The Tiers of Privilege

Minneapolis and St. Paul feel like very different cities from when I moved away 20 years ago. There was a palpable difference between Minneapolis and Albuquerque; in Minneapolis in 1995, my neighbors were white, black and Hmong (thanks to new policies welcoming large numbers of Hmong refugees from Thailand, Laos and Vietnam seeking a better and safer life), and in Albuquerque, the population was largely white, Hispanic and Native American. I felt as if I had moved to a different continent. The way that people interacted is something I can’t easily describe, except that I learned the “manana” (“tomorrow”) concept from my co-workers the hard way, and was told by employers that I would always be valued because I was a Midwesterner and therefore more “uptight and on time.” The population in Phoenix now closely resembles Albuquerque from 1995 – again, the residents are largely white, Hispanic and Native American. Because the southwest didn’t shift in any obvious way, I didn’t expect the Midwest to either.

When I moved back to the Twin Cities, I was not prepared for the greater diversity in the population, but my traveler’s heart is quite excited by it. A lot of the cab drivers I have had for my medical transportation have immigrated from Somalia, some arriving the same year I left Minnesota, telling me stories about how they excitedly called their relatives back home to tell them that powdered ice was falling from the sky (snow), and their relatives always asked the same question: “For free????” There are also now large Hispanic communities settled especially around the cities where living wages might be available. All of these groups are bringing their wonderful musicianship and dancing and food and willingness to endure countless hardships as strangers in a strange land because they know that turning back is not an option.

Why am I talking about all of this anyway? Well, the U.S. has always been a country of  tiered privilege. The caste system does not only live in India, my friends; it’s alive and well, even here in Minneapolis/St. Paul, where we pride ourselves on this appearance of being so tolerant but then have something so stupid/needless/heartbreaking/violating/sickening as the shooting of Philado Castile happen. But it’s not just race that determines where you land in the land of privilege – there’s a lot of “ands” that are the deciding factors.

Let’s start at the top. Your average white dude is the ultimate king of the food chain, born with the silver spoon in the mouth. Guys, you just are. If shitty things happen to you, the system isn’t against you in “pulling yourself up by your bootstraps.” You might want to feel sorry for yourselves, you might want to stomp and cry and try to convince us that you are being picked on and we should feel sorry for you, but I can’t. I can’t.

We can take it down a notch and look at white men who are physically handicapped by a chronic illness. Men are believed faster/more often than women when it comes to pain. Why? Medical sexism. On the tiers of privilege, white men who are in some way physically deemed “less valuable” by society are on a lower tier than ordinary white men.

I’m pretty sure my place is on the next tier down from that. I’m a white woman.

But wait: knock me down a few more rungs, because I’m a white woman who is also physically disabled. Since I’m a woman and I’m physically disabled, I have absolutely no value whatsoever, a “non-person,” specifically. My cane and paralyzed face make me invisible to nearly everyone (and if you don’t believe me, you should walk through a store or down a sidewalk with oncoming foot traffic with me).

But yet…where do all of our friends and neighbors of color fit in?

My Filipino ex-boyfriend was educated and articulate (except when it came to actually being in a relationship – but that’s another story); his status as a man was relatively high, but as a man of color he ranked lower. Unfortunately he suffered from bipolar disorder, so that could be seen as a detriment, but then again, he was believed – his gender saved him from medical sexism. He always claimed that strangers looked at us distastefully when we were out in public. I think he is valued much more than I am, even though he would deny it.

My most recent Native American boyfriend had a much harder upbringing. He grew up on the largest reservation in the U.S., the Navajo reservation on the New Mexico side. Poverty, crime and mental illness brought him into adulthood. He left the rez to get an education, but for one reason or another, he has clung to the the things that have only brought pain and destruction to his life. Where does he fit into this world?

And then there are the women of color who earn even less than the men, who are physically and sexually assaulted, are obviously valued less when they are forced to remain silent in the company of men or to walk a few steps behind them. Add an “and” to them – a physical disability – and really, how much lower can one go in terms of value as far as society is concerned? I startled a Somalian woman in a waiting area once; I carry cough drops and I noticed she was having a coughing fit, so I offered her one. Her interpreter arrived a few minutes after that and she was called back for her appointment, but she made it a point to tell her interpreter to thank me in English. I did not consider it an insult that she did not know how to say it herself when she was on her own, but since I know how the public at large acts more often than not, I could just imagine that even that simple interaction added stress to her afternoon. Like me, she walked with a cane. I wondered how she was treated by her peers and family.

