We realize that in the first two parts of this book, we threw a lot of information at you, the beleaguered reader. We thought it important to explain why the US health care and insurance markets are in such a dismal state, so that you could understand where they’re heading.
Now that we’ve established our foundation, in Part III we are ready to explain how you can save yourself from falling into the trap that threatens to engulf so many Americans. As a transition from our historical and economic analyses in the previous parts to the individualized how-to manual here in Part III, this chapter offers a parable of Ken Korg, a middle-aged American husband and father who is about to have a dreadful experience with the US health system—one that will only become more typical as the years go on.
Readers of the The Primal Blueprint by Mark Sisson will recognize the name “Korg” as the mirror image of “Grok,” the ancestral human whose diet and exercise habits offer clues for regaining our health today. When we first meet Ken Korg, he is the opposite of his forefather Grok. As we’ll soon see, Ken Korg has fallen into the self-destructive diet and lifestyle patterns that plague so many modern Americans. Yet because Ken lacks the historical, economic, and medical insights that we have already discussed in the first two parts of this book, he is initially completely unprepared for the challenges he will encounter.
Keep reading to learn Ken’s fate, so you don’t have to repeat his experience.
Ken had been feeling run down for some time. Life had been unusually hectic lately, and despite a downturn in the economy, Ken had landed a promotion. In an attempt to prove himself worthy (and out of fear of being let go), he was working 60 to 70 hours per week. The kids were older now, but being understanding of Mom and Dad’s stressors was not one of their advancements. Everything they desired was more expensive, they were involved in even more activities, and their school (the best that could be afforded) was 40 minutes from the house. Mrs. Korg was also preoccupied with her business, and it was all they could do to keep up. Family meals were a rarity, as everyone was late or in a hurry getting where they had to be (and trying to beat the traffic).
Ken wondered how long he could continue this way. In the morning he was almost too exhausted to function, and in the evening— after checking email and surfing the Internet—he was “wired but tired,” unable to fall asleep until after 1 a.m.
It was during one of these sleepless nights that he realized he had been feeling even worse than usual over the past few days. He had been in a fog, his vision was blurry, and was battling a vague, persistent sense of nausea. It was the kind of nausea that made him feel like he needed to eat something, but whenever he did, it only added a sense of bloating on top of the queasiness.
As Ken lay in bed thinking about it, he became more worried and felt the nausea rise up in a wave. He got up and tried to calm himself. He ate a spoonful of peanut butter and blasted some whipped cream into his mouth. This seemed to settle him down, and he transiently felt a wave of sleepiness, so he went back to bed. As he crawled into the cool sheets, Ken thought, “If I can fall asleep right now, I can get five solid hours of sleep.”
And then it hit him. A sudden, sharp, stabbing pain in his right flank that was so severe that he thought an intruder had stabbed him.
As he jumped out of bed from the most intense pain he ever experienced, something unexpected happened: it got even worse. The pain brought him to his knees and was accompanied by sudden and profuse sweating, as well as a massive wave of nausea that culminated in a fountain of vomit so forceful that it actually came out his mouth and nose simultaneously.
Mrs. Korg awoke to the commotion to find Ken writhing on the floor in the disgusting mixture of his evening meal and the recently consumed peanut butter and whipped cream. She asked Ken what was wrong, and he honestly replied, “I don’t know, but I think I am about to die.”
Just then, Ken was hit by another wave of pain. This one was even more intense, and the location of the pain had changed: it was very low in his abdomen and radiated into his right groin. It literally felt like his right testicle was being crushed with a pair of vice grips. He immediately crumpled to the floor.
Mrs. Korg called EMS.
It was about 1:45 a.m. when Ken was wheeled through the ambulance entrance of the ER. Still writhing in pain, he thought, “At least at this hour, the place will be desolate and I will be seen immediately and get something for this pain.” What Ken saw instead looked like a disaster zone. The place was completely packed; every room was full, and stretchers with sick and injured people lined the halls. The paramedics stopped in the middle of the hall with Ken, waiting to be acknowledged.
He continued to writhe and vomit until finally the paramedic got the attention of one of the nurses. The nurse interrupted the ER doctor, who appeared to be arguing with someone on the phone. The doctor quickly listened to the nurse, turned toward the paramedics with a look of “just shoot me” on his face, and said, “Give us a minute to find another stretcher and we will make a hall bed for you.”
Ken was moved from the ambulance stretcher to another small stretcher against the wall of the hallway. On either side of him were other patients in hall beds. One was a large man with an orange jumpsuit, handcuffs, ankle cuffs, and a large gash in his forehead. Every time someone walked past, he would scream obscenities and try to fling blood at the passerby. The other patient was an elderly man, weighing all of 80 pounds, who appeared to be actively dying, with slow, feeble, gasping breaths. Between waves of pain, Ken heard one of the nurses say, “Yeah, he was on home hospice, but when he started to die, the family freaked out, revoked hospice, and called the ambulance.” Intermittently, a nurse or doctor would come by and stroke the man’s hair and give him something through his IV.
After what seemed like an eternity (actually about 15 minutes), one of the doctors walked up to Ken with a touchpad and said, “Hi, I’m Dr. Leslie.” Without asking a single question or laying a hand, he continued, “Looks like you’re passing a kidney stone; have you done this before?”
Ken responded “no” while the doctor briefly poked his belly and then gave a gentle thump to his right flank with his fist. This thump mysteriously sent a wave of pain from his flank, around his side, into his lower abdomen, and then finally concentrating in his testicle, accompanied by a brief episode of dry heaving. The doctor ordered some IV pain and nausea medicine (Toradol, Morphine, and Zofran), along with a urinalysis and a CT scan. The nurse was at the bedside with the medicine even as the doctor was ordering it; apparently they had done this before.
As the drugs were given, Ken had almost immediate and complete relief from his pain. Ken thought silently, “Thank God for modern medicine.” As the nurse withdrew the syringe from the IV port, she commented, “Your blood pressure was really high; we’ll recheck it after your pain is controlled.”
