All In Jest
Gerrit van der Hoef’s grandfather had worked in the Westminister County boat yards making tug boats. Gerrit’s father had worked in the boat yards on sailing ketches, and now Gerrit worked there on navy contract boats–mostly variations of PT boats. He had worked there for 17 years, and as near as he could recall, he had hated every second of every day that he had worked in the ship yard. The work was monotonous and back breaking. He had to bend to rivet and glue, sometimes twisting and stretching to reach a corner or up inside a built-in boat locker. He had lost his first wife because of the boat yard; the place made him so jumpy and angry all the time that she had finally left him, ran away with a shoe salesman. He did not blame her or the shoe man, just the boat yard.
His back hurt all of the time, had for years. He could not remember for sure when he had not had back pain. Although he did not like the pain anymore than any other sane man would, he had reached a sort of steady state with his discomfort. It was always there like an old scold of a wife who never shut up. He could put up with it most times, but he did not have to like it. The worst thing about it was that he still had to work.
Gerrit had seen the company doctors a dozen times or more for his back pain. Most of the time they told him to ‘suck it up’ or to ‘get more exercise’, some of the time they put him to bed rest for two days, never more than that, or a couple of weeks of physical therapy that got him off work for a couple of hours three times a week for those two weeks if the doctor was young or new on the job.
They all gave him the same answer to the same question that he asked each of them every time he saw them in clinic, “No, you are not eligible for permanent medical disability for this little back pain.”
He saw an orthopedic surgeon once who agreed with the company doctor’s advice and suggested further, that if he wanted to get off work permanently, he had to stick a pin in his eye, or accidentally on purpose, cut off a thumb. That choice seemed a little worse–not much–than having to work in such awful pain; so, he always went back, grousing and ill-willed.
Then his symptoms changed rather markedly. One day on the job–the injuries that took him to the doctors always happened on the job–he lifted a box of rivets and twisted to set the box inside the hull of the punt he was building. The box was not even heavy. He developed a sharp increase in his background back pain. That did not trouble him overmuch, it happened frequently. This time, however, he also developed pain that started in his right buttocks and radiated all the way down his leg to the toes, and it was far worse than his back pain had ever been.
Evangelina Santa Maria Juarez was a tired woman. She was tired of working all the time as a motel maid for a tyrannical Korean boss and a shiftless husband who drank up all of Evangelina’s overtime. She was tired of dragging her two sons away from the Diablos, young Pachucos, who thought they were the Messiahs for the downtrodden Hispano-Americans eking out meager livings in the barrios of the Southwestern United States. The Diablos were nothing but gang punks with no future, and Evangelina hoped for better for her boys. More than anything, she was tired of keeping no more than a step or two in head of the feared immigrations. Evangelina was a seventh generation illegal immigrant in the United States, living part of every year in Mexico when she was apprehended, despite all her efforts, and deported, only to return through the revolving door that served America as a border. None of her family, and no one of her immediate acquaintance, had ever become a citizen or even an authentic green card holder.
After a particularly grueling day at the motel, Evangelina sat on the Metro-Line bench with two other women waiting for the bus. A black boy, no more than twelve, walked in front of the three homeward bound domestics on the bench and began to make obscene pelvic gyrations at the work-and-life-weary women. They steadfastly refused to pay the boy any attention. He acted as if he were going to unzip his pants and expose himself. The three women turned aside their heads. He laughed hysterically and cursed them. He walked up to Evangelina and blew a piercing shrill athletic whistle in her face causing her to jump backwards involuntarily. Then he suddenly snatched the poor woman’s purse and sped away with the speed and agility of a startled rabbit. Reflexively, Evangelina leaped up and tried to run after the nimble child. Her blood pressure shot up to 210/110, her heart rate skyrocketed, her breath came in gasps as she raced to the end of the block after the audacious little thief. She collapsed fifty yards from the bus stop.
The bus driver called 911, and an EMT crew on a city fire department ambulance rushed Mrs. Juarez to the JNMH emergency room. On examination, Evangelina was found to be awake, but unable to respond to anything but painful stimuli. The emergency room physician found her to be unable to move her right side, and to have lost all speech. He checked the roster of neurology services physicians on call, found Dr. Norcroft’s name beside the day’s date, and called her answering service.
