Flying infusion confusion

I’ve lost my voice. My lungs are half full of crap. I’ve spent the night coughing my head off. My mind is bleary and my hands are shaky. But the pump informs me that I must change its infusion set.

Three days ago I got bold and put a mooched AccuChek set on my upper thigh. It is one of those super-short 90-degree sets, so I got away with it even though I don’t have too much sub-q fat on my legs to infuse insulin into. Trying for a repeat performance this morning seemed like the least amount of brain work. Besides, they come two to a box, so the other one was just sitting there in the medicine cabinet.

I tore open an IV prep pad and swabbed down my target area, about two inches left of the current site. I tore open the clear plastic package and set aside the hose and shower cap. I placed the set in the spring loaded inserter device, pulled off the needle cover, then pealed back the two tape covers, and cocked the inserter.

That’s when something went wrong.

Snap! Poinnnnnnnnnnnnnnnnnnk! Tink! Thunk! Splat.

Man shoots himself while cleaning gun screams the headline. So that’s how it happens.

Helpless… in slow motion… I watch my infusion set fly through the air, bounce off the mirror, rim shot at the sink, and fall to the floor, where it lands sticky-side down and gets full of cat hair. Hmmmmm…I guess we’re overdue for vacuuming.

Now remember that I am poor. Now remember that my health insurance thinks that insulin pumps are not medically necessary for Type-1 Diabetics. So it really isn’t much of a mystery why I am standing in front of my sink in my underwear contemplating inserting a cat-hair covered infusion set into my body. If I throw this away, sometime down the road it equals three days less pumping. Three days sooner to the train wreck of taking shots….

Making sure the safety is on, I put the set back into the inserter, doing my best to pull off the worst of the hairs. Part of the bandage has gotten folded over, damn it. I try to pull it flat. The sticky pad sticks to my finger and the set comes out of the inserter again. Crap.

I free my finger, and push the set back into the inserter once again, this time holding on to the needle. By some miracle I don’t stab myself, but at this point my antiseptic technique is way beyond the five second rule.

I place the inserter against my leg, release the safety, and as I pull the trigger I remember that I forgot to “pinch up.”

Snap! Aggggggggggggggggggggggggggggg! (Serious pain).

I frantically rip the site out and throw it back to the floor as bright red blood dribbles down my leg. Damn. Tagged the muscle tissue.

Three days shot to hell. I cough for a few minutes then peer into the medicine cabinet and pull out a Comfort set. But by now my leg it too traumatized to allow any more needles in. I resort to putting into my stomach, where I have not bothered to shave a clear spot. Now instead of cat hair, I’ve got my own stubble to deal with. The curse of having a manly hairy chest. As my Grandpa was fond of saying: if it’s one damn thing, it’s another.

Good morning world. Good morning diabetes. (Cough, hack, wheeze). Can I just go back to bed please?

Saying goodbye

With a single key stroke it was over. Hopes, dreams, decades of toil. All gone.

My emotions are mixed. Sad. Relief. A sense of loss eased by the knowledge of inevitability. All that we are and all that we do turns to dust in the end.

Before the darkness of diabetes was another darkness. One where the music of gurgling water filled the soft glowing spaces I worked in. When I was thirteen years old my mother decided I needed a trade to fall back on incase whatever profession in went into didn’t work out.

She was able to apprentice me to a local custom photo lab where I was initiated into the mysteries of processing film and making prints. It is part technology, part chemistry, part art. I loved it. I never got around to getting the profession.

Over the years I worked in a variety of labs and started my own the same year I married Debbie. More by dumb luck than skill we became successful over the years. I still recall one of the first “expensive” things I bought for the lab in the early days: an anti-fatigue mat to stand on as I shuttled prints from our one enlarger to the sinks. It cost ninety-nine bucks and Deb when through the roof. You see at the time our little lab was earning only $700 a month gross.

Years later I came home from the lab (now in its own building instead of our guest bed room where it started) and casually mentioned to my wife that I had bought a third film processor. “What did you pay for it?” she asked. Sixteen-thousand, I replied. Deb nodded thoughtfully, “Yeah, that’s a pretty good price.”