The remainder of the ER visit went fairly smoothly. Ken provided a urine sample (which came out the color of iced tea), and returned with lots of blood cells but no infection. The nurse rechecked Ken’s blood pressure and found it high at 182/94, but much improved from the 205/110 reading when he first arrived. The nurse suggested he get it rechecked at his family doctor (which he didn’t have), as it may just be “white coat hypertension” or the chaotic environment in the ER.
The doctor came by and told him the CT scan showed a 3 mm kidney stone lodged at the entrance to the bladder. Apparently the stone passed through the kidney into the tube that connects to the bladder. It was the movement of the stone through this very small passageway that caused all his pain. Currently it was stuck at the entrance to the bladder, which is the smallest portion of the ureter. The doctor felt it should pass without complication and offered to provide medicine to relax this passageway, along with prescriptions for pain and nausea medicine.
By this point, the ER had actually started to clear out and the doctor was able to take more time with patients. He pulled up a rolling stool to speak some more to Ken. Mrs. Korg and the kids, who had ridden in the family car while the ambulance wheeled Ken away, were finally allowed to come back, as the crowds had cleared enough to not have to worry about violating any federal privacy laws.
The doctor informed Mr. and Mrs. Korg that in addition to the kidney stone, there were some incidental findings that would need follow-up. The doctor inquired about Ken’s use of alcohol, because the CT scan showed evidence of fatty liver. Ken said he only had a couple of beers or glasses of wine a week, but the doctor seemed skeptical because the condition is most commonly seen in alcoholics. In addition, the CT uncovered the presence of some gallstones in his gallbladder, but there was no evidence of inflammation. Nonetheless, Dr. Leslie was providing referral to a surgeon. Along with the gallstones, Ken was to also have the surgeon comment on the incidental finding of a 1 cm nodule on the tail of his pancreas. This was likely nothing, but it would need to be “evaluated” because there was some chance of this being cancerous.
When Ken received his discharge instructions, he was told to follow up with his family doctor to recheck his blood pressure and to begin a workup of his fatty liver. In addition, he had a referral to the urologist for the kidney stone and a general surgeon for the gallstones and the nodule on his pancreas.
Ken was happy to be out of pain, but he found himself wondering how he was going to fit all this into his already overburdened life. Further, he tried to remember the particulars of his insurance policy, as he handed over a credit card for a $500.00 “co-pay” that the discharge clerk told him his policy required. Ken wondered what other surprises would be coming in the mail and how he would afford it.
On the way home, they swung through the drive-through pharmacy and ended up paying $180.00 for the prescriptions because they were not covered by his insurance plan. The Korgs got home just before the sun came up. Mrs. Korg called Ken’s boss and let him know he would not be at work today. Ken crawled into bed and fell asleep, unaware that his adventures were just beginning … unaware that he had fallen into the belly of the beast.
Ken awoke around 1:30 p.m. to the ringing of the doorbell. Apparently, his wife had called the carpet cleaning service to come over and steam clean the vomit out of the bedroom floor. Ken got up and served himself some coffee, adding a splash of non-dairy creamer and a packet of artificial sweetener. As he shook off the cobwebs from the night before, he began to look through the Yellow Pages for a primary care doctor. It was assumed at the ER that he had a primary care doctor, but that wasn’t the case. The kids had their pediatrician and Mrs. Korg relied on her OB/GYN for most of her medical needs, but Ken had not had any medical needs up until now.
Ken began by calling the offices that were geographically closest to home. For the first office, the phone rang about seven times before it connected to a voice menu. The menu offered nine different choices that did not fit Ken’s need. The last choice was for those seeking to become new patients. Ken pressed “0” and was connected to some horrible background music and a pleasant voice that assured Ken, “We value your time and appreciate your patience.” Ken held on line for about 20 minutes before he gave up and went to the next office in the Yellow Pages.
It took two more identical attempts before he connected with a real human at the fourth office he called. The receptionist seemed to be caught off guard, and was curt and irritated. Ken surmised that she had picked up the wrong flashing line by mistake. She asked if Ken could hold, but Ken immediately responded “NO!”, and the receptionist realized she would have to see this one through. She asked Ken what health insurance he had. Up until the previous night, Ken would not have known offhand, but after answering that question a dozen times by this point, he was able to immediately answer with the name of his provider. The receptionist, seemingly relieved, informed Ken that their office did not participate with his insurance.
Ken asked what this meant, and the receptionist explained that as out-of-network providers, they could still see Ken as a patient, but his out-of-pocket costs would be much higher and he would have to file all insurance paperwork himself. The receptionist recommended against this as she jokingly told Ken that in their office’s experience, his particular company was notorious for providing shoddy customer service. Ken empathized.
He thanked the receptionist, but asked her advice for how to find a primary care doctor who would take his insurance. She told Ken to check with his HR representative at work; they could tell him which providers were “empaneled” with his company’s insurance. Ken thanked her and hung up.
Ken then decided to try to contact the offices of the urologist and the surgeon that the ER had referred him to for follow-up. Again, there was more hold music, reassurances about the value of his time, and a long phone menu. This time there was no option that fit Ken’s needs, but a reminder that a proper referral from a primary care provider or the ER was required, and a warning that if you are having trouble to go to the ER or call 911. Ken continued to try to get through several more times that afternoon, until finally the phone menu connected Ken to an answering service; apparently the office had closed. Ken thought he may have found an end-around to the byzantine phone service, but was disappointed when the operator could only contact the on-call doctor if Ken was a current patient of the practice. Ken hung up on the operator in disgust.
Just then he felt a twinge of pain in his groin. Not wanting to experience pain like the day before, Ken took one of his prescribed Lortab 10 tablets and waited for relief.
With the evening setting in and Ken’s pain subsiding in a narcotic fog, he and Mrs. Korg and the kids hopped in the car to get some dinner at McDonald’s. As they were eating, Ken noticed a pharmacy next door. He decided to check his blood pressure on the machine at the front of the store. Maybe now that things had settled down, his blood pressure may have normalized.
After the cuff finished deflating, Ken stared at the red numbers on the screen: 186/94. He decided to buy a home monitoring blood pressure machine so that he could keep an eye on things until he could see a doctor. Maybe the machine at the drug store just needed calibrating.