I am always disappointed when I see/hear someone say, “Why don’t they just ____”? as if we are simple creatures and there’s a one-size-fits-all answer. There isn’t. (That’s why they should stop just conducting medical studies on middle-aged white men if they want real-world results. I mean, hey, we finally figured out that heart attacks are worlds apart between men and women!) The most important thing to understand is that just because things look a certain way from where you’re sitting doesn’t mean that everyone else feels the same way. If you can’t see past yourself, then your world is very small indeed.

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Amateur Hour: How Vanderbilt/NIH Undiagnosed Diseases Network Failed Me

Earlier this year, I worked for four hours sorting and copying approximately 350 pages of medical records to send to Vanderbilt University in Tennessee when the coordinator for the NIH Undiagnosed Diseases Network notified me that my case was being sent there for review. I divided everything by year and specialty. I inserted notes and highlighted everything that should be of special interest.

I took it as a bad sign when I received an email that was poorly written, and rightly so:
I need you help with some missing records the UDN has requested on you. We are missing the records from the Movement Disorder Neurologist and  also labs associated with Thyroiditis Workup are not complete. Please request these records be faxed directly to us at *********** or **********. We cannot move forward with reviewing your case until we have these records. Please feel free to contact us if you have any questions.” They weren’t actually missing the records from the movement disorders neurologist; the EMG results were included in what I forwarded to them. (Special note: capitalizing random words is an elementary mistake in and of itself and certainly doesn’t belong in official correspondence.) I wrote back and asked what needed to be obtained for the thyroid workup because I was going in for an appointment in the near future and could have tests ordered. However, I didn’t hear a response for weeks. Their suggestion to contact them with questions was not sincere because they didn’t respond to repeated calls or emails for three weeks total. I went to my appointment and guessed what they would want ordered, then forwarded them the results.

It didn’t matter, though. Last Thursday July 14th I received a letter in the mail from the head of the team saying that after a “stringent” review of my case, they were turning me down. They decided that because I have a strong history of autoimmune diseases that I must consider myasthenia gravis.

Here’s the problem, though: I considered myasthenia gravis already back in 2010, and again this year, and it has been ruled out by tests including the painful tasing of my face in April. All of those notes and tests were included in my paperwork. The 53 doctors who have seen me so far have positively said that I don’t have that. I also say I don’t have that. I have not found any documented cases where patients have received a working brain shunt to move CSF to relieve the symptoms of MG. I have hundreds of pages documenting my numerous symptoms and surgeries, and instead the Vanderbilt team chose to tell me to go back to the U of MN doctors (who, by the way, told me to go away and not come back) to get treatment for MG because “they would know how to treat me.” I am not allowed to appeal this decision or have any other team look at my file. The UDN door is forever closed to me now.

The next two paragraphs I’d like to address to that team directly:

Fuck you, Vanderbilt, you backwoods amateur cocksuckers.

This is what I don’t have: myasthenia gravis, lupus, MS, normal pressure hydrocephalus, communicating hydrocephalus, Creutzfeld-Jakob, IgG4 proliferation, scleroderma, pseudotumor cerebri, diabetes, secondary tremors, tumor, chiari malformation, or rheumatoid arthritis, among other things. After seeing so many doctors and going through hell and having to research A LOT on my own, Vanderbilt, your suggestion makes me think that my file landed in the hands of a beginner’s group. I’m way ahead of you, by years, and I didn’t even finish my medical degree. Every single one of you needs to go back to studying onion skin cells under your 10x microscopes because you obviously can’t handle the hard stuff.

As I feared, Vanderbilt chose to give much weight to the three doctors in the circle jerk at the U of MN claiming I had some sort of “facial weakness” that would imply MG and completely ignores the issue with the cerebral spinal fluid, which in turn ignores the vertigo, fatigue, slurred speech, numbness, and cognitive problems. It would also imply that I implanted a shunt for the fun of it – because I want something that I’m allergic to that causes a shit ton of pain in my body. It also means that they completely ignored the notes that indicated that my symptoms subsided when I had working shunts. Now I am back to the starting point, meaning no one knows what I have or how to help me. (Please note: I am still going through testing for the mast cell activation syndrome and I am watching the results slowly trickle in; my guess is that I’m going to have to repeat everything because nothing is extraordinary in the outcomes at this point.)

