The Disappearing Patient

CHAPTER 1

The occupational therapist Ella May Swaezy, looked out through the clinic door into the hospital hallway. The transportation assistant was wheeling Mr. Elderberry into the clinic. Mr. Jeffery Elderberry was making his first visit to the occupational therapy department. He had been evaluated by the acute care OT, Mary Owens, shortly after he was transferred from the Intensive Care Unit to the regular Mill Crossing Hospital ward. But that was more than a week ago. Mary had written in the chart that he seemed unaware of why he was in the hospital though he was aware of his inability to use his right hand. His clinical picture had puzzled the doctors. He didn’t seem to have had a stroke or visible trauma. They had considered having him medivaced to the University Hospital on the other side of the state however, his fiancee’ and mother had been persuasive about the benefits of keeping him near them. The young foreign physician, Dr. Ranini, had been putty in their hands. He had followed their requests and transferred Mr. Elderberry to the regular hospital floor from Intensive Care Unit when he regained consciousness after 12 hours in ICU. The mother had signed an assurance that she would personally be responsible for any cost not covered by his Blue Cross/ Blue Shield insurance.

Mr. Elderberry was the adopted son of Mr. Winston Elderberry, banker and Mrs. Roberta Weiner-Elderberry, past president of the Altrusa Club. They had been unable to have children of their own. When Mrs. Weiner-Elderberry reached age 42, her husband who had always catered to her wishes, agreed to adopt a 5 year old grand-nephew who was orphaned when his parents were drowned in a boating accident on a reservoir. He had had the advantage of private schools as many white children in the South do.

When he reached the rebellious teens, he decided he would rather go to college as far away from his adopted parents as possible. Because of his outstanding scholarship in high school, he had his pick of most colleges. He chose the University of Alaska at Anchorage as that was as far away as he could get and still be in the United States he thought. He was unaware that the University of Hawaii was even further west than U of A. When it was pointed out to him, he explained that he was afraid living on an island would be too confining. He had excelled in his studies because of his affinity for the marine animals he worked with. Coming home to a job with horses and cows was a little difficult, but not nearly as difficult as living with his parents. He had decided to live with them until he could get on his feet. Financially, because of the availability of the special program and his liking for the professor, he had majored in biology with a specialty in Marine Mammals. He had wanted to go on for a graduate degree but his banker father had said he would no longer be responsible for the cost of his schooling. After a month of angry telephone calls, he apparently came to a peaceful acceptance of this situation and returned to his southern hometown to accept a job as an assistant to the large animal veterinarian. His mother had secured the job for him through her friendship with the veterinarian’s wife, also an Altrusa Club past president.

The occupational therapist, Ella May Swaezy, remembered Jeffery Elderberry though she had attended public schools. They had met during joint youth meetings of the local Southern Baptist churches. Ella May had viewed those teens who attended private schools as somewhat exclusive and had kept her distance from them at the church youth conferences. She thought they probably thought she was of a lower class because of her public school education. Her rather liberal parents had made a conscious decision to enroll their three children in the 90% black public schools. Mr. & Mrs. Swaezy had come to the South from Omaha, Nebraska when he was offered a lucrative job as a pharmaceutical salesman on a route through many rural counties and towns in several states. They had felt the small town experience would benefit their three children and chose to settle in Mill Crossing a small city of 20,000 population. Ella May had had her own experiences with rebellion. She felt her parents interfered in the public schools more than they should. They were always attending school board meetings.

Ella May reviewed the available information, which she had picked up from the chart and from small town gossip as she watched Jeffery Elderberry wheel himself slowly over to the adjustable therapy table. He seemed to be using the ham of his right hand to help to propel the wheelchair. Ella May made the quick observation that his wrist and forearm did not appear to be affected by his hand paralysis.

Since it was her first encounter with Jeffery, she decided she must do her own evaluation of his condition.

Hello, I’m Ella May Swaezy. I will be your occupational therapist working with you to help you get your hand functioning again. Ella May reached out and took his right hand from where it lay on the arm of wheelchair. It felt normally warm to the touch. She went on to explain that she would be examining his hand in order to determine which direction they ought to go with his therapy. Ella May seldom worked with complex cases, as they were usually taken to larger more, well-equipped institutions. Her usual caseload was stroke patients, arthritis sufferers and a few car accident victims. Consequently, she had gotten down her textbook on treatment techniques and reviewed the section on evaluation of the hand. The book lay nearby under a cushion. She didn’t want the patient initially to be aware that she was not confident of her skills. After they had become a little more acquainted with each other, she would feel OK letting him see the book. But she had made a list of things she needed to test for and that list lay beside her on the mat.

Skin condition & color

Edema

Hand odor

Skin elasticity

Contractures

Bilaterality (ADL)

Mobility

Deformity

Range of Motion Pain

Temperature

Touch-Pressure

Two point discrimination

Grip & pinch strength

Moberg Pick-Up Test

Proprioception

She always automatically evaluated psychosocial issues with each patient, too, so she did not need to put that on the list. That had been drummed into her during her classes in occupational therapy school.

