Insulin for breakfast

I was ambushed in the hallway not ten paces from the door. I had slipped in the ambulance entrance because that’s the most likely way to get into the building and to my office without being seen. Of course, I wasn’t likely to succeed because my office faces the giant glassed-in fish bowl that’s the nurses’ station, but it was still worth a try.

As this was going to be my first day seeing patients again, I wanted a slow start. I was, well, nervous. Nervous that I’d forget something important. Nervous that I’d make a mistake. Not confident that I can function in my clinical role, once again, I have not packed lunch.

I was supposed to have half an hour to get my bearings, and do a through chart review on the two patients I was to see this morning. I normally do a brief chart review anyway, but I’d been gone so long that who knows what might have happened in my absence. Plus, I simply needed to remember who the hell these people were in the first place.

Last week, when I peered ahead at my schedule, some of the names were unfamiliar to me. I called up their records to see their faces and strangers starred back at me from their driver’s license-like mug shots on the computer. Yet below the mug shots were notes, apparently written by me, documenting visit after visit after visit after visit. Clearly these people were my patients and many of them, it appeared, I had worked with for years. But both the visits and the people themselves were missing from my memory. They were alien and the chart notes seemed like someone else’s—stirring no memories, awakening no recall.

It was worse than unnerving.

Of course, if that had happened with all the patients scheduled to see me this week, I would have left my keys and resignation on my desk and walked away. But luckily not all my patients were blank canvasses. Some were fuzzy, like distant mirages, but still in my memory. Isn’t she my Butterfinger addict? Hmmm…. Is that the one with the little dog… No, that’s her sister. Wait, isn’t she the one who stabbed her husband with a steak knife at the family reunion?

Yet still others were crystal clear. I could remember everything about them: The patterns of their blood sugars, the meds they used now, the meds we tried but failed with in the past, what motivated them, what their roadblocks are, the names of their children, their stresses and challenges.

Why some were so clear; some were so fuzzy; and others so completely absent from my mind, I have no clue.

But the slow start I was geared up for was not to be. As I made my way down the hall, one of the providers popped out of a treatment room like a spider and literally grabbed me. With a vice-grip-like hold on my bicep, she spun me around in the opposite direction of the safety of my office. “I need you to do an insulin start. Right now.” A cold chill cascaded over my body. Insulin starts are the most delicate, most difficult, most dangerous thing that I do clinically.

Normally, I relish the opportunity.

Insulin, done right, is the best weapon in our anti-diabetes armory. Insulin, done right, makes people happy and whole again. But insulin has a bad rep. It’s widely feared for no fair reason. To start insulin is more than just a, here, this is how the pen works. We have to deal with the fear factor and overcome it. Patients need to understand how it works, and how it doesn’t work. I need to ensure the starting dose is high enough to work but not too high. Bringing people down too quickly triggers relative hypoglycemia, and worse. Retinopathy “explodes” when sugars are normalized too quickly. But choose a dose too low to do any good, and patients get frustrated at taking shots without results.

Normally, I’d have a week’s worth of BGL data to study and make sure we knew the range, the curve, the shape, the lowest reading and the highest. And I’d have an hour with the patient.

This time I had no data and a time frame of only 15 minutes.

My new patient is a “visitor” from Mexico, pawned off on us by the free clinic as being too complicated for them to manage. Her sugars are screaming high. Her English is good but her husband doesn’t speak a word. He’s come along to be supportive, but she needs to provide him a running translation.

I feel like a fish out of water. A shirt without a tail. A bear out of the woods. OK. I seem to be out of good idioms.

After being introduced, I take the couple back to my office. My brain is like a car on a cold morning. I keep turning the key and it goes Wrrrrrrr….Wrrrrrrr…..Wrrrrrrr…. but never quite fires up and runs. I try to keep a calm exterior, but inside I’m freaking out.

Don’t fuck this up. Don’t fuck this up. Don’t fuck this up.

She has kind eyes, but is afraid. Dissipating that fear is job one. Assessing her further, I note that she is globally chubby, with significant truncal fat, and has heavy staining of acanthosis nigricans around her neck. Adding all of this up tells me she’s probably more insulin resistant than usual. Her starting dose needs to be adjusted accordingly. I throw my go-bag in the corner, take off my coat, and put it across the back of my chair. I motion to the pair of chairs under my new painting of the little airplane diving into the storm. Siéntese, por favor.  