As Ken searched the shelves for a blood pressure monitor, he felt the familiar sensation of heartburn after his meal of chicken nuggets and fries. He purchased some Prilosec-OTC along with his blood pressure machine and then went back out to the car where Mrs. Korg and the kids were waiting. Mrs. Korg, seeing the package, asked, “What is that?” Ken answered, “You don’t want to know.”
That evening, Ken set up his home blood pressure machine and took several readings before bed. Most readings were in the 180s/90s, but two were around 190/110. Ken decided to do a little Internet research on blood pressure before going to bed. He read about the long-term risks of hypertension, but most sources reassured him that if he was asymptomatic there was no need for emergency evaluation. As Ken felt another twinge of pain from his kidney stone, he reminded himself that pain (or just having a kidney stone) may be driving his blood pressure up. He went to bed around 11:30, resolving to visit the urologist’s and surgeon’s office in person (thereby avoiding the phone labyrinth) to arrange his follow-up. He would also drop into HR to get a list of “preferred providers” so he could establish a family doctor.
Unfortunately, Ken could not fall asleep until after 1 a.m. Unbeknownst to him, the bright blue spectrum light from his computer screen had disrupted his melatonin secretion, which made it nearly impossible to fall asleep.
Ken woke to the sound of the alarm on his iPhone at 6 a.m. He felt hung-over and groggy. He popped a dark roast coffee into the Keurig. When it was done brewing, he threw in some non-dairy creamer and poured in a couple of packets of sweetener. As he drank it, he experienced a little rush of euphoria and felt the cobwebs dissipate. He made another cup in a travel mug and left early for work, without breakfast.
As he drove, he checked his email and calendar on his iPhone. He was excited to see that a two-hour meeting for later in the morning had been cancelled. Ken decided to use this time to drop into the offices of the urologist and the surgeon to arrange his appointments. This would dovetail nicely into lunch. Ken got to work and arranged an appointment with his HR rep at 1:15 p.m. He would be able to get his appointments, have lunch, and line up a family doctor all in one swoop.
Ken’s morning went fairly smoothly and was topped off by the likely passage of his kidney stone. As he was getting ready to leave for the urologist, he felt a sharp twinge in his testicle and thought, “Oh no!” He went to the bathroom in case he got sick. He attempted to pee, and felt the pain increase and then suddenly release. As he began to pee, he noted that he was peeing almost pure blood. Then it turned the color of iced tea, and then turned pale yellow. As he finished, he felt some burning and a tiny black speck came out and stuck to the side of the urinal. Ken surmised that this was his kidney stone. He could not believe this tiny thing that looked like a speck of pepper had caused him so much misery. He thought about trying to retrieve it, but decide that was too disgusting and flushed it down the urinal. Ken muttered “good riddance” as it swirled away.
Ken left the building with a new lease on life, knowing that his tormenter was gone.
Ken’s first stop was the urologist’s office. After a dizzying attempt to navigate the medical center’s many parking lots, ambiguous signage, and multiple directories that gave no hint of which way to turn for a given room, he finally made his way into the correct office. Inside, the waiting area was full and a queue of people hovered near the receptionist’s window. As he dutifully waited his turn, he looked around the room and noted that the patients waiting seemed bored and annoyed. Old magazines were strewn about and the TV was playing the Dr. Oz show.
Once Ken reached the front of the line, he noticed the receptionist seemed to be ignoring him: she was preoccupied with her computer screen, tapping it repeatedly. After a few minutes, she seemed to complete her task and finally looked up at the exact moment he was glancing at his watch. She registered a look of contempt.
Ken relayed his situation, explaining that he needed to schedule an appointment. The receptionist asked Ken why he had not called to make an appointment. Ken, now irritated, pointed to the bank of flashing phone lines and stated that he had tried for an entire day, but could not get through. The receptionist stared for a moment, and then opened up another window on her computer. She pushed a clipboard filled with forms towards Ken and instructed him to “get to work filling these out” while she began to search for an appointment. Ken could detect a sense of urgency in her voice.
It was almost lunchtime when Ken completed the forms—a lengthy “Notice of Privacy Practices,” a slew of insurance questions, and a very small section requesting his clinical information. She smiled and told Ken that the next available appointment was in six months. Ken expressed his disbelief while the receptionist glanced over the forms he had filled out. She seemed relieved as she looked at them, tapped some more on her computer screen, and announced that she could fit him in six weeks. It seemed that the urologist was an in-network provider.
As Ken left the office, he realized his last similar experience was at the DMV. Nonetheless, he felt a sense of victory as he walked toward the elevator towards his next appointment at the surgeon’s office.
It was 12:30 by the time Ken left the medical center, feeling famished. Realizing that he was not going to have time for the drive-through, he stopped at the nearest convenience store to grab a meal bar and a diet soda.
Ken unwrapped the meal bar as he drove off for his meeting at HR. Ken arrived a few minutes early, so he read an old copy of Men’s Health while he waited to be called in. He perused articles advising him how to get “shredded” in six weeks, how to drive his wife crazy in bed, how to relate to his kids, and how to fine-tune his retirement portfolio. Ken felt inadequate. He rolled his eyes and thought, “I can’t even get a damn doctor’s appointment in six weeks, much less get ripped.”
Ken was called into the HR manager’s office. Ken briefly explained his situation and the difficulty he had trying to find a family doctor. Ken told the HR rep that he thought having health insurance meant that his medical bills would be covered, and consequently, finding a doctor would not be a problem. The HR rep simultaneously closed his eyes and rolled them upward. He apparently had heard this before.
He explained that in order to keep their health care costs down, the company sought bids from competing insurance companies. The company selected the bid that provided them the lowest premium costs possible. The insurance company used the low bid to entice most of the employers in the region into contracting with them. Having secured most of the “covered lives” in the region, the insurance company then used their market share in negotiations with the hospitals and doctors in the region. Since the insurance company had captured almost all of the people in the region who were likely to pay their bills, they were able to negotiate rates that were barely above the hospital’s and doctor’s cost of providing care. Those who could not (or refused to) operate on such a tight margin were the out-of-network providers. If Ken selected someone in network, his insurance would pay the total bill after he paid a co-pay that varied based on the situation (routine visit, emergency care, or preventive care). If Ken selected someone “out of network,” the co-pay still applied, but in the case of his policy, only 80 percent of the in network rate would be paid, and Ken would be responsible for the rest.
