother had done for her.  The bowl displays a girl holding a watering can and has window boxes and pumpkins.  It looks like a McCoy yellow stoneware antique bowl.  A quick Google search informed me that the Nelson McCoy Pottery company in Roseville, OH had multiple monikers and even more imitators.  My research left my hopes for the Antiques Road Show in doubt, but I don’t need to question the authenticity of the bowl.  I experienced the veracity of the love poured out by the mixing bowl’s previous owners.  No matter who produced the bowl, it had resided in the kitchen of women who had been conscripted into cooking for more affluent, paler families in order to return home and provide for their own kinfolk.  The love and nurturing in that bowl is palpable.

As I sifted my flour the first time, I understood the sacrifices made by those who came before me to blend us into a society that often saw us more as chaff than wheat.  I allowed my mind to wander into Christmases past when love was more abundant than material wealth and neighbors held a fruitcake in higher esteem.  I turned the baking hand crank for the second round of flour smoothing and summoned thoughts about my childhood. The sharing of foodstuffs in community used to mean more to people than it does today.  During the holidays, in particular, everyone cooked and went from house to house eating and socializing.

Through these memories, I assessed the societal metamorphosis from my small town upbringing to a world of tense faces buried in handheld gadgets who no longer interact with each other.  I added my cinnamon, cloves and freshly grated nutmeg as memories of my first neighborhood raised the corners of my mouth into an irrepressible smile.  The centripetal force mental rolodex landed on the idea my ancestral culture has added flavor to the world and these United States.  Those essences also have become more fragrant and more potent as they have been developed in the heat of injustice and disparity.  We continually announce our presence in the communal oven that sits under the melting pot burner.

Green and red cherries, pineapples and citrus rinds bathed in spiced rum while resting in my great-grandmother’s bowl.  The aroma rewound my temporal lobes about 72 hours.  During Thanksgiving, we were discussing the National Anthem and the Pledge of Allegiance.  I shared that the tune for the National Anthem was originally an English drinking song.   I wondered if Kate Smith knew that history when she gave her performances.  I was fairly certain that Whitney Houston had no idea of the song’s beginnings as her voice shook the country in 1991.  We continued to chat until the natural order or Black academia lead us to J. Rosamond Johnson and James Weldon Johnson.  If you don’t recognize these names, chances are you would not have been helpful as we searched the memory banks to pull out all three verses of the Lift Every Voice and Sing, The Black National Anthem.

“God of our weary years, God of our silent tears…”  Now, I am fully engulfed in a full-throated anthem to help me with the task of assembling the cake.  Music has always been a balm for me and the womb that tends to define a safe space.  As I sing, I stir emotional memories that lead me to other memories and I allowed some my own silent tears to have their voice.

I am standing in my mother’s kitchen with her father, my Grandaddy John.  The chemotherapy for his lymphoma has changed him in ways less noticeable than his balding head, but much deeper in their effect.  He is weak and this reality shifts some of my granite beliefs into quagmires.    The young medical student who trusted the indomitableness of the men in his family now had to face the fact that were no panaceas and even strong men can grow weary.  Life taught me that there is no sustained Burger King existence and we don’t give to have it our way, at least not for very long.  That year I transitioned from sous chef to the principal baker because Grandad just didn’t have the strength.  That year Grandad transitioned to the realm of the ancestors and I learned to accept that the bittersweet blessings from my family would enhance the academic rigor of Yale University’s training and make me a better caregiver.

Whenever we call one ancestor, others inevitable follow.  So, I thought about mom, who loved the fruitcake and the tradition of her father, followed by her son, making it for her.  I would bake one and take it to her (unless she came to me) every year.  After laying Grandaddy John to rest, I was the maker of the fruitcake.  The last Christmas we spent together in the physical world she complimented me and told me that was one of the best fruitcakes I had made over the years.  My sister still doesn’t really eat it and my brother also didn’t care for it.  So, it was one of those small secrets between mother and child that makes the kid inside the adult feel special because we seldom stop wanting to please our parents.  My mother-in-law and I share the appreciation of a homemade fruitcake now, which just affirms God’s all-encompassing work to create community mirroring the blessed trinity.  Humans love connections and God’s family values often extended well beyond what nominal Christians present through televangelism.

