Friday, November 26, 2010

Interesting Reading Lately

So, I've been spending lots and lots of time on the Scribophile website.  It's a land where writers can read and critique other people's works, and have their own work critiqued.  Unfortunately, I've never been able to put down a good story, and I've been immersed in a work by another author until tonight when I finally got to the end.  I really hope it gets published - it's a fascinating story that deserves to have lots of people enjoy it.

My own writing, on the other hand, needs to get back on track. It's time to go back and reread the critiques that were generously given by other writers to tighten up the first two chapters of Inertia.  I'm still not in love with the title, but it gives me a name for the book when it's up for critique on the site.  The suggestions I received have been fantastic and eye-opening.  The more I hang out on the site, the more I want to upgrade to the premium membership so I can post all of the chapters I've written so far and start getting some feedback.  Those who have critiqued me have noted interest in seeing how Hannah's character develops, but I can't show them anything more than what I have posted so far.

I'm excited to do the revising, and in a way, dreading writing the next section of the book.  It's going to take time and attention to get it down on paper and I haven't felt that I have the stamina to make it happen.  I don't want to do a half-assed job with it, but the longer I wait, the longer I'll have nothing written.  Sometime you just have to take the first step.  If I'm lucky, once the story starts to come out, it will flow out onto the pages.  And if not?  Well, it wouldn't be the first time I deleted entire sections that I decided I hated.  I had written 17 chapters back in November 2008, hated the whole thing, threw it out and started over.  Fifteen brand-new chapters later, I think this book might have a shot.

Monday, November 22, 2010

Another layer unfolds.

I'm still sticking to the author's rules for getting published.  As noted, I've successfully completed the steps that got me to picking a working title for my novel, and submitting (and having accepted) the academic article about our medical mission to China.

The next step (in chronological order of accomplishment, of course) was to keep writing the novel.  To this end, I've successfully harnessed the idleness of one who was ill enough to actually get admitted to a hospital for 5 days.  During my hiatus from reality, I managed to put down about 4600 words, which equates to about two chapters, or 20 typed pages.  These weren't just any random 4600 words, either.  Major plot points happened.  Hannah went to Emil's wake where she found out secrets about Garrett that he didn't share/neglected to share, which throws her whole life into a tailspin.  Never mind the fact that he kissed her.

Of course, I think these things are fascinating and, of course, spectacularly written, but... it's entirely possible that it all sucks.  So, according to the rules, the next step is to have someone critique the work.  To this end, I've joined Scribophile, an online critique group, and have posted chapters 1 and 2 on the site for critique.  Whereas my mom gives really great, honest critiques (she tells me when she thinks some parts suck), we do think awfully alike, so I've put myself out there and have my fanny hanging in the breeze on Scibophile hoping not to get spanked too badly.

It's time for Marc and Hannah to walk down the aisle, and this is the major climax of the book.  I'm going to have to really take my time and get this right, so I'm going to let my posted writings sit on Scribophile for a while and go back to the paper and pen (which is working for me right now).  The next chapter is waiting in the wings of my mind, ready to take form in words.

And when I get bored or frustrated, I'll go back to researching the agents that will be at the Writer's Digest conference in January.  (This is under the rules about finding an agent so you can get published.  Very important for when the book is actually finished.)  If it's going to be worth the money, I'm going to have to finish this novel and start to get it polished.  My goal is to pitch it in January, and if anyone buys my pitch, they're probably going to want to read it.  And the rules say, don't pitch it if it isn't finished.

So, for now, I'm right where I think I need to be, until I read another article with another rule that I know I'm not following.  Did I mention the rule about having a Twitter account?  I have one, and I follow lots of people, but other than that, I'm not sure what to do about it.  I just don't see the fascination.  I'm much more of a Facebook girl myself.

Michelle :)

Sunday, November 7, 2010

I killed Emil...

I just reread this scene, and I'm really happy with how it came out - which is really bizarre on a first draft.  Feel free to tell me how to make it better.

