Questionmark Etiology

A short story by Jonathan Mitchell

The pain was excruciating if not intolerable. It started at the uppermost position of Arnold Springer's forearms and radiated down to the very tips of his fingers. His fingers also felt numb and tingly. He moaned a little bit but tried to restrain himself, remembering that he was in a waiting room full of people and did not want to disturb them.

The wait seemed interminable. Was the time really passing as slowly as Arnold thought or was it just his imagination. Often, time passed more slowly, or so it seemed, depending on the circumstances, such as these extenuating ones. Just to be sure, Arnold looked at his watch. Three fucking hours already since he had come into the waiting room of this godforesaken HMO! He could not believe it, but his imagination had not been playing tricks on him. He had worked for Acme Accounting for nearly five years now, had been a loyal employee, never absent, never late and now they had done this to him and the others. They had switched the employee's health coverage from Blue Cross to this piece of shit HMO. They had done this in order to hold down the company's expenses of which exponential escalation of health insurance costs had been a major factor. In Arnold's opinion, the whole managed care phenomena was just a by-product of the conglomerate-ridden 90's.

Arnold had been a bookkeeper by profession, balancing ledgers, reconciling spread sheets using Excel software. His work had not enabled him to become a people person and he often had trouble asserting himself. Not this time, he thought to himself and managed to get up the temerity to walk to the front reception desk.

"Do you realize I have been waiting for three goddamn hours!" Arnold managed to exclaim to the receptionist, engrossed in a historical romance novel, oblivious to the suffering of the impatient patients sharing the roomspace with her.

"The doctor will be right with you, Mr. ......".

"Springer," Arnold managed to spit out between clenched teeth.

"Please sit down," said the curt receptionist and then looked away from Arnold, returning to her romance novel.

After a somewhat more seemingly interminable wait, the receptionist called out, 'Arnold Springer', and Arnold followed the 22-year-old Medical Assistant out of the waiting room and into the foyers of the doctor's offices.

The medical assistant chewed gum, chomping on the gum reminiscent of a cow on its cud. Between loud chews she managed to say, "sit right here, Mr. Springer." She deftly placed a blood pressure cuff around Arnold's arm, taking his blood pressure and writing it down.

"Step up on the scale, now, Mr. Springer," the ingenue managed to say without bothering to ask Arnold to take off his shoes, still chomping on her gum. She wrote down Arnold's weight.

"Follow me," she said, reminding Arnold of the character Lurch on the t.v. show The Addams Family, though she was much shorter and had a much higher pitched voice. She directed Arnold to the nearest examining room, telling Arnold to strip down to his underwear and put on this robe that all of the HMO's patients were supposed to put on before being examined.

He sat in the examining room, waiting for Dr. Blasubaramanian, the physical medicine specialist from Bombay, India.

While waiting for Dr. Blasubaramanian, he thought of the whole bureaucratic nightmare that he had had to endure with this HMO. First, there had been the same day appointment. Instead of an M.D., he was seen by a 28-year-old physician assistant who somehow seemed to lack the training to get to the root of his problem. After insisting on seeing an M.D., he was given a family practice doctor, who had not bothered to examine him but had recommended that he take some nonprescription strength Motrin which he could purchase over-the-counter. Two days later, he had called back the physician, saying he felt that he needed a specialist but she said that he could only get a referral to Physical Medicine if he first acquired a personal physician who could make the referral and she apologized profusely for the HMO's neglect in telling him he needed his own personal physician to make the referral. He was put on a three week waiting list before he could see his own personal physician. Finally, after some more rigmarole, he had managed to get a referral from his personal physician to Dr. Blasubaramanian, one of the HMO's physical medicine specialists, for a more in-depth look at the problem.

Finally, Dr. Blasubaramanian knocked softly and without waiting for Arnold to answer, opened the door to the examining room and introduced himself to Arnold in muttering accented English.

"What seems to be the problem?" asked Dr. Blasubaramanian curtly.

"I have these unbearable pains in both my hands and wrists and also this tingling sensation in the tips of my fingers. I have been having some trouble using my hands lately, and have even been dropping things sometimes."

