Friday August 21, 2018 -
Level 1 -
It was Colleen’s idea to go. Her brother Curtis and his husband Rusty have a cabin in the woods of Natahala National Forest in North Carolina. Colleen has always liked cabin vacations. It stems from her childhood. She used to go to a mythical place called Lake Neddy for vacations which she remembers with such rapture that you would think it was Asgard. During our many vacations we took three to a cabin in Maine. It was a beautiful area and despite my reservations, I enjoyed myself.
Curtis, Colleen’s brother, and Rusty his partner are cut from the same cloth. Curtis and Rusty have a lovely cabin by a stream. It is secluded, cut off from the grid and deep in the Great Smokey Mountains. No internet, no cell service, no Netflix, no wireless. In my view all the things that make life worth living. It would be just us, the woods and the stream. They loved the peace and quiet. Just the sound of the stream.
I have never been fond of such trips. It is my baseline ADHD. If I had a limited time off from my stressful job, I did not want to simply sit and look at the lake. I wanted to “Do something”. Sitting was not doing anything to me. It only tended to make me more agitated.
Furthermore the plan was to get our family together, my two sons, my daughter in law Emily (who sometimes thinks I am a troll), a French Terrier named ‘Moe’, and my mutant eighty four year old mother in law -more on her later-, all in the same cabin. My mother in law showed up with a heavy suitcase for only a two day trip and not one but two purses.
We were going to sit, talk, and listen to the stream.
I was filled with dread.
Level 2 -
So we packed up my 4x4 with my mutant mother in law in the back seat and left Indianpolis for the eight hour drive to what I felt would be the movie set for ‘Deliverance’. The truth is it was filmed not far from there. The kids were meeting us in Cincinatti. We were then going to caravan to the woods. I did not know we were starting the descent to the the river Styx yet. That first realization began, as they often do, at a McDonalds.
It was there Charon was waiting.
It was a simple plan. We would stop, void, and get some food for the road. My mother in law wanted only a small water, no ice. She was given a large water with ice instead. She was not happy. I ordered what would later lead to the fourth worst day of my life, a sausage burrito. I loved those things.
I need to explain a few things first. ( visualize an anatomic slide of the upper GI tract appears on screen. I use a a laser pointer). The esophagus is a part of your digestive system. I know this because I am a board certified Obstetrician/ Gynecologist and the esophagus has been used to throw up on me by more than a few patients. It is a tube about twenty centimeters long that is composed of smooth muscle and connects the top of the throat to the stomach. It works by a remarkable process called peristalsis. This action causes the muscle of the esophagus to contract rhythmically to propel food from your throat to your stomach. It works so well that if you ate something while standing on your head, the food would still be pushed to your stomach. A fun thing you can try at your next dinner party.
Now there is more. An important junction between the esophagus and the stomach is the Gastro - esophageal sphincter. This stays closed so that the acid of the stomach doesn’t spill into the esophagus and cause reflux and burning. The sphincter should open when food hits it, then close. At least it should do that according to the manual. (Slide disappears)
Back to McDonald’s. (Produces McDonald’s bag) We pulled out of the driveway and returned to the freeway. I wanted to wait until we got on the freeway to start to eat so I could relax and use the cruise control. I started on the burrito. It was warm, cheesy, and wrapped in my favorite carbohydrate, a flour tortilla. All seemed well until the last bite. As soon as it passed my throat I knew I was in trouble.
It was 11:00 am and the slope to Hades started to incline down.
Level 3 -
The pressure in my chest began almost immediately. It was like a tennis ball that would not move. The pain was amazing. We were on the freeway and I was driving. I had to stop. I had to move the ball. That is the thing about the esophagus, it does not stop working. The wonderful mechanism of peristalsis now becomes your foe. In it’s desire to move the ball, it builds up pressure and when it is not working it will follow the path of least resistance and come back the other direction. I managed to make it to the next exit and pull over and threw up for the first time.
I thought that would do it. Relieve the pressure. It has worked when I have had similar episodes before. And for a few minutes it did. I walked around for a few minutes and thought whatever was in my chest had passed the valve, dropped into the dump truck of acid that is the stomach and move on down the river.
However, most of the debris I was evacuating was saliva, and very little solid material. You make saliva all day and swallow it. It follows the same journey as the rest of your food, lubricating your pathway. When you can’t swallow it too builds up in your mouth like the leading edge of a storm surge telling you a wave is coming.