She first began to query him about when he first discovered the paralysis. Meanwhile she kept his hand up on the therapy table, informally testing his range of motion as she gently moved the joints of the flaccid hand. She was aware of the time passing as the rehabilitation unit coordinator had only last week reviewed evaluation and treatment unit costs.

I first noticed that my hand wouldn’t work when I awoke the morning after my fiancee’ and I had gone out to the reservoir to go skinny dipping. We got into an argument there, about the kind of wedding to plan. Ella May felt surprised at his candidness as he hardly knew her. It usually took patients a longer time to warm up to the occupational therapist and begin to share private information like this.

Ella May had reached out and taken his other hand in hers, as well. He seemed to hardly notice that she was now holding both his hands. The left hand seemed to tighten as he discussed the argument. Jennifer wants to have a big wedding and asked me to talk to the pastor about using the First Baptist Church so we can ask more guests rather than have it in the First Presbyterian Church where her family has always attended. I don’t want to have such a big wedding. We can get 300 people in the Presbyterian Church. But she wants to invite all her sorority sisters, about 35 cousins, second cousins and their families, both our whole high school classes and all the members of both our churches. That, in addition to both our families, makes about 500 people. First Pres just won’t hold that many. She wants to have six bridesmaids, which means I’ve got to have six attendants, too. I just don’t want that much fuss. In order to stop arguing, I opened a bottle of wine I had in the car. We drank the whole liter. It did stop the argument. But by the time I awoke next morning, my hand wouldn’t move. At first, I thought it was just asleep, that maybe I’d laid on it. But after about half an hour, when I couldn’t even get a tingling feeling in it, I really began to worry. That’s the last thing I remember before trying to stand up and feeling myself falling.

Ella May had picked up a pencil and was pressing it various places on his left hand. She encouraged him to go on talking, as she knew when he was concentrating on talking, he would be less likely to pay attention to what she was doing and consequently try to influence her findings. When I didn’t show up for breakfast, my mother came up to call me and found me lying on the floor by the bed. She called the ambulance and they brought me here to the hospital. The first thing I remember was coming to in the ICU with old Doctor Morton poking me with a safety pin. I found out that he’s the only neurologist here in Mill Crossing.

Jeffery slowed down after a seemingly pressured and rapid fire telling of his story. Ella May lay his hands back in his lap and looked him full in the face. You haven’t responded to any of the ways I’ve been touching your right hand. Your left hand seems to react normally but just nothing from your right. But everything else about your right hand seems to be normal, no swelling, nice and warm, no tight joints. Do you have any idea at all about what the problem could be?

Jeffrey’s greeny-hazel eyes met hers. I have no idea, but I know it does mean I can’t go back to work at the vet clinic. You’ve got to have two hands in handling big animals.

Ella May asked him if Dr. Morton had discussed his electromyogram with him yet. Jeffery said, No, I haven’t seen Dr. Morton today. Isn’t this his day to go over to Bostina to that rural health clinic?

Since Ella May had paid little attention to Dr. Morton’s extracurricular plans, she had no idea that he had such a schedule. Generally, she didn’t feel she traveled in the same social world as doctors and their wives so she seldom listened when they discussed such events while writing their notes and orders in the chart room. She shook her head to indicate a negative response to Jeffrey’s question. Her thoughts distracted her for a moment from the patient as she remembered reading in the chart that his electromyogram was normal. Now her findings also showed that his whole hand seemed to lack feeling and motion. With the stroke patients she usually saw, there would be some part of the hand that had partial sensation or responded to her touch. She wanted to tell Jeffery that his case didn’t seem to fit into any pattern, but she knew she couldn’t do that. She’d be in big trouble if she undermined the doctor’s prerogative to tell the patient what was wrong with him. Jeffery didn’t seem to care much anyway. He didn’t indicate any impatience to have a diagnosis. As Ella May wound up her evaluation, she told Jeffery that by tomorrow she ought to have some idea about how they should proceed and that she’d discuss it with him then to see if he thought they were aiming in the right direction. She went over to the wall phone and paged transportation to take him back to his room. As the transportation assistant wheeled him out, Jeffery turned and waved his waist level floppy right hand at her while pushing the wheel with the left.

Puzzled by the whole encounter, Ella May moved slowly toward the chart room. She seldom communicated verbally with the docs so she began to plan how she would concisely write what she had found. Somebody she didn’t know was looking at Jeffrey’s open chart. The man was a lab tech that Ella May had seen at an inservice on the new fire regulations. She said to him Are you going to be using that chart long? He closed the chart and handed it to her without speaking. He got up from the swivel chair and left the chart room. Hum, she thought to herself, That’s strange. I’ve never even seen him in here before. He usually never leaves the lab except for lunch. But time