Illegal aliens

I’m guilty of viewing everyone as a citizen of humanity. I don’t give much thought to nationality. But this thing in Arizona brought the whole citizenship concept bubbling up to the top of my frontal cortex over the last few weeks.

And, believe me, this entire issue is not as simple as it sounds. For the record, even though I work in a border state, we aren’t part of the border health system. I’m in the north, where the vast majority of the population are Hispanics that have been here since the Re-conquest in 1693. They have very little in common with Mexican citizens, even speaking a different dialect of Spanish.

That said, we have a sprinkling of non-citizens. Some passing through, some coming to work here. Some legal. Some illegal. The only problem the illegals give me is they can’t get insurance, are generally dirt poor, and don’t qualify for Patient Assistance programs for medications. Treating their diabetes becomes a game of harm reduction using the $4 Formulary at Wal-Mart.

Now, I hear stories of hospital ERs along the border having to close because they’ve bankrupted themselves serving illegals who don’t pay. I don’t even know if that’s true or not. I’ll bet there are urban ERs in cities with no illegals (if there are any such cities) that face similar cash crisis just from uninsured citizens who are forced to use ERs as their primary care physicians.

I think it is easy for many people to get on a high horse about “illegals” and spout off about refusing them health care and sending them back where they came from. On the surface that sounds only mildly cold, but sensible. If we do not really have the resources to help our tax-paying citizens; how can we justify spending money on people who have snuck in, are breaking our laws, and not paying their way?

But not so fast. The world is not as black and white as all that. It is a million shades of gray, and I want to introduce you to just one. And I’ll call her . . . Maria. That’s not her real name of course.

Maria is now 18, but I’ve know her since she was 14-years-old. When I first met her, she was a chubby little thing with significant acanthosis nigricans on the back of her neck. AN as we call it, signals high levels of insulin, which is suggestive of developing insulin resistance and is probably the only visible warning sign (other than obesity) of developing Type-2 Diabetes. It is a dark, velvety patch of skin, and we generally only see it in non-whites. The poor kid was thinking it was dirt and had been trying frantically to scrub it off for months.

Her blood sugar was already in the pre-diabetes range, but not horrible. We decided to approach her problems with the old fashioned diet and exercise approach as she was not happy with her weight anyway. Just cutting out the Cokes took ten pounds off her in six weeks.

But now, four years after I first met her, Maria is back in my office, skinny accept her belly. Her baby is due in late August, and I’m running what we call an Oral Glucose Tolerance Test, or OGTT on her. I use a super-duper accurate blood glucose machine called a HemoCue 201, which is accurate to within 2% of a lab value, to get a base line fasting blood sugar. Then I force her to drink high-tech Kool-Aid, and retest her at set intervals.

It’s the old-fashioned (but standard of care) way to dx gestational diabetes. The process is time consuming, so it gives me a chance to do some health education of a more general sort—like making sure she’s not doing crack cocaine or sniffing glue while she has a passenger inside her body.

She is telling me that she had applied for a job as a maid at a hotel in Santa Fe, but could that they couldn’t hire her.

Oh really? Why not?

She shrugged, “I don’t have a Social Security card, and with the new laws they won’t hire anyone who doesn’t have one.”

Not putting two-and-two together to get four, I naturally assume her parents for whatever reason didn’t get her a card when she was born, so I say, Why on earth don’t you have a card?

“Ummm… well, I’m not a citizen,” she tells me. She blushes, casts her gaze downwards, staring at her hands in her lap.

No shit. I didn’t know that. Well, you grew up here, didn’t you?

“Yeah. I’ve been here most of my life.”

How old where you when you came here?

“Six.”

So, you’ve been here since, like, first grade?

“Kindergarten, actually.”

Do you even speak Spanish?

“No.” She laughs, “well, a few of the ‘bad’ words.”

You and me both!

So the conservative hawks would see this girl deported to Mexico. This pregnant teenager who does not even speak Spanish. This woman-child who did K-through-12 in our schools. This kid whose lived virtually her whole life here.

She didn’t swim across the Rio Grande, or scale a border fence. She isn’t a drug dealer. In fact, she was trying to get a job. A job not too many citizen are interested in having.

Welcome to the real world. Not black and white. Not living color either, but a million shades of gray. A million Marias.

A world that is not as simple as we’d like it to be.

The Red Chair Chronicles

After 30 days, I really didn’t want to go back to work.

I wasn’t ready.

Not in mind. Not in body. Not in spirit.

But I’m also realistic. We do need to eat. To pay for electricity, propane.

And I do need health insurance.

And this is not the time nor the economy to try and find new work.

So… So really I had no choice. But at least I could look forward to sitting in the Red Chair of Courage.

It all started three days before I returned to work last Monday, and it started with batteries. Lots and lots of batteries. I have the TENS unit on for 12-14 hours per day and it is a battery sucking hog, gulping a 9-volt dry every three days.

Unlike AAA cells which can be bought in 20-pound bricks for dirt cheap, the blocky 9-volt generally comes in 4-packs and most definitely are not cheap. Clearly it was time for a battery charger.

