The Player

By Bruce H. Dobkin|Friday, November 01, 1996
RELATED TAGS: CANCER
When I first met Mr. Drimmer in the Neurology Department’s outpatient clinic, he was slouched in a wheelchair with one of the widest seats I had ever seen. Even seated, he cut an imposing figure. Two aides, broad, mustached security men and gofers, flanked him. The three were as bulky as any group of pro football linemen who had maintained big appetites years after their playing days were over. Drimmer was a patient of my colleague Jerry, who introduced us and handed me a pile of medical records. I exchanged a few pleasantries with Mr. Drimmer as I leafed through the comments of several neurologists, orthopedic surgeons, and diabetes specialists.

Can we keep it short? Mr. Drimmer said. I’ve got an important business meeting in two hours.

Jerry stepped in and said that this visit should be Mr. Drimmer’s top priority. I could already see from his records that the exam would take some time. I didn’t want to miss something in what looked like a complex and serious medical problem.

I often went out of my way to help Jerry. His internal medicine practice had evolved so that he provided highly personalized care to business executives and Hollywood headliners--a role that made friends for the university, and especially for our medical school, and led to substantial philanthropic gifts for research and other programs. Mr. Drimmer bought and sold businesses that were worth billions, and Jerry wanted to get the family into the donors’ pool. Against Jerry’s request, I had insisted that I examine Mr. Drimmer on my common man’s turf, rather than at his estate, as he preferred. I am more comfortable putting some distance between me and the persona of the mogul or celebrity.

A year before our meeting, Mr. Drimmer could play 18 holes of golf. But six months after that, just before undergoing surgery on the right knee, his legs wobbled so much that he could not play at all. He and the orthopedic surgeons blamed this on the arthritis in his knees. Rather than rely on their diagnosis, however, I asked Mr. Drimmer to describe to me, in his own words, just how his mobility had changed over the past year, prodding him to reconsider the sequence of events.

He said the trouble with walking had been increasing, although the knee pain wasn’t getting any more intense or frequent. Since his surgery six months ago, he told me, he had been exercising daily with a physical therapist. They used the indoor pool, spa, and professionally designed gymnasium in Mr. Drimmer’s main house. But the daily swims that he found so comforting were becoming little more than a float in which his arms were providing more power than his legs. And despite the exercise program, walking had become an ordeal. For the past several months, he preferred to be pushed in a wheelchair. At recent dinner parties, he hung on to his beefy aides to transfer to a dining room chair. His knees still hurt when he bore his weight on them, but not enough to explain his lack of strength.

I’ve also had a tingling and numbness in my thighs and feet, he added. Other doctors have told me it was caused by my diabetes.

I nodded. High blood sugars and low levels of natural insulin in diabetics can cause harmful substances to accumulate in nerves, causing gradual degeneration of the fatty myelin that sheathes the nerve’s axon. Axons are the long arms of the nerve cells; they reach out of the spinal cord and extend to the muscles and sensory receptors of the arms and legs. Degeneration of the longest nerves, those that go to the legs, might account for Mr. Drimmer’s numbness and weakness. That, at least, was the consensus of the many specialists who had contributed to Mr. Drimmer’s thick file of medical records.

In rare cases a diabetic will suffer a rapid decline because of tiny blockages in the nerves that bunch together on either side of the pelvis in glistening clumps called the lumbosacral plexuses. If his diabetes was indeed causing this degeneration, Mr. Drimmer was probably not helped by his having a kitchen staff that was, he admitted, skilled in preparing the snacks and delicacies he demanded; his frequent indulgences might especially predispose him to diabetic nerve damage. Yet Mr. Drimmer’s decline seemed surprisingly rapid and profound. After all, from what I could see on his medical records, oral medication was effectively controlling his blood sugar levels.

