Friday, 18 May 2018

Field Notes from a Medicare Disaster: Four

It was the Ides of February, 2016. Toronto was as grey and damp as an old dishrag. I was working hard on a new project that involved prying politically embarrassing information from the death grip of the University of Toronto and the even more secretive bureaucrats of the Department of Canadian Heritage. When I am on the trail of a good story, especially a hidden one, I tune the rest of the world out. I didn't hear him when he called the first time. I did hear a bump, but there are always bumps and thumps in our old house, usually emanating from its ancient radiators. I heard the second call though, because there was an edge to it, a determined calm stretched tight over panic like emotional plastic wrap. Daughter number two tells me I was on the phone with her when I suddenly said, gotta go, Dad needs help, and hung up on her. I have no memory of that. I do know that when I ran down to the kitchen, I found that he had fallen to the floor, couldn't get himself upright.

We had lately had a few of these moments of radical awkwardness, though nothing as serious as his fall at the cottage the previous summer. He had been finding it harder and harder to get his feet under him after a stumble unless he had something big, like a door, or a grab bar, to pull himself up on.  I am still strong ( not as strong as in my early twenties when I held back, with one hand, a tipped over 200 pound light stand about to squash my puppeteer colleagues in the middle of a show). Yet I found it hard to help him get up. He couldn't seem to cooperate with me. It wasn't as if I was trying to move dead weight, it was that his weight seemed to have a confused mind of its own working against my best efforts.

Being faced with my inability to do something always annoys me, and so I was annoyed. I looked for someone to blame-- him. How the hell had he managed to fall in our small kitchen which has so many things to grab hold of within easy reach? Like the counters? Like the fridge?

I don't know, he said. I don't know why I fell.

Somehow, I wrestled him up and onto a chair, which is when I  realized his neck was red with blood, and there was a red splash on the white fridge too, and ohmigod, a long smear across the floor. What the hell, I yelled, and then deliberately forced myself into a different state, a semblance of calm, because I also noticed, finally, that the bottom half of his left ear was dangling by a shred of skin, just hanging there beside his neck as his blood ran bright and free.  My father had been reliably cool in the face of frightening things such as this, including: eruptions of blood from my friend Ian's broken nose (Dad actually reached over and pulled Ian's nose sideways, back and forth, to make sure it was broken: yup it's broken Ian, he said); or, when I passed out during an asthma attack on another kitchen floor (he'd kept adrenaline in the fridge for just such an occasion). His capacity to cloak himself in deliberate calm helped make him a good surgeon. Yet it wasn't natural to him so he had developed interesting methods to soothe himself when faced with unexpected disaster --such as things going south in the operating room.  He told me that he just stepped back from the operating table, sometimes turning his back on it altogether, and then he hummed or sang a jaunty tune. Didn't the OR nurses find that strange? I asked. They never mentioned it, he said.

I don't sing when I'm scared. Instead I grab hold of my voice and wrestle it down from wherever it's perched to something steady and low which settles me as I hear myself speak.That allows me to step away mentally just long enough for thoughts to gather, so I can organize what to do and in the best order. I heard myself say, in a very neutral voice, hey, your ear doesn't look as pretty as usual, which is too bad because I've always liked your ears. And then I did what I'd learned in first aid class, age 16, from one of my Dad's partners, Dr. Noel Doig. He too had been a leader of the Doctor's Strike. He had immigrated to Canada to get away from Britain's National Health and spent many hours explaining to his Saskatchewan colleagues exactly why the National Health didn't work well, exactly what had to be avoided in Saskatchewan for doctors to do their jobs properly. He was a bright, ethical, empathetic man with musical talent: he built a clavichord in his basement one winter just for fun. And he had a talent for teaching too. He told a memorable story to my first aid class which encapsulated a simple way to slow a rush of  blood pumping from a limb  He described what happened when an older woman fell down on a London street and a varicose vein in her leg burst. A good Samaritan came upon her in a rapidly expanding pool of blood. He  tried to engineer a tourniquet from his necktie, but she was saved by another bystander who knew better, who simply lifted her leg above the level of her heart, then applied pressure. Remember, he said: first, elevate the limb, then apply pressure, then get help.

Elevation is not really applicable to a half- ripped off ear because, unless a person is already lying down, it's well above the heart. So I grabbed a pile of clean dish towels from a drawer and applied pressure, then replaced my hand with his while I called 911.

Why are you calling 911? he asked.

Because your ear is half off and there's a lot of blood pouring down.

Just get me a bandage. I'll be fine, he said.

You need someone who can sew it back together, I said. I mean I could try, but you wouldn't like it.

