Wednesday, June 20, 2012

Patient #5: "Clyde"

     Yes, I do house calls.  I like the change of scene.  Besides, patients are extremely cordial in their own homes and many facts that remain hidden in the office are revealed.
     People don't ask for a house call unless they're pretty desperate.  It's usually a family member who calls on behalf of someone who is too worried about being an imposition to request a home visit himself.
     That was Clyde's case.  
     His family could do nothing with him.  He had been going downhill for months.  At first he didn't want to go frogging anymore.  Even his grandson couldn't coax him into the boat to spear a few, or to catch some bass or bream.
     "I used to make a living on them things," he'd boasted.  "We'd go out at midnight and fill our sacks with 'em, eight hundred frogs at a time, sell 'em in the morning and go home to a big breakfast of grits and eggs,  and lay down to bed."
     "C'mon, Grandpa, don't you wanna go out fishin' with me again?  You got to get well.  Do what the doctors say."
     Soon he didn't want to leave the house at all.  His wife pointed out that he was dragging his right foot as though he had lost the strength to keep the toes pointed forward.  But he hadn't noticed.  He said the shoe was bad.
     His appetite was good, he didn't have any pain, and he was his usual ornery self, so what was everybody complaining about?
     Weeks went by.  He developed headaches.  He'd ask for BC's several times a day.  His legs got so weak that he spent most of his time on the couch. 
     I'd known Clyde for nearly twenty years, but I hadn't seen him at my clinic for over ten.  He'd discovered he had veteran's benefits and was able to go to the VA for free.  Since he'd never had real health insurance this was a boon.  Even though he was 78 years old he wasn't eligible for Medicare because his life of frogging and fishing and cattle-raising hadn't generated enough income for him to pay into Medicare. 
     He lived in a four-room bungalow with a tin roof at the side of the road.  There were children's toys scattered in the yard at all times.  There were chickens and dogs penned up out back.  Sometimes he and his wife rocked in the swing on the front porch.  These days they mostly sat in the living room watching TV. 
     His daughter lived a block away and his grandson and his family had set up house within walking distance.  They all got together every day, catching up on whatever small news might have accumulated, talking about the woes that had befallen neighbors, predicting rainfall, remarking on the status of the lake down the road, the same lake where still lived hundreds of thousands of frogs, and the snapping turtles that ate them, and the alligators that ate the turtles, and the people who ate the gators, all participating in a rural Southern version of the cycle of life.
     His family told him they wouldn't take care of him any more unless he got admitted to the VA Hospital.  I remember Clyde once telling me that he didn't cook.  "That's woman's work!" he had said definitively.  He never entered the kitchen. Was his wife now saying she wouldn't cook his meals? 
     That was how they managed to get him to the hospital.  It's also how he was dragooned into two failed lumbar punctures, attempts at siphoning off a sample of spinal fluid to analyze for signs of infection or cancer.  He insisted on signing out of the hospital after this experience, angry because the neurologist wanted a third try ("It hurt like hell, no way was I gonna do it again!") and homesick. 
     Homesick?  What an odd inference.  But I am convinced this was a big factor in his renunciation of the VA.  No one told him how long he would be staying.  They ran test after test.  He didn't understand their rationale, and there were too many different doctors.  Besides, with the exception of his four years of military service  Clyde hadn't been outside a fifteen mile radius of his hometown (repeat: pop. 120) more than a handful of times in his life. 
     "I ha'int got reason to go nowheres.  What do I got to do with cities?  I got all I need right here!"  
     The VA is stark and chilly, with a blue fluorescent tint and beds that smell of antiseptic.  Even with his wife in constant attendance he felt imperiled.
     So he came home and a week later they called me.  Clyde said the only doctor he'd see was me,  and whatever I said to do, he'd do.  I'm not the kind of doctor who says, "Come to the office for an appointment next week."  Perhaps my boundaries aren't good.  When people call to be seen at the clinic they can always just walk right in.  I told Clyde's daughter I'd finish my kitchen work and be over at 8 pm.  
     The whole family was girdled around the sofa where Clyde lay,  as though embracing him with their vigilence.  I sat next to him.  
     "I bet you ain't never thought you'd see me like this, " he said drolly.  
     His skin was bloated and the color of slate.  His tremulous hand held a urinal in place.  His legs were propped up on a chair;  no one seemed unsettled by his state of undress.  I went through the ritual of the medical exam, as important as a liturgy, carefully checking his blood pressure, pulse, heart sounds, muscle strength, lungs, pupils and reflexes.  I asked him questions about his headaches, vision, gait and memory.  He was bewildered when I wanted to know why his family thought he was ill.  "Nothin' wrong with me...maybe they're the ones with the problem," he answered.  Confabulation is a symptom of dementia.
     Not so long ago he had shouted at his daughter to get out of the way!-- three grenades were being thrown into the room.  She laughed, but he was fervent in his desire to protect her.
     This weekend  Clyde lost the ability to control his urine.  He sat on the sofa in his underwear with a urinal in his hand all day.  He couldn't walk to the bedroom, so his wife simply spread sheets under him at bedtime and tried her best to keep the place clean.  Now he couldn't even stand up.
     Hydrocephalus is a rare condition that can affect older men and is characterized by dementia, incontinence and gait problems.  It is caused by an accumulation of cerebrospinal fluid around the brain--a substance that is normal unless there is too much.  The only treatment, which is curative if done early in the course of the disease, is a shunt that drains fluid from the meningeal sac to the abdominal cavity.  The symptoms of hydrocephalus are caused by pressure on parts of the brain that govern balance, strength, bladder function and cognition.
     I explained to Clyde and his family why it was important to have the shunt procedure scheduled immediately.  While there were other possible causes of his symptoms, such as viral meningitis, HIV, or tuberculosis of the spine, a neurosurgeon might bypass the lumbar puncture in favor of treating his condition quickly.  I recommended an ambulance to the hospital and an appointment the next day with a neurosurgeon.
     As if by magic Clyde agreed.  His family was stunned.  They had been trying to convince him to go back to the hospital all week.  Why don't people listen to their families?  Families are smart. Why was Clyde obeying me, someone he hadn't seen for ten years?  I wasn't even wearing my white coat--in my hurry I hadn't changed out of my gardening clothes.  
     "Don't ask me," his wife said, smiling. 
     When the paramedics arrived I asked Clyde if he understood what was happening.  Maybe he just hadn't grasped what we had arranged for him.  
     "You're gonna take a big hose and stick it in my head, and drain off the water like a swamp," he answered, "so I can go fishing again." 

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