The Bad Leg Blues Part 2

Part 1 is here.

Everyone knows the American health care system of “insurance” sucks. If you’re lucky enough to have a generous employer that pays for your “membership” in a good plan, then you might have reason to believe the country is full of highly qualified doctors, ultra efficient hospitals and faultlessly reliable high-tech tests; the rest of us, even those that pay into our own insurance plans, are left dealing with bureaucratic bullshit. It can get so that you feel like you need your insurance company’s permission to sneeze.

Moral #4: Get yourself a good insurance plan. Or plead poverty. Being middle class really sucks in America.

So when I got on the phone to see an orthopedic doctor to have my knee examined, almost three months after banging it up on the mountain, it was par for the course that my first choice of practice, in Kingston, had just had a falling out my insurance company, and they wouldn’t take me. I had to go instead up to a practice in Catskill and Hudson. There I was wheeled in for an X-ray before I even met with a Doctor. This could be forgiven as a necessary precaution, even though it was perfectly obvious I hadn’t broken any bones. It could also be considered a good way to get the ball rolling on billing my insurance company; after all, that’s how the medical companies make their money.

Anyway, I finally get to see the good orthopedic doctor. He confirms that, from the X-ray, I have not broken any bones; this I already know. He then takes a brief look at my right leg, which still won’t bend back properly, and confirms that it’s injured; this I also know. Then he says that we’ll need an MRI to confirm the damage; this I know, too. It’s why I came here – to get the authorization. In the meantime, I understand that he’s hesitant to give his diagnosis without running the latest high-tech tests. The MRI, after all, should be accurate.

Medical lesson time, folks. This is how your knee is held together. The two horizontal pink crescents in the middle are known as your meniscus.

I am, by now, however, frustrated. I’m not running, I’m not sure whether to bike, there’s nowhere to swim, I’m feeling off balance when I walk, and I’m spending far too much of my time dealing with doctors and my insurance company, trying to gee them all up so that I can get this damn MRI authorized. After a week of pushing and of juggling with two neighboring medical offices, I win. I get an appointment with the imaging company for the MRI in the morning, and an appointment with the orthopedists next door an hour later so as to review it. This, at least, will save me half a day’s additional driving.

Moral #5: Don’t stop, keep on pushing.

When the day comes around, the assistant who takes me in for the MRI acts like I’ve never had one before; I don’t tell her I had one on the head a few weeks earlier. (They’re pretty boring, to be honest. The biggest problem is remaining still in a confined space. Me, I just listen to the sound of the electronic magnets doing their job and imagine them as techno rhythms.) I do ask how the pictures reveal themselves however, and the assistant gives me my very own CD of the MRI as I walk out of the place. Hey, that’s service. I go straight to my laptop in the car and pop it in; it only works on PCs. Ah well, I’ll be in with the orthopedist in no time and he’ll show me and explain it in person.

Moral #6: be careful about gloating that you’re on a Mac. The rest of the world has yet to catch up.

Oh, look: here’s a picture of the right knee from the front. You never knew all this, did you? Me kneether.

The orthopedist is running an hour late. Shit happens. It does, however, mean he’s got an hour in his day to make up, and who knows which patient he’ll take it from. When he walks in to see me, there’s some initial confusion about the MRI, which I’d been assured would be waiting for him. He suggests that he can always call me with the results; I tell him that wasn’t the purpose of making the appointment and waiting around the last three hours. He goes off, I hear from his assistant that they’ve found the MRI, and then he walks in with the results.

“Turns out you’ve ruptured your ACL.”
“I what?”
“The MRI shows that you’ve ruptured your ACL. We’ll need to schedule surgery.”
I’ve heard about the ACL; I read up on it when studying the meniscus. The Anterior Cruciate Ligament connects the femur to the tibius, and controls your lateral knee movements. Tearing it is pretty serious and usually requires surgical repair. You can live without it, but you’d have to abandon most lateral movement: no more football for me, for example. Running trails with their twists and turns would likely be out, too.
“What’s involved?” I ask, my heart sinking.
“Traditionally, we would take tendon from elsewhere in your body and fix it on the torn ends, but now we use cadavar tendon. From someone who doesn’t need it any more.”
“Cadavar? You mean from a donor? A dead person?”
“That’s right. You’ll be on crutches for a month afterwards; then you’ll be in for a lengthy period of rehabilitation. The operation is usually totally successful, but for some people it can make things worse.”