"I see," Dr. Blasubaramanian paused a bit. "What sort of work do you do, Mr. Springer?"

"I do bookkeeping for Acme accounting."

"Does this work involve any sort of strenuous repetitive motions of your hands?"

At first Arnold seemed to be having a little trouble understanding the good doctor, possibly because he was an English as a second language person, but finally it clicked.

"No, not really."

"Oh, I see." Dr. Blasubaramanian continued. "Do you play any sports."

"No, not really, I just bowl occasionally," said Arnold truthfully. Arnold was wondering when the doctor was going to examine and treat him.

The doctor's line of questioning continued. "Do you play any musical instruments?"

"No."

"Very interesting," muttered the doctor in his Indian accent.

The physician decided to perform Phalen's test. "Please flex both your hands back as far as they will go."

Arnold complied and he moaned at the pain.

"Now, flex your hands forward as far as they will go, touching your fingertips to the lower palm of both of your hands."

Again, Arnold complied and moaned at the pain.

Dr. Blasubaramanian picked up a pin and rubbed it against the front of the tips of Arnold's fingers and asked, "does this feel like it is numb?"

"Yes", replied Arnold.

Then, the doctor stroked the pin gently across the back of Arnold's fingertips. "Does this feel different than what I did last?"

"Yes, it does."

The doctor nodded knowingly and jotted some notes on Arnold's chart.

Now, he decided he would perform Tinel's test, taking out a reflex hammer and tapping the median nerves of both Arnold's right wrist and left wrist, noting very carefully Arnold's facial reaction to the tapping.

The doctor again made some notes in the chart.

"Now sit over here, please, Mr. Springer."

He directed Arnold to this gadget, an electromyograph machine with some wires and electrodes and some needles connected to some pieces of paper with the words Oxford Synergy written on the front of the device.

"Hold out your right wrist first," requested Dr. Blasubaramanian. The doctor put some paste on Arnold's right wrist and attached a few pickup electrodes to the wrist. He repeated the same procedure on the left wrist.

Dr. Blasubaramanian turned the machine on and it began to make a humming noise. After a brief time, Dr. Blasubaramanian tore the pieces of paper from the printer and observed what looked to Arnold like a bunch of unreadable squiggly lines that had been made from the machine. Dr. Blasubaramanian noted carefully the nerve conduction velocities and the amplitudes of Arnold's median, ulnar and radial nerves in both his right and left hands. He then jotted the results onto the chart.

"Mr. Springer," Dr. Blasubaramanian started to say and then paused, his usual repoirtoire when delivering the patient bad news.

"According to your nerve conduction velocity studies you have a distal latency in both your right and left median, ulnar and radial motor nerves of 4.7 milliseconds. Normally this value should be 3 milliseconds or less. You have something called bilateral carpal tunnel syndrome, albeit more pronounced in the right hand than in the left, this is what I suspected when you first told me your history. I also come to this conclusion based on the fact that both your Phalen's and Tinel's tests were positive in both your right hand and left hand. You are right- hand dominant, correct?"

Arnold nodded.

"However, based on your occupational history and your life-style activities which I queried you about earlier, you are a most unusual case. Carpal tunnel syndrome usually occurs in persons who often make repetitive stressful hand motions, either in work or in hobbies. By chance are your parents blood relatives?"

"Of course not!" answered Arnold, utterly flabbergasted and perplexed as to why the doctor would ask him such a question, totally out of left field.

"Sometimes there are genetic causes of carpal tunnel syndrome in persons who don't make constant repetitive hand motions or use their hands a lot, albeit it is very rare, having an incidence of less than 1 in 50,000 in the general population. I can refer you to Dr. Fish, our medical genetics specialist if you would like, but even with the knowledge that you have a mutant gene causing all this misery, it won't change the treatment course."

Arnold shook his head, declining a referral to the geneticist.