Here we go again, little plane. Into the jaws of the storm we’re both destined to fly.

I sit in my chair and open my rat’s nest drawer. My approach to drawers is to simply let them fill up until you can’t cram another thing into them, or until you have to move your office. Over the last eight years, I’ve found myself moving offices more often than cleaning drawers.

I rummage around for a minute, and then get out a saline training pen and a few pen needles and lay them on my desktop. Something is missing. There should be more stuff. Think. Think, damn it!

I don’t have a clock in my office, but I swear I hear one ticking.

Like a swarm of gnats, snippets of thoughts buzz around in my head. Bzzzz...…site rotation…titration…air shot…bzzzz…needle sheath…plunger…hold time…hypo warning…bzzzz…sharps disposal…BG target...room temp…bzzzz...bzzzz...bzzzz...bzzzz...

I can’t really grasp one complete thought. They are all in motion, all fragmentary, a blizzard of fragmentary sticky notes that are not yet a speech. They are all the things I need to tell her but I can’t figure out where to start and how to weave the thoughts together. In the past the various elements just flow through my mind, mouth, and hands. Normally, when it comes to insulin starts, I’m graceful.

Today is the mental equivalent of the first time I wore ice skates.

Um… sorry if I seem a little distracted. I’ve been out for a time and I’m just back on the job…

I don’t know how it went. To me it seemed awkward. Rushed. But I don’t think I did anything wrong and Bill Clinton didn’t interrupt the process. I guess I’ll know how I did at her follow up in two weeks time. Or sooner if I fucked up.

As the day wears on, we have two new diagnoses that I don’t think I handled as well as I should have. I also see some old patients. I’m able to download their meters with little difficulty, but the swirling patterns of dots and lines aren’t whispering to me in their secret language. I’m not seeing the mystic ebb and flow of insulin and sugar that normally appears to me like heat applied to messages written in invisible ink.

The pain in my gut rises and falls like the tide, but as the short day wears on I find that more and more, the fog in my mind is beginning to lift.

My last patient is a pumper on a CGM. I plug her Dex 4 into my laptop and the computer sucks the data out of the device like an electronic vampire. I turn the screen to share it with the patient and an advanced nurse practitioner student who has been assigned to me for the back half of the day to begin to learn all things diabetes. I warned her she was being led by a blind man.

“Wow,” says my student.

“Augh,” says my patient.

I don’t say anything. The tangled mass of colored trace lines on the computer screen looks like the cat has gotten into grandma’s yarn collection. I can’t make sense of it, but fell I should be able to. I wrote the book on CGM, fer God’s sake. Literally.

The silence stretchs on. Uncomfortably so.

Finally, my student clears her throat, “Uh… What am I’m looking at?” she asks.

I snort. I have no fucking idea. It’s the truth, but probably not the best teaching method. My patient giggles. They love it when I swear. OK, I tell my student, this is an X-Y graph. We are looking at time left to right and the level of the blood sugar vertically. The device checks the glucose level in the interstical fluid every five minutes. Each test has a mark. The trail of marks is called a trace. I run my finger along the computer screen to show her. The marks change color every day and we can… we can… Suddenly, I see it. My finger freezes. Wait a minute.

Well, what do we have here? Hidden in the forest, I suddenly spot a grove of trees. Amongst the chaos, a pattern is emerging.

Wrrrrrrr….Wrrrrrrr…..Brum-burm-burm…Vroom!

My brain restarts.

Nearly hidden by wide variation during her sleeping hours, and the insane tangle of variety that follows her breakfast, her blood sugar traces show a pre-dawn rise. Every day. In a flash I know she needs more basal insulin an hour upstream. I smile, This we can fix.

Tomorrow I’ll pack lunch.