His assistant hands me a pre-printed sheet about ACL surgery. My eyes race to the bottom line. Full rehabilitation: 28-32 weeks after surgery. That means I won’t be running again properly until Christmas. I’ll be lucky to be on skis next winter.

A torn ACL is not a pretty picture.

I’m shocked and I express this. I remind him that we all thought it was meniscus. (See part 1.) The doc confirms this, but tells me that the MRI report states otherwise. He asks me to lie down and demonstrate my range of motion. He measures the angle of movement on my good leg versus my bad leg. (120 degrees versus 140 degrees.) That’s the extent of his hands-on testing for the day.

“I’d like you to have four weeks of physical therapy before we operate,” he says. “We should be aiming to strengthen your knee. Otherwise the operation can do more harm than good. And we should be trying to improve the range of motion as well.”

I feel like saying that if we can improve the range of motion and strengthen the knee in physical therapy, then why do I need an operation to begin with? After all, he’s just described my symptoms. But to be honest, I’m too damn confused. I’m depressed, too. A month’s PT and then an operation will put me on crutches during the very period I’m meant to be moving – to the top of a mountain I should add. And with less travel in my schedule, I was so looking forward to this year’s spring and summer races on the roads and trails, to getting out and biking more, to enjoying this beautiful natural sporting landscape known as the Catskills. Now I’ll be spending the year in rehabilitation instead. It all seems so crazy – and though I know it’s my own fault, I can’t help reminding myself that I ski’d away from my accident, went home and sledded with my son, completed a triathlon five weeks later. I did all that on a torn ACL? (However much I’m thinking I should have rested it more, and that doing the Triathlon didn’t help, I know for a fact that it’s no worse than it was the day I had the fall and still ski’d my way home.) Maybe I’m superhuman and didn’t know it.

But the doctor doesn’t want to hear any of this. He has that hour to make up in his day. I’m out of the office before I can ask a really specific question – like, can we actually look at the MRI together and you show me how bad this is?

Moral #7: Don’t trust a doctor who doesn’t lay his hands on you.

In the car park, I call my physical therapist; I may as well get the ball rolling. She’s the same one who advised me to get my knee checked out by an orthopedist, who thought it was easily repairable meniscus damage. (She did also mention a Baker Cyst, which sounded feasible though, to my internal diagnosis, a little less likely.) She’s well known round these parts, highly regarded, an athlete herself. When I tell her the diagnosis, she is shocked. And I mean, shocked. “You should get a second opinion,” she says immediately, even as we schedule two sessions of therapy a week for the next four weeks.

The meniscus, on the other hand, can get scraped up and torn, and bits can peel away. It’s annoying, painful even, but can usually be fixed with what is called arthroscopic surgery.

The next day I call my primary doctor, the same one who was so certain the week after my fall that the leg would heal itself. He’d been kind enough to give me his cell number after I got the headaches and I use it, for the first time. He hears me out, and he too seems surprised about the ACL diagnosis. Shocked, even. Who did you see? He asks. I tell him. Oh, he says. Two things. One, I want you to get a second opinion. And two, even if it is ACL, and you do need surgery for it, I don’t want that guy operating. In fact, you should go to Hospital for Special Surgery in New York for your second opinion. Sounds like you need an expert.