“What do you have, Jerry?” asked Sybil Norcroft.
She was trying to keep the exasperation out of her voice. It was her fourteenth call of the evening, the eighth to the emergency room.
“Stroke. Aphasic and right hemiplegic.”
“She’s alert, but otherwise unresponsive to verbal stimuli. The EMTs at the scene reported that her level of consciousness was such that she was completely out and had a super high BP. She came around in the ambulance on the way in.”
“Do you have a CT or an MRI?”
“No insurance. We presume she’s an illegal.”
“We still have to take care of her. Go ahead and get a CT with and without contrast. I’ll come in and see her. Why don’t you alert radiology that we might have to do a head and neck angio as an emergency?”
“I was just waiting for you to take the responsibility. The hospital will take more chunks out of my already scarred up little patootie if I order any big studies on a no-pay. They won’t even grumble when you do it.”
“Gimme a break, Jerry. I’m a neurosurgeon. Everybody feels free to take open season pot shots at me. Comes with the territory.”
“And makes you tough. I’m just a poor sensitive hospital employee. I can’t take all this confrontation.”
“What a BSer you are, Jerry. You’ll have me weeping. See you in forty-five minutes.”
“Good-bye, Sybil. Drive in safely.”
The CT scan was normal. Sybil evaluated Evangelina. By the time of Sybil’s examination, the Mexican-American woman was able to say a few words.
“Hello, Doctor.” “Yes.”, “No.”, and “Me duele la Cabeza!”
Sybil thought she heard a high pitched bruit over the carotid artery on the left side.
“Jerry, I think she has a high grade stenosis in the left internal carotid. She’s got a bruit. Listen.”
She handed Jerry her stethoscope, and he thought he could hear the rasping sound of blood pushing through a narrowed arterial lumen also. He nodded.
“We’ll have to get an arteriogram,” she said.
“Mrs. Juarez, can you hear me?”
She had regained pretty decent speech over the past hour.
We have to do a test to look at your arteries. Maybe you will need to have an operation. You have had a small stroke. We need to find out it we can prevent you from having another one. Okay?”
“What do you need to do?”
Mrs. Juarez’s speech was thick and slurred but understandable and had more content now.
Sybil explained the procedure of the angiogram including its hazards.
“Do you understand all that, Mrs. Juarez?”
“I think so” Evangelina said haltingly.
The ER attendants shaved Evangelina’s right groin. Sybil accompanied her to the radiology procedures suite. Local anesthetic was instilled in the shaved and sterilized groin, the skin was nicked, and a large bore needle was passed into the underlying femoral artery. The angiographic catheter was carefully inserted through the needle and threaded up the artery into the arch of the aorta and into the carotid arteries. Iodine contrast material was instilled, and a series of x-rays recorded the passage of the x-ray dye along the course of the vessels. The study was normal, both in the extracranial vasculature and in the vessels of the brain. Mrs. Juarez was wheeled back to the ER and then to a hospital room.
Evangelina’s husband, Jorge, was constantly at her side, fretting. He called the nurses every time Evangelina coughed, winced from the tender area in her groin, or had trouble speaking. Evangelina steadily improved until she was able to begin moving her right extremities on the second hospital day and to speak in multi-word English sentences to the nurses and in volumes to her husband.
At quarter to midnight on the third day of her hospitalization, Evangelina suddenly stopped being able to talk or to move her right arm and leg. Sybil rushed to her bed side and found the woman to be very frightened. She seemed to understand what Sybil was saying. Jorge was hysterically excited and had to be ejected from the room.
He shouted at Sybil.
“Look big doctor lady, you aren’t dealin’ with no trash. I’m a person too. What you people done to my Evangelina, eh?”
“I’ll see you in a few minutes, Mr. Juarez. Take it easy. You are not helping matters.”
“You just kicking me out so you can ‘speriment with my Evangelina. I’m gonna sue. My Evangelina don’t get better, I’m gonna sue!”
Sybil examined Evangelina. When she pinched the Mexican-American’s arm, Evangelina withdrew it promptly with what appeared to be very nearly normal movements.
Sybil stepped out of Evangelina’s earshot and asked the nurse, “Bring me two ccs of distilled water in a large syringe with an eighteen gauge needle, please.”