The waves had subsided some. I thought we could press on. “It will pass now” I thought. We were two hours from home and five hours from our destination. The kids were ahead of us still unaware of what was happening. I knew Colleen wanted to go, but she was sensitive to the situation and concerned. She has seen me do this before and also thought it would pass. When I got back to the car, she had moved over to the driver seat. She looked worried but we couldn’t really talk due to her mother’s mutant powers.
I got in and we drove on. The road was very steep now.
Level 4 -
Women carry the most amazing variety of things in their purses. It is like just going to the store requires the amount of gear one would find on a back packing trip to Thailand. In my mother in law’s case it was snacks.
She too wanted to help and had a non stop commentary that usually started something like, “I have heard that....” then insert something completely crazy.
She began to rummage through her main bag and her auxiliary back up bag - she always has two - to find the treasures of her snack supplies. She would start with her catch phrase then offer gum, a coke for the bubbles, peanut butter crackers, crackers without peanut butter that she stole from restaurants years ago, cookies from Kroger's that no one would buy unless you were eighty four, seltzer water, etc. The sheer volume of food was staggering and she would not stop offering the very thing I could not have, until she completed the inventory. When I would tell her no thank you between waves of pressure she would scoff and say, “Well I heard it works....”
You see my mother in law is a sweet, kind, mildly racist, alternative medicine enthusiast . All of her life her information about the world came from talk radio and later Fox News. What makes her so maddening is that when you present any evidence to her that her view of the situation is bat shit crazy, she refuses to accept it and resorts to the catch phrase, “Well that is not what heard....”.
.
So we loaded back into the car and the doomed expedition continued. The pressure returned with a vengeance. We would make it a few miles and have to pull over again for me to attempt to throw up. I threw up repeatedly across the entire state of Kentucky.
It is hard to throw up and look ‘cool’. It is a repulsive sound and the natural human reaction it to move away. I remember as a young man I was on a date and I was sick. I so wanted to impress the girl so I would make an excuse to go look at something lean against the fence, throw up and attempt to go back. I did not look cool. We did not go on a second date.
So for my poor wife, who was as trapped as I was between the desire to go on and her concern for me, was miserable. Both of us fighting the urge to leave my mother in law at one of the rest stops I was barfing at “by accident”. Each time I was trying to find a way to get away from them find a modicum of privacy to retch in peace. Walk for a bit, hope it would pass as we paddle further down the river into the heart of darkness.
As a physician, I know that there are few diseases more disquieting than those of the intestines. Some of the terrible infectious plagues of the world mostly affect the gastrointestinal system causing everything from intractable pain, obstruction, dysentery, and general misery. Most of the treatments we use are to ease the constant peristalsis action that sends waves of misery through the system. As we traveled through the roads of Kentucky where numerous civil war battles were fought, we had none of those medicines or treatments. Like The confederate soldiers of old, I had to suffer through it, wait for it to improve, or be left by the road to die. It was getting worse and not improving.
I just knew for sure that the crackers my mother in law stole from a Denny’s salad bar twelve years ago was not the answer.
She really, really wanted to help -
Mother in Law: Dr Oz says when you have an upset stomach it is most likely a manganese deficiency.
Colleen: A what deficiency?
Mother in law: Manganese. You know I have chronic pain in my stomach. I have tried the supplements but the dollar store stopped selling them so I have a person that ships it too me in it’s raw state. Dr Oz says that is best (Produces a large rock from her bag) then you chip some flakes and put it into your juicer.
Colleen: Good lord Mom, you are eating flakes from a rock? Where did you get that?
Mother in law: Henry at the Crestwood Apartments orders them for me. He knows ALL about the inter-web. He set up an account for me and I just got my first shipment.
Colleen: Shipment?
Mother in Law: They come in a large crate. Very heavy. They carry it up to my apartment for me. It’s wonderful.
Colleen: We are going to stop this Mom. You can’t eat rocks, even if they are in the juicer!
Mother in Law: Nonsense! That is not what heard. It’s not rocks, it’s manganese!
Glenn: I do not want any of the rock!
Pause
Mother in Law: (scoffs) …well we don’t have the juicer here anyway
It made no sense to keep stopping. I had the original paper McDonalds bag so we resolved to use it as needed and try to press on. General Lee would have been proud. It was going to pass, it had to.
Finally, for a short period of time it seemed to improve and I fell asleep. I dozed fitfully for a brief period of time. My mother in law had reached the bottom of her bag and for the moment ran out of things to say. She was sitting behind me. The peace was fleeting. She leaned forward unable to go to long without talking. She is like a shark that must keep swimming to live. She bumped my chair slightly and warbled, “Glenn are you asleep?”