Chapter 13

I weaved through the room until I got to the far side of the bed.
“Ruby,” I said, “where’s Bronte?”
“Hannah, what are you doing here?  Can you…”
I cut her off. 
“I can’t.  I’m off the clock and under the influence.  Garrett’s here – I’ll stick to emotional support.  He wants to come in.  What happened?”
“I have no idea.  One minute everything was fine, the next, his pressure bottomed out and his heart rate dropped and then stopped altogether.  I would have called Garrett sooner, but I was in a scramble to start coding him.  As it was I had to have the supervisor call him because I was in the middle of doing chest compressions.” 
“That’s fine, is Bronte on his way?”
“Yeah.  We paged him first.  He should be here any minute,” she said, and she turned to the code sheet.
“We’re due for another epinephrine,” she called, and handed it over to Elyse, the nurse who was giving the meds.
“I’m going to bring Garrett in, are you guys ready?”  I looked around the room and found Alden.  Thank God the nurses weren’t the only ones in the room with brains.
“Epi’s in,” Elyse called, and Ruby marked the time on the code sheet.
“Family’s coming in,” Ruby called, and the side conversations hushed as I made my way back out the door.  I met Garrett just outside the door.
“Ready?” I asked.
He nodded.  I wrapped my wrist around his upper arm to guide him and started talking as we walked through the door.
“There’s a lot going on right now.  From what Ruby told me, he was fine and then suddenly his blood pressure dropped and his heart rate slowed and then stopped.”
The forest of white coats made a path that effectively guided us to the far side of the bed.  The side rails of the bed were down to allow Elyse access to the intravenous sites.  It also allowed Garrett access to his father’s arm.  He hesitantly rested his hand on his father’s and gave it a gentle squeeze.  I released his arm and rested my hand lightly on his shoulder so he knew I was still there.
“Hold compressions,” Alden called, and the room was still, all except for the medical resident at Emil’s groin who was holding the Doppler to the femoral artery.  Instead of the whoosh-whoosh of a pulse, there was only the static caused by the medical resident searching for a pulse.
“What’s the rhythm?” Alden called.
“Asystole,” Ruby answered.
 “Elyse is giving him medications to try to start his heart again,” I said quietly.  “Ruby’s in charge of keeping track of what’s been done.  Frank is doing chest compressions to circulate the medications so they reach you dad’s heart and Cheryl is using the ventilation bag to breathe for him and give him oxygen.”
Garrett nodded, staring down at the bed.  His expression was resigned, almost stoic, until there was a commotion in the hallway.  Garrett’s head snapped up, and he darted for the door.  He caught Rosemary just as she was about to enter the room and I saw the terror in her face as she took in the scene.  Her eyes were wide and her hand covered her mouth.  She buried her head in Garrett’s shoulder and as I approached them, I could hear him murmuring in her ear.  Another woman, who must have been Rose’s partner Martha, stood a few feet back, tears streaming down her face.  I could hear what Garrett was saying now that I was next to them.
“Are you sure you want to go in?” he asked Rose.  She nodded, her face still buried in his chest.  “It’s not pretty, and he doesn’t look like himself.”
“I don’t care,” she sobbed, “I want to see him.”
I motioned to Martha to come closer, but she shook her head.  I looked around quickly, and found a chair in the hallway that wasn’t being used and pulled it over for her.  She nodded, and rested her hand on the back of it.  It was clear by her rigid posture that she wasn’t about to sit, but it was the best I could do for the moment.  I turned back to the room to see Garrett walking Rosemary over to the bedside.  I quickly followed them in, not knowing how Rose was going to react, and wanting to be close in case Garrett needed help. 
As they reached the bedside, she reached down for Emil’s hand and then her knees gave out and she was kneeling at his bedside.  Garrett kept his arms around her, and I quickly pulled over a chair.  Together, Garrett and I helped her into it, and once she was settled, he stood behind her to watch.  I put my hand on his back, and then moved a few steps away, letting my hand slip down to rest on the footboard of the bed.
Dr. Bronte came in at that point and spoke with Alden and Ruby.
Around us, the code team continued to give medications, do CPR and breathe for Emil.  Rosemary’s shoulders shook as she cried and Garrett rubbed her back, tears streaming down his cheeks.  This wasn’t fair, and I wanted to yell, but there was no one to yell at, no one to blame.  It wasn’t fair for them to have to go through losing their father after losing their mother.  And it was so incredibly frustrating to know that there was nothing I could do to stop it from happening. 
Dr. Bronte came over then to speak to Garrett and Rosemary.
“From what the nurses and doctors are telling me, I don’t think your father is bleeding again.  I don’t see any benefit from taking him back to the operating room for another surgery.  It’s not going to stop what’s happening here.”
Rosemary sobbed harder, and Garrett took a deep breath in and held it before letting it out again.
“What are you saying?” he asked, steeling himself for the reply.
“The medications aren’t working, and although we can continue to try to resuscitate him, the outcome isn’t likely to change.  I believe we’ve reached a point where this is out of our hands.  Do you want us to keep trying to bring him back?”  Dr. Bronte was as gentle, yet as honest as he could be.
“Garrett,” Rosemary said, her voice hitching, “I think they should stop.”
“I know, Rose, me too.  Dr. Bronte?”  Garrett let the question hang in the air.
“Ruby, what’s the time?” Dr. Bronte asked.
“One twenty-nine a.m.” she replied.
“Time of death, one twenty-nine a.m.  Thank you every body.”  And with that, Dr. Bronte dismissed the medical team.
The sounds of activity faded, and one-by-one the members of the team left the room as Dr. Bronte stood with me next to Garrett and Rosemary.
“I’m very sorry,” Dr. Bronte said.  “If there’s anything else I can do, Hannah knows how to reach me, and you have my card.  And again, I’m very sorry that there wasn’t more that we could do.”
Garrett shook his hand and thanked him, and I walked with Dr. Bronte to the door of the room.  Martha was sitting in the chair I had given her, her elbows on her knees and her head in her hands.  I walked over to her and invited her into the room.  When she looked up, the room was nearly empty, except for Garrett, Rosemary and Ruby.  Ruby was finishing with the monitor so she could turn it off.  Martha seemed hesitant, until Rosemary’s brittle voice called, “Martha?”  With that, she was up and crossed into the room so quickly, I didn’t bother to try and keep up.
Garrett had stepped back and sunk into a chair against the wall.  I pulled another chair over next to Rosemary for Martha, and she sat, putting her arm around Rose.  I handed her a box of tissues, then grabbed another for Garrett and myself.  Rose leaned forward, resting her forehead on her father’s arm and let out a high, keening cry, then dissolved into shaking sobs.  As tears streamed down my face I wept for a man I’d never actually met and realized that I’d never gotten so close to any other family in my career.
“Hannah,” Rose choked.
“Yeah, Rose?”
“Does he have to have all those tubes in him?”
“Not any more.  Do you want to leave while we take them out?  You can come back in as soon as we’re finished.”
Rose nodded.  She and Martha pushed back their chairs and gathered up their tissues.  Ruby left to get the supplies we would need and some fresh linens.  Garrett didn’t make any motion to leave.
“Are you sure you want to stay?  This part isn’t really pleasant,” I warned.
“I’ll be ok,” he said, “I’d rather be where you are.”
“Oh,” I said, surprised.  “I don’t have to help Ruby.  I can ask another someone else to come in and I can go out to the waiting room with you.” 
He shook his head, closed his eyes and leaned back in the chair.  I felt a little better that he wasn’t watching.  Ruby came back in with the supplies, and we began getting Emil cleaned up.   As we worked to remove Emil’s tubes and drains, I felt Garrett’s eyes on us.  I looked up to see him studying his father and then shifting his gaze back to me.

