The (almost) daily stories, chronologically.
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Friday, August 21, 2009
This was decision day.
In the spirit of the American Insurance Industry, the first question I got asked was about what kind of health insurance I had. I replied that I had Coventry, a company who appears to have a bit more money to spend on their web site than I do.
I was handed the pictured device (which I call the Jaw Jacker), told that it was $US170, came with an extra set of pads, and then was told ... "We'll bill your insurance for it. They are not going to pay, but you don't have to pay us until after the claim is rejected."
Thank Kibo that we have insurance. Can you imagine what it is like to be un-insured? Same price, but you pay now. I really think the tag line "We deliver exceptional value every day, driving solutions that help people enjoy optimal health," came directly from the Dilbert Mission Statement Generator.
The surgery date is 8 September. I have to get a repeat MRI two years later on the same machine that was used in 2007, a pre-op physical to determine if I can likely survive the anesthesia, and I have to take an hour long class on life with the hard neck brace. That's not too much to expect for a little over two weeks, but I immediately began thinking of many other things that must be done before the surgery.
One of the good things about our business is that our two most active customers are in Singapore and Australia, which means they seldom drop by to see us in Boston, Washington DC, Richmond, or Las Vegas, especially during business hours. We work from our homes, which will also mean that I will not be forced to deal with the home environment, the office environment and the trip between the two.
In other words, I am very fortunate.
Saturday, August 22, 2009
After the surgery, I will be taking a yard work holiday, which means that there is so much more to do before 8 September. We went to the Stihl dealer and picked up the super hedge trimmer, which you see pictured here. Despite the fact that my left arm hurts like hell after using it, this is the most fun I have had destroying things since I bought my first serious chainsaw in 2001.
I have decided not to cut off all my hair, as I had originally intended. There isn't all that much of it left, to tell the truth, and "washing my hair" really only amounts to spraying a little soap in the general direction of my head, and rinsing off. There is no longer any need to dry it, even during a humid Virginia summer.
Sunday, August 23, 2009
I finally told my parents yesterday. Today, I'm telling everyone else. In fact, you might even be reading this entry because you just got the email.
When your neck is as monstrously uncomfortable as mine is, the Jaw Jacker is more comfortable than you might think. Who knows if I have it adjusted correctly, but I'm not turning blue and it takes a load off the spinal column. Patients are encouraged to experiment with the device before the surgery, and since this one comes apart into two pieces, I will not have to come up with slashed T-shirts and button down shirts that can withstand blood stains. The old frumpy polo shirts will suffice.
On Friday, UPS delivered my reconditioned and repaired Sennheiser headphones. As you can see from the photo, even large circumaural phones fit without interfering with the Jaw Jacker, meaning that at the very least I can enjoy music in the prone position.
Monday 24 August, 2009
No developments today, so instead it is a good opportunity to introduce two things into the discussion: [a] My proposal to insure all Americans, and [b] an explanation about why the current system works against all parties' interests ... except one.
As far as [a] goes, let me brand this as The Flanagin Plan. It is simple, and takes all the political fun out of the game: At 65, one must participate in Medicare. At 18, one may choose to participate in Medicare. From birth to 18, you are covered under Medicare at no charge to you. Anyone may buy any other supplimental or replacement insurance product that he chooses, at rates determined in the existing insurance marketplace, and that marketplace will remain essentially as it is. The Medicare tax we now pay will be doubled from its current rate of 2.9% to 5.8%. (I am counting both halves: so under my plan the employee will pay 2.9% as will the employer, each of whom currently pays 1.45%.)
The argument I would like to hear is that Medicare is good enough for us to insist that our oldest citizens have it, and not good enough for the rest of us, and simultaneously a threat to the private insurance market. Under The Flanagin Plan, people who make this argument will be required to (re)take RHCS 201, conveniently taught by my neighbor, Dr. Mifsud.
Which brings me to [b].
In non-medical businesses, we spend a good bit of time talking about the terms "customer" and "vendor." If you have worked for a large company in the past thirty years, you have heard this metaphor stretched to its limit. These terms are largely related to the direction the cash flows: if you are getting the money, you are the vendor. If you are paying, you are the customer. In this metaphor, the thing being sold is called the "product."
In the world of vendors and customers, the customer is in charge. Unfortunately, in the business of medicine, the patient is not the customer.
