Friday, November 27, 2015

Walking Out

Walking Out

John sat on his podiatrist’s examination table. You know the feeling. Bored. Anxious. Impatient. Resigned. He looked around the room, hoping to find something interesting. Anatomy posters. Jars of supplies. Latex gloves; size XL. A tube of lubricant. John shuddered involuntarily as his imagination kicked in.

John was a thinker and a dreamer. He was introspective and lived in his head. He had been thinking about the course of his life and, especially, his increasingly-submissive relationship to the authority of the medical establishment. It occurred to him that there was something about losing control of his choices, and even control of his own body, that was deeply disturbing.

John knew this large clinic and he knew examination room 4; he had been here before. He had also been in Room 2 twice and in Room 1 once. That was an interesting coincidence. He had committed to some minor surgery in this room last spring. They had wheeled him down the hall to an outpatient surgery room to remove a small itching growth from a place on his back that he could neither see nor scratch. It only took a few minutes but had cost a fortune.

John was still paying it off, $75 per month, and also still paying off earlier run-ins with medical care. He had been declared disabled and awarded access to Medicare, but his share of the costs of staying alive still seemed to persistently eat into his ability to have any satisfaction in life. He felt helpless and hopeless.

John noticed the small sign that said, “Diabetic patients: please remove your shoes and socks.” He dutifully removed his shoes and socks. He had already silenced his phone, as requested by the little sign in the waiting room, and carefully massaged-in a shot of “SaniSqurt” as requested by the little sign at the reception desk. John had filled out, signed and returned the compulsory pre-visit forms. He wasn’t coughing or sneezing so he did not feel obliged to put on a “complimentary face mask for your convenience.” He had an impulse to pick up a magazine to read but didn’t touch it. He considered where he was and decided to opt for caution in favor of his freshly-sanitized hands.

John had been referred to this foot doctor when the endocrinologist, treating his diabetes, had noticed damage to the sole of one foot. Actually, John had pointed it out. He had fallen a short distance off a ladder and caught himself on that foot. The foot had been damaged earlier and the irregular shape of the underlying bones had produced a noticeable internal bruise when he landed on it.

This podiatrist was personable in a brisk and direct sort of way. He had prescribed custom-formed insoles. John had been wearing them for a month now. This checkup should confirm that they were well-fitted. But, John’s Medicare had declined to pay for them so he needed to ask about that too.
John was grateful for modern medicine. It had really saved him. It had seriously, literally, saved his life. Either that or it had almost cost his life. It was hard to tell. When it came to medicine, you had to submit yourself to the authority of others, invested by law with the ability to help you or hurt you with impunity.

It had all started when he got a splinter of wood in his toe on the way to the bathroom. He had naturally been barefoot in the middle of the night. John had removed the splinter, dosed his toe with hydrogen peroxide and alcohol, put on some antibiotic ointment and covered it with a bandage. This was no life-threatening emergency so he didn’t drive to an emergency room. They would just clean it and cover it like he had.

Something was still wrong. The toe didn’t start healing. After 4 days, John finally decided that he needed professional help. He drove directly to his doctor’s office and, begging and pleading with as much dignity as he could sustain, was slipped into the schedule.

He was seen, for his only time in Room 1. The doctor probed inside the wound with tweezers. She took an x-ray even though, as she explained, wood had about the same density as flesh and the film wasn’t likely to show anything. Not finding any problems, she referred John to a specialty wound-care clinic that could start seeing him next week.

In the meantime, a small piece of wood came out, which John wrapped in a tissue to show to his wound care nurse. John considered the orders and ranks of profanity that might be appropriate. He wanted to curse himself. He wanted to curse his doctor. He wanted to curse the unfairness of life and the futility of trying to sustain hard work, good judgment and conscientious effort. He wanted to name enemies and exhaust himself in hate against them. Somewhere, John found the capacity to forgive. He felt a fullness behind his eyes and an ache in his chest. Somehow, he summoned the will to fight on, finding within himself another desperate reservoir of courage and a heart full of grace.

John continued visiting the wound-care clinic faithfully three times a week. He was uncomfortable every time they wanted to do some more “debriding” of flesh that they had given up on saving. It looked to John like they kept on removing the kind of pink undifferentiated cells that the body produces as part of the natural healing process. But, they insisted, it was bad tissue and this part of him had to be cut off.

He was especially unhappy with the sloppy nurse who, neglecting the usual mask, breathed on his toe wound while she inspected it. She seemed to enjoy using a sharp instrument to probe into the hole and scrape on the bone while announcing with evident pride, “See, it goes all the way to the bone.”
John was a responsible sort and inclined to think deliberately and think critically. He had done research and had read about the fibrous membrane, called the periosteum, that she took such delight in scraping. He suspected that it also protected the bone from outside pathogens. Scraping it for the perverse satisfaction of proving that you could was not likely to be helpful. Silently, he submitted but smoldering resentment billowed from the embers of his anger. For a while, he succumbed to the temptation of bitterness.