It's all about the voice...

I read a few really great articles in my latest Writer's Digest magazine.  Thank you to my darling husband for renewing my subscription.

Food for thought - I have a tendency to be a chameleon.  I can very easily take on attributes of what I am exposed to.  Leave me down south long enough, and you'll notice a subtle drawl.  Put me in a group of strong personalities, and I'll take on the same boisterous attitude.  A group of intellectuals, I'll happily get academic.  Pub night?  Time to tell stories.

Finding my own identity has taken years of time and patience.  This year I feel like I'm really starting to know who I am and what I'm about, and it's starting to show in my writing.  (It's probably thanks to my writing that I even started on this journey of self-discovery.)

I have something to say and a story to tell, and I can't use the writing patterns of Stephenie Meyer, Diana Gabaldon or J.R. Ward.  (Despite how much I love their books!)  Unfortunately, if I just finished reading or listening to any of their work, it starts to come through in my own.  Being aware that I do this is the first step in not letting it happen, and I think I'm really starting to get a handle on my writing voice so I can say what it is I want to say.  With any luck, once said, someone will want to hear it.

So, it is in that frame of mind that I sign off to go and cook dinner, get the kids ready for school and bed, and hopefully, find some time at my keyboard to get Hannah, Garret and Marc a little further along in their story.  If only there was such a thing as a 36 hour day - I might be able to get the laundry and the book done in a reasonable amount of time.


Friday, November 5, 2010

China Medical Mission Article Will Be Published!!

I received an email back from the International Nursing editor today ACCEPTING my article for publication!!!  There are 3 articles ahead of mine, so the plan is to use the time to refine the submission and include pictures of the experience.  I'm guessing summer of 2011 for a publication date.  She also paid me a very nice complement, saying that she didn't see a lot of revision being necessary because it was "very well written."

As my Uncle David just told me, I'm going to be spoiled now because usually it takes a very long time to receive a decision about whether or not the manuscript is accepted.  I was prepared to wait and expected to be rejected thinking that my manuscript might not be up to the standards of the Journal of Emergency Nursing.  To have such a tremendously positive response only 2 days after the original submission is beyond encouraging!!

For those of you who aren't familiar with this publication, it's the official publication of the Emergency Nurses Association - the national organization that represents emergency nurses.  ENA is the emergency nurses' equivalent of the AMA or the American College of Emergency Physicians.  To say that I'm honored would be an understatement.

A huge thank you to Brian Faley for helping me realize that my article was ready and for walking me step-by-step through the submission process.  I may have stalled indefinitely if it weren't for him basically saying, "What are you waiting for?  Let's do it."

I'm also so grateful to everyone from the mission (Dr. Chiang and his wife Julie, Dr. Kane and Dr. Hernandez, Jane Burke and of course my darling husband Eric) and my friends and family who supported me in putting this article together.  Not only is this a major professional accomplishment, but it's also a very personal one.

So on that note, I'm going to take my perma-smile-self out with my husband to celebrate.


Thursday, November 4, 2010

Alas, I've emerged from the depths of the Internet

I started my evening reading one of my favorite publications:  Writer's Digest.  I devour it.  From cover to cover it's as relevant and informative as the Journal of Emergency Nursing is to my nursing practice.

In this month's issue there was a lot of talk about online forums such as critique groups, personal websites, blogs, tweeting and I'm sure a myriad of others that I have yet to read about.  You may have noticed the first impact of this issue, this here blog.  I finally woke up and smelled the latte and got myself a blog just like the How to Be a Real Author instruction manual said I should.

As a result, I've now submitted the China medical mission article for publication, and am working with the title "Inertia" for my novel.  I don't know if I can express in words the magnitude of these accomplishments.  The draft of my article and a cover page that read "Book Name" have been plaguing me for about a year.  Now thanks to this blog and the feedback I've been getting from all of you, I've pushed the peanut forward, so to speak.

I'm aware of the reality that my article could be rejected, and I think I'm prepared for that, although I guess I really won't know until I hear back from the Journal of Emergency Nursing, but that's not the point.  The point is that I actually asked someone to consider publishing my work.  

Like my mom says, you'll never score a basket if you don't shoot the that particular sport.

It's late, and I do need to get up and get to work in the morning, so I'll keep it short tonight.  If it suits you, consider checking out my author facebook page.  You can click the "badge" on the right side of my blog (hard to miss), or you can search me out under "Michelle A Kobayashi".  If you want to peek in on the updates as they post, feel free to "Like" my page.  The page is in its infancy, and I don't know how it will evolve, but I'm really excited that it's started.

Baby steps.


Sunday, October 31, 2010

Chapter 5 - Freshly revised.