Medical businesses, whether people (doctors) or businesses (hospitals, labs, etc.), are still the vendors, or as they have been rechristened "service providers." The insurance company has become a vendor who enjoys the unique ability to dictate the profit margins, and conceal the terms of the deal.
Doubt me? Try this some day: Call a random sample of medical businesses who might reasonably provide the product, and ask "How much do you charge for an appendectomy?" The question is rather crudely phrased, but the answer will be same if you are able to get one: "It depends on what kind of insurance you have."
The useful piece of information in the response is not the price, or even an approximation thereof. The useful info is that from the standpoint of doctor or hospital, you are not the customer. In the example, your appendix is the product, and you are simply the life support system for the latest opportunity for a little money to change hands.
Thursday, August 27, 2009
I had a couple of busy days that were also not much fun from a pre-ACDF perspective. But there is news.
Let the negotiation begin. The $170 Jaw Jacker is available here at a bit of a discount. Perhaps I misunderstood, and the fellow said it was $70.
My buddies at Coventry sent me their latest OK for getting my neck re-MRI-ed prior to September 8th. When you read the number of restrictions, the letter seems to really only grant the MRI folks the "right" (?) to file for reimbursement.
I also found out that they have authorized a stay in hospital of up to 23 hours. Think about it. Twenty-three hours. Two digits of precision and somehow magically less than one day.
As I have told Glenda, let the practice sessions for the lying begin now. At the 22nd hour, I will begin professing through sign language that I have never felt better, that like Lazarus I have awakened from the dead.
Friday, 28 August 2009
I get the feeling that I am getting to this surgical event just in time. Yesterday, at 5:20pm, the middle finger on my right hand just disappeared from my awareness. It certainly ranks as the strangest event of all the neck related saga. The interesting part is that my brain closed up the gap, so to speak, and my right hand felt as if it had always had just three fingers. I'm turning into a Simpson.
It returned with sudden buzzing numbness about ten minutes later.
Today is Snow Leopard day, and mine should arrive silently at the front door. It is nice to have something else to think about.
Tuesday, September 1, 2009
To commemorate the 70th anniversary of the start of WWII, I had my second physical in as many days, complemented this time with blood work and an EKG, as opposed to yesterday's more or less worthless, and certainly redundant trip to my primary care physician. Want to know why health care costs are so high in the USA? This is a part of the reason.
Today's vitriol will be aimed strictly at the ergonomics of the patient education system at the hospital where the procedure will be performed. After the EKG, I was shown into a broom closet equipped with an old computer running Windows XP on a very blurry tube.
I have been twice published in the field of CHI (Computer Human Interaction), and I regard my knowledge of the field as good. Here, we have a text book case of usability negligence. Patients facing neck surgery are required to watch a scripted presentation that lasts for 77 slides. The nurse does start it for you, so you only have to click the mouse 76 times to see all the slides.
The monitor is placed too low on a table, with no adjustment to its location possible, and each time you must lean forward to reach a rather captive mouse to make the click. If you don't have a neck problem when you start, by the 50th or 60th slide you most certainly have developed the early symptoms.
Friday, September 4, 2009
First, a wave to my mother and father who have discovered Internet access at the public library. Hi Mom! Hi Dad!
It has been a bewildering series of tests and exams this week. I have lost so much time doing shuttle medicine that I was not able to keep up with things at work. And the diagnosis changed a bit during the week, so the treatment will, also.
On Tuesday morning, I am up for the fusion of C4/C5/C6/C7, using what are called dynamic plates. When you get beyond the fact that this procedure is taking place on a human being, it is more or less car repair. A few screws, a few plates, a little body work.
While the surgery itself is not noticeably more difficult nor time consuming (every additional minute under anesthesia is a risk), the recovery process is considerably longer. Six weeks in the hard brace; six in the soft brace; bone growth stimulator.
The dynamic plates allow for a bit of vertical collapse, and the plates are put in with the full 2mm extension. Gravity operating on your head [1] crams the vertebrae together, which [2] creates load on the bone, which [3] stimulates bone growth, which [4] improves the fusion, and [5] prevents osteoporosis getting an early and immediate start.
I am currently looking for more information about the electromagnetic bone growth stimulator. My surgeon warned me not to take it to the airport --- said he in a stage whisper, "It has a timer in it, you know." After my experience with the TSA's detailed inspection of my foot massager (shown to the right: just some wooden balls on metal rods; it looks like a very small abacus), I think I will take his advice.