By the summer of 2001 we had eight employees working in three darkrooms and running two giant daylight “mini-labs” the size of Volkswagen busses. I worked seven days per week. Long days from dawn to dusk, sometimes beyond. We had customers in all 50 states sending us their B&W film. We were rolling in money. Our future seemed bright. When I walked into “my” darkroom I felt at home. It was a safe cocoon of sights, sounds, and smells that eased the soul.

Then came 9-11. Then came Anthrax. Then came x-raying of mail. And the distant threat of “digital” all the sudden stuck like a tsunami. In the last three months of 2001 I lost 80% of my businesses.

Of course we tried to change and adapt. We even ending up buying a digital enlarger that cost more than our house did. Money I’d love to have back now.

Like a hypo, the red line on my balance sheet just kept dropping, dropping, dropping. As the painful years went by we went from 100 rolls of film per day to 100 rolls per year. This month I’ve processed only two rolls of film. Processing one roll takes almost as much time as processing 50.

I’ve been losing time with my family to earn less money than it takes to keep the lights on in the building. It was time to put the businesses down. The only humane thing to do.

So I wrote a good-bye letter on the web site, posted it, then deleted all the files that gave photographers our services, prices, policies.

It was over. File transferred. And it was over.

San Miguel Photo Lab. 1989-2009. Rest in Peace.

Happy frickin’ Valentine’s Day

I’m feeling so guilty about what I am about to do that I snatch my name badge off my shirt and stuff it into my pocket. I don’t want anyone to know who I am or what I do for a living. I look left, then right. No one I know. No one paying attention to me. What I’m about to do may not be a crime, but it is certainly a sin.

Then, taking a deep breath, I plunge into grey ethical water. I take not just one, but two trays of cupcakes off the shelf and put them in my shopping cart. Twenty-four white cake cupcakes. Twelve with blue frosting, and twelve with chocolate. The red ones had already sold out. I quickly cover the carb stash with my coat and exit the bakery department towards the lettuce and other fresh veggies trying to look nonchalant.

The fact I have been dispatched for cupcakes is actually, believe it or not, an honor. You see, the cupcakes are for Rio’s kindergarten class’ V-day party. They are also having a veggie tray and hotdogs and I don’t know what else. Each parent was assigned to bring something different. We were assigned the cupcakes as we are the most reliable parents (hence the honor part), and in the teacher’s opinion the cupcakes where the most important key element without which the children would be devastated.

But I couldn’t really get on board with filling 22 six-year-olds full of high fructose corn syrup for a holiday invented by Hallmark…

Anyway, I escaped Wal-Mart undetected by patients or colleagues and delivered the trays to Rio’s class where I was welcomed by 21 little voices in unison: “It’s Rio’s dad with the cupcakes!” Well. That was pretty cool after all.

But I’m ashamed to admit, this is not my only Valentine’s Day guilt. Actually, guilt has never been much of an issue for me. I used to have a pretty strong moral compass that lead me through life so I guess I’ve never had much to feel guilty about.

So my V-Day confession: I’ve been on two dates with a woman who’s not my wife. Yikes! What the fuck are you thinking/doing, you ask? And regular readers will probably suspect that I’m setting you up for one of my notorious literary pranks where I lead you down the wrong path just for fun. Not this time. I’m deadly serious and deadly confused.

In all fairness to “the Other Woman,” I should point out right now that she didn’t regard either date to be a date. So bear in mind this is a one sided story.

My friend Laura just moved, so I was over at her new house helping her install a huge moon-shaped rack for pots and pans, putting up track lighting, and doing other handy-man type stuff that I’m really not that good at, but ends up falling to me frequently because all my friends are women, and I’m the only representative of the testosterone set in my circle.

“You look stressed, what’ up?”

Well I had to tell someone. So I spilled the beans. I accidently when on a date with a drug rep, I told her.

“Wow. Ummmm…OK. Now wait a minute, how can you accidently go on a date?”

Now that is a very fair question. So here is how it happened. I’ve know this drug rep for about three years. I flirt with her every 3-4 weeks when she drops in. So if you do the math we’ve maybe seen each other 44 times at 15 minutes each time, so we’ve only spent a little over six hours together. Ever. Despite that, we’ve become close.