Chapter 5

We walked out through the back door of the unit to the hall where the lockers were kept.  They were in plain sight in the hall between the ICU and the rest of the hospital, so the facades were wooden with built in locks instead of the cheap gunmetal grey that could be found in most of the staff lounges in the hospital. 
“Lucky number twelve,” Garrett said as I dialed the combination to my lock.
“It is to me,” I said.
“Really?  Twelve is your lucky number?  I was only kidding when I said that.”  His voice was a bit lighter than it had been in Emil’s room, but still just as deep and smooth.
“Not exactly.  My lucky number is ninety-three, but if you add the nine and the three you get twelve.”
“So I can keep twelve, then?” he asked, now smiling.
“Why, is that your lucky number?”
“Since I was seven.  I can’t even remember how it came to be that way.  I think that one day I just decided that I liked the number twelve and that was it.  From then on, every time I got to pick a number, it was always twelve.  Sports jerseys, bets on the games at the casinos, you name it.”  He smiled as we walked toward the cafeteria.  “What about you?  Ninety-three isn’t a very common number.”
“In my family it is.”
“Your whole family has the same lucky number?”
“Yeah, I guess we do.  It’s a bit of a long story.”
He nodded, but thankfully, he didn’t press me for details, and I let it go.  My emotions were a little close to the surface, and I really wasn’t up for a Sally conversation right now.
“So how long have you been a nurse,” he asked me, as we got onto the elevator.  I reached over and pushed the “G” button, and the doors slid closed.
“Five years,” I said.
“All of them in the ICU?”
“Yup.  Born and bred there.  It’s all I’ve ever known.  I like to think I’m good at it, so for now I’ll stay.”
“Well, I’ve spent my share of time in hospitals with my mom, and I’d say you’re pretty good at what you do.  You know how to talk to people.  Not every nurse can do that.  It’s a shame.  I think it should be a job requirement.”
“Thanks,” I said, as the elevator door slid open.  We got out and made a few turns, finally reaching the turnstiles at the entrance to the cafeteria. 
“You’re right,” he said, smiling, “I never would have found this place.  That’s going to take some getting used to.”
We each grabbed a tray and plastic utensils.  Garrett stopped and stared, bewildered at the different stations.  Central Medical is a big teaching hospital in one of the wealthiest counties in the state.  We didn’t have separate employee and visitor cafeterias.  Instead, we had one large cafeteria that had everything you could possibly want, from sushi to kosher food.  The sushi was made off-site and brought to the hospital daily.  By six o’clock at night, the case was nearly empty. 
“Okay, let me give you the tour so you know what your options are.  To the left on the back wall are the beverage cases, and after that is the fresh fruit.  Straight across from us on the far wall is the equivalent of a home cooked meal – roast of the day on the slicer, veggies, starches and soups of the day.  Next to that is the grill where you can get burgers, grilled cheese and stuff like that.  They also have French fries and chicken nuggets there.  The next station is pizza.  It’s thin crust, and could give the local pizzerias a run for their money.”
“To the right,” I continued, while Garrett’s eyes widened, “is the sandwich bar and just past that is the salad bar.  They also have things like yogurt and cartons of milk and orange juice.  You’ll see the small refrigerators in between the main stations.  And if you’re really desperate, they have coffee, just past the salad bar, but that’s only for an emergency.  It isn’t very good.”
“This is unbelievable,” he said.  “I was thinking I would get a sandwich out of a cooler and a soda from a vending machine.  Even then I figured I was being optimistic.”
“Welcome to Central Medical Center,” I said.  “If you think this is good, you should come back during the day shift.  At lunch they have a Panini station and at the center island they have local restaurants come and prepare the special of the day.  It brings variety to the hospital employees and visitors, and it’s good advertising for the restaurant.  A nice little win-win for everyone.”
Garrett finally settled on a chicken sandwich and fries from the grill, and I managed to find sushi that I liked and tacked on a salad from the salad bar.  We paid and walked into the seating area to find a table.
“Wow, déjà vu,” Garrett said, as he sat down at the table.
“Really?” I said, “What part felt familiar?”
“I feel like I’ve sat down at this table with you before.  I remember looking across at you and seeing the soda machine in the background.”
“I was in your déjà vu?” I asked, surprised.
“Yeah.  Why, do you think that means something?”
I was suddenly reluctant to share what I believed about déjà vu.  “I’m not so sure I want to say.  You’ll probably think I’m crazy.  My fiancée gets all freaked out when I talk about psychics and things like that.”
“You’re trying to tell me I’m psychic?”
“No,” I laughed.
“You’re psychic?”
“No,” I laughed again, “definitely not.” 
“Then why would I freak out?” he asked rhetorically.
I stared at my sushi as he took a bite of his sandwich.  He would probably think I was an idiot if I told him we were destined to meet and my credibility as a nurse would be shot.
“You’re not going to tell me are you,” he said, breaking into my mental debate.
“I probably shouldn’t get into anything too personal, seeing as how I’m your dad’s nurse and all.”
“So you’re telling me that you being in my déjà vu is personal?”
Oh no.  “That’s not what I meant, it’s just that I guess sharing my thoughts on déjà vu are personal and I wouldn’t want you to get the wrong idea and then worry that I’m crazy and shouldn’t be taking care of your father.” 
My voice trailed off.
“I should just stop talking now.  I’m only making it worse.”  My face was beginning to flush – the redness creeping into my cheeks.
Garrett laughed – not in a mean way, but it a way that disarmed me because it said I was being silly. 
“I’m sorry,” he said, “I don’t mean to laugh, but I didn’t realize this was such a big deal.  I was only making conversation.”
“Well,” I said, “it was very nice of you to pretend to be interested.”
“I wasn’t pretending.  I actually am interested.  I just didn’t realize that my interest would make you uncomfortable or I wouldn’t have said anything,” he soothed in his deep voice.  “I always thought déjà vu was due to some kind of dizzy spell or lack of oxygen to the brain or something like that.  Who knew it was related to psychics?”
“I’ve read a lot about psychics and the afterlife and what happens to our souls when we die.” 
“Cheerful subject,” he teased.
“Coping mechanism,” I said simply.  “One of the books I read explained déjà vu in a way that made sense to me, so I adopted it as part of my beliefs.”  I looked back up, wondering if I dared to go on.  His face was soft and his eyes warm.  He didn’t interrupt me or talk for me, so there was no way for me to judge what he was thinking.  By now I would have known if Marc was interested or not and I would have adjusted my response accordingly.  With Garrett I was in unfamiliar territory. 
Finally the silence got to him. 
“Are you okay?” he asked.
I took a deep breath.  “Just making sure you’re not going to bolt for the door and have me replaced as your dad’s nurse.  You’re sure you want to hear this?”
“I’m sure.”
“Do you promise you won’t run away screaming?  That would be embarrassing.”
“I promise.”
“And you’re not going to have me replaced?”
“Hannah, relax.  Psychics don’t freak me out.  I really want to hear your explanation about déjà vu.  I’ve always wondered, and no one ever had a good answer.  I’m actually intrigued.”