The nurse turned her head away from Evangelina and smiled broadly and knowingly.
The foreman took Gerrit van der Hoef off shift and demanded that he go to see the company clinic doctors. His back was rigid with pain, and the right leg hurt like the worst toothache in his life. The doctor raised his right leg straight off the examination gurney. Pain and tingling rushed down his leg, and he cried out.
“Positive Lasegue’s,” the doctor said. “Let’s see how you do with some bed rest. If the leg pain keeps up, we might have to send you to a specialist. I’ll get Kim to give you a shot. You get yourself flat in bed for two days and call me then.”
The pain got worse, not better. Every time van der Hoef had one of his cigarette coughs or strained to have a bowel movement or made the least twisting motion, he developed radiating pain down his leg. The pain seemed to grow worse by the hour and was progressively more easily elicited. On the third day at bed rest, Gerrit could not stand it any longer. He called the company physician.
“I can’t stand it, Doc. You gotta do somethin’. I’m dyin’. I gotta have surgery, or somebody’s gotta shoot me. Somethin’. I’m never gonna be able to work again. What am I gonna do?”
“Come back into the clinic. We’ll give you another shot of Demerol and get you started on PT,” the doctor told him.
Gerrit dragged himself to the clinic with the help of his harried wife—his third–who was late for her work at the cafe as a result. The four kids had to fend for themselves that morning. Kim, the overworked clinic nurse, gave him the narcotic injection as soon as Gerrit limped in the door. In half an hour he was feeling mellow. The pain had diminished fifty percent.
“Feeling better, Mr. van der Hoef?” The doctor asked solicitously.
“I guess so. But I’m tellin’ you, Doc. That was the most terrible thing I ever felt. I gotta have a CT or some sorta test. I can’t go through that again.”
“The company can’t cover a CT or an MRI this early, Mr. van der Hoef. I’m sorry. We have to have the mandatory three months course of conservative therapy before we can get the big expensive tests. We’ll start you on PT and see if you get better.”
“And what if I don’t, Doc? This pain was terrible. I gotta have relief.”
“Well, Mr. van der Hoef. None of us has the authority to violate the company’s health care guidelines. We’ll just have to see how you do.”
“Meantime I suffer,” van der Hoef said sulkily.
“I’m hoping not,” said the doctor. “We have to give it a try, don’t we? We wouldn’t want to rush into an operation we didn’t need, would we?”
Gerrit wondered which ‘we’ the doc was talking about. Gerrit van der Hoef was the only guy in the room who seemed like he might need an operation.
“What if I wanna see a specialist? You know, get a second opinion, like that? No offense meant, Doc.”
“The company will still make you wait, Mr. van der Hoef. They’ve been at this a long time with a lot of different guys from the plant. They know best. Let’s give it a try, what do you say?”
“What choice do I have?” The question was muttered sotto voce. “How long’re you gonna give me off work?” he asked, now looking earnestly into the doctor’s face.
“Probably three weeks, maybe a month.”
“A month!? I don’t think I’ll ever be able to go back to that kind of work or any heavy work. Why don’t you just give me a medical retirement? I deserve it?”
“A bit premature, don’t you think? We haven’t even tried conservative therapy yet. The company will not even think about you getting medical retirement until you have gone through everything they require for the treatment of bad backs.”
“But what if you say, Doc? I mean, if you tell them I can’t work anymore, what’re they gonna be able to say? You’re the doctor, right?”
“I work for the company, plain and simple, Mr. van der Hoef, same as you. The old days when the doctor made that kind of decision are gone forever. That is a company decision. I’m sure you know that.”
“Yeah, I guess so.”
Gerrit van der Hoef was miserable every minute of the three months on PT. The hot tubs and massages felt good for a few minutes, the pain killers cut the worst of the discomfort for a while but left him with a fuzzy head and constipation. None of the treatments gave any lasting relief. The last two weeks, Gerrit was placed on the company’s mandatory work hardening program–lifting boxes, pushing trolleys, pulling on graded latex bands. He collapsed to the floor and refused to do another exercise on the twelfth day.
