Vol 41: The other shoe
Many years ago, I was employed as the chief resident for foot and ankle surgery at Mount Sinai Hospital in New York at both the main Manhattan and the smaller Queens locations. Back then, most of my time was spent in the hospital on the floor tending to an extensive list of patients that my team and I were consulting on. When I wasn’t there, I could otherwise and fairly frequently be found in either the emergency room or the operating theater, quelling but never fully satisfying an insatiable curiosity about the narrow interval between good versus poor health and the full use of extremities versus a sudden disabling incident that changes a life.
Fast forward more than 10 years and now that I’m in private practice, I’m never in the hospital. I strictly see patients in my office and life is very different.
In a hospital setting, you rarely get an opportunity to form a lasting relationship with patients, particularly once they’re discharged from your service. In a clinic setting, however, bonds are more readily formed and it’s much easier to cultivate a strong community of patients who then recommend friends and family members to your care. The ongoing connection is the most appealing aspect of private practice for me.
Today’s report piggybacks off the fortunate circumstance of seeing patients recurrently over their lifetime and revisits a patient named Diana, previously written about in my ‘as the orchids bloom’ column. Diana recently returned to my office after suffering another medical setback.
You may recall that at the age of 19 she began experiencing heavy bleeding with menstrual cramps and was ultimately diagnosed with endometriosis. Diana then underwent surgery to remove two cysts on her right ovary followed by another surgery several months later to remove six cysts on her left ovary. She was told that she’d never be able to have children but went on to deliver two healthy sons.
After the birth of her second son she experienced intense repetitive seizures and, at its worse, she lost consciousness when her blood pressure became critically elevated. Her life-threatening symptoms prompted a battery of tests and Diana was diagnosed with post-partum preeclampsia. For the past 18 years, she’s been on anti-seizure medications.
At our last visit several years ago, she’d begun gardening, specifically growing orchids, to help control her stress levels.
In June 2020, Diana was at home gardening in the middle of the day. It was the early midst of the Covid-19 pandemic and the country was on lockdown. She had to step up from her garden to get onto the driveway that leads to her house. While doing so, she lost her balance and her right leg pivoted outward as she began to fall. As she tried to regain her footing in those quick few seconds, there was a contorted twisting motion with direct pressure applied to her knee and Diana heard her leg snap.
The searing pain was immediate and so excruciating that she immediately belted out a loud scream. For 20 minutes she laid on the floor afraid to move, her entire upper and lower leg now red, swollen to double its size and unbelievably painful with light palpation and minimal motion.
Slowly and carefully she maneuvered her weight onto her other side. With the help of her son, she hobbled into the house. As soon as her husband got home and saw the condition she was in, he rushed her to her general doctor who specializes in internal medicine. Diana was given four injections in the front of her knee, four in the back of her knee and then another in her hip. He also wanted to prescribe an oral pain medication and a muscle relaxer but she refused, hoping the injections would suffice. When it didn’t resolve entirely, an MRI was ordered.
Because of the lockdown and office closures, everything was delayed. A week of trying to manage constant pain passed before the imaging – a week of uncertainty before Diana learned her results were positive for a complete rupture of the anterior cruciate ligament (ACL). Diana was referred to an orthopedic surgeon who to her surprise informed her that she didn’t need surgery. She was referred for physical therapy but it was two weeks before an initial appointment was available.
As Covid-19 restrictions were slowly being lifted, Diana had her first assessment, and realized she was completely incapable of raising her right leg while lying flat on a table. Her therapist also pointed out the significant muscle atrophy to her right leg. She was scheduled to start therapy in two days but the country went into another lockdown and the therapy office was closed for six weeks.
Diana underwent three months of therapy after they reopened but she didn’t notice any improvement. Her knee was essentially non-functioning and after four months of pain and patience, she could barely walk. She sought a second opinion from another orthopedic surgeon who immediately, based on the position of her knee, how she was walking and her MRI results, asked why she wasn’t wearing a locking support brace. But, until that time, she’d only ever been advised to wear an elastic bandage. Diana was told that she needed to have surgery immediately but until non-emergent surgeries were allowed, she was advised to get a locking knee brace and to continue with a modified form of therapy to strengthen her muscles.
Diana had been in limbo working from home for the past four months and eventually returned to the office setting. When the time arrived, she scheduled her surgery and in preparation took a Covid-19 test. In yet another notch on the string of what could possibly go wrong, her surgery was cancelled because the ACL graft wasn’t available. The surgery was rescheduled and cancelled again for the same reason. By the time she did in fact undergo surgery, she had to get another Covid-19 test, at her expense, delaying the procedure yet another day.
After surgery, Diana underwent therapy for another four months but she never regained full extension and flexion of her leg. Her orthopedic surgeon delivered the devastating news that she’d developed an extensive amount of scar tissue, which was restricting her mobility and she’d need to have a second operation to correct it. Diana debated about whether to undergo surgery a second time, but when she began to lose mobility and experience pain in her heels because of her uneven gait, she knew there was only one conclusion.
Fourteen months later, she underwent that second surgery and while she knows she will never fully recover, she has regained more mobility. Fortunately she has insurance but, since her injury, her out-of-pocket expenses (i.e. insurance co-payments) for the hospital, her surgeon, anesthesia and physical therapy have mounted to more than $14,000.
She tries not to focus on the money, clinging to a feeling of gratitude for the second surgeon, his correct diagnosis, therapy and her progress. There’s a part of her that wonders when the other shoe will drop, afraid that another setback is near. But whenever those thoughts arise, she says a prayer and returns to her garden where she is quickly comforted by the peace that it bestows and the faint promise of better days ahead.
This is The KDK Report.