Intrigued.  This was different.  I was used to eye rolls and short tempers when it came to my theories on the after life.  It was the one time that it was convenient for Marc to suddenly be religious.  In my opinion, Marc was Catholic-lite.  Church on Christmas and Easter, and psychics and ghosts were sacrilege.  The rest of his life was as secular as it gets.  I’ve done nothing but struggle trying to share this side of me with Marc for the past seven years.  Now, I was sitting across the table from Garrett, a near stranger, and he was intrigued.
“Okay, here goes.”  I paused, collecting my thoughts.  “I believe in reincarnation.  I also believe that we all have a reason for being born.  The bottom line is that our souls come to Earth to have an experience that will allow us to grow and mature.  Also, we tend to travel in groups, which explains why some people seem more familiar than others when you first meet them.”
“I noticed that about you.  I was trying to figure out where we had met before,” he said, “but maybe it’s just that I knew you in a different life.”
“You’re just saying that to make me feel better about telling you this.” I teased.
“I’m not.  Honestly.  You’re not the only person that I’ve had this happen with, either.  My college roommate was the same way – oddly familiar even though we’d never met.  We’re still friends to this day.”
I thought about this.  Even if he was saying these things just to be polite, at least he wasn’t making me feel like a freak.  This was a nice change.
“Maybe you were brothers in a previous life,” I suggested.
“Maybe,” he said, smiling.  “I wonder how we knew each other.”
It was a rhetorical question but I found myself wanting to answer it.
“Is there more to your theory?” he asked, breaking into my thought.  “I’m not sure how this explains déjà vu.”
“I’m getting to that,” I said, smiling, coming back around to the present.  “Remember how I said we came to Earth to gain experience and mature?”
“Go on.”
“Well, I think that before we’re born we get together with the group of spirits that we travel with through our lifetimes, and we make plans for how we’re going to accomplish our goals while we’re here.  Say, for example, you need to learn patience.  Maybe five of your spirit-friends agree to come back as your children so that you can experience what it’s like to be the parent of five.  Or,” I shrugged, “maybe you need to experience a major loss.”  My voice caught in my throat and I stared down at my napkin.
“Mmmm,” he said, and I relaxed into the sound of his voice.  I hadn’t realized how high strung I’d been today.  We sat there in silence for a minute, my thoughts wandering back to Sally and what it took to deal with losing her.  I always wished I knew why she had to die so young.  It’s one thing to believe that everything happens for a reason.  For years I’ve let my mind stop there, accepting it as the explanation of why we had to suffer something so terrible, but in reality it would be so much easier to know what that reason was.  Then I could decide for myself if the reason really justified the means.  I hated not knowing.  This thought brought me back to the point of the story. 
“So,” I continued, “we make plans, but when we’re born, we don’t remember them.  And we have free will, so anything can happen.  We can make choices that totally send us off course, either delaying us, or causing us to totally fail in accomplishing our goal for this lifetime.  On the other hand, when we’re on the right track, sometimes our conscious mind links up with our subconscious mind, and we have déjà vu.  It’s like a little glimpse of the map with a caption that says, ‘You’re on the right track, just keep going.’”
I looked up, and Garrett was staring at the table, his eyes unfocused, obviously deep in thought.  I couldn’t read his face.  Was he really as open-minded as he said he was, or was he looking for a polite way to get away from me?  I was kicking myself for not keeping my thoughts in my head.  Marc was right.  I was a freak.
“So you think it’s possible that I planned to lose both of my parents in the same year?”
I was shocked that he was taking this so seriously.  Trying to get over my mental stutter I thought again about what he had said. 
“Your dad’s still here,” I reminded him.
“I’m not so sure,” he said flatly.  “But even so, it feels different thinking that this is part of some plan.  Less random, I suppose.”
I nodded in silent agreement.  “If there’s one thing I believe, it’s that everything happens for a reason.  I used to think that if I was patient, I’d meet back up with the people who have already died and I’d finally know for sure what those reasons were.  And then I realized that when I die, all of these trivial human things won’t matter any more, and the reasons I’ve waited for so patiently will be meaningless.”
“That’s depressing,” he said with a crooked smile, his eyes flickering up to meet mine.
“Tell me about it,” I smiled back.  “I’ve never really tried to explain this to anyone outside my family.  My mother and my sister have roughly the same beliefs that I do, so we don’t talk about it much any more.  And like I said, my fiancée isn’t interested.  I don’t bother to bring it up around his friends, because he makes a big deal about my freaky ideas.  It’s embarrassing.”
“Why would he do that?” Garrett asked.
 “I think he’s just insecure with his own feelings about death, and the idea of it just creeps him out.”
“So why would he embarrass you about it?”
“I don’t think he realizes that I feel that way,” I said.  And here I was, back to defencing Marc, again.
“I’m sorry.  I’m not trying to upset you,” Garrett’s voice softened, and I realized that his words were sincere.  “I just find it hard to believe that he would act that way and not realize that he was making you upset.”
“Yeah, well, that’s Marc,” I sighed in resignation.
“And you’re sure you want to marry him?”
Geez, that was a personal question.
“Of course I’m sure.  Besides, it’s too late to back out now; the wedding is only two weeks away.  People are already sending gifts.”
“If you haven’t said ‘I do’, it’s not too late,” he said, matter-of-factly.
“But I don’t want to back out.  Marc and I are perfect for each other.  I think I’ve found my soul mate.”
“I think?” he said with one eyebrow raised.
“I have,” I corrected, putting on the most sincere smile I could muster.  Why was I always defending my relationship with Marc?
Garrett sat thoughtful for a moment, leaning against the back of his chair. 
“Are you ready to walk back up?” he asked.
I glanced at my watch and started when I read the time. 
“I should have been there five minutes ago.”
Garrett stood, picked up our trays and deposited them on the return carousel.  From there we retraced our path to the elevator in silence. 
“So what about your friends,” he asked as we waited for the elevator to arrive.
“What do you mean?” I asked.
“What do your friends think about your déjà vu theory?”
“I told you, I don’t bother to bring it up around them because of Marc.”
“I thought those were his friends,” he said.
“Same thing, in this case.  I was never much good at keeping my own friends.  I wasn’t close enough with anyone from high school to bother staying friends with, and I only had one college friend who I bothered to keep in touch with.”
“And what does she think?” he asked.
“She’s married to Marc’s brother, so she falls into the category of ‘people-I-don’t-share-my-theories-with’.”
“So if you don’t talk about this stuff with your family, your friends or your fiancée, who do you talk about it with?”
“Random strangers, it would seem,” I said, cracking a smile.  It hadn’t occurred to me until now that Garrett probably had enough on his mind, without my babbling about my stupid theories.  But then, it was his own fault for asking so many questions.
“Strangers, perhaps, but maybe not so random,” he said, meeting my eyes as he pushed the silver button that opened doors to the ICU.   His eyes were gentle and understanding, not harsh and dismissive.  Why didn’t I have this with Marc?  He was my soul mate.  He should be able to listen to me better than this stranger I hardly know.