The tennis ball was still there. Stubborn and unrelenting. But now a new thought grew. “She is eighty four. She has had a good life. We could kill her here and leave her at one of the confederacy grave sites. If archeologists find her she would carbon date to the right era. Except for the Rush Limbaugh pin she wears. It could work and I could then vomit and die in peace”
I continued to fill the McDonalds bag so lost in my illness that I failed to realize it was made of paper. Thin paper. Finally , the contents began leaking through into my hands and shirt further making the horror of the trip more acute. It was then, after over three hours into the adventure that my mother in law produced from her purse a plastic garbage bag.
She said, “Oh my I kept looking around this for the snacks. Would this help?”
We were still four hours from our destination. The brakes were gone, and we were careening down the steep road to the netherworld out of control.
Level 5 -
As we left the now many spots in Kentucky where I marked my passage, we entered Tennessee hurtling towards Knoxville. Here we entered the outer range of the Great Smokey Mountains and the Cumberland Gap. It is challenging country with steep hill sides and narrow valleys. The Cumberland Gap was made famous by Daniel Boone as he lead settlers West out of the mountains to the fertile plains beyond.
What it meant for us was that freeway exits were rare and we were one hundred miles from Knoxville. The pain was not stopping and for the first time in my stubborn mind I contemplated going to the hospital. We were hours from home. We were out of our Obamacare insurance network where we had something like a twelve million dollar deductible before they would begin to help. But as John Adams once said, “Facts are stubborn things”. I was not doing well, trapped in a car in the mountains with a crazy octogenarian and my poor wife who was worried and not knowing what to do either.
Then we saw it.
Ahead of us the traffic in both lanes had completely stopped. We were in the mountains, there was no exits. No way to move forward or turn around. Hundreds of cars and trucks were at a complete standstill. Colleen called the kids who were in the other car and after all the stops were now over an hour ahead of us. She told them “Dad has a little stomach trouble”. I was dying but she did not want to worry them. They informed us they were also in the same traffic jam!
Colleen got a signal and checked google. There was a traffic accident somewhere in the distance and like the peristalsis of my bowels the traffic just kept building up. We were trapped. No way to turn around. No way forward. No exit. Google told us Daniel Boone had died. He was not coming to rescue us.
I summoned my reserves. I now had a plastic bag and in between waves of pressure I tried to rest. I resolved to turn inward and persevere. I will not let General Lee down!
For my mother in law this predicament was not to be endured. One of her favorite polemics is the subject of traffic, how bad it is wherever she attempts to go anywhere and she must know the cause. It is like a personal affront to her sense of regal stature and she will not hesitate to talk about it given the opportunity. As she had for the moment exhausted her health and snack advice she appeared to relish this new subject with an almost Pavlovian glee.
Colleen told her the accurate information from the internet. There was nothing to do but wait. It could be an hour of more. This was not acceptable to her mother. She must know more. So in the maelstrom of her reasoning she reached the conclusion that the huge semi trucks we were parked beside must know more. “They have CB radios!” It mattered little to her that the massive vehicle was just as stuck as we were and even if there were Martians invading up ahead, there was no place to go.
She opened her window, leaned her skeletal body out, shouted to the truck driver to open his window and share the vital intelligence with her. He did not. Colleen shouted at her to get back in the car and promptly activated the child lock control from the front seat. My mother in law sat back in frustration muttering that the traffic was a plot of some kind likely caused by democrats.
I threw up some more.
After awhile the traffic began to move some. We grew hopeful. The map showed a place ahead. It was called Jellcio Community Hospital. We were miles from any other help. We resolved to make for the hospital like a ship looking for a port in the storm. Despite the Harry Potter like name something needed to be done.
We were in free fall now. The road was gone and the abyss lay ahead.
Level 6 -
I need to explain my mother in law’s mutation. Very much like one of Professor Xavier’s gifted students she possesses a unique genetic mutation. It doesn’t matter what anyone one is suffering from, she also will soon develop the same symptoms. Or she has already had the problem and wants to share her ordeal in exhausting detail.
She is an Omega power level in her vampiric hypochondria mutation and it is far and away her favorite subject to discuss. So the more ill I became, the more she would share her own bouts of ‘bowel obstruction’ and how she would treat it with various regimens of alternative medicine quackery. So when we pulled into the Emergency room of this little Tennessee town next to the high school football stadium she appeared to grin. There were new diseases to discover here.