The physical therapist recorded in his notes, “Patient unwilling to cooperate, seems more interested in getting medical retirement benefits than in getting better. Seems to have some real pain, but hard to tell. Has a lot of overlay. Will refer back to clinic doctor for disposition.”
Gerrit’s wife wheeled him back into the doctor’s office in a wheelchair for his appointment. The doctor thought that was overtly theatrical and made a note to that effect on his progress sheet. The man’s face looked pale and drawn, the result of stress, apparently. The company was downsizing, and the doctor presumed that van der Hoef was afraid of losing his job. He could not be fired while still on the official sick list. The doctor saw cases like this all of the time.
“Well, Mr. van der Hoef. I see we’re done with the PT. Ready to go back to work, are we?”
“Whadda you think?”
The patient’s face was morose and angry, his voice truculent.
“We’ve been through the mandatory conservative treatment program, how’d we do?”
“I did lousy. You don’t look too bad,” complained Gerrit.
“Ha ha,” the doctor laughed heartily.
Gerrit did not join in.
“Look, Doc. I don’t know whether you know it or not, but I’m in a world of hurt. The only thing I got out of that treatment is that now I’m a junkie. I got more pills than Carter. I gotta have something done. Gimme a break.”
“We can try and get some x-rays.”
The doctor was looking more sympathetic now. He sneaked a quick glance at his watch. His next patient was waiting. He had to keep up the flow. The efficiency team monitored his patient numbers and the length of time per patient on a daily basis. He could not afford to get behind.
“Here’s a request form for a set of lumbars. The administrative assistant will set up the tests for you. I’ll review the films and see you in a couple of weeks.”
“Can’t you hurry it up some, Doc? I am in misery. I swear.”
“There are others waiting for their tests. The company has a strict policy about fairness. I’m sure you’ll live another two weeks, Mr. van der Hoef.” He smiled broadly in an affable grin. He glanced down at his watch again.
The plain x-rays of Gerrit van der Hoef’s lumbar spine were perfectly normal. When the doctor told him that, Gerrit’s face fell.
“It can’t be. I got so much pain in my leg I can’t stand it. There’s gotta be something!”
The man was clearly distraught.
The doctor did the straight leg raising test again. The shriek of agony the test elicited was convincing. There was indeed something wrong.
“Let’s see you walk on your heels, Mr. van der Hoef.”
The white-faced patient struggled to his feet and did as he was bidden. The right foot raised off the floor only half the distance achieved by the left. The doctor made a quick perusal of the company’s guidelines for CTs and MRIs. Partial foot drop qualified.
“We’ll get a CT, Mr. van der Hoef.”
It was the cheaper of the two tests.
“That should help us get to the bottom of this.”
“I heard the MRIs are better. The foreman told me I ought to have an MRI.”
“CT is less expensive, Mr. van der Hoef. The company prefers CTs.”
van der Hoef lost his temper.
“How come they have doctors at all. They could just use a computer or a robot. Maybe just an accountant. That’s all that seems to matter nowadays, money.”
“Now, Mr. van der Hoef. Try not to be like that. After all, your medical care is free on your work comp claim.”
“I’m bein’ overcharged at that. I’m gonna get my lawyer to get me an MRI and a specialist. The foreman said I should oughta see that Dr. Norcroft. She’s the best. This has gone on long enough now!”
He had developed a significant head of steam.
“All right, all right. Don’t get upset, Mr. van der Hoef, I think I can swing getting you an MRI. The foot drop fits the profile. I think they might go for it.”
The doctor backpedaled rapidly.
The company did not look with favor on doctors who got complaints from patients or their families, and the executives of the company made a doctor who got an attorney involved in a problem pay, with his job usually. There were plenty of doctors out of work. The company doctor did not want to swell the ranks. He was caught between a rock and a hard place. Ordering the MRI was only the lesser of evil for the doctor.
“‘Bout time. And it’s ‘bout time you gave some thought about me getting a medical retirement.”
“I’ll do that, Mr. van der Hoef. I’ll surely do that,” said the Dr. earnestly and sincerely.
He had no intention of doing any such thing. There were three review boards above him who could deal with that nightmare when the time came. He would stall as long as he could, but there was no use antagonizing the patient who was already being unreasonable.