Now I know what you are picturing. You’re thinking, this post-middle-aged fool has gone gaga for some 20-year-old blonde, blue eyed siren who’s bra size is greater than her IQ.

Give me some credit.

The Other Woman in my life is only a few years younger than I am. She’s Spanish-Hispanic like my wife. In fact, there might be some resemblance. Something in the eyes especially—the placement on the face. The color, dark pools, like guarded deep forest animals. Keepers of secrets. Hard to read. Their lips are similar too. This woman is also as beautiful on the inside as she is on the outside.

About a month ago I slipped her the Red Blood Cell Books url. She called me the next day, excited. “This is so awesome, let me know if I can do anything to help you sell the book.”

That was an offer too good to refuse. We arranged to meet at Starbucks after we were both off of work to talk details. I promised not to flirt, just businesses. She allowed as how I could no more stop flirting than I could stop breathing but that she knew I was harmless. I filled Deb in on her offer and let her know what day I’d be home late. Deb doesn’t have a jealous bone in her body, good thing with my world being full of women and girls.

I got to the Starbucks early, secured the two comfy chairs and dug into an article on Incretin Mimetic Therapy and Cardiovascular Risk. Yeah. My life is that exciting. Five minutes before our appointed meeting my cell phone rings. She’s had the day from hell, and hasn’t had a bite to eat. Starbucks won’t cut it, can she take me to dinner? Sure.

And we had the most wonderful dinner. And it felt sorta like a date. Actually better than a date because I didn’t have a date agenda. We talked about my book. But we also talked about Shakespeare and our kids and history and what doctor was screwing his nurse and….

….and before I knew it three hours had passed and we both needed to call it a night. In her rush to meet me she had forgotten her jacket. It is cold in Santa Fe at night in January 7,000 feet above sea level. As we headed for the door she made some comment about being stupid and forgetting her jacket.

Hold on, I said slipping my go-bag off my shoulder and setting it on an unoccupied table. I started to take my jacket off.

Her eyes flashed wide, “don’t you dare!”

Shush, I told her. I draped my jacket over her shoulders, grabbed my bag and held the door open for her. I’ll walk you to your car.

And as we walked out we heard the hostess say to the manager, “Chivalry isn’t dead after all.” We both laughed. Without thinking, I extended my elbow to her and she slipped her hand into the crook of my arm and we walked arm-in-arm down the street to her car.

At her car she returned my jacket, gave me a quick hug and we told each other what a great time we had and let’s do this again. I got home way later than planned, and to my surprise, was greeted with a kiss from my wife; the first real kiss from her in well over a year.

All in all, perfectly innocent. Or so I thought at first. But over the next few weeks I found this woman on my mind. A lot. No perverted running-naked-through-the-woods fantasies or anything. Just on my mind.

Driving to the clinic one day my commuting partner commented on my mood: “You seem unusually buoyant these last few days.”

Really? I hadn’t noticed.

“Your humming for God’s sake.”

So I gave her the reader’s digest version of what was going on, wrapping up with you know I not looking to have an affair with her or anything. I just really enjoy her company.

At which point my commuting buddy actually snorted. “If I had a dollar for every time that came out of a man’s mouth I wouldn’t have to work for a living.” Her view: I was kidding myself.

At which point I realized I was in trouble. And over the next few days, with this woman increasingly on my mind I began to feel increasing like I was a cheater, at least in my heart if not in my actions, which many will argue is just as bad.

The problem with the damn heart is it is autonomic. On the physiological front it beats with no conscious thought. And, damn it, as it turns out, love is autonomic too.

So my moral compass spinning out of control in a magnetic storm I decided to seek out advice of my most trusted female friends. Universally they surprised me. I expected outrage that I had developed an interest in someone not-Debbie. Instead they were all like, gee, we love Debbie, but if anyone deserves to have an affair and some happiness, it is you. See, it is no secret that for the last seven years my wife has increasingly ignored me both physically and emotionally.

But at the same time one of my core beliefs is that you need to be true to yourself regardless of the environment. You can’t justify breaking your own ethical code due to circumstance. You have a moral compass for the same reason a ship has a compass. Hey, sometimes you end up in the fog and need to know where you are going.

