28 September 2008

RAY'S SMALL SAPHENOUS VEIN

When Ray was in his early twenties, he discovered that slipping quietly into the neighborhood pub for a cold one was not a great idea. Especially if he was flying solo. The disparity between his height and the relative height of others was, somewhat to his surprise, provocative. Ray is 6'7''. Total strangers have approached him, glaring with rage, and said, "I used to play basketball too, m------------. You think you're better than me!" Even though Ray follows a strict policy of not responding to provocation, the provocation is sometimes immediately followed by a swift kick. Usually the perpetrator is trying for Ray's gonads, but usually the perpetrator is unable to throw a kick that high. The kick usually lands somewhere below knee level. Often the perpetrator is wearing steel toed work boots. Many marks have been left on Ray's legs between the kneecaps and the ankles.

Ray remembers a couple of occasions waking next morning with a nasty purple lump on side of his leg. Now in his late forties, Ray assumes that one of those steel toed impacts ruptured a valve in his small saphenous vein. Ray had noticeable vericose veins before he turned thirty.

Between age eighteen and age forty eight, Ray has had health insurance for 5 out of those 40 years. Recently, because of his pending application with Social Security Disability, Hamilton County JFS approved Medicaid coverage for Ray. A CNP at Alliance Healthcare referred Ray to the vascular clinic at UC. He was scheduled for a preliminary vascular sonogram. A month after that, Ray was at the Vascular Clinic, standing on a 12" high wooden box to facilitate the examination.

The vascular surgeon was Dr. Anne Burrows. She, an intern and a med student all crowded around Ray and whistled in awe when he removed his trousers.

"Got some snakes in there buddy!" the Dr. Burrows announced. She asked about pain, about any lesions or numbness Ray might have experienced.

Ray received a crash course in vericose veins. Nobody chastized him for "not coming in sooner." Most of the patients at the clinic have been waiting for weeks, or in Ray's case months.

The consensus was: the enlarged veins in Ray's left leg would benefit from compression stockings. These are the rubberized fabric "socks" that create more compression in the lower leg, less higher up. They "mimic" the action of the small saphenous vein, the doctor said, although they are no replacement for a healthy vein. Watch out for skin lesions, she said, and pointed to discoloration on the inside of Ray's left leg just above the ankle. "Looks like you've already been there. That's iron staining the skin. It comes from capillaries bursting, and the hemoglobin from the blood leaves iron to stain you like a tatoo."

The doctor talked about skin care, about circulatory reflux, and told Ray they would scedule him for a vascular sonogram. She quizzed Ray on his wound care technique, and he described how he managed with a lesion when it appeared.

"It was two winters ago, when I was still housed. I used this thick clotrimazole cream. It's an anti fungal, but it stopped the furious itching."

Burrows nodded. "Could have been some opportunistic little fungus got in there. Or not. Clotrimazole might kill the odd bacteria as well, and if it stops you from scratching, that helps it heal as well."

Satisfied that Ray was informed, she wrote Ray a prescription for two pairs of compression stockings. Ray made an appoinment with Beth from Compass Medical Supply. Beth came to the Vaz Clinic once a week and fitted patients with compression stockings.

All of this happened in the fall of 2007, shortly after Ray qualified for Medicaid through Job & Family Services. Ray would make three trips, once per month, to the Vascular Clinic, in the belief that Beth the compression stocking lady would be there. She was there, according to Compass Health, the first Tuesday of each month.

But she wasn't. Ray returned in November and nobody the reception desk knew what to tell him. He was not allowed into the Vascular Clinic's suite of exam rooms without an appointment, but he was able to flag down a passing nurse, who told him that she'd heard Beth had jury duty.

Ray returned in December, and again Beth wasn't there. This time, neither the reception desk nor any medical person he chatted up knew anything about Beth's whereabouts.

In January, Ray called Compass Medical on the first Tuesday before squandering his bus fare on a wild goose chase. A very young, very confused woman placed Ray on hold several times to confer with her collegues. She was not able to obtain any information about the mysterious Beth.

In February Ray had an appointment with his C.N.P., Stella Meyer. Stella seemed to remember that Compass used to mail equipment to customers. Ray called Compass later, and a woman told him that this could be done.

"Has Beth ever fitted you before?"

"Ahhh, no. I've tried the last two months to see her --- "

"How about the prescription? Does it include pressure in milliliters of mercury?"

"It does."

"Is it signed by the doctor?"

"Yes it is."

"That's all we need then. You mail it to us, we mail you back your compression stockings."

"Outstanding," said Ray.

"Now all I need is your Medicaid carrier?"

"Amerigroup."

"Oh. I see. Well, I'm sorry sir, but we no longer accept Amerigroup. Have you tried Mullaneys in Pleasant Ridge?"

Over the next few weeks Ray did indeed try Mullaney's, and three or four other vendors of medical equipment. The various reasons they declined to accept the prescription he presented included: The doctor included no contact information, the doctor's signature was illegible, and one vendor even decried the lack of a DEA number. The fact that it was not a prescription for Schedule 2 narcotic drugs, only compression stockings for enlarged veins, was apparently beside the point.

By May, Ray is trying to remember what the point was. Maybe he should just start all over again. So he tries to get another appointment with Vascular, in order to obtain a legible prescription. But the appointment clerk explains that too much time has passed since his last appointment, and consequently he will have to get another referal. He has left voice mails with Stella, requesting that she send Vascular another referal. He enjoys the warmer weather, and wears long pants the better to avoid grossing people out. Ray's small saphenous veins bulge like oak tree roots slowly displacing a sidewalk's concrete. And all Ray can do is what he does best: he waits.

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All original text (C) 2007, 2008 David J. Carney. All rights reserved.

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