Two-and-a-half hours later, I take my cakes out of the oven and my satisfied smile is sustained not only by the products, but by the process.  I have used my grandfather’s recipe as a guide, but asserting my own ideas.  I have my great grandmother’s bowl and the steadfast love and support of my family to make a fruitcake in the new home my wife and I now enjoy.  I have also used Pam and dispensed with shortening, flour, and wax paper to keep the cake for sticking to the pan as it bakes.  Pleased with my work, I take a few photos to share with my brother and sisters whose taut faces are checking their phones for something instaworthy.

The love and the nurturing in the bowl is still quite real to me.  The memories of kitchens hundreds of miles away permeate our new structure and anchor it for me.  The family fruitcake gives stability to counteract the vicissitudes.  I start looking for the peach brandy to continue the tradition.

I have christened the new kitchen.  No matter where I am, the heart makes it home and even if the bowl turns out to be a vintage, 1920’s McCoy Pottery original, no monetary figure can displace it’s internal, eternal value.

Crossing the bridge

I never believed that men were designed by God solely to be hunters and protectors in a way that prevented them from showing love. My memories hold numerous examples of men who cared for their families, and not just financially. My brother and I had a number of male figures who, as they watched us, modeled behavior and illuminated the path that would guide us to adulthood, manhood. There are so many stories. This, however, is a different kind of story about the time when Uncle Greg underestimated the steely resolve of two little boys in his care.

Jay and I had spent a good portion of the afternoon playing outside. I was glad to have a sibling because I was never alone. I had a built-in best friend. Still, freeze tag, hide-and-go-seek, and especially red rover, could become boring rather quickly with only two participants. As we took a break, the hunger that had been masked by boredom came into clear focus. We decided that we wanted to go to BBF (Burger Boy Food-O-Rama), which was Bluefield’s precursor to McDonald’s. The allure of of well conceived marketing campaign was not lost on us. Only BBF would do. The die was cast.

The great obstacle to our determination was the lack of transportation. We asked Uncle Greg to take us to BBF. His initial response was, “wait ‘til later.” I should probably explain that my mother’s youngest brother was on the phone when Jay and I decided it was time to make our way to burger land. We were dutiful in our intent to wait as Uncle Greg had instructed. Mom was a no nonsense woman, so her children were taught one the pillars of African-American childhood and we ALL knew better than to interrupt someone while they were on the phone. Notwithstanding, the joint spirits of hunger and excitement overtook us and we couldn’t resist. After several agonizing seconds that surely fell short of even one full minute, we knew it was time to ask again “Will you take us to BBF?” Perhaps it was the distraction of the other person on the line, or the frustration with two nephews who were devolving into petulance but, Uncle Greg’s second response was decidedly terser. “If you can’t wait until I am off the phone, then you can just walk to BFF…”

In my maturation, I would learn to understand hyperbole, but six year old Steven was a literal being. Uncle Greg had just told me and Jay to WALK TO BFF. My seven year old brother, despite his superior wisdom and experience offered little improvement to my ridiculous plan. I was barefoot, but still believed we could just walk to BBF and get some food. Unrestrained by the fear of failing or a list of reasons not to go, off we went.

Most of Bluefield sits on some hills, so our initial steps were aided by gravity as we walked past the basketball goal dad had mounted on a telephone poll.  We passed the Green Plymouth Fury owned by Uncle Greg with a mix of arrogance and ignorance as we told ourselves, “we don’t need the car, he told us we could walk.”  We made our way through the neighborhood noting all the familiar sights and landmarks.  Because we had good home training, we politely spoke to Mr. and Mrs. Alexander and Mr. Martin as we passed the home on Greenbrier Street.

As we turned on to Lincoln Street, I wished we had passed a cobbler.  Lincoln Street was not yet paved when Jay and I set out on the burger trek and the rocks and dirt were less comforting than the pavement, but I would not be deterred.  We walked on, passing the church and other neighbors, innocent, bonded as brothers and really, quite content.  As we approached the corner of Wayne Street and Grant Street we began to consider the HUGE hurdle that lay ahead, the Grant Street bridge.

Greenbrier Street and the rest of the “East End” of Bluefield developed on the other side of the tracks, the Norfolk and Western railroad tracks, specifically.  In order to access the predominantly and historically African-American neighborhoods in “nature’s air conditioned city,” one had to cross the railroad tracks on one of three main bridges:  Mercer Street, Grant Street, and “the little bridge down the way.” 