The MRI was done a month later. Gerrit stayed in bed the whole month’s time except to get up to the bathroom. Even going to the bathroom was a dreaded experience. He shuffled along and dragged his right leg. He could no longer bear standing long enough to urinate; so, now he sat on the toilet like a woman. Even that made his back and leg ache enough to require a pill. He was in so much pain when he had an MRI that he could not lie flat on his back nor hold still long enough to get decent images.
The company physician received a terse report from the spine radiologist, “Magnetic Resonance Images unsatisfactory owing to poor patient cooperation.”
“I’m sorry, Mr. van der Hoef. You did not do what the radiology techs asked, now did you? You had to hold still to get the pictures they needed, and you did not do that,” the doctor said in his own defense after Gerrit exploded when he was told of the lack of results of the test.
It had been three weeks since his ordeal in the MRI chamber. He had not yet forgotten it.
“Do you think you can hold still for another test, Sir? I mean, between the two of us, is this a problem of claustrophobia?”
“No, Doctor. It hurts me to lay down. It hurts more every day. Please. Doesn’t the Hypocritic Oath or whatever you call it, have something about taking pity on the patient? I’m begging you.”
The man’s vulpine face was knotted in pain and humiliation. He was starting to cry.
“No need for that, Mr. van der Hoef. I’ll see to it that you get a shot of Demerol and Phenergan and a couple of Valium pills before you have the next MRI.”
“Thanks, Doc. I really appreciate that.”
He was back in control.
“Can you sign for me to be off work until after the test?”
He checked off the boxes on the company’s printed off duty form and signed it.
“When can we get it done?”
“I’ll have Kim check.”
It was four and a half weeks. Gerrit had to crawl to the bathroom by the time the MRI was done. His brother and a neighbor had to carry him into the imaging center on a makeshift stretcher. He was writhing in pain. The center nurse administered the medications. When Gerrit was wheeled into the MRI scanning room an hour later, he did not care.
Two weeks later, Gerrit called the company doctor and explained that he would not be in for his appointment. His right foot did not work, and he developed too much pain to walk. The physician was sorry that the insurance did not provide for an ambulance.
“What did you see on the test, Doc?” Gerrit’s voice was tired and dull.
He had taken a Percodan an hour before, and it was difficult to keep his thoughts focused.
“Oh, didn’t you get the message from the clinic administrative desk?”
“Oh, too bad.”
The doctor silently cursed the inefficiency of the system. The message girls were high school dropouts who were paid minimum wage, and the company was reimbursed 50 percent of that by the federal government because the workers would have to be let off welfare without a safety net otherwise. He groused that it was just a ruse by the socialist liberals to circumvent the welfare law passed clear back when Bill Clinton was president. But it was not his responsibility. When he went home at night, he did not have to think about it. He looked at his watch. Two more hours.
“So what’d it show, Doc?”
“Uh, yes, the MRI.”
He riffled through the mounting pile of papers in van der Hoef’s chart.
“Radiologist says you’ve got a great big herniated nucleus pulposis. Loose fragment. At L4-5.”
He paused to let the patient absorb the news.
“What does that mean…in English?”
“Ruptured disk. You have to have an operation.”
Gerrit moaned. He was quiet for a moment.
“Let’s get it over with. I’m ready to commit suicide. Do you do the operation?”
“Oh, no. You need to go to a specialist.”
“Like who and when?”
“I’ll have to get the people at the administration desk to check and see who’s on the panel of surgeons. It’ll take a few days.”
“More time? This is crazy! My foot’s paralyzed already. I’m a doper, and I can’t get out of bed for the pain.”
“Foot’s paralyzed, you say? I’ll check that.”
Gerrit waited on the line while the physician checked the diagnosis and symptoms list.
“Good news. We don’t have to wait. I can run your case before the committee on Thursday. If they approve, you can see the surgeon as soon as he or she can fit you in.”
“Okay, Doc. Oh, and Doc, please call me yourself. Maybe the ones at the administration desk don’t care all that much.”
“I’ll surely try, Mr. van der Hoef. We’re pretty busy around here, but I will write myself a note.”