We now pause for a rather pathetic interlude: Tony trying to get an appointment with the HSS. Tony is initially enthused when the first doctor on the HSS web site’s alphabetical web site list of physicians turns out to be not only a knee specialist but also the former Hunter Mountain Ski Sports Center Physician. Yes! But of course a phone call reveals that he doesn’t take Tony’s insurance. Tony calls the HSS referral line instead to see if there’s a doctor on the list who does take the insurance; he gets voice mail. He calls his insurance company and finds someone who is actually quite helpful, even going so far as to suggest that they can do something called “prior authorization” – if everyone involved agrees that HSS is absolutely the right place for him, a payment plan can be worked out, even if Tony has to pay out of pocket and be reimbursed. While he is hearing this, the HSS calls back. The woman on the phone is very friendly – until she hears of Tony’s insurance. But she remains helpful, deciding to put him through to a specific doctor’s office. The assistant at that office – ah, how I don’t miss that brusque New Yawk City rudeness – tells him that not only does their practice not take Tony’s insurance, but that his insurance company’s talk about “prior authorization” is BS: “that’s not how it works.” Tony asks the price of a consultation and then for the first available appointment. The assistant tells him. He pauses, says he’ll take the appointment; being ten days away, it gives him enough time to try and get the insurance company to authorize it. The assistant refuses. “We need to crunch the numbers,” she says. Either Tony agrees to pay privately, or wait until his insurance company comes through. The assistant assures him there will always be an appointment available and suggests he rings back when he knows how to pay for it.

You know that promise you keep hearing when you’re dealing with bureaucracy? “This message may be monitored for quality assurance.” Well, it’s not all smoke and mirrors. The next day, Tony comes home to find two messages on his phone from the HSS referral woman. Turns out she not only put him through to the doctor’s office, but listened in! And she is furious that Tony couldn’t get an appointment – even when he offered to pay for it. “We don’t like the insurance system either,” she says. “Our business is to get people the best possible health care.” At last, a human! She wants him to complain. Oh, he’s happy to do so. She asks him to recount what happened via e-mail. He does so. Fortunately, he can write quickly – though in that e-mail he stresses that what he really wants is just to have his damn insurance company set him up with the HSS so he can find out what the hell is wrong with him. He gets an e-mail back thanking him for his complaint and a promise that they will try and get him an appointment with someone, regardless. It’s the last he hears from HSS.

Moral #8: Don’t expect your cheap insurance to get you in with the same doctors as professional athletes. You don’t move in the same world.

And this, my friends, is a color-enhanced picture of a torn meniscus. Not mine, I should add.

He gets one more phone call that day. It’s from the orthopedists in Hudson, the ones who had just told him to get a month’s worth of Physical Therapy. They can schedule the operation for next Tuesday. Next, Tuesday?. Tony asks the assistant if she’s not aware the operation was meant to be a full month away. Clearly, she is not. But hey, she says, we can schedule it for a month away if he’d like.

Moral #9: Don’t trust anyone who wants to schedule an operation ahead of when it should be scheduled.

This is too great a lack of thorough professionalism for his liking – all the more so since his primary doctor has told him to stay away from this surgeon. Tony says he’ll call back. (And he does, later, to get copies of his records.) In the meantime, he starts down a path he should have started down three months ago. Instead of responding to every villager’s pass-the-day question, “Hey, how are you?” with the usual “Oh, fine thanks,” he stops and tells them the truth. His wife is bored by it, but others are surprisingly forthcoming: it’s like unlocking a door to an inner sanctum. Half the people he knows have had knee problems – or else their spouse or sibling has – and of course they all have advice. But while this advice is freely unprofessional, it reaches strong consensus. Those who know of torn ACLs express surprise that Tony is walking round with one. Those who have had torn meniscus – which suddenly seems as prevalent as the common cold – offer up the same two or three doctors’ names as having fixed themselves/their spouse/their sibling with uncomplicated arthroscopic surgery. One was even out road-racing within a week of the op. All these doctors are with the practice in Kingston that had told Tony two weeks ago they’d stopped taking his insurance. He calls them again. Their spat with his insurance company is in the past. Yes, they take his insurance. A month since deciding to grab this bullocks by its horns, he finally gets an appointment with a local, respected orthopedist.

Now, maybe, he’ll find out what’s wrong with him.

Moral #10: Do trust your friends and neighbors, they’ve often been through the same problem. And don’t ever feel obliged to tell people you’re fine when you’re not.

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