Friday, October 29, 2010

Medical Mission to Dali, Yunnan, China October 2009.

On October 19, 2009, a team of American clinicians boarded the first flight in their journey from Newark, New Jersey to Dali, Yunnan, China.  The team, lead by Dr. Cary Chiang, consisted of three emergency physicians and three emergency nurses from Hackensack University Medical Center, in Hackensack, New Jersey, U.S.A.  Together with a medical team from the Dali Oriental Women’s Hospital, in Dali, Yunnan, China, they would form the first joint American-Chinese outreach program in the Dali area.

Dali is located at the southern tip of Lake Erhai, approximately 197 miles (317 km) west of Kunming, the capital city of China’s southwest Yunnan province.  Many small villages are nestled in the mountains surrounding Dali.  These are some of the poorest villages in all of China.  There is limited access to health care, and when available, the people are unable to afford to pay for treatment.

Many years ago, Dr. Chiang learned of the circumstances of the people in this region through a charity run by a relative.  This charity, the United Mom’s Charity Association (UMCA), headed by Chun-Hwa Cheng, works closely with the local Chinese government to identify villages in need of support.  In addition to providing money to build adequate schools and sponsoring individual children, UMCA also raised money through the Coin Foundation.  The Coin Foundation is an American charitable organization founded by Dr. Chiang and his wife, Julia Chiang, to purchase supplies to bring a health care outreach program to these villages.  Without the cooperation of the local Chinese governments, and the funds provided by these charitable organizations, this mission would not have been possible.

With the money donated by UMCA and the Coin Foundation, the Dali Oriental Woman’s Hospital purchased medications for the mission. The hospital is a private facility in Dali that works with the local government to provide healthcare.  Patients can receive both inpatient and outpatient care, and the doctors practice both Eastern and Western medicine.

The American team had very little information about what to expect once in China.  There was no advanced contact with the Chinese team, so the itinerary was not known.  Despite the fact that Dr. Chiang had toured the region two years prior, there was no specific information regarding what kinds of medical needs the people had, making it impossible to know what kinds of supplies to bring.  No medications could be brought into the country; instead, the Chinese medical team would provide them. Due to their familiarity with the local patient population, Dr. Chiang deferred to the Chinese team to choose the types of medications to bring on the mission. 

CLINICAL DAY 1:  Drug Rehab facility, Lian Tien Shang, Binchuan County

After two days of travel the teams drove to the first clinical site at a drug and rehabilitation facility in Binchuan County, Yunnan.  The state-sponsored facility, which has received donations from UMCA in the past, was located apart from the local villages.  With so many unknowns, and no experience to guide them, the local police brought a small group of patients from the local villages to be seen by the doctors.  This allowed them to have control over the number of people that would be seen at the clinic.

The Dali team set up a small pharmacy and provided the American team with prescription pads written entirely in Chinese.  They also provided a list of all the medications available in the portable pharmacy, written both in Chinese and English, but many were unfamiliar to the American clinicians.   After a quick survey of the physical layout, the American team broke down into three doctor-nurse teams, with one translator to share between them.  Despite the fact that Dr. Chiang spoke Chinese, he still needed assistance with unfamiliar medical terms and with understanding the local dialects.  The language barrier was the most significant challenge.  The Chinese team stood back while the American team started seeing patients.