After physical therapy, Rio and I headed for Best Buy, but all the parking spots were all taken, and we ended up parked next-door at Staples. Hmmmmmmm… well, Staples might have a battery charger.

The staff, who we must recall are not rocket scientists, directed us to a battery display near the front of the store and told us that was all they had. Later, a check of their web site shows all Staples stores have a good variety of what we were looking for. At the display, there was nothing for 9-volts; but there was a clear line of sight down the aisle that lead to the back of the store.

And from all the way across the store, the bright-red chair caught Rio’s eye. It was a large, modern, executive office chair. Burnished aluminum and red leather. Really, really, really red leather.

Rio just had to sit in it.

So to the back of the store we went. After giving it a test spin or two, he urged me to try it out. I sat down and it was… comfortable.

Damn comfortable.

Now my physical therapist has been on my case to stop “slumping.” I didn’t know I was a slumper, but apparently I am. Still, beats being a slacker. And my super-comfy chair at work is a slumper’s chair. Think bean-bag on wheels. I needed to get something with more back support. Something that would force me to sit up more straight.

The red chair did just that. Plus it made me sit up straight while still being comfortable.

I held my breath and checked the price tag, which was blank. This was clearly a several hundred dollar chair. Or more. I scan the nearby shelves, but don’t see any in boxes. I should just walk away.

But instead we walked to the front of the store. Ummm, hi. There’s this red chair in the back of the store that I’m interested in, but there’s no price tag on it.

“Yeah,” replied a kid who didn’t look old enough to have a job, “it’s thirty-two bucks.”

There must be a red canvas chair or one of those no-better-than-a-stool “student chairs” in the back of the store I didn’t see….. I… I don’t think we’re talking about the same red chair. The one I was looking at is a full sized executive chair. Leather and all.

“Yeah, it’s the display model. We’re clearing it out for thirty-two dollars. Or maybe it’s thirty three. Are you interested in it?

We’ll be taking it home with us.

It turned out to be $32.50, at the cash register the clerk asked how it felt to save three-hundred and twenty five dollars. It feels very good, I told her.

Getting the red chair into the car took some work, but in the dead of night, on the way home, Rio and I dropped it off at my clinic office. He stuck his fingers in his ears because he was sure I’d set off the alarm. Geez, you enter your ATM code into an alarm system one time, and no one ever lets you forget.

Driving to work for the first time this last Monday, my stomach was full of butterflies. One of two things can happen when you’ve been away from your job for a full month. Either people really, really miss you… or they realize that they really didn’t need you around after all.

It turns out I was missed. By patients and by staff (well, all but two staff). My first week back was a blur of 30 minute appointments, half of the time spent trying to explain why I had been gone, reassuring that I wasn’t leaving, and talking about the red chair—which turns out to be a universal hit. People love the red chair.

Different people have added different significance to the red chair. My Mother took it to be God’s way of telling me to stay put. One of my peer educator gang (who are in the know on the real cause of my troubles) views it as a battle flag, a declaration of war, a statement of “I’m staying, just try and make me leave.” Historically, flying a red flag means you’ll “take no quarter.” A pirate ship hoisting a red flag sent a clear message: surrender at once or we’ll kill you to the last man. Santa Anna hoisted a red flag at the Alamo.

Another peer educator weighed in with a different view. She saw it as the red cape a toreador would use in a bull fight. My wife dryly remarked that if I had to resort to slitting a certain person’s throat, at least her blood wouldn’t mar my chair.

Over all, I think the fact that there is a bold new chair in my office signaled to my patients and the staff that I wasn’t going anywhere soon. Why would you buy a new chair if you were leaving?

An interesting collection of rumors had circulated in my absence about why I was absent. Some were obvious: they heard I had quit. They heard I’d been fired. They heard I was really sick.

One person heard I had taken a bunch of things home from my office that didn’t belong to me and that I had been fired. That one was half true. I did take a bunch of stuff, but it was all mine.

I’ve paid for 95% of my visual aids out of my own pocket. I’ve had three offices in five years, each a smaller home at a better address. I’m now in the heart of the action, but it was time to reduce the amount of stuff I have. It is too crowded in my little postage stamp. I took home the stuff I don’t use as often. Like my anatomical model of a Roswell alien (in the three years he’s been lurking with the legitimate anatomical models—a human torso, a pancreas, eye, heart, kidney, and the like—only five people have noticed him).

For the most part, I just used my absence as a teachable moment. I picked up an awesome 3B lower spine model on eBay to help me understand what had gone wrong in my own body. I took it to work, I showed it to people, talked about back pain, and talked about non-medication treatment options for pain like my TENS unit.

Of course some people I couldn’t resist kidding with. About mid-week I was working side-by-side with one of my crew with a particularly gullible patient who I have a good long-standing relationship with. “What happened? Where were you?” asked the patient.

Oh, I got stabbed by a Peruvian Prostitute, I replied.

“Really?” slightly shocked, but not too surprised.

Without missing a beat, my assistant shot back, “No, not really. She was from Bolivia.”

But the apprehension I had driving in that first day back was quickly enveloped in and by the work. The feeling of helping. Of realizing that you are the caretaker of knowledge and insight that others need. That others have no other source for.