As we entered into the emergency room bay, I began to deteriorate. A huge wave of cramping started and I had my largest emesis episode yet walking to the registration. I could hardly talk. Colleen rushed in and gave the necessary information to the registration clerk who in her Tennessee drawl called back on the intercom , “I need a nurse, we have a pretty sick man up here”
I was escorted back to the triage bay and placed on the gurney. The familiar process of assessment began.
“What happened?”
“Past history?”
“Allergies?”
“Current medications”
“Insurance?.....oh out of state Obamacare...(Pause). Ok let’s move on”
I didn’t know what kind of treatment I would get. I knew it was a small hospital in a little town in the Tennessee hills. The likelihood of specialists being readily available was small. And, as crazy as it sounds, once I got in there I felt better. I thought maybe that last big emesis did the trick. The infernal McDonalds burrito bite and finally dislodged and I was not “Lovin’ It”.
It did not last. The pressure soon returned. The ER physician came in. He was a handsome middle aged man with glasses, a southern drawl, and an excellent bedside manner. He knew I was a physician as well and explained his thoughts on the evaluation.
I am a fifty seven year old man with hypertension and chest pressure that is unrelenting. He wanted to make sure I was not having a heart attack. I was fairly sure it was the burrito, but at this point my confidence was gone and I readily gave myself over to the process. I began to think, “I am going to die in Rocky Top”. Intravenous lines were started, blood was drawn, and EKG was obtained.
I was no longer a doctor, I was a patient.
Colleen was there, looking very concerned. My mother in law lingered at the doorway and declared “I need nourishment “. She began rummaging for crackers then walked into the patient care area looking for prey. She found it. This was the hospital the victims of the traffic accident were brought. Thankfully there were no fatalities. She returned to the waiting room and found a policeman talking to three African Americans and the driver of the vehicle whom she would later describe as a “Druggie”. According to her account the “Druggie” was driving with his leg up over the dash board to stretch out a cramp. He lost control of the vehicle leading to the pile up.
This was like manna from heaven to her. A special treasure that involved traffic, a crazy plot, a ‘druggie”, “black people” all at a hospital emergency room with ill people that she could sense with her mutant powers.
Later I learned when she took upon herself to call the cabin to update the worried Curtis and the rest of my family, who had now arrived, about my condition. She first told them the entire traffic accident tale in exhausting detail. Then as a coda she told them I was being treated for the same thing she suffers from and she can feel it returning. It was Christmas in August for her as she carefully munched on her decade old saltines.
While waiting for the results of my tests the pressure I was feeling that had abated returned. It was not as bad but it was till there. I was vomiting less. There was less to come up now. The ER physician returned. My blood pressure was slightly elevated but the remainder of my cardiac tests were normal. “Better than mine”, he said to reassure me.
It didn’t.
He felt I very likely has what is called a esophageal stricture. This is a scarring or narrowing of the gastro-espohageal sphincter that prevented food from entering the stomach. It was blocked. He offered to give me some medicine that might relax the sphincter and perhaps it would pass. Having no other choice I agreed.
Colleen and I discussed going home. I was worried about how much all of this was going to cost. Everything in American Emergency rooms is an up-charge. Every time the nurse walks into the room to give me anything there is an additional fee. I was sure we were already at several thousand dollars in bills. The sad truth of American medicine is that in addition to trying to recover from your illness, you are being robbed at the same time with absurdly over priced treatments. You are in such a vulnerable state, you have little choice to agree. I am a physician. I knew exactly what was happening.
They gave me the first dose of the medicine. It did not work. They asked how the pain was now on a scale from 1 to 10. I always hated that scale. What the hell is the difference between a “6” and a “7”? So I said when I came in it really sucked. It sucks less now. The nurse actually wrote that down and left. Her husband was the offensive line coach for the high school football game tonight and she wanted to wrap up her shift so she could get to the game next door.
The ER physician returned after I had another small episode of emesis. As I knew, they did not have a specialist here that day that could take care of me. It was his day off and he wanted to attend the football game. We discussed discharging me to drive the 7 hours home or another dose of medicine. I settled on the second round of medicine and we planned to stay at a local hotel tonight and head home in the morning.
Colleen found my mother in law who had wandered into an exam room with some children who had a cough and now she too was developing shortness of breath. Such is the strength of her powers. She wanted o be checked by the ER physician. Colleen took her into the parking lot to take her to the hotel then come back and get me.
A few minutes after she left the ER physician returned hurriedly. He wanted to find me some help so arranged for me to be transferred via ambulance to a bigger hospital in Knoxville an hour away. Knowing the staggering cost of an ambulance, I asked if I could travel by private car. He agreed. I quickly texted Colleen to return. My mother in law was delighted. She wanted to take another pass through the ER.