At the moment, I think it must be this fashion accessory. The model certainly looks happy, doesn't she? My friend David Janszen speculates that to be so happy she may have it near the wrong bone.
Tuesday, September 8, 2009
I had the surgery on Tuesday, as planned. It took 280 minutes, which was not the original amount of time that I thought would be involved. The rule for estimation is 20 minutes each to open and close, with one hour per level (pair of vertebrae).
The not too informative photo is how I looked as I was rolled into the hospital room where the 23 hour clock began ticking.
Wednesday, September 9, 2009
Just as the insurance company predicted, I was discharged from the surgery unit after 23 hours under the care of Henrico Doctors' Hospital. The keys to being discharged are simple to meet: [1] You must be able to pass urine, and [2] you must, at least for a short while, be able to stand the pain without morphine.
I took my cues from the nurses, and cut off the morphine pump about four hours before the doctor arrived. The euphoria of being able to feel the fingertips in my left hand was enough to carry me through the post-op visit. I was a case study in boiled frog syndrome, and I had just leapt from the pan in time.
Saturday, September 12, 2009
I am not the ideal patient; I don't like to stay still, and I don't like to be asked a lot of questions about how I am doing. My wife must be a saint.
I survived the first two full days of the post ACDF world (Thursday and Friday) largely by chaining myself to Steve's chair in our music room like Odysseus was lashed to the mast, in both cases to hear the Sirens' songs.
Planning for a few days of full time pain can be done, and I hope that most readers of this journal will have had no previous experience. When pain is unrelenting, it is most similar to the feeling that you have on a long automobile trip and there is no rest stop in sight. Gradually, the bladder swells, and the thoughts of where to take the badly needed bio-break supersede all other thoughts. Pain is the same kind of persistent phenomenon.
I have gradually resumed reading today, but Thursday and Friday were music and narcotics. I was unable to sleep for more than two hours at a time, whether in the bed or Steve's chair. Reorientation from vertical to horizontal was a challenging prospect.
Sunday, September 13, 2009
Today's lesson: YMMV (Your Mileage May Vary). I had something resembling normal sleep ... for a while ... last night. I decided to drug up prior to bed, and Glenda and I spent the evening listening to Schubert. Between the drugs and the exhaustion, I way overslept the drugs' half-life, and woke up around 4:15 feeling like my neck was broken in two parts.
It is a good thing that Glenda likes to do needlework, because I don't say much these days. I seem to have about three hours of conversation in me, and my voice turns into Miles Davis without the vitriol when the minutes are used up. Glenda has noticed that since I can't nod my head like a Westerner, nor wobble my head like an Indian, I have taken to expressing my consent through uttering intermittent, amorphous grunts like my Australian friends use to transmit the message, "Yes, I'm still listening ...."
The big plastic wrap bandage comes off this afternoon, and I will take some pictures of it so that readers will know what to expect 125 hours downstream.
Audiobooks to the rescue of the bored: Now that I possess the mental focus necessary to read, I have started reading the novel Cutting for Stone, recommended to me by my friend Phil, who is the author's brother. It is a very good modern novel. I first started reading during my 23 hour day in hospital, and briefly considered writing Phil to tell him how much I liked it, and how absorbing it was. But under the influence of morphine, I felt exactly the same way about the intellect curdling lunacy that is Glen Beck, and it made sense to wait. I suppose this is why you can't sign contracts under the influence.
It seems a little strange to be reading a novel whose protagonist is a surgeon when I have so recently been on the other end of the scalpel, but it is a good read. While the Kindle is light, the iPod and its audiobooks are even lighter.
Saturday's post included another letter from Coventry Health Care saying that the bone growth stimulator I first mentioned here meets the qualifications of medical necessity, but that our plan does not cover medical devices. Well, it's still nice that they thought of my well being their profits.
Special Edition: Pictures from September 13 2009
Here at last are some pics 125 hours after the event. The bandage is off, and we can see what is going on. You may click on either photo to see a roughly screen size rendering of the same. There is nothing quite like five days of not shaving to really add to the aesthetics. I will have to let to go another week before I attempt to shave because the jaw jacker must be off to do the shaving.
The colors are reasonably accurate, which is to say, I am really that red. As you can see there is less bruising than there is irritation of the skin from the tape. It feels great to have my skin breathing again.
Photo credit: Glenda Flanagin, Nikon D300 and N-series macro lens f/6.3, on camera flash.