Ken’s head was spinning.
The HR rep handed Ken a list of providers that looked like a Chinese restaurant menu. There was a long listing of in-network providers and a much shorter listing of out-of-network providers. Ken scanned the list. It showed the name of the practice, the name of the doctor (or doctors), the address/phone number, the insurance accepted, and finally the amount of time one would have to wait for an appointment. More than half of the practices listed were followed by the statement “not accepting new patients.” The remaining practices all specified that they did not accept Medicaid and were not accepting new Medicare patients. The few practices that took Ken’s insurance had a wait time of four to six months. The out-of-network providers showed wait times of four to six weeks.
Ken asked the HR rep why he shouldn’t just schedule with an outof-network provider, saying “paying 20 percent of the bill wouldn’t be too bad.” The HR rep reminded Ken that the 80 percent that was paid was 80 percent of the discounted amount that in-network providers had agreed upon, and that this amount was barely above operating costs. The bill from the out-of-network practice would be much higher, so Ken would not just be paying the 20 percent, he would also be paying the difference between the discounted and actual rate charge by that practice. Further, most practices required that he pay this on an up-front basis, or on the day of service. The HR rep explained that the practices that simply filed insurance and then later “balance-billed” the patient found that those bills rarely got paid. Most patients just assumed that insurance was covering their visit and were perplexed when a large bill arrived many weeks later.
Furthering the confusion was the fact that both the insurance and the practice sent a statement of what was paid and what was owed, and it was very hard to interpret what was a statement, what was a bill, and how much was paid or owed. The HR rep showed Ken that most of his remaining appointments were with employees who were turned to collections by medical practices because the ensuing confusion had resulted in the balance of their bill not being paid. A couple of employees were having trouble securing a home loan because of being reported to credit agencies showing up on their credit report. The HR rep strongly recommended Ken select an in-network provider just to avoid this kind of headache.
Ken explained that he had issues with high blood pressure and fatty liver and didn’t know if it was safe to wait that long. The HR rep suggested Ken secure an appointment and perhaps go see a doctor at the urgent care or ER in the meantime. Ken mentally performed a face-palm as he took the list and shuffled out of the HR rep’s office.
Ken got back to his office with about 20 minutes to spare before his next meeting. He looked over the list of practices he got from HR. He thought about the advice he was given about staying in network and decided to start calling some offices on the in network column. He looked them over and started with the office closest to home. The phone rang several times, and then connected to the familiar menu and the pleasant voice assuring him that his time was valuable. He “pressed 5” on the phone menu to schedule a new patient appointment. The mailbox was full and could not accept more messages. Ken returned to the phone menu and “pressed 0” to wait for an actual human. After 10 minutes, Ken had to give up to make it to his meeting.
Ken was preoccupied throughout his meeting. He could not believe that all of his efforts resulted in an appointment with a urologist in six weeks for a kidney stone he had already passed, and an appointment with a surgeon to see about gallstones and a spot on his pancreas that he never even knew he had. Furthermore, he still had not secured a family doctor to address the more basic problems of high blood pressure and the mystery of his fatty liver.
At more than one point, Ken was asked by the chairman of the meeting, “Ken, is this boring you?” Ken was dying to answer honestly, but instead he said, “No sir, I’m sorry.”
By the time Ken got out of the meeting and was packing up to go home, he felt so agitated that he realized that this was probably driving up his already high blood pressure. Ken resolved to put it out of his mind for now. Realizing that any help with these issues was going to be weeks or months away, Ken also resolved to take things into his own hands. He needed to lose weight and to eat healthier.
On the way home Ken ran by the grocery store to peruse some of the low-fat, low-sodium microwave dinners. Perhaps he could use these as a first step to lowering his weight, getting the fat out of his liver, lowering his blood pressure, and perhaps even making his gallstones go away. He looked over his options and chose a couple of weeks’ worth of sub-500 calorie, low-fat, low-sodium entrées that were approved by the American Heart Association.
Ken awoke the next morning in his usual groggy state. He decided to check his blood pressure on his home monitor. He tried to perform some deep breathing and relaxation before he actually pressed the button to start the machine. Once he reached his “moment of Zen,” he pressed the button and awaited the reading. He looked at the results on the LED readout. The numbers 178/92 were staring back at him. Ken became determined to get an appointment with a family doctor today.
When he got to work and settled at his desk, he dialed the first practice on his list. Again, he waited patiently as he listened to the voice menu. Eventually he “pressed 5” to be put in the queue to schedule a new appointment. Knowing that this would not be answered quickly, he put the phone in speaker mode and went about his tasks.
Ken was feeling quite productive and had almost forgotten about the hold music that was providing the background noise for his morning’s work. He had even forgotten that he had been holding most of the morning, but was abruptly reminded when the repetitive music was interrupted by a voice that said, “Sunnyvale Family Practice, can you hold?” Ken snatched the phone off the receiver and yelled, “NO! I’ve been holding all morning.” It was too late: the hold music was back on before he could finish his sentence.
He must have been heard, however, because the woman’s voice came back on line in about 30 seconds. Ken explained his situation and his need to establish a family doctor. Silence. About 10 seconds later, the woman on the other end asked Ken about his insurance. Now a veteran, Ken was quick to respond as he already had his insurance card laid out on the desk in front of him. Ken gave the name and policy number, and heard the tapping of keys in the background. Ken inferred he had finally given some information that this person cared about.
After about three minutes of key tapping, the receptionist announced that she could get Ken a new patient appointment in six weeks. Knowing that this was as good as he could hope for, Ken pounced on the appointment. He was reminded to bring all of his insurance information and to fast after midnight the night before in case his provider needed to order any blood work. Ken was thrilled and thanked the receptionist, who in turn flatly thanked Ken and said, equally as flatly, to have a nice day. Ken hung up the phone and thrust both fists in the air in triumph.
But his sense of victory faded quickly as the thought entered his head: “How messed up is it that I am this excited to get an appointment six weeks away for what could be a serious problem?” Ken still felt good. He had done the right thing. He would be getting proper health care.
