NaBloPoMo 2017: Field Notes from a Life in Medicine
Had my knee MRI yesterday. I had been looking forward to it for over a week, trying to predict what it would show. I was thinking a serious meniscal tear, since I have had crackling in my knee for so long and I surely must have arthritis by now, from all the falling on it I did in my youth. I lay perfectly still and started to get sore where I expected to feel medial meniscus pain. I could not wait to know the results. I just wanted to know what I’m dealing with, so I can figure out next steps, get moving.
Since it’s a weekend, I won’t know the radiologist’s report until tomorrow. Suddenly part of me doesn’t really want to know. What if it’s really bad and the only option to regain function is surgery? What if it looks like I’ll be permanently disabled in some way, never able to get back to my previous level of activity? What if that prognosis totally throws me off and I let myself go, become a sedentary lump, weigh over 300 pounds, and die in five years from heart disease and depression? Truly, this could end my life, some poisonous voice hisses in the recesses of my mind.
But hubs is the ordering physician and he looked at the images with me tonight. Lots of fluid/swelling. Bruises on both bone ends of the joint. Good news, the menisci are intact and look normal! Woo hooooo!! Posterior cruciate ligament also looks normal—thick, uniformly black (swelling and inflammation are light on this image), well-positioned. Can’t find the ACL. Huh. He says 10% of people don’t have one. That’d be cool, because if I never had one then it couldn’t be torn. But the bone bruises alone are not enough to explain the swelling and pain. So either it’s so inflamed that the fluid obliterates it on the MRI, or I have completely ruptured it and the little stumps have retracted out of view.
I had wondered which I would rather have, a serious meniscal or ACL injury. I had leaned toward the latter, because the ACL can be fixed. Meniscal tears really don’t heal; the body smooths them over somewhat with time, but the end result is just less cartilage, faster wear, and more tear. The problem with an ACL injury, however, is that it increases the risk of future meniscal tears. So either way, the knee will never be the same and now I have to deal with it.
We will wait for the official report, and I may see the sports orthopod. Here’s what I don’t want from that appointment: For him to tell me, “Cathy, you should stop playing volleyball or anything that requires jumping, sudden movements, or the like. You’re too old and your knee will just be hurt again.” I will be polite, but in my mind I will think, “You can’t tell me what to do, I’ll play f*ing volleyball if I want to, and I will do it with or without your help.” What I would love for him to say is this:
“Cathy, here is what’s going on in your knee. It’s likely that these factors contributed to the injury (lists possible risk factors that he knows from my history), and also it was a freak accident that can happen to anyone, especially jumping female athletes (which is true). It’s a good thing you’re pretty healthy to start with, and that you had gotten fit these last few years. What do you want to do now?”
I’ll tell him that I really want to get back on the court and play. I’ll tell him I want to keep doing all the training I’ve been doing: elliptical, Kangoo running, TRX, pistols, golf, and Betty Rocker workouts. I want to take up new things like Orange Theory, kickboxing, martial arts maybe, and who knows what else? I want to be the most active person I can be, and I want to JUMP. I’ll tell him that I want to be responsible about it; I’m not going to ignore the risks and be stupid. I want to know the risks, the evidence as it applies to me as specifically as possible, the 44 year-old mom with lax ligaments and super-flat feet.
Then I hope he tells me, “Okay then here’s the plan. We gotta rehab the knee really well. Ya gotta be patient. Keep up with your trainer, strengthen all the muscles around your knees, continue working on core, posture, and form. When you start jumping again make sure you know better how to land, train that muscle memory and get it down, own it. Take your time, and take it easy when you start again. There are braces you can use when you play that will help keep the knee stable. And you still might hurt yourself again, there’s no way to predict what will happen. But if that’s what you want to do, I’ll do my best to help you get there.”
Because here’s the deal, my friends: I own my decisions, but I need help to make them in the most responsible and informed way possible. I don’t need someone paternalistically telling me what to do, how to live my life. I need the doctor to explain to me the risks, benefits, and costs of what I may want to try. Then I need to him to trust that I will make the best decision for myself, based on my own core values and goals. I understand that nobody can predict the future. But I also have a clear vision of the future I want. I want to live a very active life, able to try new things and connect mind with body with spirit, and with other people. I want to look back in 10, 20, and 30 years and say, “I did what I wanted to do, I made my decisions with the best information I had at the time.” I may hurt myself again. I may end up with a knee replacement before age 60, and never run or play volleyball again after that. But if I get there having thoroughly assessed the risks of my actions, having taken all reasonable steps to proceed safely, and having continued to have fun and enjoy my mobility as long as I could, then hopefully I will regret very little. I would much rather live this scenario, than get to that age wondering, “What more could I have done? Did I sell myself short?”
This is how I discuss decision making with my patients, particularly when it comes to screening. Their decisions must originate from their personal values and health goals, not mine or anyone else’s. How do they understand the risks, and which worst case scenario of screening or not screening, treating or not treating, will they regret less? A very athletic yet osteoporotic 65 year-old woman really does not want to take medication. So we review her daily dietary calcium, vitamin D, protein, and vitamin K intake. We make sure she continues weight bearing exercise every day. We pay attention to balance, flexibility, strength, vision, and fall risks. We reassess her risks and goals every year to make sure that we are still on the path she chooses for herself. I present her with as much evidence as I can, for efficacy of medication, her personal fracture risk, and potential consequences of fracture. In the end the decision is hers and hers alone; I serve as consultant and guide.
Meanwhile, knowing what’s likely happening in my knee gives me peace and confidence. Now I can make a plan. I’m convinced this is why my knee feels better tonight than it has in days, although the ibuprofen I took this afternoon probably also helps. I have a new compression sleeve that fits under my dress pants. I can get back to my workouts, and maybe add on a little every week. My motivation to eat healthy just got a fierce boost (Betty Rocker really helps with this—I have no financial interests in her business, I just really like what she does and how she does it). I’ll start physical therapy soon. No volleyball for likely 6 months. But I got this. Bring it.