Tuesday, September 15, 2009
It has now been one week, so it is time to take stock. First, let me state that I have adjusted rather well to the jaw-jacker neck brace, and I do think I will be able to make it another five weeks without clawing at my flesh too much. After seven days, my beard has grown out well past the velcro stage, and is now a comfortable and completely organic liner between my skin and the jaw-jacker.
At the end of our all company teleconference today, a couple of people commented that my voice seemed back to normal. It doesn't feel normal, and there is a constant sensation that I am about to break into a swine-flu simulation cough, but it is good to know that I can pass myself off as healthy over the phone.
The pain is really quite bearable, and I would have to say that today I am no more uncomfortable than I was a week ago headed into the surgery. Admittedly, I was very uncomfortable before the surgery, but from reading on the net, my progress seems to be ahead of schedule.
I have dropped from 88Kg to 84Kg, consumed three liters of homemade yogurt, and learned that the new Cuisinart can puree anything, including solid bone, although you may not like the results as well as the original.
Eating is really quite a chore, and despite my love of dining, I think that it may be time to give up on trying to make things interesting, and go for sustinance and calories. We will soon run out of gazpacho, vichyssoise, fresh mushroom soup, and the other fun and tasty things.
Humans' survival is tightly bound to our incredible adaptability. Example: through cooking, we adapt food to our teeth in a few hours rather than waiting thousands of years for our teeth to evolve to handle baby back right off the pig. But a danger therein is to consider every condition to be possibly permanent. Unless something very unusual (and bad) happens, my inability to eat well will go away in a few weeks. From what I have seen of India, it is possible to live off yogurt and rice and lentils, flavorfully combined in the same meal. In fact, I have several Indian cookbooks and some skills in that area, and I think it is time to get them out.
On the other hand, perhaps I will just grab a pint of Haagen-Dazs Rum Raisin and hope my arteries don't clog shut.
Thursday, September 17, 2009
Nine days down range, I would have to flag today as the day that I began to feel ``better'' in the sense of post-surgical. After considerable experiences with hernia repairs, knee repair, elbow repair, and having my gall bladder out, there seem to be three components to post-surgery discomfort:
First, there is the pain associated with the surgery itself. The cut, the whatever went on inside the body, and the disruption to the surrounding tissues.
Next, there is the exhaustion that comes from difficulty sleeping. I suppose that this may not be a factor in every surgery --- I don't recall much difficulty sleeping after my knee repair; I tossed my knee up on a pillow, put ice on it, and slept.
Finally, there is the post-anesthesia black cloud. Exhaled breath tastes vaguely of something metalic and strange (sevoflurane?), and a mental congestion and acedia seems to saturate thoughts.
Today, the latter evaporated, although I am still having the usual problems with perceptions of salinity, and complex foods like red wine taste absolutely terrible. I wonder if this is the way wine tastes to people who say they "don't like the taste of alcoholic beverages?"
Friday, September 18, 2009
Today was the first post-surgical visit for an evaluation. It was also my first trip in a car, and I feel luck to be staying at home most days.
The remaining tape was removed from the wound, and the first X-rays were taken (picture to the right). The gaps between C4/C5 and C5/C6 can be expected to close up some more over the next month.
I was pronounced to be making a somewhat better than average recovery, a statement that I assume takes into account what was done, the unexpected encounter with large bone spurs, and my age. To tell the truth, if I never got any better than this and merely did not have to wear a brace, I would consider this a considerable improvement over the pre-surgery level of pain and discomfort.
I was sent home with the PEMF (Pulsed ElecroMagnetic Field) bone growth stimulator which I will cover in a separate entry. It definitely has that suicide bomber look to it, and it even ticks at a rate just over once per second that adds slightly to the sense of anxiety.
Glenda deposited me back at home, where outside of two afternoon conference calls, I dozed most of the afternoon while she nobly dealt with the groceries and the exchange of our rental car for our own that had been in the shop.
In the late afternoon, I tackled the first thing that can be called a meal: a veal and pork ragu over little wagon wheel pasta (piccolini). The small bowl of it looked like something you might serve a child, but I was able to both eat it without making a mess and enjoy it.
Monday, September 21, 2009
We started getting bills on Saturday. The first one covers the jaw jacker, the entry that began this narrative. The first bill proves both that my hearing was OK (the billed price for the jaw jacker was, indeed, $170), and that something is terribly wrong with the income redistribution system that is American Health Care.