It was six weeks later, and the night before the appointment was tough. Starting around 1 a.m. Ken was restless and hungry. He was also “wired and tired” as usual. He very much wanted a few tablespoons of peanut butter and a blast of whipped cream, but he was supposed to be fasting. As a result, he was unable to fall asleep. He was worried about what the doctor would say and if anything serious was going on. He tossed and turned until Mrs. Korg kicked him out onto the couch.
The alarm on his iPhone went off at 5:30 a.m. Instinctively, Ken swiped the face of the phone and shut off the offensively cheerful marimba tone of the alarm. He felt absolutely hammered … and hungry. Despite the instructions not to eat or drink anything before his lab work, Ken rationalized if he did not have a cup or two of coffee he would likely fall asleep at the wheel. Ken threw a breakfast blend into the Kuerig and added some Coffee-mate and Splenda to the cup.
Ken arrived at the hospital and came into the front entrance. It was a beautiful lobby with hardwood floors, lined with vibrant paintings of local landmarks on the walls. He asked the very nice retired lady at the volunteer desk for directions. To his surprise, she actually walked him down the corridor and around the corner and said, “Just beyond that row of planters to the right.”
Ken felt upbeat as he headed down the hall, but as he approached the row of planters his heart sank. In the waiting area were at least 40 bored and angry-looking people. When he reached the front of the line for the reception desk, he gave his name and birthdate, and was strapped with a wristband before being handed the familiar privacy papers and consent-for-treatment papers he had signed at the other offices. He then looked for an open seat that was not too close to anyone that appeared contagious.
As he sat watching CNN and flipping through outdated copies of “O” magazine with Dr. Oz on the cover, Ken realized, to his relief, that this was a shared waiting area for the laboratory and the radiology department. Ken was called back fairly quickly. A heavyset girl asked him to take a seat in what looked like an old school desk. She snapped a blue rubber tourniquet around his arm, pushed on a vein in the crook of his elbow, and swabbed it with an alcohol prep. Ken’s heart raced as he prepared for a needle poke. She approached the area with a plastic tube with a needle on the end. Ken turned his head. Suddenly he felt … nothing! Damn, this girl was good! She shoved glass tubes inside the plastic tube and they rapidly filled with his blood. She snapped the tourniquet loose and taped a cotton ball over the puncture site. She said, “You’re good to go, the results will be at your doctor’s office in about an hour or so.” Ken glanced at his watch. Plenty of time to drop by Starbucks.
After scarfing down a grande latte and a large blueberry scone, Ken drove to the doctor’s office holding his iPhone on the steering wheel, watching the blue dot that represented his car until it met up with the red pin that represented his destination. The building was in a small complex of doctors’ offices. The parking spaces were almost all full and the landscaping was untended and overgrown with weeds. Ken found a parking space and walked to the door marked “Sunnyvale Family Practice.”
Ken walked through the door into the waiting area. Everything looked familiar. There were about six people in the waiting area. The way they were seated suggested only three patients, each with a family member. The office was filled with old chairs arranged in groups of three or four with beat-up end tables. On the tables were even older magazines: WebMD, “O,” and Prevention seemed to dominate. Two-thirds of the magazines had pictures of Dr. Oz on them. The TV was playing (you guessed it) the Dr. Oz show.
Once it was his turn, the nurse led Ken into a cubby where she took his temperature, weight, and blood pressure. She shook her head at him and made a “tsk tsk” noise when the LED readout showed 183/94. Ken explained that was why he was here, along with the fatty liver. The nurse tried to make Ken feel better by suggesting he might have white coat hypertension. He didn’t bother to tell her he was getting similar readings on his home BP monitor. From there she escorted Ken to an exam room and asked him to strip down to his underwear bottoms and place the gown on with the opening to the back, and that his provider would be in shortly.
Thirty minutes passed and Ken was getting uncomfortable on his perch at the end of the exam table. After 45 minutes, Ken decided to get up and study the anatomy chart hanging on the back of the exam room door. Sure enough, as soon as Ken got close enough to read the lettering on the anatomy chart, the door burst open and nearly hit him in the face.
Ken jumped backwards and felt the cold air rush up the back of his gown. The young lady that opened the door looked visibly irritated that Ken was not on the exam table. Ken shuffled back to his proper place, being careful not to expose his boxers in the process. Once Ken was seated, the young lady introduced herself as Nancy Jones, the nurse practitioner. She explained that she would be performing his initial history and physical exam and that she would be managing his care with input from the doctor. Ken was tempted to say that he had expected an appointment with the doctor, but did not want to rock the boat or insult the nurse practitioner.
The nurse practitioner pulled what she called a “cow” (computer on wheels) up to the exam table and began to ask questions. Ken watched as she ticked off boxes on the computer screen. She did not look up as she asked questions in a rapid-fire manner; most of the questions were of the yes-no variety, and there was not much opportunity to really tell his story. He had a fairly clear view of the screen that she was working on, and found himself disturbed that she was filling in elements of the physical exam even though she had not yet laid a hand on him.
When she was done tapping on the computer screen, she began her exam. She briefly looked in his eyes with an ophthalmoscope and then used her stethoscope to listen on either side of his neck, and then briefly on the front of his chest. Ken found it odd that she had tapped on the body diagram on the computer screen in areas that were not examined. She had entered information on the abdomen, back, and extremities but did not actually end up examining him in these areas. Ken decided to shrug it off.
She then pulled up the results of Ken’s lab work and clicked on what he presumed were the abnormal results. When she finished, she told Ken that his blood potassium was a little low, and that his blood sugar was moderately high. His total cholesterol was elevated, as was his LDL and triglycerides. She also said his HDL or “good” cholesterol was not as high as she would like. She explained that he would need to be started on medication for his blood pressure and his cholesterol, and that his fatty liver was due to his elevated cholesterol.