Jumper on the ledge

I can’t believe I just taxied right off the fucking runway. One moment I’m headed for the terminal, the next moment we’re off in the grass, my landing gear is mired in the mud, and the plane is stuck fast. I shake my head. How did that happen? Did I pass out? Get distracted? Did the steering fail? Fuck! I advance the twin throttles. Both radial engines spool up with a throaty roar, the airframe vibrates, but we do not move. I throttle back before I shake the silver beauty to pieces. Then I advance just the left throttle. The left engine snarls to life, the plane shakes and groans, but again we do not move. I yank the throttle back to idle. Shit! I sit for a moment, exhale, collect my thoughts, then I key the mike and call the tower. Uh, november triple four six kilo, I, uh, have a little problem here…

Sunlight filters in the window between the slats of the blinds and across my bed, waking me. Crap. I need to call the FAA this morning and explain to them how I taxied off the runway at an unauthorized spot yesterday and got stuck in the mud. Hell of a way to start the day.

I swing my feet to the floor and my eyes fall on the glucometer on my nightstand.

Oh. Wait. I’m not a commercial pilot anymore. It was a dream. Or… or… is the diabetes a dream? As cobwebs dance across my mind, I try to sort it all out. The gleaming plane stuck in the mud seems so real. The world of diabetes and illness seems like a fuzzy, distant dream… and yet… and yet I think what feels real is the dream and what feels like a dream is real. How can that be?

I rub my eyes and see my clothes and stethoscope laid out on the Victorian chair in the corner of the bedroom. Then I remember. I’ve been sick. Very sick. And today I must go back to work. Not at the airport, but at the clinic. The sliver plane off the runway in the mud, so real moments ago, fades as the reality of diabetes and chickenpox crowd in. Silver planes are dreams. Reality is desperate times and desperate people. Sickness and poverty and fights with insurance companies. I have been commanded to return to this reality: It is time. You must return. You must come back to work.

But I do not want to go back to work. I do not feel fit for duty in mind, body, or spirit. But the powers that be are insistent, and my boss—the most brilliant clinician I know—feels that exercising my brain in its old patterns might be just what it takes to get it to start working again. The neurological equivalent of jump-starting a car.

I am so unconvinced that I do not even pack lunch.

Now on the one hand, I’m not terribly sick anymore. I’m no longer contagious. Most of the scabs have fallen off. I’m able to stay awake for most of the day. But on the other hand, I’m not terribly well, either. My mind still does not feel right, and the pain in my gut remains omnipresent—sometimes worse, sometimes better. I feel a mere shadow of my former self. Perhaps the shape is the same, but there’s no contour, no depth. I believe this disease should have killed me but someone dropped the ball. Probably, just like UPS and FedEx, who can never seem to find my house, the Grim Reaper got lost en route. Now I’m in limbo like a lost package that no one knows what to do with. Do we forward this onward or return it to the sender?

I’ve been asked to come into the clinic in the middle of the day and to stay only as long as I feel up to it. I have no patients on the docket. I’m just to catch up on phone messages, emails, and get familiar with the new version of our electronic medical record that was installed in my absence. Without my normal mental powers at my command, I am unable to conjure up an excuse not to comply with the request. But I dearly wish I could.

The sun high in the sky, I drink a cup of coffee and eat a Kind bar. Then I pack a pipe with Black Cavendish, put on my grey wool coat, pull my dusty go-bag off its hook by the door, and step outside.

Climbing back into my jeep after more than a month feels surprisingly “right.” Sort of like putting on a comfortable old pair of shoes. Still, on the drive over to the clinic I can’t shake the feeling that I’m going to my own execution. I don’t want to be doing this. Along with the nagging pressure/pain in my gut, I now have butterflies in my stomach. The devil on my shoulder whispers in my ear: Just drop into the median, do a U-Turn, and turn tail for home. Tell them you tried, but just couldn’t make it. They’ll never know.

Like a jumper on a ledge, I want to, but for some reason I do not. I forge onward.

The day is sunny and bright. Normally the kind of day that’s full of promise. The hour’s commute seems to take forever, but in a good way. After all, I’m in no hurry to get where I’m going.

It has been one month to the day since I last worked. Most of the four weeks off is a fog of sweat-drenched nights, nightmares, ER visits, fear, fatigue, and confusion.

Not exactly a vacation.

I park at the edge of the main parking lot instead of “up back” where employees are supposed to park. I can barely walk and I want to conserve my energy for the day. As I make my way stiffly down the hall to my office, my brain seems mired in molasses. Everything is familiar and yet nothing looks quite right.

My office door is closed tight. I usually leave it open. In my imagination, I briefly envision yellow-and-black crime scene tape sealing it off. I shake off the image and push the door open. The energy-saving motion detector wakes up and turns on the lights for me. I drop my go-bag and car keys on my desk, and as I turn to close the door, I see it.

