When doctors and patients bargain over health

Special to The Times

I'm staring at a brand new pet: my lucky turtle. He's sitting on my desk right next to my computer monitor, smiling at me, cheerful and friendly. He's low maintenance, my turtle -- just a little silver charm, a trinket. He was given to me by the daughter of a patient who came to see me recently.

"Floyd," her father [all names have been changed], hasn't fared as well as the turtle.

It started on Monday. He had chest pain and pressure, went to the ER and was sent home with a diagnosis of anxiety. By Friday his pains were worse, so he came in to see me, wondering what else it could be. He told me that he had this pain and pressure, which started in the middle of his chest, then fanned out across both sides and to his back. Antacids didn't help. Lorazepam, which he had been given for his "anxiety," served only to make him sleepy.

All my instincts said to send him back to the ER, and I said so, several times. That's when the dance began. You see, he didn't have insurance and was determined not to rack up another huge bill he couldn't afford on his retired bus driver's pension.

Some people wouldn't care about the cost, figuring someone else eventually would pick up the tab. Not Floyd. He was a proud man. If he ended up with a bill, he was bound and determined to pay it.

He mentioned at least three times how he was still smarting from the $5,000 tab when he went in for an infection on his foot. His final take on that experience was that in the end, they never did get it fixed, and he just as easily could have gone to a family doctor. As much as I appreciated his confidence in us lowly family physicians, I still tried to impress upon him the necessity of having his current symptoms treated by the ER doctors.

He railed against the medical system, how doctors didn't know how much something was going to cost, but surprisingly the exact amount turned up pretty quickly on a bill in his mailbox at the end of the month.

I told him he needed an EKG. He wanted to know how much that was going to cost -- said they dinged him for more than $100 for one in the ER, and the machine did all the work.

Now I felt like a used car salesman -- I had to beat the other price, and did. (I didn't really take a class on this in medical school.) He finally consented, and got the EKG. It had worrisome changes, but he pooh-poohed this news, telling me that the ER doc had said they were there before, that they were no different than those from an EKG four years earlier.

I insisted that he still needed to go back to the ER. Not a chance -- then he went into that bit about it costing five grand for his foot the last time he went in. Not that again.

So I started negotiating with Floyd. He wouldn't go to the ER? Fair enough. Last I checked, I couldn't shackle him and haul him over there. Finally, we ordered some outpatient cardiac enzymes and a chest X-ray. I told him that after I saw the results, I'd call him and make a plan.

A half-hour later, the X-ray report came back looking pretty good. Sigh of relief. Two hours later, the cardiac enzymes came back in the stratosphere -- a clear sign that his heart had been damaged and his symptoms were due to a heart attack, as I had feared. Great.

I called Floyd and got his answering machine, so I tried his daughter, who answered on the first ring. She suspected that Floyd probably had turned off his phone so he could take a nap, and agreed to go fetch him and haul him down to the ER.

By the following morning, Floyd had been through the wringer. He was taken directly to the cardiac lab, where he was found to have four blockages and a huge clot in one of his coronary arteries. The entire back wall of his heart was nonfunctional. The cardiologist put in three stents. Shortly after that, he "crumped," medicalese for going downhill fast. He started bleeding from the site where a catheter had been threaded to his heart for an angiogram and ended up on a balloon pump to keep his blood circulating.

I'm glad Floyd wasn't awake when all this was happening. He'd want to know what a balloon pump was and how much it was going to eat into his retirement. Then he'd want to know about the stents, and complain how a thing so small can cost so much.

The following morning, I swung by the ICU. Floyd was hooked up to a ventilator, clinging to life. Naomi, his daughter, wasn't around. I ran into her in the hospital lobby. She had just come out of the gift shop, stocking up on candy bars, puzzle books and magazines for the bivouac in the ICU waiting area.

And the turtle. Yes, in the midst of her anguish, she had taken the time to think of me and buy me a lucky turtle. She pulled it out of its package and peeled off the price tag. Through tear-stained eyes, she proffered the gift to me, the doctor who told her dad to get to the ER. She told me it was lucky. I was humbled by her thoughtfulness. Here she was, wondering if she was about to lose her dad, and she was kind enough to give me a turtle.

I didn't deserve this. I had tangled with Floyd and let him walk away, back home to take a nap.

I like turtles. From my antediluvian days in undergraduate zoology, I recall that a turtle is a reptile, cold-blooded. But it's not really cold-blooded. When the weather is nice, its blood warms up; when it's cold, it cools down. It goes with the flow.

And that shell. Wouldn't it be nice to have a hard, protective shell to duck into and get away from danger? I like the soft, vulnerable inner part, too. We all need to be soft, able to feel, especially those of us in medicine.

I'm looking at my turtle right now. His smile speaks to his comfort with himself. I wish I had a shell. And boy, do I wish Floyd had one too.

I just got word from the ICU that Floyd is doing a little better. Not a lot, just a little. But small advances are good. They're going to remove the balloon pump. That's a good sign. Maybe Floyd's got a lucky turtle too. He'd have Naomi to thank for that.

Dr. Steve Dudley is a family physician in Seattle.

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