As the first patients arrived, there was confusion among the American teams regarding the role of the nurses and doctors.  Not knowing what was expected, the teams obtained blood pressures, pulse rates and performed thorough assessments including lung and heart sounds.  After obtaining a history of the chief complaint, and performing a review of systems, the doctors prescribed any necessary medications by writing the number of the medication from the pharmacy list on the prescription along with the number of pills the patient should receive.  Patients then proceeded to the portable pharmacy to have the prescription filled.

After the clinic was closed and the supplies were packed up, the American team discussed what could be done to improve the process of seeing and assessing patients.  Jane Burke, RN, drew upon her years of experience participating in medical missions in Haiti and made some suggestions.  The lack of interpreters was the most important challenge to overcome.  In her past experiences, each clinician was paired with a translator, allowing the nurses and doctors to each provide care specific to his or her role.  Unfortunately, during this first clinic, the clinicians were tethered together due to the necessary sharing of the interpreter.

Overall, the team was encouraged and looking forward to the next day’s clinic armed with the first day’s experience.

CLINICAL DAY 2:  Town Hall, Deju, Midu County

The second clinical day began with a two-hour drive up winding mountain roads.  The view was simultaneously breathtaking and terrifying.  The most impressive feature was the plots of farmland cut into the near-vertical sides of the mountains.  Villagers could be seen maneuvering gas powered tilling machines up steep slopes and carrying the day’s harvest in baskets strapped to their backs or slung over poles balanced across their shoulders.  The American team began to understand the physical nature of the lives these farmers led.

Once on location, the Chinese medical team went ahead and set up their own stations in the town hall, directing the American medical team to the stage behind them.  Again, there was almost no communication between the two teams.  The Chinese doctors began seeing patients, while the American team discussed whether or not they should follow the Chinese or Western customs.

The Chinese doctors performed very little hands-on physical assessment.  They obtained a blood pressure and a pulse, and then interviewed the patient.  Based on this, they rendered a diagnosis and prescribed medications if appropriate.  The patients sat across a small table from the doctors and everyone remained seated during the interaction. 

The American team discussed the benefits of conforming to the local cultural expectations versus practicing the hands-on medicine they were accustomed to.  The team began the day using the Chinese format by sitting behind desks provided by the village, but quickly migrated out from behind them to be able to perform physical assessments.  The nurses shared one blood pressure cuff between them since the Chinese team was using the ones they had provided the day before.

At one point, Michelle Kobayashi, RN, spent time in the back of the room at the pharmacy.  She attempted to identify some of the unknown medications by looking over the packaging and the package inserts.  While this was somewhat helpful, there were many mystery medications still on the list.  A list of Chinese generic names was compiled with the intention of contacting the Hackensack ER PharmD for help with the list.  Unfortunately, there was no way to contact him.  The team was having difficulty with cell service, and they wouldn’t be returning to the hotel that night, so Internet access was not an option.

At the end of the clinic, the American team was feeling very unbalanced.  The ever-present language barrier created a lot of downtime while the translator bounced back and forth between doctors, and the nurses were feeling very useless sharing one blood pressure cuff.  In lieu of providing medical care, they handed out lollipops and small toy cars to the children.  It was satisfying to see them smile and get excited about their treats.  Soon, more children began showing up at the clinic.  Once the clinic was finished seeing patients for the day, the American doctors also got involved with handing out the little cars. 

Overall, the American team was feeling dissatisfied with the process.  The nurses felt useless, and the doctors felt constrained by the language barrier.  Again, there was no feedback from the Chinese team.

CLINICAL DAY 3:  Courtyard of local government offices, Yilang, Midu County

After sleeping at a local inn, the clinicians began the morning on a friendly note.  The different teams smiled and waved at each other, with face and role recognition now setting in.  After breakfast, the teams travelled to the summit of the mountain to the local government administrative offices to set up another clinic.

Here, the physical layout of the courtyard made it so that all of the interview tables were lined up in a row down a narrow sidewalk.  The American team was now set up directly next to the Chinese doctors. The American nurses pulled one table aside, and Michelle Kobayashi, RN, and Eric Kobayashi, RN, took turns with the blood pressure cuff, obtaining blood pressures and pulses, while Jane Burke, RN, brought the “triaged” patients to the next available American doctor.   The Chinese doctors continued to perform their own blood pressure and pulse assessments

In this case, triage consisted of writing the name of the patient in Chinese on the prescription pad, which was done by one of the support staff from the Chinese team, as well as obtaining and documenting the blood pressure and pulse rate.  Once the name was obtained, there was no need for the nurses to have a translator.  It was relatively easy to convey to the patients the need to expose their upper arm for the blood pressure cuff.

As time passed, the triaged patients were also brought to available Chinese doctors.  Without intending to do so, the American team began to develop a patient flow process.  At the end of the day, this system seemed to work better for the American team.  The nurses were performing a function appropriate to their role, leaving the American doctors to focus on obtaining histories, physical exams and prescribing treatments. 

Overall, the American team was more satisfied with the care they were providing.  Dr. Chiang discussed the new system with the Chinese doctors, and found that they also appreciated the triage being done before the patients arrived to their station.  The new process was significantly more efficient and better utilized the skills of all of the clinicians.  It also utilized skills from non-medical support staff.  Through this cooperation, the clinic served approximately 60 patients.

CLINICAL DAY 4:  Hospital, grounds, Pingpo, Yangbi County

Due to illness, one of the American nurses was unable to participate in this clinic.  The teams drove to a village nearer to Dali, unfortunately arriving later than intended and in the middle of market day.  The streets were so packed with people that the vans could not get to the local hospital site where the clinic would take place.  The teams ended up walking a short distance, and carrying their supplies with them.