Now bear in mind during all of this I haven’t a clue what the Other Woman is thinking or feeling. This is all a crazy one-sided me vs. my shadow drama. Also in the middle of this emotional mess is my 20th Wedding Anniversary, pay cuts at work, broken down cars, and anxiously waiting the first round of reviews of the book. Will people like it? Not like I had any stress or anything.

Finally I told my wife: you know, ummmm, this woman has been on my mind a lot. Maybe more than is healthy.

Her reply, “don’t worry so. I trust you.”

Stake through the heart. Big fat stake with lots of splinters. And rusty nails. Am I still trust-worthy?

So we had our second date (so I’m thinking of this as a date). One of my girl friends asked me: so what are you going to do? I have no idea. I guess I want to know where her head and heart are at. And then I’ll take it from there. On one hand I hope she isn’t the least bit interested in me in that way. On the other hand…

So now I’ve degraded to the level of a 17-year-old boy. I go to bed the night before our “date” thinking: oh boy! I get to see her in 24 hours. The next morning I agonize about what to wear. Well these pants make my butt look good, but this shirt is more macho, but it doesn’t match the butt-pants. Then driving to work: oh boy! I get to see her in 12 hours.

The day crawls by. Having spent so many years with doom-and-gloom Catholics I expect her to call and cancel. Why? Because I’m so looking forward to seeing her that of course something bad will happen instead, right?

I meet with my primary care Doc in Santa Fe before my “date.” My Doc is resting her hand on my wrist taking my pulse, “Hmmmmmmmmmmm……you are really tachy,” she says. I know what she means: I’m tachycardic. My pulse rate is way up. My heart is going pitter-patter in anticipation. I mutter a lie about coming down with a cold. I don’t want to tell my Doc that I’m flying into an emotional hurricane without a flashlight, compass, or map.

So we meet. The first thing she says is “I love…(wait for it)…

…the color of your car!” Yep, she has never seen the mean green machine before. Sigh…

So we chat over wine and tapas (appetizers). I’m not sure if we have chemistry or if only I have chemistry. But she sets the record straight. Her bedrock principal in life is that she has not, does not, will not interfere in a marriage. Bad karma. I experience a mixture of relief and disappointment.

Hey, thin ice hypothetical question, I say to her, and understand I don’t ever anticipate leaving my wife. But if I were single, would you be interested in dating me?

She regarded me steadily with those beautiful brown eyes and said, “Lee Dubois, if you were single I’d seduce you in two seconds.”

I gotta admit, that was the biggest ego boost I’ve even gotten in my life. Ever. I know I’m taken, but it is nice to still be on the radar. Nice to know that after twenty years with one woman I’ve still got what it takes to attract another.

So it ends with my heart in a tangled mess. But it ends well. With my moral compass damaged I’ve fallen for a woman with a strong and fully functional compass. It was an even better “date” than our first one. The one person who had it in her power to forever shatter my damaged moral compass instead choose to help me fix it. I feel good. Liberated, perhaps.

On the way home my cell phone rings. “You up for being my best friend forever?” she asks.

Hell yeah.

“Where are you at?”

I’m driving down the dark interstate, happy, relieved, maybe a bit sad, still lonely and craving love and support and the feel of another human’s skin against mine. All the things my wife no longer has the energy to provide me.

I’m in the Hallmark store, I lie to her, can you believe that they don’t have a card that says ‘thanks for re-setting my moral compass?’

“What? Get the hell out of there and get home to your wife.”

So happy V-Day Dear Readers. Happy V-Day Dear Wife. Happy V-Day Dear Other Woman.

I love all of you.

Recession, health care, and what they didn’t teach us in kindergarten

Last night I took a beautiful, young, blue-eyed blonde to dinner. Don’t worry, Deb knows this kid. “BabyDoc,” as we nick-named her at the clinic, is a second-year medical student who worked at our clinic last summer. She’s now in Santa Fe studying for a major test whose score will pretty much control her destiny as to which type of doctor the system will allow her to become. No stress kiddo. As a confidence builder I came prepared with a practice test of my own.