Something new is waiting for me.

My wall is no longer a sterile blank canvas. It is graced with a painting and a note from my beloved. At some point while I was away, my wife snuck in and hung a painting on the wall. It’s a big painting of a small airplane being engulfed by a fearsome cloud—a wicked swirling blue-grey vortex.

It’s an oddly sinister painting. But I love it at once.

Why? Because the plane is in the sky—where planes belong. It’s not broken down, out of fuel, grounded by fog, or stuck in the mud like the planes that have haunted my chickenpox nightmares for weeks on end. Clearly, this little plane is about to encounter an epic challenge, but it’s flying boldly forward.

I realize at once that this plane and I have a lot in common. Like it, a storm surrounds me and I must fly through it or I must crash in the attempt. I’m not ready for the challenges ahead, but I mentally advance the throttle, bank towards the storm, and fly in.

The first hour is spent getting (slightly painful) welcome-back hugs from my various colleagues.

The second hour is spent trying to get my fucking computer working. We have three different passwords between turning on the stupid laptop and reaching the damn electronic medical record. Each password has to be at least 12 characters in length. Each password has to have at least one capital letter, at least one lower case letter, at least one number, and at least one special character. The same password cannot be used twice, each password expires every three months, and cannot be reused.

I cannot remember any of them.

I sit in front of the blank computer screen and tell myself that even without encephalitis, even without sleep deprivation, even without the wicked cognitive side effects of powerful antivirals, I likely had problems logging in every day.

I tell myself that, but I am not convinced.

The third hour is spent trying to figure out how to do the most basic of operations on the new medical record software that looks nothing like the old. Or maybe it does look like the old and I just don’t remember. Again I find the dream world and the real world converging on me and I’m not sure what is changed versus what I’ve lost. I glance outside my office door, but there’s no sign of Bill Clinton.

The pain in my gut gets worse. A giant knot. I don’t know if it’s the chickenpox damage, the swollen lymph nodes, or just garden-variety fear and stress. Maybe all of the above, but I find myself doubled over at my desk, unable to sit up straight.

One of my nurses pokes her head in the door, “You don’t look so great, you doing OK?”

I’ll live, I reassure her. In fact, at that moment, I wasn’t sure I wanted to.

The fourth hour is spent weeding through month-old voice mails and hoping that most of the people who left me messages have since contacted someone else at the clinic. Three weeks ago, for instance, there was a message from one of my patients: “Please call me right away, I only have one day of insulin left!”

I have 193 emails. Fuck that. Enough is enough. I’m going home.

I’m exhausted. Everything today was a struggle. Even the littlest things took the longest time to accomplish, and still didn’t feel right. It felt more like the first day on the job, not the 2,500^th that it really was.

But I made it through the day.

I shut down the computer and looked up at my new painting of the little plane approaching the big vortex. I don’t know if my mind will ever work right again—but somehow this plane flying into the storm gives me hope. It will be a long road, no—a long flight—to recovery. But at least today I’m off the ground.

And now that I’m back “in the sky” again, I wonder if the dreams of broken-down, stranded, and grounded planes will fly away.

Maybe tonight my dreams will take wing.

Hospital Horrors

The bullet hit me just below my rib cage, punching out a huge section of my liver and collapsing my right lung. Waves of pain rippled round my chest like a stone thrown in a still pond or echoes reverberating off sandstone cliffs.

I gasped for breath but could find none. I tried to scream but had no voice.

I rolled onto my back, clutching the entry wound with both hands, felt the wet, blood-soaked T-shirt beneath my fingers, sodden and cold.

Wait… A bizarre fact flickered across my consciousness. The temperature of the human body is 98.6 degrees Fahrenheit. The blood spilling from my torn abdomen should be warm—not cold.

I blink upwards in the near-dark room. Where am I? What happened? Who shot me? Why?

Wait a minute… Who am I?

An angry buzz, like a pissed-off cockroach. A light. What the fuck? I turn my head to the side. A glowing screen on a box. It says, “High-200.”

Wait. I know what that is. It’s a CGM. It’s telling me my blood sugar is high. The blood spilling from me? No… It’s cold, it can’t be blood.