Dr. Blasubaramanian gave Arnold a booklet on carpal tunnel syndrome and explained that this was often caused by trauma due to repetitive hand motions, causing some of the bones, tendons and ligaments in the hands to become more narrow, giving the nerves in the hand less space to work in, causing pain and loss of function in the hands. He explained that first he would treat the problem with conservative management, namely giving Arnold some injections of cortisone, the steroid of choice for this problem. He also recommended that Arnold use wrist splints and instructed Arnold in their use after injecting Arnold's wrists with cortisone. He told Arnold to wear the splints at all times, except when showering or taking a bath. Arnold was to wear the splints even when he went to bed. Dr. Blasubaramanian gave Arnold a two week follow-up appointment with him and said that they would continue with this plan of conservative management, wearing the wrist splints, continued steroid injections and nerve conduction velocity tests to see if the nerves would be given a bigger space to work in and would move faster as measured by the electromyographic equipment. Dr. Blasubaramanian further explained to Arnold that if the conservative management did not work then he would refer Arnold to the orthopedic department where surgery-a carpal tunnel release-would be scheduled. The orthopedist would remove some of the tendons and ligaments in Arnold's hand to release the nerves from the confined space that they were in, giving them more room in which to work, allowing Arnold's hands to function normally.

After Arnold left, Dr. Blasubaramanian proceeded to dictate his consultation, which would be typed by a medical transcriptionist and placed in Arnold's chart.

"This is Dr. Blasubaramanian dictating an outpatient physical medicine consult on patient Arnold Springer." The doctor continued to dictate in the perfunctory rhetoric so typical of the medical profession.

"This unfortunate gentleman is a 38-year-old Caucasian right-hand dominant male with nonconsanguinous parents, comes in complaining of intermittent pain and numbness in both hands, incoordination and dropping objects....," Dr. Blasubaramanian continued with some of the facts of Arnold's case and then started dictating the results of some of the tests.

"Phalen's sign, positive in both hands. Tinel's sign also positive in both hands. Nerve conduction velocity tests were performed in the motor and sensory median, ulnar and radial nerves of both hands. Median motor nerve conduction velocity was 4.7 milliseconds, normal being 3 milliseconds or less...," Dr. Blasubaramanian continued with the results of Arnold's abnormal nerve conduction velocities and then continued with the final parts of the report.

"The diagnosis is bilateral carpal tunnel syndrome, more pronounced on the right than the left,..." Dr. Blasubaramanian paused for a bit, thinking, deciding what else to say about the case which would be appropriate and then he decided to use one of the stock medical phrases.

"Questionmark etiology," Dr. Blasubaramanian added as an afterthought, not understanding what possibly could have caused Springer to have carpal tunnel syndrome based on his history. He dismissed the 50,000 to one odds of the genetic etiology as being just too much of a longshot. He knew that there must be something that Springer had not been telling him but he just did not know what.

Arnold had had a rough day at the office. He had to stay two hours later to make up part of the work he had lost to make up for having to spend so much time at the HMO in order to be examined and treated. He immediately thought of Carolyn Powlawski, the sexiest women in his office and how much he would like to put it to her and tried to picture what she might look like in the raw. He took off the wrist splints and then took off his pants. He tried to grab his penis in order to jack off but the pain in his right hand was just to excruciating. He then tried to masturbate with his left hand, but the pain was also excruciating. Other guys could do well with the chicks, and get their dicks wet, but not Arnold. He was not rich and not particularly handsome. He was 38 years old and not getting any younger. He wondered what Blasubaramanian would have thought if he had told him what he was doing with his hands and how he came to develop carpal tunnel syndrome.

Finally, completely naked now, Arnold decided to lay prone on the bed, rubbing back and fourth on his stomach and trying to self-stimulate his penis without the use of his hands. He then remembered that it was Wednesday night and looked at the clock and saw that the time was 7:30. He realized that if he did not get a move on, he would be late for the meeting.

It was eight o'clock on the dot and Arnold was pleased that he was on time for his Wednesday night 12-step meeting of Sex Addicts Anonymous, before the meeting he started to open the door to the meeting and noticed what the sign on the door said and read the words to himself.

Who you see here.
What you hear here.
When you leave here.
Let it stay here.

None of the other participants at the meeting had anything to worry about. Arnold had problems of his own and he would be too concerned about these problems to pay attention to what anyone else in the meeting was saying so they would not have to worry about him violating their trust.

The End