The nurse decided to start Ken on Prinivil (Lisinopril) to lower his blood pressure and Lipitor to lower his cholesterol, and gave him a pamphlet to guide him on the dietary changes needed to improve his blood sugar and cholesterol. The pamphlet looked familiar and included a shopping list that matched what he was already attempting (including the Healthy Choice and Lean Cuisine microwave meals he had already suffered through). She then abruptly got up, shook Ken’s hand, and left the room, stating that the nurse would be back shortly with his papers and to help him arrange a follow-up in four to six weeks. She told Ken he could go ahead and get dressed.
Just as Ken got his pants up, the nurse returned with his prescriptions and some computer-generated instructions about hypertension, elevated cholesterol, and the low-fat diet. She had already arranged an appointment date in four weeks. Ken didn’t even bother to check his schedule to see if the date was compatible, as he was fearful of losing his appointment. As Ken was leaving, he ran into the doctor in the hallway. He was dressed in jeans and a bright red Hawaiian shirt. He sported a ponytail and an earring. He was friendly and shook Ken’s hand, welcoming him to Sunnyvale Family Practice.
In the weeks that followed, Ken was feeling a little bit more upbeat. He began taking his blood pressure and cholesterol medicine and was doing fairly well with his low-fat diet. His enthusiasm to get better made him able to surf the waves of hunger that hit him throughout the day. Instructions he received during his kidney stone follow-up revealed that his new diet—low in sodium and fat—already put him on the right track for preventing future kidney stones, and that he didn’t need to do anything different. His blood pressure was also trending down nicely, measuring 122/73 at his latest check on his home monitor. Ken finally felt like he was getting on top of his health, and might actually get to see the kids grow up, get married, and have children of their own.
While Ken was pleased with his progress, and his numbers looked better on his home blood pressure monitor, he couldn’t help but notice that he just did not feel that good. His muscles ached as if they had been beaten with hammers, and he felt quite weak, especially in his hips and thighs. It was hard to stand up out of a chair without the assistance of his arms. Ken was also having bouts of weakness and shakiness combined with the sweats. It felt like his blood sugar was dropping. Ken was very disciplined with his low-fat diet, and these spells represented the only times Ken was falling off the wagon. When Ken had these spells, the only thing that seemed to help was to scarf down something sweet. These spells were not particularly severe, but their frequency seemed to be increasing.
The other thing Ken noticed was that his libido was gone. Recently, Mrs. Korg, happy that Ken was taking charge of his health, announced that she was feeling amorous. Ken was pleased to oblige, but found himself completely unable to do so. They shrugged it off to fatigue from work and all of the scrambling around to meet appointments, but Ken secretly worried that he would be back at the doctor’s office begging for a prescription for a certain little blue pill.
A few mornings after Ken’s epic fail in the bedroom, he awoke with a funny sensation of tingling in his lips and tongue. Ken crawled out of bed and went into the bathroom. When he looked in the mirror Ken could not believe the image staring back at him. His lips were massively swollen, and his swollen tongue was protruding between them. He screamed to his wife: “Dit in heah!” Mrs. Korg walked into the bathroom and, oddly, her first reaction was to laugh because Ken looked so ridiculous. It did not take long for her to stop laughing and to become concerned. She asked Ken if he could breathe OK. Ken replied that he was having no problem breathing, he just couldn’t talk right. They both realized that if the swelling got much worse, breathing might become a real problem. Mrs. Korg called the Sunnyvale Family Practice on his behalf, since Ken’s tongue was interfering with his enunciation. She surfed the automated phone menu (which started off with “if this is an emergency, hang up and dial 911”) for five minutes and then held for 10 minutes. When she got through, she explained the situation to the receptionist and asked to speak to the doctor. The receptionist advised her that the doctor was unavailable and that she needed to go directly to the ER or dial 911.
Once they arrived at the ER and walked up to the registration desk, the clerk’s eyes bugged out almost as big as Ken’s lips. She immediately called the triage nurse to the front. Ken became more concerned when the battle-weary nurse’s eyes also bugged out and she immediately walked him back into the ER. Ken was surprised at how many patients were in the back and how much activity was going on, since the parking lot and waiting area had been almost empty. As the nurse walked past the central workstation, she tapped on the glass and pointed at Ken’s face. One of the doctors looked up from the computer that he was engrossed in and immediately jumped up. Now Ken was really worried.
Ken was brought into a large room and told to sit on the bed. The nurse and an ER tech quickly pulled Ken’s shirt over his head and applied three sticky pads to his chest. The tech hooked a red, black, and white wire to the sticky pads and put oxygen on his nose while the nurse put an IV in the crook of his left elbow. Ken could not believe the size of the IV needle, and clamped his butt cheeks together as the nurse forced what felt like a pencil through Ken’s skin.
The doctor was standing at the foot of the bed and called out to the nurse which medications he wanted. The nurse seemed to ignore him, and it was evident to Ken that she was already three steps ahead of the doctor. The orders seemed like just a formality. The doctor introduced himself as Dr. Leslie, and Ken tried to lisp that they had met before when he had his kidney stone. The doctor ignored Ken’s attempts to speak and tried to use a tongue depressor to look in the back of his mouth.
The doctor asked the nurse to bring a “Krike Tray” and a “4 Shiley” to the bedside and he pulled out a Sharpie pen. The doctor touched Ken’s neck, tracing his index finger from the notch of his Adam’s apple and then down a short distance to his windpipe. He then took the Sharpie and marked the skin where his index finger was resting.
Dr. Leslie explained that he had just marked the cricothyroid membrane that resides between the Adam’s apple and trachea. If Ken’s swelling suddenly increased, and they had to perform an emergency procedure to secure his airway, the precise location for the incision would be marked ahead of time.
The nurse opened a large surgical tray next to him. Ken’s heart raced as he looked at the scalpel and surgical instruments. As the doctor explained that he was having an allergic reaction called “angioedema,” the nurse poked him in the arm with a shot of epinephrine while another nurse pushed a steroid called Decadron, along with Benadryl and Pepcid, through his IV. The doctor explained that this allergic reaction would most likely not respond to the medicines they had just given, but they still give them on the off chance they may help.
Ken’s head was spinning, and he tried to think of what he may have eaten or come in contact with that could have caused this. Just then Dr. Leslie asked him, “Are you on any medicines whose names end in ‘pril’?” Ken thought for a moment and then realized that his blood pressure medicine was Lisinopril.