I also still don’t have disability money coming in. My hearing won’t be set until about a year from now, but my chances are only about 10% in my favor at the moment because I still can’t get a diagnosis or the NIH to work with me. I’m not being dramatic, I’m being realistic. My attorney would tell everyone the same thing.

If you have read this post in its entirety, thank you. I’m not asking for advice; that’s not how I operate. This is just one of those times where the Carousel of Crap feels extra shitty.

The Princess and the Pee

There were three things rolling around in my “Personal Belongings” plastic drawstring bag – one “hat” that is used to measure output, and two tall brown jugs with screw-on lids and my name on them. It was time to collect my pee.

The jugs were about 4.5 inches wide and 4.5 inches deep but a whopping 12 inches tall, which meant that in order to fit in my half sized refrigerator, a shelf had to come out. I made sure that I set everything up on an empty bladder so I didn’t have to scramble to do it later. I rearranged my fridge and put the jugs on the top shelf so that they would already be cold, ready for the first deposit. I very loosely screwed the caps on. I got the box of green latex gloves out of my medical supplies and sat them next to the toilet; I was not going to be transporting the collected goodies with my bare hands. I put the “hat” under the seat.

Luckily The Saint Paul had a good sense of humor about the whole situation too. He was on cooler duty for me; I sent him a picture of the one I thought would fit the jugs and he picked it up on the way to my apartment after work. However, when we tried to fit the jugs, they were just about 3/4″ too big, so I had to send him back out for a bigger cooler (that I could still carry by myself while also using a cane). I thought I would only have room in my freezer for a 5-pound bag of ice and so that is what he came back with for me.

Bright and early the next morning I started drinking water.

As luck would have it, I had plans to see someone that evening whom I hadn’t seen in at least 13 years who just happened to be in the city because of a work obligation. When you get an opportunity, you do everything you can to take advantage of it! This friend was going to be only blocks from my now deceased dad’s and uncle’s hair salon (still owned by their good friend), so I thought, “Hell, I’m going to get some wigs cut too.” I managed to get a short bus for 3:45 pm to take me to the salon, and to pick me up and take me home at 10 pm, so that meant that I could only pee from 7 am to 3:40 pm, and about 10:30 pm to 6:45 the next morning. It’s a good thing I’m a planner. It’s also a good thing I have the bladder of steel. I told my friend I’d see her at a certain time and that I couldn’t pee while we were out (without offering an explanation).

I did pretty well. I took in about 80 ounces of water between 7 am and 2 pm, and managed to get a bunch of samples before my bus rolled up at 3:45. However, I did hit a few snags. First, the “hat” didn’t sit well under the seat – I almost completely lost the biggest collection and I had to jump up midstream and pull half of the container up from out of the toilet. It wasn’t dunked in the toilet water but I did manage to get both hands wet, and was so grossed out that I had to do a surgeon’s scrub before I could finish peeing, but I had to do it really quickly because I hadn’t been able to wipe my booty so I had to kind of stand bow-legged and squat like a cowgirl who had been riding the trail for days so my legs didn’t also get drenched (thank goodness for the bidet). Second, the “hat” didn’t have a very big pour spout, so when I went to the fridge to transfer my drop to the jug, I had to pour very, very slowly. I had a lot of time to contemplate my urine. I remember thinking, “Man, that smells really fruity. Why does it smell really fruity? I’m not even borderline diabetic.”

Another thought: “There are some FetLife men who would mourn the loss of this tasty liquid.” Another thought: “Replace ‘tasty’ with ‘nasty.'”

I managed to not use the bathroom once between 3:45 pm and 10:30 pm, so no samples were sacrificed in the name of reconnecting with old friends. Everything went into those jugs.

I only ended up filling up one of the jugs with my samples, and my special instructions were to bring the sample packed in a bag of ice packed in a container of ice to the hospital. However, since this cooler was much, much bigger than the one that was only slightly too small, I had to improvise when I realized the ice only reached the bottom 2 inches of the cooler when it spread out. I knew I only had minutes before the cab showed up to transport me to the hospital, so I started grabbing the nearest things – throw pillows from my couch to fill the large spaces. I stuffed those around the pee jug in a bag, then poured the ice in. There was still space not covered in ice. What to do? I had an old bag of nearly petrified cut rhubarb in the freezer that I thought was going to be used for custard bars (seriously, make these rhubarb custard bars), so that was thrown on top. Perfect.