The two young sojourners had become even more emboldened now, perhaps because Uncle Greg was nowhere to be found yet and we thought—as so many children do—that we were grown. The bridge itself, though it seemed enormous, was not so scary. The Norfolk and Western coal trains below provided an ample source of terror. Their movement was always announced by the accompanying cacophony. There were rows of tracks, mostly with idle trains carrying the earthen treasures that brought both grandfathers to West Virginia, but a moving train animated the surrounding terrain. Even standing over the trains produced some trepidation, but once again, innocent ignorance propelled us forward. We made our way over the tracks as we slayed the barrier that kept us confined to East End.

Life is a constant educator. Circumstances and outcomes have frequently reminded me that when I am climbing a hill and get to the top, another hill is the reward. Once we crossed the bridge, we stood face to face with Bluefield Avenue and two-way traffic. Common sense would have turned us around, but little boy reasoning though common, sometimes lacks sense. After surveying our prospects. Jay decided that I absolutely could not cross the road barefoot. It did not matter that I had made the journey up to that point without shoes, this was a turning point. The brother who would always inspire me gave me a glimpse into the future in that moment. “Get on my back,” he said. “I’ll give you a piggy-back ride.” We waited until we saw that there were no cars coming from either direction, then off we went to cross the avenue. Incrementally pleased with ourselves, we felt like we had conquered the world, our hunger, and our limitations all on the way to BBF. That’s when we saw the Green Plymouth Fury.

I wasn’t with Uncle Greg at the time, so I can only imagine the amaurosis fugax (a Latin term for a “black curtain coming down over one eye”) he must have experienced when he wrapped up his phone call and came outside to look for us. As an uncle myself now, I can understand the escalating urgency that must have ensued when he called us and there was no answer.

Uncle Greg, like dad, and almost all our uncles, was a military man. The “get ‘er done” approach informed many of his actions. So, he approached the missing nephews in a logical, if slightly panicked, manner. He recalled telling us to walk to BBF, he just had not conceived that we might take him seriously. As reality drifted into focus for him, Uncle Greg passed all the landmarks Jay and I placed in our rear view. Though it felt like we had mastered the world, we actually hadn’t advanced all that far, so a quick trip in the car relieved our uncle as he saw two little boys walking in front of the ACE hardware store on Bluefield Avenue. We kept walking because we did not realize that he was coming to get us because we were still operating under the directive that we were going to walk to BBF. Once he stopped us, we understood that our pedestrian adventure had come to its conclusion. We jumped in the car and didn’t really notice that Uncle Greg was a little anxious. We did, however, notice that the car was moving back across the bridge.

Uncle Greg took us home first so that he could explain to us that we were wrong to walk away from him and that we should not have crossed the street by ourselves.  He also wanted to make sure that we were okay and to make sure that I put on some shoes.  We weren’t entirely sure if we were going to be punished because we came to recognize Uncle Greg’s deep concern for our well-being and the consequent fear of what might have happened to us.  He was just so happy that we were all right, we didn’t get a time out [no one got a time out then, by the way.  It was 1972 so time outs came in the form of switches and belts then].

I learned that two minds together can hatch some plans that are improbable, but not impossible. Jay would be a lifelong inspiration to me and his spirit still helps me and carries me when I need it. I also learned that you cannot take everything grown-ups say seriously…

Tender After the Frost

For her first labor and delivery experience, my mother returned to the comfort of her mother, like many women do.  As a consequence, my brother was born in West Virginia, as was my sister.  Camp Pendleton, California was the starting point for my journey on this earth, but that location was only meant to fill in a blank spot on my birth certificate.  When I was about 5 weeks old, we moved to West Virginia, my parents’ home, to live with my grandparents while dad went to Vietnam for his one of his tours.  When dad returned to the U.S. safely, we spent a little bit of time being a military family.

I have vague, yet important, memories of time spent on the base at Cherry Point, NC.  I especially remember our dog Petey.  His was a rambunctious baby beagle who had the misfortune of nipping at Jay’s nose—John David became J.D. for a brief period before the simplified, “Jay” took root.  Petey was still at the animal shelter when we moved back to West Virginia for the second time.  It really wasn’t his fault because Petey was just being a puppy, but it scared my mother to think that our pet might harm us. Protecting us was always her goal.I don’t think we ever had a dog again and Jay never really got over his fear of dogs. 