What color are red blood cells? I asked her.

She leaned forward, her body tense, I could see the wheels turning in her head: was this a trick question?

Don’t over-think it.

“….red?”

Yep, good. You’re at 100% so far, next question: where are brain cells found?

She laughed and weeks of stress dissolved from her face. The first lesson I taught BabyDoc when she worked with me was how to choose the appropriate diabetes medication for a patient. The answer then, as now, is not the one that will do the job the best; but the one the patient can afford.

I’ve always know that money and medicine do not mix. They are oil and water. But such is the world we live in, that we are always pouring to two elements into beakers together and shaking like the devil in hopes that someday the two will magically blend. I think making a profit on health care is a sin. Note that I said a profit, not a living. People in health care need to make a living; but I’m taking about Wallstreet here. Insurance companies “make” money by denying care. Bluntly, coldly put: they literally kill people to make money.

I am grateful every day that I work for a non-profit. In fact, I was offered a job with a private practice a few weeks ago at nearly double what I make now. It was real tempting. Wow. I could pay my bills with no stress. I could buy gifts for my wife. I could afford a mistress…

But loyal idiot that I am, I turned it down. I belong in rural health. I’m needed and I love my work. To her credit, Deb supported the decision. Encouraged it even. No small thing as her life would have been sweeter had I taken the offer. But she’s been with me for 20 years now (Wednesday was our anniversary), and, well, maybe she does understand me a little bit after all. Most people spend their entire lifetimes searching for where they belong in the universe. I’m blessed to have found my spot.

Of course, life being what it is, right after I turned down the job a new crisis hit; and for the first time I really understood just how bad the economy has become. More on that in a bit. Back to the restaurant.

The normally hopping-on-a-Friday-night Santa Fe Baking Company was nearly deserted. “I come here a lot to study,” BabyDoc told me, “one of the waiters told me that they are cutting hours back. Not enough customers. It’s scary.”

I’ve heard this refrain before. Out of the blue one of my drug reps called me last week and said: “How did our grandparents survive the great depression?”

What?

“Well, you seem to know everything, and I couldn’t think of who else to ask.”

Well, my grandfather worked at Denver University during the great depression. Family lore has it that to avoid laying anyone off the University cut pay 50% from the president down to the janitor and that they were all just damn grateful to have jobs.

But my rep friend wasn’t asking about economics. She wanted to know how people survived emotionally. I didn’t have that answer for her.

Before my dinner I was in Albuquerque at the teaching hospital where I’ve been asked to talk to Residents (docs in training) about what makes us D-folk tick. I do this once per month. This month I noticed shabbily dressed men with cardboard signs on almost every street corner. In one block there wasn’t only a guy on each corner, but one in the middle of the block too. There are always some folks “panhandling” in the down-town areas, but the sheer volume was both un-nerving and depressing.

Morale at the clinic is a bit lower than usual. Two weeks ago our boss called an emergency staff meeting. That hasn’t happened since…. well, ever. She was up front and honest with us. We were “in the black” but out of money. Having a business background, I was probably the only person in the room that understood exactly how that can happen.

Business 101: Cash Flow is King. Businesses, including non-profits, buy stuff, sell stuff, and have overhead. So long as the stuff you sell brings in either the same, or slightly more, than the stuff you buy plus your overhead, you are in the black: either at break-even, or making a profit. If you are spending more than you make you are in the red: sooner or later you will go out of business because you are losing money. Let us assume we are in the black. We have no worries, right? Wrong. If the folks we sell stuff to take three months to pay us and the folks we buy stuff from want to be paid in 30-days we have a cash flow problem. Cash flow has nothing to do with profitability. Cash flow is having the money you need, when you need it, to pay your bills. You can actually be in the red and have “positive” cash flow. Or like our clinic, you can be in the black and not be able to make payroll.

So you are probably asking yourself how this kind of business model applies to a non-profit community health center. So we sell stuff. We sell the services of our health care providers, nurses, and support staff. That is our product. We also sell medications, and bandages, and immunizations, and the like. But, wait, you say. Your clinic is a non-profit. Yes, but we still need to generate enough money to cover the cost of our existence.