Chilly blue light spills from a bedside clock. Fighting waves of pain, I sit up, reach for the reading light and turn it on. My T-shirt is soaked and dark. But not with blood. With sweat.

I yank it up over my head. My chest and stomach glisten with a thousand dewdrops of sweat, but the skin is intact. I have not been shot.

Was it a crazy dream?

Another wave of pain ripples through my body. Not shot. But not a dream. Something is wrong. Desperately wrong.

I’m supposed to be healing, they tell me. Give it time, they tell me. But every day the pressure in my gut and the clouds in my mind get worse.

I struggle to the living room. It’s 2 a.m. Rio and Debs have fallen asleep on the couch, the room illuminated by the DISH TV screen saver.

I rest my hand on my wife’s chest and give her a gentle shake, “Wake up, baby,” I whisper hoarsely, “You need to take me to the ER.”

She barely stirs. Rio sits bolt upright like a Jack in the Box. “What’s wrong?!”

The night is dark and the drive seems to take forever, and as the stars wheel overhead the pain subsides. As we pull into the mercury-vapor lit parking lot of the Regional Medical Center, an hour from our home, I wonder if I’ve dragged my wife on a fool’s errand in the wee hours of the morning.

But we are here now, might as well see this through.

The night, well, morning, is cold. Aggressively cold. The kind of cold that worms its way through many layers of clothing to nip at your skin. The walk from the parking lot to the front of the hospital is a long one. All of the close spaces are reserved for doctors and overweight security guards.

The rotating door at the front of the medical center is locked at this hour, but the side entrance at the ER is open 24-7-365. The glass doors slide aside, Star Trek style. At this point I’m just back to feeling the odd pressure that runs down the base of my ribcage on both sides. I feel a bit silly and try to decide what to say to the night clerk.

Ahead of me is a young girl with a tear-streaked face and puffy eyes. The night clerk waves her in. Then he turns to me. He is a giant of a man. And not a happy one. Clearly, it has not been a good night for him. His ID badge says he’s a RN. He locks his cold eyes on me and demands to know my businesses.

Ummmm… abdominal pain. I say meekly. Ummmm, bad enough to make my wife drive me over here from Vegas in the middle of the night.

He curtly demands my name and birthdate, finds me in the computer, and tells me he’ll get to me as soon as he can. He gestures to the waiting room the way one might point a dog to the door. As the night wears on, I find he uses these curt hand signals more than words. He does, however, address me as “Sir.”

He does not prove to be so respectful with one of the other nocturnal visitors to the ER.

As we leave the reception desk, I survey my options. There are only a handful of people in the waiting room, all keeping as much distance as possible from each other. In one corner a homeless person is passed out on three chairs. In the middle of the room a sharply-dressed MILF with faux-fur topped boots is holding a very sick child. His cough suggests severe pneumonia or perhaps even pertussis to me. The child is maybe seven, and he’s having a hard time getting enough oxygen. His mother’s hair and make up are perfect.

In another corner a very obese woman in rumpled pajamas, wearing an N-95 surgical mask, is holding a whimpering baby. N-95’s are what we give to people we think have influenza. Across from her is another woman who is talking to herself. She does not have a cell phone.

All things being equal, the woman talking to herself seems the least threat to my fragile health and we grab a pair of chairs midway between her and the woman with the mask.

How do I describe the woman who’s talking to herself? Well, skanky-looking would truly be a fair description. And not in a hot way. Her hair is long, dirty, and stringy. She’s in a filthy stained sweatshirt and shorts. She has tennis shoes, but no socks. Her knees are drawn up to her chest, and she rocks rhythmically back and forth. She alternates between talking to herself, or maybe God, some invisible people around her, and the nurse-bouncer running the desk. She wants a blanket. He tells her he has none. She asks again. Several times. The nurse finally tells her to shut the fuck up.

Debbie turns towards me, shocked. “What’s wrong with him,” she hisses. Then she looks at Skank Woman, “What do you think is wrong with her?” Debbie works at the clinic now, and also spent several years in the private practice environment, but she’s never worked an ER, so I realize she doesn’t understand what’s going on.

Withdrawal, I whisper.

“Huh?”

She’s a junkie… sorry, I should say addict. She’s in withdrawal.

Deb’s brow furrows, “Are you sure?”