The paramedics got there very fast.They crowded into the kitchen. He told them what he hadn't told me, that when he fell, he'd caught his ear against the freezer handle on the bottom half of the fridge. All 220 pounds of him had landed on that ear. No wonder it was torn. Had he also concussed himself? Again? He was confused, I thought. So, probably. But his eyes tracked as they should according to the paramedics.

But we'd better take you in anyway, they said, and bundled him out the front door and down the front porch steps on one of those clever, step-climbing chairs.He kept trying to get his arms loose from the straps, even when they transferred him to a wider gurney. They weren't happy about having to push that gurney across our flagstone path to the curb-- well, we call it a path because once upon a time it was a path, but now it's a mess of broken stones heaved in all directions by frost. It's old. Like us. Not good Miss, they said, as if they knew they'd be coming back again, and again, and I'd better reno the access route before the next time.

Daughter number one made her way over to the St. Mike's emergency after the ambulance brought him in. She was not happy, in fact she was really, really concerned. I tried to assuage her fears.  Not so bad, I said, just a tear, they'll sew him up and that'll be that.

We waited for quite some time for a doctor  whose specialty included sewing ripped ears back together.  I would have thought any emergency doctor could do that, but apparently that is not the case. An otolaryngologist is required.We waited,  and we waited, jammed in a a cubicle.When said specialist finally appeared,  at least ten hours after the call went out, he was moved to another room down the hall where he could be sewn up, a room I mainly remember as large. The emergency doctor in charge, a nice woman, told me he'd be able to go home after it was done.

Daughter number one pulled me out into the hall.

We need to have him admitted, she said.

We do? I said.

Yes we do, she said. He keeps falling, and we need to find out why.

But the emergency doctor said he could go home, I said. And his MRI is scheduled for next week.

I don't know why I argued with her. Maybe I wanted to hold at bay the idea that something was seriously wrong. After all, that doctor who discharged him from this very hospital in the summer had insisted everything would be fine, all he had to do was count to ten after he stood up and before he took a step. The neurosurgeon had been concerned,  yes, but not certain what exactly the problem was.Thus the MRI.

The MRI is scheduled for the middle of the night, she said. They could do it while he's an inpatient much more easily. What if he goes home and falls again?

Good point, I said.

Please let me handle this, she said. Just let me do this, because you won't use the right words.

A fraught moment of decision: should I hand over my role as the adult person in charge of his care to a daughter who had been a child herself seemingly moments ago ( okay, okay she had two children of her own, but still...). Age makes itself known when a parent finally recognizes that her children have acquired skills not readily at hand in her own bag of tricks. I remember my Dad still deferring to my grandmother though he was a doctor with three kids and a huge medical practice, while she barely spoke English and her education was of a different order altogether. He considered her the smartest person in the family. I wanted to go to a convention in Vancouver with a youth group I belonged to. I'd had a bout of asthma that had almost killed me and he thought it wouldn't be safe. I appealed to her. Are all the other kids going? she asked him. Yes, he said. So she goes, said my grandmother, and that was that, I went.

Daughter number one had by then spent several years working  on policies related to physicians and their work. She knew the jargon and the rules; she knew which phrases would resonate, which policies could be referred to, trigger words in effect. I know  how to ask sufficiently probing questions to expose a system's failures but that is altogether different from getting systems to behave and do what they're supposed to. What we needed was relief from a patchwork of appointments and incoherent information with no responsible physician  to make sense of it. We needed a proper  work-up in the hospital by someone who had  access to all the gathered evidence and who could get more as needed. Okay, I said. Do it.

She took the emergency room doctor out in the hall. I know she explained the history, what remained to be explored, that  an MRI had been ordered by a staff neurosurgeon in this very hospital, scheduled to be done in a few days, that there had been a serious fall requiring hospitalization only a few months before, and several little falls since, and now this--yet there was still no diagnosis. She  pointed out the danger of letting him go home, the liability that could ensue.  I kept out of it as ordered, although that phrase of hers, you won't use the right words, had really got under my skin. After all, if I am anything at all it is a purveyor of correct words.

When the two of them came back from their huddle, I was told that he would be admitted after all, it was just a matter of finding a bed.

Is that how it works now? I said to daughter number one, after the doctor went away. Does one have to know trigger words to get the correct response, to get reasonable, responsible treatment?  Is that what this system has come to? That smacks of Israel where you need protectzia to get you in the right doors. 

Protectzia means exactly what it sounds like. You know somebody who knows somebody important who can take you out of that long line up with a wave of the hand. It means there is no real equality, only differing degrees of power.

It's not about protectzia, she said, it's about the right words.

But it's the same problem if only a few of us know what those words are.  Equality of care for all, regardless or bank balance or personal relationships, was the foundational concept underlying Medicare, wasn't it?

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