In due time, John was admitted to the local hospital, diagnosed with a MRSA infection, and placed on intravenous antibiotics. John had done research on this as well. He knew that MRSA was the acronym for an antibiotic-resistant strain of Staph infection. He knew that it was most-frequently transmitted by careless health-care providers. It was dangerous, and could be difficult to treat. He had a personal theory about how he had picked it up, but there was no point in making accusations that he could not prove. Besides, he felt like shit.

A few weeks after he was discharged, the inflammation in his toe remained active. He was scheduled for a “bone scan” in the Nuclear Medicine Lab and injected with radioactive Indium-111. In due time, he was informed that the infection had “gone to the bone and that amputation of the toe was indicated.” “Yea,” thought John, “That was predictable.”

His doctor, taking a superior tone, informed him that he should have taken the splinter to the emergency room. Maybe all this trouble could have been avoided.” John suspected that the ER staff would not have found the remaining fragment of wood any better than the wound care nurse had.
John began to consider the fact that his days of dancing with his wife, hiking in the woods and playing ball with grandchildren were behind him. He fought the temptation to begin living inside a persistent cloud of grief.

Several weeks after the toe amputation, his doctor observed that the foot was still swollen. Suspecting a blood clot, she scheduled him for an ultrasound study to look for blockages in his veins. In due time, the results came back negative. Nope, no blood clot.

His doctor then referred him to a bone specialist who was able to take him as a new patient — in seven weeks. “It’s the best I can do,” insisted his scheduler, adding, “I’m actually putting you in early here.” John, understanding his total dependency on the good will of strangers, pretended to be grateful.

The bone specialist suspected arthritis and ordered a new bone scan which was, of course, positive for inflammation throughout the foot. Evidently pleased with himself, he prescribed an especially-strong anti-inflammatory drug that can cause severe damage to the stomach lining. John suspected that suppressing symptoms was not likely to cure any underlying problem. John was not surprised to feel indigestion along with his indignation. But, he could do nothing but take his medicine and accept whatever care was offered.

After two more visits, the bone specialist noticed that the foot was beginning to change shape and referred John to a big-city foot specialist who could begin seeing him in two months. John considered himself lucky to be getting such good care and professional attention. It’s good to see a professional have the humility to know when they’re not getting the job done. Or, he considered, maybe they’re just washing their hands of any responsibility for me.

After three weeks, John decided that the changes in his foot were getting scary. He had been in an Engineering department and had managed projects. He knew how to make things happen when he felt it was important enough. Again, he generated the urgency to be seen right away.

The big-city foot specialist took x-rays and came back looking a little pale and sickly. He told John the problem was known as “Charcot foot.” Because of prolonged inflammation, the bones in his foot had gotten soft, like chalk, and had broken in at least 12 places and started to dislocate. He had his nurse immobilize the foot with a cast. John cheerfully opted for “My Little Kitty Pink.”

Again, John did his research. There was a strong probability that his diabetes had contributed to the process. But, it seemed to him, bone softening would be a natural body response to extended acute local inflammation. John was no longer confident that he was lucky or that he had been getting professional care. Through incompetence or indifference, John was getting screwed. And there was precious little that he could do about it.

It did not improve John’s attitude when he discovered that the new cast was rubbing his pinkie toe and had opened a new wound. John tried to return to the wound care clinic but found out that he needed a new referral for them to treat a new wound. He could not be silent about things that mattered. Problem-solving John persuaded his doctor, that same day, to provide the referral. Part of his cast was cut away and the new wound was treated. Getting justice should not be this hard.

Returning to his big-city foot specialist, the offending cast was removed entirely and replaced with a tall, rigid boot. John was also given a prescription for a wheel chair, which was special-ordered and dispensed about a month later. He began to wonder if this doctor simply looked pale and sickly all the time. Things had not been going well in this case for at least ten months now. John, reflecting on his doctors’ delays and false-starts, imagined visions of malpractice suits dancing in their heads. Would they be found liable for sincere ignorance or conscientious stupidity?

On a later visit, John was told that the bones in his foot, having collapsed, had now permanently fused into a new alignment. The foot would always be misshapen and require special caution and care.  Especially the bulge on the bottom would be prone to having the bones break through from the inside, causing a new ulceration. John considered the metaphor of not being to stand on his own two feet. He gave up most of his remaining hope for personal ambition, comfort and convenience, but determined to go on, as best he could, given these challenges.