The committee vote was a narrow one. The nurses, doctors, and therapists on the panel all voted for the surgery. The administrative staff all voted against the surgery. The vote went along party lines as was predictable. The swing vote in favor of surgery was cast by the lone chiropractor on the committee. It was her first time to vote in favor of an operation. The committee was justifiably proud of their record of saving the system’s patients from the expensive hands of the surgeons. After the meeting, the chairman asked to see the chiropractor in his office.
At his request, and because she was on the approved panel, Gerrit van der Hoef was brought to Sybil Norcroft’s office a week later. She was booked up for six weeks ordinarily, but the foreman from the plant called her and explained the plight of Mr. van der Hoef. She made room.
The interview, examination, and evaluation of the x-rays and MRI images took a little more than five minutes.
“You have a ruptured disk that has produced complete paralysis of your right foot, what we call a foot drop. Your only hope is to have an operation. You won’t die if you don’t, but you will likely have pain like this for the rest of your life if you don’t have the operation. I can’t promise that your foot will get better, but surgery is the only way it can. Where have you been all these months?”
Gerrit explained his struggles, his attempts to get medical retirement, to get care. Sybil went through the thorough informed consent discussion and had Gerrit watch the film on low back surgery prepared by the American Association of Neurological Surgeons. He signed the consent form for the operation with alacrity and enthusiasm. Because the schedule was so full, Sybil applied to the insurance company for permission to do the operation that evening. There was a two hour delay while the administration desk at the company fretted over the bad precedent to be set if quick assent was given, but finally, they gave in. They had too many other matters to deal with when the end result had already been okayed by the operative permission committee.
The operation took thirty-one minutes, the half hour between nine and nine thirty that night. Gerrit woke up in the recovery room pain free but still with a partially weak foot. However, he had definite movement in his foot that had not been present before the surgery. He could raise his toes two inches. He was discharged the following morning in good condition.
Mrs. Juarez cringed when she saw the impressive syringe and the huge needle in Dr. Sybil Norcroft’s hand. Her eyes bulged in fear.
“This is going to hurt some, Mrs. Juarez. I am going to give you this anti-stroke shot. You should be much better in two hours. Nurse, will you start the timer?”
The nurse made an elaborate display of setting a medication timer for two hours hence. Sybil cleansed a large area of Evangelina’s anterior right thigh and slowly inserted the large needle and then slowly instilled the placebo, distilled water. That innocuous solution was remarkably painful and was as convincing a medication as any hysteric ever received.
When the dinger on the medication timer went off two hours later, Evangelina broke into a broad happy grin, moved her right arm and leg, and said, “Oh, thank you, doctora, I am so much better.”
Tears glistened in her eyes. Jorge Juarez let down his glowering defenses and grudgingly thanked Dr. Norcroft.
Evangelina spent the next two weeks in the stroke rehabilitation center and was discharged with a cane to receive her future treatment on an outpatient basis.
Sybil saw Gerrit in her office one month later and again two months after the operation. Gerrit expressed joy at the relief of his misery and his newly regained ability to walk without clenching his hand around a bed post and gnashing his teeth to withstand the pain. The foot drop improved to 50 percent of normal but did not progress beyond that point. On each visit, Gerrit implored Sybil to grant him full and permanent medical retirement. She refused saying that he should be fine and able to return to work without limitations in six months which was three more months than what she thought it would really take. Gerrit was angry but resigned himself to his fate and returned to work with a foot brace in place.
Gerrit called Sybil two months later.
“Dr. Norcroft, I have some more back pain. Can I get off work?”
“Does it go down your leg?”
“Is it bad?”
“Does it hurt all of the time?”
“Only when I work. That’s why I think I should be off work. I think I should be medically retired, if you want to know the truth.”
“Let’s give a try at light duty for a while first. I’ll sent a note to your foreman. Call me if things get worse.”
He called a week later.
“The company doc put me off work. It hurts more.”
“I’ll get my secretary to arrange an appointment to see you as soon as I can.”
“Thanks. You’ll need to sign my off-work slip. It’s up in three days.”
Sybil gave a little sigh.
Gerrit was in her office the third day. He seemed to be in real but not severe pain. Sybil started a conservative regime and signed his off work slip.
He called back in thirteen days.
“I got leg pain, Doc. It’s getting pretty bad.”
Sybil groaned inwardly. Had she missed a piece of disc?
“We’ll make an appointment ASAP. I think I can see you tomorrow.”
