Thursday, September 03, 2009

Health Care, How Care: Part 2

shoulder x-rayAspects of our daily American lives call out for trust. We need to believe that our food is safe for one. Likewise, we long for the days when we just knew for sure that doctors could fix what ailed us.

With this nation now consumed with thoughts of health care, it is not always best to divorce the subject from the personal. This is the second of a multipart post relating my wee private experiences in the wonderful world of medicine, a field too often conflated with medical science. Part 1 on not having hip-replacement surgery is here. I’ll cross-post this at Harrumph!

Now, let’s consider my shoulder operation.

In my early 20s, I was used to full shoulder dislocations. While there is a cliché that swimming is an injury-free sport, ask a swimmer. I had been a breaststroker, which tends to bring with it damaged knees and shoulders, including dislocations. Both of us on the high school team ended up with full dislocations in which the shoulder would pop out of joint. Joel’s went up by his ear and mine down by my rib cage.

With the nerve, ligament, tendon and muscle damage, the pain of each dislocation is, how shall we put it, exquisite.

Moreover, I had very stupidly body surfed at the tail-end of a hurricane out in the Hamptons on Long Island. Catching a great wave, I jetted well over dry sand, only to find my fingers embedded like a spearhead while my body continued. That wrenched the shoulder into its components.

The catalyst for getting the dreadful modified Putti Platt procedure came less than two years later. I was helping a girlfriend move apartments. As it happened she was a Ph.D. in medicine and the woman with us was an M.D. They both saw me turn white from the pain as my shoulder popped down below the joint. I was wearing a tee shirt and they being medical sorts knew exactly what was up (or down).

The pain was blindingly intense. All I could think of was lessening the tearing of the body parts by getting the ball back in the socket. I grabbed my misplaced right upper arm with my left hand and pushed it away from my ribs. Sure enough, this caused the ball to be sucked back into the socket or rather yielded to the straining muscles to relocate it. In that moment, I went from agony to bearable severe pain.

Time for the big fix

My companion said it was time, past time, to stop avoiding the surgery just because I had never had any operations. Moreover, she did her research at NYU Medical and knew the best orthopedic people or professors who knew them. I had an inside track to the best evaluation and cutting.

She wangled an appointment with a famous joint surgeon for the evaluation. He literally wrote the books.

That didn’t start well. The man was a serious artiste. He heard my tale and quickly and very firmly informed me that I was totally wrong, that I could never have relocated the shoulder solo. In fact, he pulled out a text on orthopedics what proved that in writing. I would have had to have gone to a hospital, had weights applied to the limb and let the doctors guide the joint into alignment.

I looked at the front of the book to discover that he was the author, the expert. Yes, indeed, his circular citation was to convince me that my experience had no validity. My laughing surprised him but did nothing to change his mind. However, when he learned that the two witnesses had an M.D. and Ph.D. in medicine between them, he allowed as how this might be the first such case he had ever heard of for self-relocation.

Regardless, he did agree that the big cut and shortening of muscles and tendons was the only way to go. However, he limited his surgeries to wrists and hands, so he wasn’t the guy.

My girlfriend though personally knew the head of ortho at NYU Medical. He agreed to supervise the operation, unofficially doing it though the residents nominally performed these.

I was resigned, sort of. I was quite the drama queen about this, even having to travel to St. Vincent’s emergency room nearly my West Village apartment with the shakes a couple of nights before entering the hospital. Another girlfriend was there and went with me, only to hear that it was sheer nerves.

There was the tableau like a Viking funeral in the small hospital ward. I thought little of it because I was being so self-centered, but in retrospect it was absurd and theatrical for a small parade of current and former girlfriends visiting before the surgery to wish me well and bring me treats. Several of the men in the other beds later commented on how nobody was visiting them and I had enough attention for everyone.

The night before the operation, a nurse shaved my chest and arm. Then in the morning, they painted me with iodine solution and drugged me (demerol maybe?). The drug was powerful and I recall being paralyzed as they wheeled me to the operating room. The ceiling needed scraping and painting all the way down the long corridors.

Then in my diminished capacity I had the realization that my surgeon, the head of the department, should have been in scrubs, but I saw him walking toward me in street clothes. Wearing his wonderful, full smile too, he slapped me on my good shoulder before talking. He said they had discovered an infection two beds down and could not risk opening up my pecs and shoulder. He was sending me home.

My medical girlfriend was at her apartment a few blocks south. When I could dress and walk, I went to tell her. It was a tiny Rashomon moment. I ranted at high volume and speed, displaying my anger at being finally emotionally and intellectually ready for the scalpel, only to be cast out. She recalls as clearly that because of my heavy sedative and painkiller, I spoke and moved in extreme slow motion. It was all she could do to keep from laughing at me.

One would suppose given the seriousness and randomness of the dislocations, I would head in as soon as I could. However, a wreck intervened. While visiting a high-school chum in New Jersey, I was a passenger in his car when a drunk hit us as we parked. My friend got a broken hip but I just had another dislocation.

Another high-school acquaintance was a lawyer who advised us, telling me to get my shoulder looked at. I didn’t think that was necessary, but he convinced me. He sent me to an unusual orthopedic surgeon, one who specialized in children and one who didn’t like to cut unless necessary.

Until those visits, I had heard only the three different operations to prevent recurrent shoulder dislocations. The wrinkles were things like whether they also put in effect a hook and eye in the ball and socket to keep them mechanically fixed. No doctor had said there was any non-surgical alternative.

The cheap solution

This doctor, however, fixed me with a $25 chest expander — four large springs on two handle grips — like they advertised in the the back of comic books. Using it for long periods daily in effect did what Putti Platt’s operation went for. Tightening the pecs and tendons made it much, much less likely that the ball would disengage from the socket. I also learned to ease off if anything felt loose, as in opening my arms to spread a bedsheet or doing some acrobatic moves under those sheets. Stay still, tighten up and keep bones where they belong.

So, I have friends, mostly swimmers and including teammate Joel, who have had one or two of those operations. A lot of pain, permanently limited lateral motion and a long recovery (and some ugly scars) are included. The chest expander and hundreds of hours, maybe thousands of them, of exercise were a better deal.

So in this time of passionate concern of health care, are there any lessons from such anecdotes? I would think they might include:

  • It can be well worth standing up for yourself with any arrogant doctors, as the surgeon who evaluated me. He could well have badgered me into stifling my certainty and not getting apt treatment.
  • Pressing for viable alternatives may be as important as the proverbial second opinion. Everyone involved just knew that drastic reconstructive surgery was the only solution. Yet that turned out to be very wrong in this case.

There was a time when I trusted doctors implicitly. Of course that was the same period when I truly bought into the magic of transubstantiation. I was a kid.

As an adult moving to different cities and seeking physicians for preventative and curative reasons, I learned differently. I have also learned a hard lesson for a fairly introverted person. It’s tough, but you have to be your own advocate if you expect reasonable medical care.

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