I got to the M Health building at the U of MN hobbling with my cane in my right hand and this cooler big enough to fit a small man on my left (bad) shoulder and slowly made my way to the lab. When I got to the front desk, I notified the clerk that I had a temperature-sensitive sample, so she asked me to follow her to the back area with the phlebotomists so they could accept it and log it. The woman who ultimately took it was flustered and momentarily angry when she saw my throw pillows – she assumed that I had forgotten the ice part. I grabbed the rhubarb off of the top and threw it in the trash and she took the cooler to the back to pass it along to the technicians.

While I was waiting for my cooler to reappear, the clerk and I realized that another cooler that was sitting there was leaking water all over the floor. She opened it and it contained another pee jug. I was surprised to see it laying sideways completely submerged in water – I guess they had complete confidence that the screw top was a tight seal and there would be no transference either in or out? Either way, the clerk and I started working on mopping the floor up with paper towels. Of course, I did another surgeon’s scrub at the sink immediately afterward. If I’m not okay with getting my pee all over my hands, I’m not crazy about Stranger Danger’s either.

There is a distinct possibility that I will have to repeat this test a few more times. If so, I will be more prepared – more ice, less rhubarb!

You Know, Like The Nasal Spray

Tonight was supposed to be a date night with the boyfriend. Unfortunately, I’ve been nursing a headache all day that has been getting progressively worse, so we’re postponing until tomorrow night and I have vowed to not make myself ready for public consumption tonight even a tiny bit. Instead I’m listening to Enigma and thinking about how to put all of this week’s news together.

When I was little, I had a lot of problems with asthma and allergies. There was one time I had gone hog wild with the Cracker Jack tattoos and then went into anaphylactic shock shortly after from who knows what and was rushed to some kind of urgent care (though back in the 1970’s it wasn’t called that), and my mom and I remember that the doctors and nurses were momentarily amused to discover how enthusiastically I had stamped them onto my arms and legs when they hurriedly stripped me down to shoot me up with multiple adrenaline shots. I always had allergic reactions that seemed to come out of nowhere. I would have hives show up on my little cheeks that couldn’t be explained. We tried so many things, including eliminating dryer sheets and perfumed laundry soap. I could only bathe with certain soaps – I remember being disappointed that my friends had fun soaps with glitter, while mine tended to have real oatmeal and vaguely resembled excrement.

Often my allergies would turn into full-blown infections. My little body was so worn out from the allergic reactions that the microbes had an easy time of taking over, every time. I know now that specifically I am even more vulnerable because I have both IgG3 and IgG4 immunodeficiencies, so I cannot fight off infections like other people can, and my infections will always last longer.

One of the many things I always struggled with is cigarette smoke. I knew from a very young age that I was allergic to it; it wasn’t just that I didn’t care for the smell, but that it made my throat close up, like I was having an allergic reaction to it, much like what people experience when they are very allergic to cats (a more common allergy than dogs), or when they have a peanut or egg allergy. After being exposed for a few hours to cigarette smoke, it’s inevitable that I will develop an infection. Three of my four parents were smokers and so I always had sinus infections, bronchitis, ear infections and pneumonia growing up. Nowadays I’m thankful that most places in the U.S. have adopted laws banning smoking in indoor public places.

Animals are tough too. We had a cat that I loved very much but we ended up having to re-home her with our aunt after it was confirmed just how allergic I was to her; our dogs were outside dogs at my mom and step-dad’s house, but my dad and step-mom had an indoor dog. It seemed like I always had a sinus infection and/or bronchitis and/or an ear infection.
There are other allergies that I have noticed over the years that are not the usual suspects for most people. For instance, I get hives all along the entire surface of my body that has been in contact with brand new furniture. I’m not sure if it is the dye in the fabric or the chemicals in the padding that I’m allergic to, but it’s miserable. Also, commercial perfumes that the general public wears and Lysol are incredibly toxic to me. (When I used to work in the cubicle farm at Bank of America in Phoenix, I used to stand up and yell “Stop spraying!” if a co-worker started spraying Lysol in his or her cube because my throat would immediately start closing up. Everyone thought I was nuts.)