We have to pay our staff. And we have to pay payroll taxes on our staff. And we have to pay the power company for our electricity. And we have to buy the medications, and bandages, and immunizations. It is still a business. The only difference is our goal is our mission, not our bottom line.

We do get some grant money, but last time around all the rural health money went to red states. Go figure. We’ll talk about politics and health some other day. We “write off” a great deal of care, as we turn no one away based on ability or willingness to pay.

Back to the staff meeting. Our boss told us something that I hadn’t seen in the news: insurance companies were increasingly delaying paying doctors, clinics, and ambulance companies. Not just us, but everywhere. Even Medicare/Medicaid is stretching, stretching, stretching payment times. We were owed over a quarter of a million dollars for services previously rendered, covered, and properly billed. The bulk of that money had been owed to us for over 120 days.

Remember cash flow? So all of our expenses are up front, and we get paid later. We make that work with cash flow. We pay for your care by using the money we got from caring for the other guy last month. Oops. But now we haven’t been paid for caring for the guy last month. Or the one from the month before that. Or even the one the month before the one the month before that.

What was that loud crash? Oh, just us hitting a brick wall at full speed. The payment delays have exhausted our cash reserves. We have no way to pay our bills, to pay our staff, to buy band aids and stuff.

Other clinics in our state are in the same pickle. Some just laid off the most recently hired staff to trim their payrolls. Our boss knew the value of her human capital: her staff was her most valuable asset. She could have closed the clinic earlier everyday; but that cuts services to our patients and creates new problems down the line by reducing our billable services. Now she could have just cut all of our pay by 15%, which is the amount we were short for the next pay period. Which is in theory fair. Of course someone who makes $8.50 per hour can less afford a 15% pay cut than someone who makes $30 per hour. I think lower paid folks are disproportionally effected by flat cuts. So she could have devised some sort of graduated pay cut to try and level the playing field.

Instead she told us, with some tears, that she understood that everyone’s circumstances were different. She asked each staff member to look into their hearts and pocket books and decide what they could do and we’d see if it was enough.

About half the staff voluntarily cut their hours. About half took a pay cut and kept working the hours they always worked. I was one of those. I went back to my desk and tried to weigh what I could do with what I felt was right. The ethics of same work for less vs. what’s best for your patients. In the end I let my moral compass guide me to do the right thing. As we are 15% short, my share of the problem is 15%. I took a 15% pay cut and kept working my 40 hours. I have no idea how I will pay my bills. It will work out somehow. (So if you haven’t bought my book yet, this would really be a good time.)

Now what happens if you pay the government late? Well if you owe them too much they throw your ass in jail. But otherwise you pay a penalty. And you pay interest on both the penalty and the money that you owe, and all of that piles up alarmingly quickly. The government gives itself 90 days to pay doctors and clinics. OK. I can live with that. But pay on time. And if you are late, pay us interest. What is good for the goose is good for the gander, as my Grandmother used to say.

Now insurance companies, God help you if you are late, especially if you actually use your insurance. They’ll cancel your policy. But every other Wallstreet player loves it when you are even a few hours late. That way they get to load you down with late fees and criminally high interest rates.

Mr. Obama: we need a law that tells payers that if they delay paying money rightfully owed to medical providers for covered work properly done and billed: then they must pay a late fee. 100% comes to mind as a number high enough to be an incentive to pay on time.

The other half of our organization, which does even more work that never gets paid for at all, is our ambulance service—which covers a 1,000 square mile area of rural northern New Mexico. To get though the month they took 35% pay cuts. The service may have to go from a 24-365 professional organization to a volunteer organization if things don’t get better.

My nightmare for the future, a patient picks up the phone and dials 911:

“Hi! You’ve reached the Ambulance Service. Our normal business hours are from 8am to 5pm Monday-through-Friday. If you reach this message during our normal hours of operation it means we’re busy serving another customer by transporting them to the hospital. Leave us a message and we’ll get to you as soon as we get back. Emergences are handled on a first-come-first served basis. If you are calling after business hours apply a tourniquet and call us back after we open on the next business day.”

Sound crazy to you? It is much, much, much closer to reality than you want to believe.