Hey, I thought Bill Clinton visited me last week, I’m not sure of anything. But that’s what it looks like to me.

“Still… for God’s sake, she’s a human being. Why is he treating her so badly?”

Nurses are like that with addicts sometimes, I tell her. They can be very judgmental about substance abuse. Which is fucked up on so many levels I hardly know where to start. But beyond the whole nursing charter of caring for the sick, the fact of the matter is that a great number of addicts got started down their rocky roads by being put on powerful prescription painkillers by us. “Us” being the medical community at large. When you can’t get Percocets or Lortabs anymore, you turn to heroin.

My view is that the circumstances of life that separate the guy sleeping under the bridge from the guy in the corner office on the 33^rd floor are razor-thin. We are all human, I try never to forget that in life in general, but especially in my clinical practice. Only a small degree of luck, good or bad, separates the corner office from the shelter of the bridge. I do have a couple of patients I think are despicable people. I groan to myself when I see them on my schedule, but they have diabetes, and by God I will not let diabetes win, and I try my damnedist to treat them with equal respect and care.

Sorry, I got off track again. My focus is still fucked. Anyway, when it comes to junkies… sorry, addicts, I think we in medicine need to take the opposite track from the one I see so commonly. I believe we need to take ownership. Odds are we caused their mess; we need to fix it. Of course, I also remember what it felt like when several years ago in this same ER when they mistook me for a junkie and treated me like they were treating this lady.

But of course, there are two sides to every coin.

And, I added in a low whisper to Debbie, because while I didn’t know for sure, but I was dead certain of it in my heart, She’s probably one of his frequent flyers. She probably comes in two or three times a week when she gets strung out.

“Can’t they help her?”

Probably not. She probably doesn’t want help. She wants some painkillers, which, really, is the last thing she should have.

Finally, Skank Woman stops asking for a blanket and starts screaming for one, “For God’s sake I’m fucking freezing my ass off out here you asshole! Why can’t you give me a God-dammed fucking blanket?!”

Instead of giving her a God-dammed fucking blanket, security is called. Her tiny body is surrounded by two men and one woman in black uniforms. Collectively, the three of them have the biggest butts I’ve even seen, at least in one place. Clearly, the “A-Team” is not in place on graveyard on weeknights. The male nurse joins them. I don’t hear it, but Debbie later tells me she overheard the nurse tell her, “I’m your worst nightmare.”

Way to show you care, Mr. Healthcare Worker.

For the moment, the show of force scares the addict into submission. I know what’s going on. They can’t turn her away, not by law, but they are under no obligation to be nice. If they make her visits uncomfortable enough, maybe she’ll give up and go somewhere else in the future. And, truth be told, there probably isn’t much they can do for her. And, hey, for all I know, this bully of a nurse moved heaven and earth to get her into treatment at some point in the past only to have her leave after one day.

Still, if I had been at the ER desk, I would have given her a God-damned fucking blanket.

The gasping child is taken back. The obese mother with the mask gets sick of waiting and leaves with no word to anyone.

Finally, with a “come here, dog” gesture, I am admitted. Then I’m appalled to discover that not only is the giant nurse the night receptionist, he’s also the triage nurse. He’s doing two jobs. In fact, I’m to discover that budget cuts have left the ER at the only major medical center in the northern part of my state manned with only two nurses and one doctor at night. It will prove to be a long night, and the better part of the next day, before I leave the building.

 I’ve not read it, but someone once told me that James Michener filled dozens of pages of his epic Pacific tale with the word “wave,” over and over again, to depict the monotony of an ocean crossing. If I wanted you to really get the feel of our ER visit, I’d say:

We wait. And wait. And wait. Hours pass.

We wait. And wait. And wait. Hours pass.

We wait. And wait. And wait. Hours pass.

We wait. And wait. And wait. Hours pass.

We wait. And wait. And wait. Hours pass.

We wait. And wait. And wait. Hours pass.

But if I repeated that for 18 more inches of blog column you’d all fall asleep. I did. Deb didn’t. But being increasing pissed-off really gets her fueled up.

When we were eventually parked in a bay, the attending nurse ordered me to strip and put on a paper-thin gown, then she put an IV in my arm, drew many tubes of blood, promised to get me a blanket (which I did get much later, so they weren’t out), and sent me half-naked across the basketball court-sized ER to give a urine sample. The single unisex bathroom was filthy. There was urine on the floor and bloody gauze piled up on the sink. I’m barefoot.