When Ken told the doctor, he stated that this was far and away the most likely cause of his angioedema. Dr. Leslie explained that his airway was already quite swollen and that they would be watching it very closely. Dr. Leslie said that if the swelling got any worse in the next half hour, he would recommend an elective intubation—a procedure where he would receive sedation, an instrument would be used to expose his vocal cords, and a plastic tube would be placed in his trachea; he would be on a ventilator until the swelling went down. Dr. Leslie also explained that the swelling of the tongue and lips makes this procedure much more difficult than usual, and this is why the cricothyrotomy tray was sitting next to him. If things worsened and they could not get the breathing tube in, they would make a surgical incision in his neck in order to get his airway secured by that route.
Dr. Leslie tried to be reassuring by telling Ken that these were all just preparations for a worst-case scenario, and that in most cases the swelling would just subside on its own. Ken was not feeling that reassured.
Over the next two hours, Ken sat in the gurney and stared at the cardiac monitor. Mrs. Korg sat in a chair next to the surgical tray that was covered with a green towel. Ken was scared that his heart rate never dropped below 120 on the monitor. Every 15 minutes or so, the doctor would come in and look at his airway. Ken watched through the door as the ER descended into chaos. Paramedics passed by with stretcher after stretcher of some of the sketchiest looking people he had ever seen. It looked like everyone came straight from the “people of Walmart” website.
After two hours, Ken’s lips and tongue started to shrink. The doctor was pleased, but wanted to watch Ken longer to make sure he didn’t rebound. Within another hour and a half, Ken’s lips and tongue were back to their normal size.
Dr. Leslie had already paged the on-call doctor for Sunnyvale and told them what had happened. It had been decided that Ken would be taken off the Lisinopril, and that he would be listed as allergic to ACE inhibitors. In its place, Ken would be started on HCTZ (hydrochlorothiazide) along with a low-dose potassium supplement. Dr. Leslie wrote for a one-month supply of Ken’s new medicines and had already arranged a follow-up for recheck at Sunnyvale in three weeks. Ken was disconnected from everything and discharged home. On the drive home, Ken was picking the monitor pads off of his chest when he realized his appointment with the surgeon was tomorrow morning.
Ken went home and had a Healthy Choice microwave dinner while the kids chowed down on the Chick-Fil-A they had picked up on the way home. It took all of Ken’s willpower to eat the rubbery green beans while smelling the delectable odor of French fries and fried chicken strips.
By the time Ken finished scanning the Internet about pancreatic nodules that night, he was terrified and struggled to fall asleep.
Ken was dreaming about his appointment with his surgeon when the marimba tone went off on his iPhone alarm in the morning. He dreamed he was told he had pancreatic cancer and had months to live. As he slowly woke up, he worried that he might be like Randy Pausch of “The Last Lecture” fame. Ken tried to put it out of his mind as he went through the motions of getting ready.
At the surgeon’s office, Ken had barely gotten situated on the exam table when the door burst open and a tall, elegant gentleman in a white coat walked up with an outstretched hand saying, “Hi, I’m Dr. Parker.” Ken shook hands, and silently worried why he was seeing the doctor instead of a nurse practitioner. Did this mean that something serious was afoot that warranted actual contact with the doctor?
Dr. Parker explained that he had looked at his CT scan and had seen that he does have some calcium-containing gallstones, but the gallbladder showed no signs of inflammation. As he talked, he simultaneously laid Ken back on the table and poked and prodded his belly. Dr. Parker went on to explain that he also saw the nodule on the tail of his pancreas. His voice registered an air of embellished concern that spiked a rush of fear in Ken.
Dr. Parker pulled Ken back to a sitting position and seated himself on a rolling stool at the foot of the exam table. Ken was sitting above Dr. Parker, looking down on him. The meaning of this positioning was almost palpable. Dr. Parker started with some reassurance, stating that it was unusual for pancreatic cancer to appear in this location and that the nodule did not have a typical appearance for pancreatic cancer. Dr. Parker had assumed (correctly) that Ken knew the gravity of that diagnosis. He went on to explain that it may be a benign incidental finding, but it could also represent other types of cancer such as lymphoma.
Finally, Dr. Parker noted that this had been discovered incidentally on a renal stone CT scan that images in 5 mm slices. The fact that the slices were so big creates an opportunity for the computer to misinterpret as it reconstructs the data into two-dimensional images. He therefore suggested repeating a CT scan on a machine with more imaging detectors and with thinner slices of 1 mm. Dr. Parker also recommended that Ken get his study done at an outpatient imaging center rather than at the hospital. He felt their equipment was superior, and the cost was much less than what the hospital would charge.
Dr. Parker walked Ken to the front desk and signed a request form, telling the receptionist to schedule Ken’s CT scan. The receptionist asked what times were best for Ken while she was waiting for the phone to pick up at the imaging center. Within a few minutes, Ken was scheduled for his CT scan for the next day and for a follow-up appointment with Dr. Parker in one week. She said that Dr. Parker would have the results called to him, and that he would call Ken with results and any further instructions.
Ken left the office concerned, but impressed with how smoothly everything went. He got the distinct impression that the surgeon was used to getting things his way. The response from the outpatient imaging center was much more like Nordstrom’s compared to what he experienced trying to arrange his appointments. His upbeat mood faded, however, when he began to notice the aching in all of his muscles and how generally fatigued he was. Ken reflected on the fact that, while he was not feeling well when this all started, he actually felt better when his blood pressure was high and his cholesterol was untreated.
When Ken got to work, the first thing he did was rearrange his schedule to allow for his CT scan the following morning. His boss and the secretary were visibly irritated. It was clear everyone was getting tired of Ken’s medical issues. Ken silently worried that his promotion, or perhaps even his job, might be in danger. But the possibility of pancreatic cancer weighed heavy on Ken’s mind, and he realized that he had to do whatever it took to get this issue resolved. Ken dragged through the rest of his work day, distracted by what tomorrow would bring.
