Rickets?

My job brings me into a lot of strange houses. This one has to be one of the strangest. What I knew going in was that the patient was self-pay, that is he did not have Medicare, the only form of insurance that The Company accepts. And he was having trouble coming up with enough of a cash payment to make the administrators think it was worth their while to send a physician out. Glancing at his chart, I saw that the patient had what the doctor who saw him before me termed "familial rickets." That is, two of his daughters have rickets as well.

You don't hear too much about rickets anymore. In fact the word itself seems antique. It comes from an Old English word 'wrickken,' meaning to twist because the legs of those with rickets bow inward. Their bones are soft and prone to fractures and their teeth fail to mineralize properly. The most common form of the disease is due to a lack of the active form of vitamin D, either because of deficiencies in the diet or lack of sunlight or both; for a while it was quite common but now we have all but eradicated in this country. But there is another form of the disease that is very rare and inherited. The mutation causing the disease resides on the X chromosome, meaning that fathers give it to their daughters. I reviewed all of this during a lit search on my iPhone as we drove out to see our patient.

There was no heavy ornately barred security door found on most of the nearby homes. In fact there was no storm door at all. There was no doorbell. When we knocked, a boy of about 11 with a challenging expression and no shirt answered. We asked for Henry and he led us through a dingy, sparsely furnished living room, past another slightly older shirtless boy, and into a back bedroom. Our patient was a man of 46, obese, short in stature, with bowed legs, also shirtless, lying on a dirty mattress. He invited us in.

Self pay patients are unusual. And because no one from The Company had visited him in over a year, I figured he had a specific reason for wanting to see us, so I asked him straight out. He gave a direct answer. He was due in court on Monday for a child support hearing and needed a physician's note stating that he was bed-bound and unable to attend. Apparently, as he had grown heavier, he developed back pain, and now in addition to being unable to walk he could no longer tolerate sitting except for short periods. He had not even tried to sit up for the last 8 months. Despite this, he was a fairly cheerful fellow, well-spoken, happily conversant. He seemed to understand how bizarre all of this was. When a third shirtless boy came in asking to use the computer, he breezily said not now, Darnell. The kid kept at it so Henry put an end to the pleading with: "Leave! Goodbye." though his the tone of his dismissal was somehow affectionate, familiar. I almost cracked up.

In order to examine Henry's back, my medical assistant and I had to physically roll him onto his side, not an easy task for a man shaped like a Weeble. Henry walked us through it, so to speak. Apparently, whenever he needs to leave the bed, which isn't often, he calls a couple of larger sons to help pick him up. I had some stationary with me and wrote him a letter on the spot. I could easily testify to his rather lump-like status, and I felt for him. But what I wanted to ask, but avoided doing because we had just met, is what's with all these kids? He has eight! This man who had been on SSI for over 30 years, who had never walked, who was poor as a church mouse, just kept on making babies. And most disturbing, not one but two of his daughters inherited his crippling disease, an outcome that should have been entirely predictable. I can believe that he was never properly educated about his disease. I can even buy this despite the fact that his sister, who also has rickets, passed the disease on to one of her sons. But what I find nearly impossible to fathom is that he never considered slowing down on the baby-making after his first daughter developed the same crippling condition. And while not all of his children live with him, as demonstrated by the child-support suit, both of his daughters do live in his small house. I would imagine this is a way to consolidate SSI checks, about $650/month each, to the point that they can support a household.

Despite what I may think of his choices, the man needed better medical care than he was getting. At this point, though there is probably not a lot to be done about his major diagnosis, he also had untreated hypertension. And if I could help apply for Medicare, which he should be eligible for, we could probably get him a bed with a trapeze set-up that allows him to sit up, along with physical therapy that may help address his back pain. Until we can put all of this in place, I told him that I would come back for free in about a month to check on his blood pressure and see how he was doing.