Short Order Medicine:
Short Stories for People With Short Attention Spans

Chapter Eleven: Pearl

I first met Pearl Webber in my family practice in 1978 when she presented with back pain. Several years before, she developed sciatica that brought her under the scalpel of the orthopedic surgeon who happened to be available at the time, Dr. James Knoles. As is often the case after back surgery, she had some temporary improvement, only to be followed by steady worsening and increasing disability. Unfortunately, she developed her back problems during the era before CAT scans became the diagnostic standard so she was subjected to painful myelograms (x-ray dye injected into the spinal canal) on several occasions. With the myelograms came the headaches, and with endless back pain, came increasing use of narcotic analgesics. Her myelogram showed increased disc disease so she had a second operation by Dr. Knoles, without much benefit. She first came to our office about a year and a half after her second surgery. Initially, it wasn't clear why she was coming to our practice, other than not wanting to endure the half-hour drive down the road to see her orthopedist. I came to learn, after a few visits, that Pearl could no longer see Dr. Knoles because she claimed he had fondled her repeatedly during physical exams. She claimed that he had her remove all of her clothing for a back exam and in the course of testing the motion range of her joints, his hands and pelvis totally inappropriately contacted her body and the exams lasted quite a long time. Most of us are used to performing back exams in one to two minutes (range of motion, leg reflexes, strength, straight leg raising, sensation, usually suffices). A five to ten minute exam in the loosely gowned nude with groping breast palpation and truncal contact seemed to be unprofessional if not criminal misconduct. Of course, I couldn't be sure that this desperate patient in pain might have fabricated much of this story but the chickens would come home to roost. Within one year, I saw two other patients who claimed to have been fondled by Dr. Knoles. Their stories were consistent and before I had to decide what to do with this information, the case hit the local newspaper. Over twenty women came forward with claims of sexual abuse at the hands of Dr. Knoles. He was tried, convicted, and his career promptly ended. Pearl’s back was no better for the resolution of this case.

My partners and I discussed treatment options for this unfortunate patient and after unsuccessful trials of physical therapy, we agreed that we had no choice but to help with pain relief, using narcotic analgesics. Even on large doses of oral narcotics, including morphine, Pearl continued to complain bitterly of her suffering and asked if we could refer her to a neurosurgeon who could cut the sensory fibers in her spinal cord to get pain relief. She stated that she would rather be wheelchair bound than endure a life of pain. As it was, she walked using wrist canes and whenever she came to the office, she would need to be brought back to an exam room without delay because she could not tolerate sitting in the waiting area. This occurred during the era when patients could be admitted to hospitals for back pain, just for pain management. These patients would be put in traction, given Demerol injections, and have heat pack treatments by physical therapists. A typical stay would be one to two weeks, and several weeks of weaning off Demerol to milder narcotics would nearly always be a problem. On one occasion, Pearl did so poorly with in-patient care, and appeared so totally unable to care for herself further, we sent her to a nursing home on oral morphine for what was essentially palliative care. Pearl was about thirty-five at that time, looking at a short sad life with no future. She wanted her spinal cord severed.

Coincidentally, Pearl's daughter presented to the emergency department with complaints of back pain. Paula was about twenty years old at that time and had what seemed to me to be a back strain. Because of everything I had been through with her mother, it was nearly impossible to offer narcotic analgesics to this young woman. My quandary was solved when her husband, Pete, who went by the nickname Bip, angrily demanded that I give her Percodan (strong, addicting narcotic) for her pain. I tried to explain her case rationally to both of them, but his violent demeanor made it much easier to simply refuse his demand on the basis that it was not appropriate treatment for Paula’s condition. He dragged her out of the ER threatening to take her elsewhere, which was fine with me, but he also snarled at me "I'll see you in your grave, Sterngold." This was the first threat to my life.

Having my life threatened by a psychopath was an interesting side effect/liability of my work. The principle emotion it evoked was anger. I was also frightened, as I was quite aware of the potential reality of mortal threats. When I was a medical student at Stanford, during a Christmas party, a resident physician was shot in the chest by an angry boyfriend of a woman with whom he had innocently danced. Even though he was wounded within minutes of surgical care from Dr. Norman Shumway et. al., the finest surgical expertise in the world could not save him. A large caliber bullet transected his aorta. Perhaps surgical care within seconds of the injury could have saved him, but minutes were too long. A wife and baby survived him. I had a wife and babies during this time in my practice career, and my instinctual buttons were pounded by Bip’s threat. I took out a permit to carry a concealed weapon and became quite competent with a .357 Magnum. I had NO desire to take another life, or even to shoot anything other than targets and tin cans, but I had to address my insecurity in some meaningful fashion and this worked for me. I had made my police reports about Bip, a character with whom they were all too familiar, and although they tried to be reassuring about the probability of attack, I spent the next year or two paying a lot of attention to my peripheral vision. Nothing ever happened. These days, 22 years later, Bip calls me 'sir'. Life in a small town. Things change.

Three weeks after admission to the nursing home, Pearl was rushed to our emergency room in respiratory arrest. Her oral morphine, her living death, overcame her and put her respiratory center into deep sleep. Nursing home attendants found her blue and unresponsive in her bed. She was given bag respiration (squeezed air bag connected to mouth and nose mask) and never completely lost her pulse. We gave her enough Narcan (reverses the effects of narcotics) to promptly awaken her and drive the breathing center at her brainstem into full gear. Interestingly, her pain did not explode in front of us as can happen when the veil of opium narcosis is torn away from the dreamy sleeper. When she became reoriented enough to grasp what had happened, I informed her that her narcotic days were over. We were going to help her to turn a new page in her life. Nursing homes and narcotics were not going to be part of this new life. She welcomed the plan and stated her willingness to go for it.