The following day, Gerrit limped into Sybil’s office, pain lines showing all over his taut face.
“Tell me about your pain, Mr. van der Hoef,” Dr. Norcroft asked.
“Started about two weeks after I went back to work. I had to lift heavy stuff all of the time, and the foreman wouldn’t let me have any time off or light duty. I think he’s got it in for me because I was gone so much from before, when I had the ruptured disk.”
“Where is the pain now, Mr. van der Hoef?”
“Was in my back mostly, but now that’s getting some better, and it’s into my left leg big time. It is miserable.”
“Left leg?” Sybil queried.
“Yeah, same as before,” Gerrit answered.
That rang a false note to Sybil. She consulted her notes.
“Uh, uh,” she said. “Your other disk was on the right. You had right leg pain. How’s the right leg?”
“Still part paralyzed.”
“I mean, how about the pain?”
“None. I told you, the pain’s on the left.”
“You certainly did,” she said.
She was relieved to hear that she was dealing with the opposite leg from before. This was probably a new ruptured disk. She hoped it was not at the same level. She checked his chart: L4-5 on the right.
“If you think this pain is like your other time–as severe and the same kind–we had better get an MRI done. I would say we ought to do it this week.”
“I’m with you Dr. Norcroft. The sooner the better.”
It was the usual struggle with the company’s insurance company. There were legions of telephone calls, e-mails, and letters over a month’s period before permission was finally granted to do the MRI. The patient was ragged with pain by then. Sybil was frustrated and regarded every administrator and secretary at the insurance company with a personal animus. The millstone-like wheels of the company’s administrative process finally ground to a halt, and the MRI was accomplished, again with the patient reduced to the level of a whining animal requiring heavy sedation. He had a herniated disk on the left at L5-S1, a new level and new side. It was a month before the operation was approved, and by then, Gerrit van der Hoef was bed ridden. This time he did not have any paralysis.
The operation proved to be somewhat more difficult this time. The space at that level was narrower, and it was harder to reach the smaller herniated disk and to clean out the narrowed bony canal surrounding the nerve root. Sybil finally had to take off more bone to achieve a satisfactory decompression. She did an L5 hemilaminectomy, taking off all the roofing bone over the spinal canal on that side and at that level. The joints were left intact to insure stability.
Recovery was somewhat slower. van der Hoef was more tired and had some more achy back pain when he returned for his one month check-up. Sybil checked his wound and it was fine She repeated a quick neurological examination and found that he was as he had gone into the operation–neurologically intact except for a partial right foot drop.
They had their usual discussion about van der Hoef being placed on permanent medical retirement with the same response from Sybil, “Wait at least one more month.”
He was better at the next month’s examination. She still told him to wait a month before a final determination was made for retirement. The next month came. van der Hoef was feeling fine.
“I want to have a medical retirement, Doctor. This is the month you promised to do it.”
“Mr. van der Hoef, I think I phrased that a little differently. I said this was the month to make the decision.”
“Yeah. And the decision had better be for a medical retirement. I gotta bad back. No way can I go back and do that kinda work. You gotta sign the papers, lady.”
His tone was pushy, bordering on belligerent. Sybil Norcroft had never responded well to ultimatums or to men bearing down on her, particularly to do something she did not want to do.
She paused long enough for it to sink in and for the ‘no’ to be a simple square word, unembroidered with adjective clauses or softeners.
His face colored.
“You are doing fine,” she told him. “I expect you to be perfectly well. You have had a ruptured disk, and now it’s gone. I don’t need to see you again unless you have more trouble. I am going to write to the company and let them know that you can come back to light duty in three more months and to full work without restrictions in six.”
“I’m disabled,” he said flatly, defiantly, daring her to contradict him.
“Minimally and temporarily,” she replied calmly.
He looked at her as if she should be wearing a size 6 hat.
“You stupid, lady,” he blustered. “Anybody with half a brain can see that I can’t do that kinda work. Never no more!”
He had raised his voice a couple of decibels, and his face was beet red. It was evident that the doctor’s unresponsiveness to his demands ran fully counter to his experience with the women of his social circle, and he did not care for it at all.