Perhaps the doctor could go in, re-break bones and install pins. John didn’t think so. Not just now, thank you. Perhaps the doctor could go in and shave-off some bone. Of course, there could be complications and John would still have to always be careful with that foot. John was too poor to take such a high risk of throwing good money after bad. He resigned himself to living a less-active and more-limited life.

Now, in Room 4, John looked down at his shoes and came to a decision. He picked them up and removed the inserts, including the one that had been custom-made for his Charcot foot. (He had received a bill for over 300 dollars for that thing!) It had taken an additional five weeks to arrive while his foot went ahead and healed.

Save for the recent ladder accident, John had been taking care of his “bad foot” for years now. The insert was good to have, but John couldn’t see paying that much out-of-pocket. He was on a fixed income. He had other bills. He had moved to a much smaller and older house, canceled his cable TV and continued to pare down expenses in a host of ways. Still, his medical expenses continued to mount. Something had to change and it would have to come through continuous struggle. John had decided that he had to pull the plug. He had to draw the line somewhere and that time was now.
John handed his insoles back. “I can’t afford to pay for these.”

“But they are custom-made for your feet.”

“I’m sorry,” John said, “I thought they were covered by my Medicare.”

“No, Medicare doesn’t cover them.”

“Then why didn’t you tell me? Why did you lead me to think that they were covered? We could have saved all this time and effort.”

“You need them.”

“After the accident, I healed without them for six weeks before you first saw me. And then I healed without them for five more weeks while they were being made.”

The nurse interjected, “Look, you signed a ‘Responsible Party’ form, agreeing to pay for them if your insurance didn’t.”

“I did? Lord, every time you walk into a doctor’s office they shove “standard forms” at you and wait impatiently if you take the time to read them. You go into a hospital and they expect you to sign a form saying that they can do anything that they want to you and that anything might happen, including you might die. But, you can’t just not sign this stuff.”

The nurse repeated: “Like I said, you signed to be responsible for the cost.”

John paused to consider, then challenged the doctor, “Look, you told me last time that I could buy a second pair for half price. Who do I negotiate with? Can I buy these for half price?”

The doctor wasn’t in the mood for this discussion anymore. “Sir, you’ll have to discuss this with our billing department.”

John wasn’t done. “Actually, this foot has been nothing but trouble from the start. I’m ready to have it amputated. Would Medicare pay for that procedure?” The doctor and his nurse whispered to each other as John continued, his voice becoming shrill, “If I were missing a foot, would Medicare pay for an electric scooter and a lift-van to carry it around in?”

The doctor looked at John and said firmly, “We need to have the nurse get a wheelchair and take you to the surgery to check your long-term blood sugar levels.”

John was distracted. “I can tell you that my sugars have been running a bit above target. I was at my endocrinologist last week. He took my hemoglobin A1c and that result is on record. Besides, it’s a simple finger-stick test these days, why do I need to go to your surgery?”

“Don’t worry, we just need to access the sensor.”

Now, John was getting agitated, “What sensor is that? Did you implant something in my back last spring?” He reached for his shoes to walk out of this place. The Doctor grabbed him and they began to struggle. John woke up from his dream. His wife was shaking him. She asked, “Were you having a dream?”

“Did I ever have a dream! You would not believe the feelings of helplessness I felt — the loss of power and control. It was like there was a universal conspiracy against me. I was swimming against the current and drowning in a strong river. Life was simply not fair. I was being carried downstream and I didn’t have the strength to fight against it anymore.”

John’s wife understood his feelings immediately. They had lived through, and struggled with these hard times together. She comforted him, “Well, it could be worse. Think how much harder it would be if we were black.”

“He who passively accepts evil is as much involved in it as he who helps perpetrate it. He who accepts evil without protesting against it is really cooperating with it.”
~ Dr. Martin Luther King, Jr.

This very autobiographical story was not (entirely) intended as a grievance piece against allopathic medicine. It was conceived and crafted to support the ending twist. I wrote it on the eve of the 50th anniversary of the 1963 civil rights “March on Washington for Jobs and Freedom” and Dr. King’s “I Have a Dream” speech. On the likely chance that someone hasn’t noticed, John’s misadventures are a metaphor for the relationship between disenfranchised and privileged classes. Seriously.
By the way, I generally detest stories that end with “it was all a dream.” I totally understand if you do too. Please accept my apologies. My only defense is that I was thinking about Dr. King’s “I Have a Dream” when I decided to write it this way. The next story, “Moving Out,” is a companion piece. It also adopts a clumsy device to give an autobiographical exposition. At least it more-directly addresses civil rights. Please don’t miss it.