When I get back, she asks if I want some pain meds. Thinking of the junkie in the lobby, I decline. I don’t mind pain, particularly. I mind mystery pain. If I know I’m not suffering a necrotic gallbladder (my latest freak-out in thinking after mentally reviewing all the various bad things that have happened to my own patients who had mystery gut pain), then I can tough out pain. It’s the runaway imagination worrying about what’s causing the pain that’s my real enemy, not the pain itself.

Then the real waiting began. Do you remember watching the clock on the wall in elementary school? The one in the front of the classroom, above the blackboard? The one that seemed to crawl with an eternal slowness, or even run backwards before recess? Yeah. I could see that clock from my hospital bed.

Finally the first of the several doctors who saw me came in. Tall and thin with piecing blue eyes, he was wearing a blue turban. I glanced over his shoulder to make sure Bill Clinton wasn’t standing outside waiting to see me. The doctor poked, prodded, asked questions. I filled him in on the illness, with Deb supplying the majority of the details I could not recall, I told him about the pain today, and about the cognitive troubles I was having, to which he responded that I seemed pretty sharp to him. Not being sure he was actually real, I didn’t know how to respond to that. I certainly wasn’t feeling even the least bit sharp.

He asks if I want some pain meds. Thinking of the junkie in the lobby, I decline.

He decides, what the hell? And orders a CT scan. I am elated. Now we can find out what the fuck is going on inside of me.

I spend the next 45 minutes trying to get my wedding ring off my finger. Deb pops the transmitter off the Dex. Years ago, I had an MRI and the tech made me pull the sensor. After the scan was done he was kind enough to take the dead sensor back in and see if it would stick to the outside of the machine. It didn’t, so I know it’s safe to leave it in my arm. Besides, it’s only one day old and I only have three left and no insurance coverage for them, going forward ,so I can ill afford to waste it; but the transmitter needs to come off.

Then for some reason, I actually remember my basal insulin. Oh. Wait. No I didn’t. My iPod remembered it for me and then reminded me. Of course I didn’t bring any basal with me, partly because it’s the last thing you think of at two in the morning when you are going to the ER, and partly because even if I had thought of it, I would have assumed I’d be long home (or admitted to the hospital) before it could become an issue. My Go-Bag has back up fast-acting, but no basal. This is partly from ex-pumper habit and partly because how often do you really need back up basal for God’s sake?

I press the call button for the nurse and ask her for a whiskey with a chaser of 10 units of basal insulin. She says she’ll see what she can do. Ten minutes later she reports that as my blood glucose is 137, the doctor doesn’t want me to have any insulin. She leaves before Debbie and I can get our heads around what we were just told. We probably sit there for 15 minutes with our mouths agape before Deb snaps out of it and has a hissy fit, demanding, among other things, that I educate these incompetent nurses and doctors about the facts of diabetes life and basal insulin.

But I am too tired to save the universe tonight. I request basal insulin numerous times over the next few hours with no success. After half a day at the hospital, they never re-check my blood sugar, and despite sneaking a unit of fast-acting insulin myself every half hour I leave their “care” at 285 mg/dL at the end of this epic.

Meanwhile, the other nurse on duty cheerfully brings me two bottles of contrast dye. “Drink up!” she says, throwing the two bottles onto my bed. “The sooner you down these, the sooner we can take pictures.” She tells me once I drink the last drop it will be 90 minutes until the CT scan.

The contrast dye is better than I remember. Last time I had some it was thick, like a Slimfast shake. This is clear. The label says it’s tropical fruit flavor. The bottle boldly displays colorful graphics of virtually every fruit known to man: pineapples, kiwis, bananas, cherries, apples, strawberries, and more. On the back of the bottle, in small print, it says: “Contains no fruit juice.”

Huh.

It tastes like weak Crystal Lite with a funky after-taste. At least it’s sugar free.

Then we wait.

And wait. And wait.

And wait. And wait.

And wait. And wait.

Shift change comes and goes, but the day shift is short-staffed, too. My part of the hospital is actually closed and I am relocated. A new doc comes in to tell me turban doc has left for the day. I go over the story again. Doc Two, who I decide in my head to call Doc Too, adds a CT of my head to the already ordered one of my gut.