Sybil tried to think of something to say to defuse his anger, to get him to leave, and to avoid telling him what she thought of his basic work ethic. He obviated that impulse of hers by turning around and stomping out of the examination room and down the hall towards the reception area and exit. Sybil followed him at a twenty yard distance. He stopped at the reception desk and roundly cursed the poor receptionist, a new hiree, eighteen years old. Sybil hurried to where he was berating the girl.
“Mr. van der Hoef!” she shouted to get over his own loud bellowings. “You have no call to treat this young woman like that. If you have something to say, say it to me. There is no need to use that kind of language. We can all behave like ladies and gentlemen!”
He was snarling, his eyes snapping azure fire.
“Lot you’d know about bein’ a lady, you bull dyke! You got no business doin’ a man’s work anyhow. I shoulda gone to a man surgeon inna first place. You can’t see what’s plain as the nose on your face. I gotta have disability. Your gonna hear more about this. You’re just the yes-man for the company just like the rest of the docs…against the workin’ man. You’re gonna hear more about this!”
He stormed out the door knocking incoming patients aside with calculated rudeness. Sybil shook her head, soothed the distraught receptionist, and headed back to the examination rooms to see her next patient.
Gerrit van der Hoef missed his next appointment, one set up for him by his company. When Sybil’s office people wrote a reminder letter to him, he returned it with a terse note written on the same piece of paper, “Found a new doctor.” Sybil wrote him off as an unsuccessful success.
It was two months before Sybil saw Evangelina Juarez in her office in follow-up. From her office window, Sybil watched Evangelina and Jorge walk briskly into the office waiting room and take their places. When the receptionist called Mrs. Juarez’s name, her husband helped her to her feet and held the feeble woman up as she hobbled miserably up to the desk to sign in. It was all the small man could do to prop his wife up. Her right side did not seem to give her any useful support.
Sybil’s exam was unremarkable. Evangelina’s reflexes were normal. There were no signs of motor damage, so-called ‘upper motor neuron signs’ suggestive of stroke damage. With noxious stimuli–a quick pinch–Evangelina was able to move her limbs briskly. She did much less well voluntarily. One oddity about the examination was that Evangelina responded only in Spanish and appeared able only to understand her native language and not a word of English. Sybil reluctantly had to resort to using one of the office girls, who was from Central America, as an interpreter.
A full year passed without Sybil or her office hearing from or about van der Hoef. The insurance paid off the bill in full and without demurrer. It was a modest one in comparison to most of those the company received from orthopedic spine surgeons with their ingrained penchants to instill costly hardware. Sybil refused to do fusions on the second operation as was the expensive routine for most of her colleagues. van der Hoef did not respond to any of the standard follow-up letters or calls sent out at six months and a year post operatively.
van der Hoef’s name came up unexpectedly in Sybil’s routine in-basket having sat there over a long holiday weekend. She paid no attention to the envelope until after she had read and reread the letter.
Dear Dr. Norcroft:
This letter will serve to inform you that you will be sued in ninety (90) days from the above date by Gerrit Evan van der Hoef for medical malpractice. The responsibility to inform your insurance company or the attorney of your choice rests solely with you. We will be in touch.
We find that our unfortunate client was obligated to sign a contract to try any disputes in a binding arbitration hearing. We hold that our client was uninformed as to his rights and about what the arbitration process versus the jury trial entailed. Therefore, we will seek to have the action transferred to the proper venue forthwith.
Paul Bel Geddes, Esq., Attorney at Law.
Sybil then looked at the envelope. The all too familiar return address for Stewart, Bel Geddes, and Loughlin leaped out at her. She let go a guttural animal growl and crumpled the envelope into a golf ball sized sphere and hurled it across the room.
Sybil received a second friendly note from Paul Bel Geddes a little over a month later. This one informed her that she was to be sued by one Evangelina Juarez. Apparently, malpractice on Sybil’s part had resulted in Evangelina’s having developed permanent weakness, loss of her ability to speak English, and, as an added note of complaint from her husband, Jorge, he had suffered loss of consortium with his wife. She had become completely unable to engage in sexual relations from the time she underwent the placement of “toxic chemicals” into her arteries. When Sybil had read the letter in its entirety, she showed it to her office manager with a theatrical mock placement of her finger down her throat to stimulate retching.