I got hugs and “don’t ever leave us agains” from both staff and patients. In addition to the folks crammed into my schedule, patients at the clinic for other reasons on seeing my car in the parking lot, or seeing my long-darkened office now had a closed door, came knocking, just to say hello.

As it so happens, this first week, I only had to interact with the human tumor twice. Both times it went OK, and now she’s gone on vacation for next week.

The paperwork of prior authorizations, insurance denials, and related nonsense was epic. The voice mail and email weren’t too bad. Both systems had filled up in the first week, so they were all old news and everything that came in for the next three weeks was lost so I don’t have to worry about it. I also had to zip out for physical therapy every-other-day for a couple of hours.

The week flew by, and it ended with my favorite activity: solving a medical mystery. Studying a collection of medical evidence that has everyone baffled. Putting together all the pieces, figuring out what is going on, and taking action to solve it.

It started when the patient handed me his meter sheepishly, “I’m glad you like mysteries,” he told me.

Damn straight. At least diabetes mysteries.

I plug his meter into my desktop and download it. And I study the insane menagerie of dots. Looking for patterns or constellations in the night sky of his blood sugar testing.

At first there is nothing. I ask questions. I probe. I let my eyes wander over the graphs, trying to find a clue, a thread, a key to the mystery. If he’s taking his basal at 8am… and the peak excursion is at mid-day, but the morning fasting is way above target even though the hour of sleep number is in range… so why the fuck does…

Then, like double vision, geometric shapes form ghost-like traces, shapes, curves—all overlying the data in my mind’s eye.

Synapses fire deep in my brain, tapping in to the mental data base of all I know and have learned. From nowhere, it seems, the answer flickers for a moment then crystallizes in my mind. In a flash of insight, all the little clues, all the seemingly unconnected bits of information come together.

Suddenly, I know what’s happening. Eureka! Guod Erat Demonstrandum!

The mystery is the perfect storm of unusually short basal insulin half-life in this patient, the timing of his injections, and the over-lapping action curves. It was great. I felt jazzed. Alive.

I lean back in my blood-red chair and smile.

It’s good to be back.

Life is good (again)

It’s early morning. By the weekend we’re supposed to top 100 degrees, but now it’s just right on my back porch. Not too hot. Not too cool. My feet are soaking up a pool of sunshine. My face and torso in the shade.

The sky is clear, dark blue, as we are a mile above sea level. In the distance, beyond the twisting canyons and mesa lands are the purple Sangre de Cristo mountains. On the horizon, the formidable butte called Starvation Peak. The only sound, the occasional high-pitched whine of cicadas. In my desert mind, the sound of summer. The prickly pear cactus are blooming bright yellow, the barrels deep orange.

I’m reading more fiction on my Kindle, taking my doctor’s advice to “take it easy” for a few days. My TENS Unit is cranked up in SDR mode; which stands for Strength, Duration and Rate Modulation. The manual tells me that this means the little 9-volt battery-gobbling machine alternates amplitude and pulse rate in a diametrically opposed way--one increases as the other decreases.

The most important effect is that I feel no pain, rather a series of soft explosions of sensation, starting small and radiating outwards, pausing, then starting again. Today I am wearing rectangular electrodes. Like Goldilocks sampling everyone’s breakfast, I’ve been trying various sizes and shapes of electrode pads. The small round ones and small square ones I find deliver a sharper, more painful sensation. Prickly, if you will. The large butterfly shaped ones are wonderful, but won’t stay stuck to my body right. They tend to crinkle up when I move, lose contact, and either zap! me with electricity or deliver no sensation at all.

None of them have good sticking properties, but today I’m trying an electrode skin prep gel to see if they’ll hold on. Debbie and Rio have been serving as my squires, helping me into my electrode armor every morning, and taping them to my skin with IV3000 bandages to say on. I’m hoping to find a solution that doesn’t involve so much adhesive on my epidermis.

The most important improvement in my life is now that the NSAIDs and Steroids have run their course, I can enjoy my vices again. Last night I had a glass of wine. Tomorrow I’ll have some Starbucks home-brewed French Roast.

But now it is time for a pipe.

I choose a thin, lightly built pipe from Poland, a quarter-bent of dark cherry-colored wood, decorated with thin carved lines resembling tiger stripes. I carefully pack it with jet black Oso Negro tobacco and light the pipe.

Ahhhhhhhhhhhhhhhhhhhhhhhhhh…

Grey smoke floats in the morning air.

Boy have I missed this…

By Monday my immune system will have recovered enough that I can return to the clinic. I’ve missed my work, my patients, and most (but not all) of my colleagues. I’m not looking forward to dealing with the Human Tumor again, but I’m well rested enough to take her on. I’ve decided to regard her the same way I regard insurance companies: a necessary evil that you need to fight every day and give no quarter to. Ever.

Speaking of insurance, however, I was delighted to discover that I have the same insurance plan that Steve Austin has. (You younger readers will need to Google his name to understand.)

Imaging, physical therapy, new tools, new supplies, new meds.

All covered.

Without a fight.

How delightful. I feel Canadian.