Lately I’ve been having some trouble with my pulse being about twice the normal rate and with my blood pressure being elevated. I also have burning and a metallic taste in my mouth, constant heartburn that no one to date has been able to pinpoint the source of, and of course the constant problems with my CSF, memory, word recall and crushing fatigue.

Back in October of 2015 at the urging of a friend, I made an appointment with Dr. Lawrence Afrin, who is fairly new to the University of Minnesota staff; he used to live in South Carolina and transitioned to Minnesota starting in 2013. When I moved here a year ago, I was trudging back and forth between appointments with doctors and labs and scans, and didn’t think much about what he had to offer me, quite honestly – I mean, I thought that what I had going on was better addressed in the areas I had already been concentrating on: neurosurgery, neurology, immunology, rheumatology. I couldn’t even find a regular primary care doctor who could handle me. I made the appointment anyway, but Dr. Afrin is in high demand, and they booked me for ten months later. I didn’t give him a second thought.

A month ago I received a call from his office with the offer to move my appointment to the end of June. I accepted. In the meantime, the same friend who urged me to make the appointment also bought me his book and sent it to me, so I quickly started reading it because of the pending appointment – “Never Bet Against Occam.” Within the first 20 pages I realized that I was reading about my own puzzling history. I started to assemble my list of questions and completed my 3-ring binder for the appointment.

Dr. Afrin is considered the national expert on a newly identified disease called Mast Cell Activation Disease (or Syndrome) or MCAD (or MCAS). It has only begun to be identified in the past 8 years, and he has been at the forefront of the movement to get it nailed down and classified. Everyone has mast cells. Everyone with this condition has a “normal” amount of cells, but they act in a very abnormal way. For some people, maybe it’s normal for them to have an allergic reaction to a mosquito bite. However, if they go into anaphylactic shock from the mosquito bite, then that might be considered MCAD if the actual number of mast cells didn’t increase.

Dr. Afrin first read through my records. Occasionally he quietly chuckled to himself as he read. At one point I asked him what was funny; he said that the signs I had MCAD were quite obvious. I told him to wait until he got to the part where I demanded to get azathioprine to try to stop rejecting the shunt, because I came up with that on my own, no one suggested it to me (I found out from his book that he prescribes chemo drugs such as azathioprine to MCAD patients in an attempt to try to find the right treatment).

In another section, he stopped and said, “Oh, Dr. T. here said that you have a mast cell disorder.” I said, “He read that I was coming to see you in the future. Let’s just ignore everything he said because he misdiagnosed me, shall we?” He laughed, but then later said I shouldn’t be so hard on my doctors in general because their main goal is quantity, not quality. I didn’t tell Dr. Afrin that he was my 53rd doctor at that point. I also didn’t want to go into an impassioned speech about how difficult it has been to lose my ability to work, to lose my house and car, my independence, and my sense of self-worth, all because doctors thought my case was too difficult and they just wanted easy cases.

Dr. Afrin thanked me for putting together such a complete medical history of the last six years. We talked about my life from birth to present and what were probably the signs of MCAD from the very beginning.

Here’s the plan: He’s going to request the biopsy samples from my upper GI (that I insisted on getting done on my own because I’ve been trying to figure out where this horrible acid reflux is coming from) so that they can be stained with the special stains that can show the concentrations of the mast cells. I’m going to have a bunch of blood work done next week. I’m also going to be sent home with a collection container that is going to live in my fridge for 24 hours. Can you guess what it’s for? Not Kool-Aid! Urine that I have to collect for 24 hours worth of peeing. That’s right. Then I have to transport that back to the lab, but first I have to pack it in a zip lock bag, pack it in ice, and then put it in a cooler. The urine has to stay cold or the components that have to be tested begin to degrade and become useless.

My sister and I had some good laughs over the whole refrigerated urine thing. First of all, I’m a bit of a germaphobe – partly because of the time I spent in nursing school and specifically in microbiology and all of that in-depth studying of bacteria, and partly because I know my immune system is weak. Second, I’m going to have to carry the cooler in my left hand because I have to walk with my cane in my right hand. Right now my left shoulder is in really bad shape because the tendons are likely frayed. What if I drop the cooler of urine? Am I destined for YouTube infamy when the bucket-o-urine splashes me in the face?

I’m thankful for this person steering me to Dr. Afrin. I’m trying not to get too excited because even though he’s 99% certain that I have MCAD, I’ve been down the 99% certain road before a few times, and it’s very emotionally draining to get misdiagnosed.