To refresh, I found the jaw jacker for sale online for $57.97, which is 34% of what we should call the Fantasy Sticker Price. Keep in mind that DME-Direct is apparently making money at this price, and it is really difficult to conceive of such a device's function as a loss-leader like one gallon of milk for $3.00 has for the local Stop-and-Rob.
Our health insurance company has come to an agreement with Advanced Orthopaedics that the price should be $94.71, of which they are willing to pay 80%, leaving me with $18.94 after the premiums have been paid. This stikes me as strange ... even the $75.77 that Coventry pays is considerably more than the street price of the device.
I learned in undergraduate economics classes that taxes are always a method of redistribution of income, and a similarly simple way to look at insurance products is that they are redistributions of risk. What bothers me so much about the above story is that in it we can see that our health insurance system is also a method of redistributing income.
Could this be a factor in why America's costs are so high with no better service? Why should anyone for any reason pay more than they need to? A more dramatic example of this type of thinking can be found in this story from Apple Insider.
You may need to read the following quote from the story several times to be sure your eyes are working properly.
Asked why Medicare refused to cover cheaper, better alternatives for users, Peter Ashkenaz, a spokesman for the federal Centers for Medicare and Medicaid Services told the Times, "We would not cover the iPhones and netbooks with speech-generating software capabilities because they are useful in the absence of an illness or injury."
Saturday, September 26, 2009
Eighteen days after the surgery, and I made my first voluntary field trip ... to Costco. Costco is probably the worst store in the world for a post-ACDF trip in a rigid neck brace: towering shelves, mobs of people moving around as if propelled by Brownian motion, and a twenty mile round trip by car. Ugh.
Nonetheless, my recovery seems to be ahead of schedule. The lingering problem is eating: I have dropped 13 pounds in 18 days, meaning that the weight loss will have to stop around May 1 of 2010 or I will vanish. I have tried red wine a couple of times, and it just doesn't sit well. Glenda and I had a gewurztraminer that she said was not up to scratch, so I don't know if my taste for whites has yet returned. The slight wet-limestone taste could be in the wine ... or not.
I have become the accidental vegetarian. For some reason, vegetables seem a lot better to eat for me than meat. I did have a little turkey yesterday, and tonight I am going to tackle a fillet steak.
Sleeping is going better, and I am adding some tips to the tips page. I realize my experience may not be like your experience, but there is woefully little information that I have found about the minutiae of day to day post-ACDF existence.
Monday, October 5, 2009
I am now four weeks post-op. For the first time since well before the surgery, I have had two acceptable nights of sleep in a row. One of the reasons is that I decided to see what it would be like to sleep without the brace, in part because I am a still sleeper (I sometimes awaken three or four hours into the night, my iPod still on my chest where it was as I fell asleep) and there is little risk of waking up with my neck in an exotic, twisted position.
Riding in the car is still the most uncomfortable experience. It does not seem to matter who drives, nor what car's passenger seat I am in, but it beats me to death in just a few miles.
On the other hand, there has been great improvement: [1] I am able to walk the 2K round trip to the stop-and-rob with no problems, and my recovery time has gone from "the rest of the day" to about half an hour. [2] I was able to mow half the lawn one day, and the other half the next.
Tuesday, October 20, 2009
Today is the six week anniversary. I jumped the gun a bit and had my six week consultation with my surgeon on Friday. Unlike so many people, I am making a text book recovery up to this point.
The X-rays show that C6/C7 and C5/C6 have closed up, and the desired fusion is well underway. C4/C5 is lagging behind, still showing about 1mm of separation, but that is normal for six weeks out. The true evaluation is to be made at six months. The complication is that there is about a 15% chance that I will need another pair of screws put in around March if C4/C5 does not fuse on its own.
I found out on Friday that they do the additional screws from the back side of the neck, and I have been told that although the surgery is not risky, it is "very painful." To which I responded with a simple, "I see." I have had eight kidney stones, two surgically removed, so a part of me says "Yeah, right. I have had worse." The other part knows that I was sent home from the surgery with 90 oxycodone tablets, and if the incision from the rear is worse, it must be excruciating.
I feel good now, but I am still weak. I have lost 6Kg, and I can see why those with the luxury of doing so take at least one month and sometimes two off work. Yogurt is still a staple for breakfast.
The bills have started to arrive, and they are more scary than any brush with death. After all, you can only die biologically once, but financially you can die a thousand times and still have to deal with the biological finality. I hope to have the new page up very soon.