I also remember human child mischief.  My brother and I hatched grand schemes. I vividly recall one caper when basically goaded each other into the idea to pour a glass of water into the plate of our babysitter (Aunt Linda).  I suppose at the time, we rationalized that the pancakes on the plate could absorb the water and they would be moist. At least, we told ourselves we had innocent motives. I don’t rightly recall who actually did it, but I know I was there when it happened.

Aunt Linda’s ability to forgive us and love us anyway is an important part of why she remains so special to me today.  Even our earliest memories can help us understand how we arrive at different points in life. The forgiveness and love extended to children carries them into and through adulthood. We carried love with us when we left Cherry Point.

Bluefield, West Virginia is a small, quiet, wonderful town.  It beautifully complemented the gift of a loving family.  While our house was being remodeled, we stayed with my mother’s family.  I was young and developing speech so my grandparents were known to me as “Bim” and Pop-Pop” prior to me acquiring the articulatory accuracy to say grandma and grandpa.  It turned out that I would grow up with Bim and Pop-Pop living next door and my father’s parents living a short walk away, just around the corner.

Every Sunday during my childhood dad’s parents would pick us up Sunday morning and take us to Sunday school.  Granddad (Sims) was a Deacon at Mt. Zion Baptist Church.   After Sunday school, mom and dad would pick us up and the whole family would attend church together with my mother’s parents  at Mt. Olive Missionary Baptist Church where granddad (Williamson) was the church treasurer.  In my naivety, I thought all churches were named for mountains—for a child growing up in West Virginia, this made perfect sense.

Tender After the Frost

I remember my grandfather saying that the best greens come after the first frost.  “If you pick ‘em before the frost, you’ll need to cook them longer and add some sugar,” he’d say.  “But, after the frost, they’re tender.”  I had no idea my future was being told in an agriculture lesson.  I couldn’t have known then, that enduring bitter circumstances is sometimes required to make things sweet. It may be presumptuous to suggest that I am a sweet guy, but I forever changed by the storms I have weathered and I hope it for the better. The peace was definitely sweet before the storm.

Sometimes, the most remarkable gifts we receive in life don’t reveal the extent of their value right away.  Time unwraps each layer of the gift as the receiver gradually senses each need the gift is able to meet.  So it is with the gift I was given in September, 1966.  On that day, I was born into a family, God’s first gift to me on earth.

My mother and father met at Genoa Junior High School in a small town in West Virginia.  To this day, my mother is happy to tell anyone who will listen that she never loved anyone else.  She recalls details of dances and proms and dates that are decades old now as if it were last week.   The memories endure  because of the love they shared.

The close knit families of coal miners and railroad workers in southern West Virginia were all familiar with one another and the Sims and Williamson families intertwined.   After a high school courtship, Herb and Elsie married when she was just 18 just after my father completed basic training for his service in the Marine Corps.  He was 19 at the time.

Unlike many who find themselves with child by complete surprise, my mother truly wanted to be a mother.  It was a goal she cherished, but it took close to five years of patiently waiting and praying like Hannah in the Old Testament before my parents heard an answer.  My brother, John David was born November 3, 1965.  He was named after our maternal grandfather, John Henry and my paternal grandfather, David Love.  Although mom and dad were living on a Marine base near San Diego, my mother returned to Bluefield, West Virginia to deliver her first child.  I wasn’t there, but I am told my infant brother was not a pretty baby, but he was loved like a precious, beautiful gift from a loving God.  (He grew up to be much sought-after, heartbreaker, high school athlete, by the way). So, I am not doling out aspersions about him, just passing on what I heard.

My parents were so happy to BE parents that they celebrated all the more when my mother found out she was pregnant with me and my brother had only spent 6 short weeks on this earth.  So, less than one year after giving birth to her first child, September came and I was given the gift of being born into a remarkable, strong, faith-filled family.  I was a surprise, to be sure, but my parents felt mostly joy and an amazingly small amount of fear as their family expanded a bit more rapidly than they might have scheduled.  They named me after my father, Herbert, and my mother chose my middle name, Steven, because she liked the way it sounded with Herbert.  This choice will bear more significance later…