Here, the physical layout lent itself to the newly discovered triage and flow system.  The hospital had a porch, where the pharmacy and the doctors were set up.  The parking lot in front of the hospital was large enough to support a queue of people who were signing in for treatment.  The American nurses brought a desk down in front of the stairs that descended from the middle of the porch.  Someone from the Chinese team sat nex to the nurse and wrote the patient’s names on the prescription papers.  The patients checked in, were given a prescription paper with their name on it and told to stand in line to have their blood pressure taken. 

Once triaged, the second nurse took the patients the middle steps to the doctors.  As the crowd grew, a second nurse was needed to keep up with the demand for blood pressure screening.  With two nurses triaging, the number of patients ready to be seen exceeded the number of doctors.  Five chairs were placed in the parking lot area next to the triage nurses to allow the patients to sit and wait their turn to be seen by the next available doctor.  However, without the third American nurse, the flow of the patients was interrupted when no one was available to bring the next patient to the next available doctor.

For a short while, Jane Burke, RN, was going back and forth between obtaining blood pressures and acting as a “flow nurse” by bringing the patients to the doctors.  One of the Chinese nurses was not busy during this time.  Michelle Kobayashi, RN, invited her to take blood pressures, and then took over the function of “flow nurse”.  By this time, there was an orderly process of moving the patients through the system: (1) obtain and document name, (2) obtain and document blood pressure and pulse, (3) place the patient in queue for the next available doctor, (4) have the patient see the doctor and obtain a prescription if appropriate, (5) have the patient obtain prescribed medications from the pharmacy.

This system was the most efficient way to provide care to a large group of people.  It was able to handle surges in volume without disrupting the process, and the patients and staff seemed equally satisfied, with approximately 300 patients being seen over the course of 5 hours.  As the day progressed, the nurse administrator and the owner of the hospital also participated in the role of “flow nurse”.  They were able to help the patients move efficiently from the queue to the next available doctor. 

Overall, the two separate teams started to blend together to better serve the local villagers.

CLINICAL DAY 5:  Marketplace, Tuanjie, Yunlong County

Now that both the American and Chinese teams were comfortable and satisfied with the patient flow process, the day began in a much more organized fashion.  With all three American nurses present, the desks and chairs were arranged to provide space for taking names, obtaining blood pressures, queuing for the next available doctor and for the doctors to interview the patients.  The pharmacy was set up to the side near a point of egress to allow for a logical flow of patients from one area to the next.

Again, the teams arrived to the village on market day, and large amounts of villagers arrived to seek care.  Prepared to handle surges in volume, triage nurses got immediately to work and began moving patients through the system.  During this clinic, the teams began to refine their processes.  The local government was able to provide additional translators, which allowed Dr. Monica Hernandez and Dr. Michael Kane to work independently instead of sharing the same translator.  Due to the prevalence of local dialects and minority languages, a third translator was provided for Dr. Chiang.

The surges in volume began to outgrow the two-nurse triage system.  At this point, the Chinese nurse administrator and hospital owner took over flow, while all three American nurses performed triage.  The volume was such that the nurse administrator moved patients from triage to the queue, and the hospital owner moved patients from the queue to one of the six doctors.

It was truly inspiring to see the Chinese nurse administrator begin to make improvements to the flow process.  At one point, she moved the person taking names from between the triage nurses to the side of the triage nurses.  This stopped the confusion regarding which lines served which purpose.  The person obtaining the patients’ names was now explaining to the villagers where they should go and what to expect.  This made the movement on the lines more orderly, and prevented patients without prescriptions from wasting time standing on the wrong line.

Overall, both the Chinese and American teams were beginning to function as one.  The process was practical and allowed each team of doctors to practice medicine according to their own customs and training.  The joint American-Chinese team saw approximately 600 patients over four hours, making it the largest clinic of the mission, without losing control of the crowd.

The remainder of the trip was spent visiting sites where UMCA had donated funds in the past.  A clinic was attempted at a local leper colony, in Eryuan county, but due to cultural superstitions and taboos, only a limited clinic was provided by the American team.  It was much more informal and did not employ the patient flow process used on the previous days.


In June 2009, the patient flow process of the Emergency Trauma Department at Hackensack University Medical Center was revised.  The medical, nursing and bedside ancillary staff (nursing assistants and technicians) worked together to reallocate resources to optimize patient throughput in the department.  By creating a teams approach that optimized the strengths of each role within the department, throughput decreased, which reduced the average length of stay.

These same principles, when applied to the clinic setting in China, had the same effect as when applied to the emergency environment in America.  The time spent on each segment of the patient throughput process was minimized, thus reducing the overall length of stay for each patient. 

What started out as a loose arrangement of two teams with differing priorities quickly developed into an efficient process that streamlined the movement of patients.  The system was flexible enough that it allowed for both Eastern and Western medicine to coexist in the same clinical setting.  Without intending to do so, the Hackensack team used their knowledge of patient flow to improve the care of the Chinese patients. 

By sharing their experience in patient flow with the Chinese medical team, the American team developed a system that met the needs of the practitioners, allowing the mission to be successful in providing care to as many of the local citizens as possible.  In the end, the overall goal of bringing medical care to the mountain villagers of Dali was met, with the benefit of seeing a significantly greater number of people than the team had anticipated.

Farm plots on the side of the mountain.  They say the Dali is blessed with fertile soil and cursed by topography.

Medical mission on the stage.

600 people came this day.

Me, Eric and Jack.  Without Jack we would have been sunk - he was our translator throughout the trip.  Miss you Jack!!