Earlier that year, 1980, I had attended an acupuncture symposium in San Francisco. By the middle of the weeklong conference, I was sure that I wanted to integrate some acupuncture into my practice. By the end of the conference, however, I could see that the only way to competently perform acupuncture would be to take further extensive training and apprenticeship in the craft. I had no practical or economic way to do this. What I could do, however, would be to expand my range of trigger point injecting (injecting cortisone and a local anesthetic in to a painful muscle, joint, or ligament area) to utilize more acupuncture points, especially the ones that seemed well correlated with clinical conditions. For example, headache acupuncture points include the sub-occipital areas (skull ridges at he back of the scalp, just above the neck), the known origin for many headache syndromes. Rather than sticking acupuncture needles into the muscle belly, I would stick a 25ga needle in and inject bupivicaine (anesthetic) and Depo-Medrol (cortisone type anti-inflammatory drug). In the back, when I came across an exquisitely tender point, I would likewise inject medication, often with gratifying results. Many of the back pain acupuncture points correlate well with clinical points of maximal tenderness. I let Pearl know that instead of giving her drugs, we would be doing these injection techniques to control her pain. She happily agreed, especially after the first trial round of shots seemed almost magically effective. Pearl went home from the hospital, on no narcotics, ready for her new life.

Once a month, Pearl would come to the office, get ushered back to a room to lie down (she still couldn’t tolerate sitting), and wait for her shots. She let me know that she had pain all the time, but it was bearable and the cortisone injections helped quite a bit. The ritual was the same each time. After a brief 'how's the family', I would palpate (push and feel with fingers) her back from the upper trapezius group (upper back/shoulder muscle to the side and below the neck) to the sciatic notch (upper buttock muscles), and she would tell me which were the worst points. I would divide the injection among the six most tender points, usually two in the trapezius, two in the mid-lumbar paravertebral (just to the side of the spine) areas, and two in the sacroiliac areas. She would apologize beforehand for her crying and then, during the injections, would moan and pant and cry out. She sounded like she was in the throes of a sexual experience, complete with agony and ecstasy. My nurse and I would look at each other in acknowledgment of poor Pearl's agony and the almost comical strangeness of the sounds coming from her. Living and working in the center of the drama of life's twisted stories, one develops an ability to simultaneously empathize with another's suffering and appreciate the cosmic humor of a particular situation. The validation of my experience comes with the relief that the patient experiences as a result of my efforts. Pearl was grateful and I was thankful that the strange noises I had caused to emanate from her mouth had given way to quiet, tearful relief.

I hoped that I could help her indefinitely with benign treatment. This was not to be. Over the next two years, her disability gradually worsened, punctuated by dramatic set backs after falling now and again. Five years after her second surgery, Pearl was again in the hands of a surgeon, now a neurosurgeon who recommended repeat surgery for further degenerated disc disease. She came to the office less often and was back on painkillers, though only schedule 3 drugs such as codeine (not as fiercely addictive). Over the next four years, Pearl had two more back surgeries, one cervical spine surgery, and was kept on Codeine and Valium by her surgeon. By then I had left the family practice to do full time emergency medicine. One of my partners became her main physician but she would come up to the emergency department every few months for trigger point injections. Pearl had become quite a fighter and through her veil of pain, she would smile and recount her successes. She had gotten married and had found tremendous strength from a new religious faith. Whatever doctors couldn't do for her, God could and would. This faith got her through some incredibly trying times. She seemed to have more than her fair share of trials. She discovered that her new husband was sexually exposing himself to her daughter. The marriage ended. More surgery was recommended. Her son-in-law was dealing drugs and her grandson was suffering from parental neglect. Her mother was a schizoid neurotic who was selling her codeine in the street for pocket change. It seemed endless, but Pearl never gave up.

After her seventh or eighth spinal surgery (I lost count somewhere after the fifth one), Pearl decided that she wanted to further her education beyond her high school degree and become something, somebody. She started some courses at the local community college but soon found that the medication she was still taking was interfering with her progress. She knew the time had come to get off all medicine. Her doctor worked out a taper schedule that would have her drug free in six weeks. Plans are so wonderful. So neat and clean. Why bother with carrying out a plan and failing or not finishing. Plans are pure and full of hope. With plan in hand, one might just feel megalomaniacal enough to taste the result and know, with no uncertainty, that success is just around the corner. It can become so tangible that the fantasy might substitute for reality, and the need to start becomes lost in the daily chores. Any time now. The check's in the mail.

Withdrawal turned into a four-month nightmare. Pearl had multiple visits to the emergency department with psychotic breaks, disorientation, possible seizures, and general torment, far beyond what any of us could understand in terms of drug abstinence syndromes. I'm not sure if we did any real medicine beyond just observing and hand holding, but somehow, eventually, the dendrites and synapses (nerve cell connections) re-aligned and Pearl became whole again.

By 1995, Pearl had been drug free for about four years. I didn’t see her in the emergency room any more, but I did run into her around town periodically. She was barely recognizable. She looked fifteen years younger than she looked ten years before. With a proud upright gait and sunny visage, she was finishing school to become a counselor. She would treat adults and kids with chemical dependency and she would share the wisdom of hard experience. She had some pain all the time, but it no longer controled her life. It was more a nuisance she learned to live with. If you've ‘got to suffer to know’, she knows. It made me happy to see Pearl. She is the embodiment of the truth that no matter how far down we can get, the future is a mystery that holds the potential for death but also for a life above and beyond one's greatest fantasy. She also is a shining reminder of the power of faith beyond our mortal existence. It is better to lose some health and keep faith than to look good and have no faith. Good looks and health are passing illusions. Faith, like true love, is forever.

All Rights Reserved © 2004 Jon Sterngold