The ER physician, who lives in Knoxville offered to personally escort us. The idea was the emergency procedure was already arranged, the Gastroenterologist would met us there and I would have a special telescope put down my throat to try to see if there was any obstruction and possibly dilate my esophagus sphincter so I could get relief. They printed my records and handed me a copy of my chest x ray. We walked to the car and were off for the hour ride. I still had the EKG pads on and an IV port in my arm.
We were falling. Darkness was everywhere. There was no bottom.
Level 7 -
We are all going to die. That is the great truth of life. There is no avoiding it. We often avoid thinking about it and stay comfortable in our denial. We all hope it will be after a long life it will be peaceful in bed with no pain and a light above us. We will hear a voice, “Welcome home thy good and faithful servant”.
It is almost never like that. The Bible tells us it will come “Like a thief in the night”. It is never what we expect. It is the protagonist in Gabriel Garcia Marquez’s masterpiece “Love in the time of Cholera” who endures so much only to die ignobly falling off a step ladder. Or the fellow determined to get the coke the machine cheated from him. He reaches in too far and pulls the entire machine down on himself. My father in law who survived cancer surgery and was ready to be discharged home. He has a turkey sandwich the day he was supposed to leave, aspirated and died as my Mother in Law was getting the bags. He was gone in moments.
That is how it will be for most of us.
I worked in a hospital where when I needed to go to labor and delivery to attend to a new birth I would pass through the medical surgical floor. In my hurry I remember looking in a room and seeing an elderly couple. The husband was laying in the bed staring straight ahead with a huge bandage covering his head. The smell of feces was in the air. His wife, with her white hair was gently patting his head with a wet washcloth. No words were spoken. She just looked at him as the last moments of their life together was drifting away. I left hurriedly to deliver a new baby.
It is a wink and that’s it.
We arrived at the second ER. I was taken to an exam room where I expected to be prepped for surgery. A young ER physician came in and proceeded to repeat everything that was already done. I informed him and pointed to the records that we do not need to repeat everything, I do not wish to be charged twice for the same thing. He left and after forty five minutes returned and told me surgery had been arranged and the specialist was on his way.
I signed eleven different forms. I did not have my reading glasses with me and the anti nausea medicine they gave me made my eyes blurry. The forms looked like Viking runes to me. I asked what the last paper was and was told it means you have read and understand everything you just signed.
I love American medicine. The people who took care of me were outstanding, friendly, and completely professional. The system we all work for is obscene.
I was feeling better. Perhaps the second dose I received in the other ER had worked. I asked Colleen if we should just go home. Colleen looked at me lovingly with her worried strained face and told me we have come this far and should see this through. We need to know what is going on.
“Besides”, she laughed softly, “you already signed the papers”.
I was taken to the Surgical suite. Since they perform colonoscopies in the same room I asked that they make sure they use the right tube. The staff all chuckled like I hoped they would, but the Indian surgeon did not. “Of course I will do this” he reassured me.
I was informed they would need to use a breathing tube to prevent me from aspiration. A plastic mask was placed on me that smelled like a beach ball. I was told to breath deeply. I remember hearing the anesthesiologist ask “Are you asleep?”. I could not answer or move. In my mind I said yes and I drifted into darkness.
A moment later I was in back in the emergency room hallway. I had no idea how much time had passed. My throat was very sore. I was told it was a traumatic intubation due to my “small airway”. I wasn’t sure if I should take offense to that or not.
My eyes were very watery. I know now they were tears. My beautiful wife was the first face I saw. She was the only face I wanted to see. I learned that the burrito was gone now. It had likely passed after the second dose of medicine. There was a small amount of scarring and some inflammation. The pressure was gone. I was alive and going to be ok.
The surgeon told me I have to avoid bread for awhile. It is a common cause of obstruction. I contemplated suicide with this news. I love bread.
It was night outside now, but not for me. I walked out of the patient care area and saw three sheriffs deputies talking. It was a Friday night and they had business there.
I shouted “I support medical marijuana!”
One of them looked up and replied tiredly, “Frankly so do I”
At the end of the hallway stood the escalator that would return me to the top and away from the darkness. I was no longer a patient. I was going home.
The next day I was feeling better and we decided to go on to the cabin. There at the top of the escalator from the depths was my family waiting. I hugged them dearly and for far too long. This is all that really matters in your life. If you are looking for the divine, you need only see the people next to you. Everything else is just noise.
We reached the cabin. It was beautiful. The light was everywhere.
Two days later my Mother in law fell and broke her hip.
She is ok now. Nothing can harm her.
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