Ken showed up at Valley View Imaging Center at 9 a.m. He was expecting the usual waiting room and registration process. However, when he walked in, he almost wondered if he was in the wrong place. The interior looked much more like a high-end law firm that you see in the movies. The floor was a beautiful hardwood, and the furniture looked like it belonged in a mansion. Gone were the rows of Office Depot chairs and out-of-date magazines. Instead there were leather couches and chairs with glass-top coffee tables and end tables. There was an incredible selection of up-to-date magazines ranging from Sports Illustrated to Architectural Digest, none of which had Dr. Oz’s face on the cover. The TV was a gigantic flat screen hanging on the front wall. There were several aquariums with exotic fish. Ken walked up to the desk and was immediately greeted by a well-dressed receptionist. The only disappointment Ken had was being handed the usual privacy disclosure and insurance forms.
Ken sat down and quickly filled out the papers. He did not have much time to enjoy the luxury, as he was called back within a couple of minutes. The radiologist briefly introduced himself as Dr. Harvey and explained the procedure. He told Ken that an IV would be started to give contrast that would make the blood vessels and blood flow easier to visualize. He asked if Ken had any allergies, especially to iodine or seafood. Ken stated that his only allergy was to ACE inhibitors and recounted what had happened to him. The radiologist stated that this should not be a problem, especially since this was a known side effect of the medicine and not necessarily a true allergy. He asked if Ken had any questions, but after his renal stone CT at the ER, he felt like he knew the drill and he told Dr. Harvey, “Nope, let’s go.”
Ken lay down on the CT scan table and the technician started an IV in the crook of his left elbow. It was minimally uncomfortable. The tech hooked a coiled tube to his IV that led to a large plastic bottle and plunger apparatus that looked like a giant syringe. Ken was then shuttled back and forth on the sliding table, while the gantry on the giant donut he were sliding through spun in circles. Ken felt as if he was being prepared for time travel.
After the technician got all of the necessary coordinates, she warned Ken that he was about to receive a “test bolus” of the IV dye. The coiled tubing shook a little and Ken felt a warm flush at the IV site running up his arm, followed by a metallic taste in his mouth. The tech asked Ken if he felt OK, to which Ken answered “yes.”
The tech told Ken that the scan would now commence. A computerized voice said, “Hold. Your. Breath,” while a Pac-Man-like icon on top of the passageway into the donut appeared holding its breath. The coil of tubing shook and Ken felt an intense fluttering at the IV site. He then felt the warm flush of the contrast run up his arm, then into his neck and chest. He got a more intense metallic taste than he experienced on the test dose. As the full contents of the giant glass syringe emptied into his body, he slid through the donut hole on the table. The warm flush of the contrast spread throughout his body, tracing the blood vessels along the way, finally culminating in Ken’s groin with a sensation as if he had just peed his pants. As the warmth of the IV contrast faded, the table slid back out of the donut hole and the test was over.
The tech told Ken, “Just relax a minute while I check the quality of the images.” Ken lay quietly on the table, hoping that the test would bring good news. Just as the tech walked in to ask how Ken was feeling, Ken got the intense sensation of ants stinging his scalp. Before Ken could assess what was happening, the sensation spread into his neck, as well as the bend of his knees and elbows. By the time the tech arrived at the side of the scanner, Ken felt an intense burning and itching all over his body and he felt like a boa constrictor was around his chest. Ken looked up at the tech, and was alarmed when the tech actually said out loud, “Oh shit!”
At this point, Ken felt his windpipe suddenly narrow down to the size of a coffee swizzle stick. Between the weight of his chest and the narrowing in his trachea, Ken could barely breathe. He looked over at the technician, who had stumbled backwards and was frantically hitting a large red button on the wall. Ken could not talk, but looked at the technician with eyes that pleaded “please don’t let me die.” The tech’s eyes were as wide as saucers, and they in turn pleaded “please don’t let him die.”
Ken turned all of his attention inward. His total being was focused on moving air in and out. He did not think of Mrs. Korg. He did not think of the kids. All he could think about was moving air back and forth through a tiny passageway. The radiologist came into the room and announced that 911 had already been called. The tech opened a small Tupperware box and drew up a dose of Benadryl and gave it through Ken’s IV. Ken started to develop tunnel vision, and all of the commotion became a distant noise, as if he were hearing it all from underwater. Ken could feel his life slipping away. Flashes of his past went through his consciousness like a highlight reel, and he felt as if he were floating up out of his body.
Ken’s vantage point for the entire drama unfolding vacillated between lying on the CT table and floating in the corner of the room. He watched with a now detached interest as the paramedics came into the room. They felt for a pulse in his neck and noted it was barely palpable. They argued briefly about whether to give the epinephrine through the IV or IM. They immediately decided to give it IM and go to IV dosing if it didn’t work. They then rapidly gave an IV steroid (solumedrol), put on an oxygen mask, and started another IV. Two large bags of IV fluids were attached and each paramedic squeezed a bag to increase the flow of fluids into Ken’s body.
The first thing Ken noted was that his attitude was no longer detached. He now cared about the outcome. Even before re-entering his body, Ken decided then and there that if he got through this, he was never again going to engage the medical system. Just as he began to wonder if he was in the bargaining stage of death and dying, he felt his consciousness being sucked back into his body. Suddenly everything was integrated again and the commotion rose to full volume. Ken took his first deep breath in what felt like an eternity, and everything around him seemed to be in a state of relief. One of the paramedics announced that his blood pressure was 100/56 and his pulse oximetry was now 95 percent. The other paramedic listened to his lungs and noted the wheezing, though still present, was much improved.
Ken was moved from the CT table to the ambulance stretcher, carried hammock-style in the sheet he was lying on. The radiologist and the tech walked out to the ambulance with Ken and the paramedics. Dr. Harvey told Ken that his wife had already been contacted and was on the way to the ER; Mrs. Korg apparently had reassured Dr. Harvey she knew the route there. As Ken was pushed into the back of the ambulance, he made another decision. Not only would he never enter the belly of the medical beast again, he was going to take charge of his own health. He didn’t know exactly how, but he new that he would find a way. He had done a test because he was worried he might be dead in a year, but nearly died today. He had gone into the abyss and came back, and he thought to himself: “I’m done with this shit.”
“If everyone was as healthy as you I’d be out of business.”