The he asks if I want some pain meds. Thinking of the junkie in the lobby, I decline. Then I wonder if she is still out there. Maybe I should have taken her my blanket.

Eventually, I’m transported to the rad-room for my CTs. On the way back the guy pushing my rolling bed tells me how tired he is, and how much his job sucks. I don’t know what to say, but I don’t ask him for any insulin.

We wait. And wait. And wait. Hours pass.

We wait. And wait. And wait. Hours pass.

We wait. And wait. And wait. Hours pass.

We wait. And wait. And wait. Hours pass.

Again, I try to score some basal insulin and am told that I can take some when I get home if I am high then. I am reminded that I was at 137 on admittance. Of course, that was over six hours ago. No other BGL checks are done the entire time I’m at the hospital.

Finally the new doc comes back. There are bags under his eyes. He has the results of the blood work, urinalysis and the CT scans. And they reveal… Nothing. Well, nothing unexpected in someone my age. Spleen a bit enlarged, no surprise on the backside of a major illness, a hint of a hiatal hernia, junk like that. But no smoking gun. No lodged bullets.

Debbie is thrilled. Perversely, I am disappointed. At that point, I would rather have been full of tumors than full of mystery. It sounds sick, looking back on it, but in the moment, worrying that I’ve completely lost my mind, I wanted something broken to be found so it could be fixed. After all, I wake up thinking I’ve been gunned down and then find out there’s not one fucking thing wrong with me. How can that be?

Are dreams and reality merging to the point I can no longer tell the difference? Was the pain real or was it a dream?

I feel fine, damn it. But I do need to pee.

And as soon as I swing my feet to the floor to get up out of bed, another bullet tears through my abdomen with a clap of thunder.

Pain. OK. That’s real. But as there’s no clear cause, it’s not addressed. Doc Too thinks my primary care doc is probably right: Internal organ chickenpox has left me a mess. When I asked Doc Too why it would suddenly get worse, he just shrugged. “Abdominal pain is funny that way,” he says. Great.

In the fullness of time, and I do mean that literally, my insurance cards are Xeroxed and I’m discharged. I’m told to get dressed and I may leave. Once again I’m offered pain meds that I decline.

On the minor victory front, as I was signing the discharge papers, my latest insulin-withholding nurse noticed my CGM transmitter and asked if it was a pump. I told her no, it was a CGM and I was rewarded with a blank look. So I gave her my CGM elevator speech and then showed her the receiver.

Her mouth dropped open, “You’re blood glucose is almost 300!”

Yes, that’s what happens when you deny type 1s their basal insulin.

I could see her trying to process how my sugar could be so high when all I had been allowed was ice chips (despite the radiology tech’s insistence I should be drinking “lots” of water as the contrast dye is hard on the kidneys and I’d had both oral and IV contrast dye). I suppose I should have educated her on how the liver works and the need for insulin to suppress the neoglucogenesis, but I was too tired and to be honest, I still wasn’t sure what clinical facts in my head were real and which were grounded airplanes and ex-presidents, plus I just wanted to get the fuck out of that place.

As we leave I’m surprised to see the sun is up. It’s fully daylight and now the ER lobby is packed. The junkie, however, is not among the throng.

My girl is hungry, and I need water, so Deb points her sporty little Juke towards downtown and roars out of the hospital parking lot. I sit in the passenger seat dazed and confused, trying to understand how the day can be so beautiful after such an awful night.

As I look out the window, I see the Abominable Snow Man.

Whatthefuck?

Yep. Plain as day. He’s standing right there on the sidewalk. He’s waving at me with his right paw and waving some sort of ring-shaped pillow over this head with his left paw. Shocked, I glace at my wife to ask her if she sees the strange aberration, and I find she’s cheerfully waving back at the great white ape.

Did you see that? I gasp.

“See what?”

Ummmm… the Abominable Snow Man. Uh, selling, butt pillows. I think.

“Sure.”

The Abominable Snow Man selling pillows on a sidewalk in Santa Fe, New Mexico, is real. The ER staff of the Regional Hospital refusing to give insulin to a type-1 diabeticis real. Bill Clinton visiting me while sick wasn’t real.

Is it any wonder I’m losing my mind?