I explained to Mr. Drimmer that I needed to test him for nerve damage and that the tests would put him in some discomfort. I began with a few routine checks, and then, while he remained seated in his wheelchair, started testing the strength of the muscle groups in his arms and legs. His leg muscles were a bit weak. I also wanted to see him walk, so I asked his aides to hoist him to a standing position. They unloaded so much of their boss’s weight that he was able to step by swinging one leg after the other. The trio performed this peculiar dance easily at first, but Mr. Drimmer wanted to quit after five steps. I urged him to push a little farther. After a dozen steps, he complained that his legs felt numb and constricted. His face was red from the exertion.

It’s as if bands are tied around my thighs and calves, he said breathlessly.

I immediately asked Mr. Drimmer’s aides to lay him on his back on a narrow examination table. I doggedly tested his leg strength a second time, which quickly winded him again. Jerry frowned and arched an eyebrow. He was silently reminding me that we were here to help Drimmer and make a friend for the university, not upset him. Drimmer’s assistants folded their arms like sumo wrestlers and clenched their fists and jaws. Everybody was getting a little tense. By now, however, Jerry could see how much weaker his vip had become after taking a few short steps. The big man had to struggle to lift each heel no higher than an inch off the table. When he attempted to extend a flexed knee, I broke the resistance of his withered thigh muscles by pressing down on his lower leg with just two of my fingers. He could barely twitch his ankles and toes, when he should have been able to flex and extend as if he were pumping a car’s brake pedal. When I finished testing his muscle strength, his aides lifted their perspiring and disheveled boss off the table and gracefully deposited him in his wheelchair.

The problem with the loss of strength in your legs could be the combination of the arthritis and diabetes, I began. But we must see if something--like a herniated disk--is pressing on your lower spinal cord.

The easiest way to look for something like that would be to put him in an mri scanner. But because of his size, Mr. Drimmer wouldn’t fit. I told him that we would have to do a more uncomfortable procedure called a myelogram.

Jerry’s jaw dropped. He needs this?

A myelogram means putting a needle into the bottom of the spinal column, then injecting a watery dye into the spinal fluid. As the patient is rolled and tilted on a hydraulic table, the dye floats up the spinal canal. The dye, which appears white on X-ray films, inches upward, silhouetting the nerves and anything else in the spinal canal. In a man this large who got short of breath so easily, the 45-minute procedure could be exhausting and a bit painful.

I explained that what worried me was how fast his leg muscles had weakened during his short walk. That pointed to something other than arthritis and diabetes. Such weakness could be caused by a herniated disk or, possibly, a tumor pushing into the one-inch-wide spinal canal. In the lower back, the canal contains the bottom of the spinal cord. From its tip at the base of the spine, about 20 stringy nerves--called the cauda equina, or horse’s tail--travel downward within a fluid-filled sac. Pressure on the tip of the cord or its tail of nerves tends to increase when we stand because the vertebrae flex backward, causing the tough ligaments that lie against the wall of the spinal canal to bulge a bit. If the canal is already narrowed by, say, a hard protruding disk, the nerves are crushed together, causing painful numbness and greater leg weakness. The symptoms ease once the patient lies down or slouches in a chair and reverses the angle of the spine, just as a leg that tingles as if it is asleep comes to feel normal soon after you change position and stop pressing on the sciatic nerve in the buttocks.

Jerry already knew what I did not say. If Mr. Drimmer was being slowly paralyzed by spinal compression, the increasing pressure on the spine might lead to loss of bowel and bladder control. In a man his size, such pressure can lead to bladder infections, bedsores over the buttocks, and phlebitis, or blood clots in the legs. Each complication would threaten his life.

Jerry turned to his patient. This procedure has to be done.

Mr. Drimmer squinted at us. One of his aides wiped beads of sweat off his forehead.

You think I might need back surgery, he began. If that’s the situation, why didn’t anyone else see the need for this? Mr. Drimmer clearly wanted to believe that he was still a player with bad knees, not a debilitated man on the verge of paralysis. I let Jerry take the first pass at convincing him.

Maybe because you pull in experts for one or two visits and, for a lot of reasons, they don’t feel that they are there to be your doctor, Jerry said patiently. You heard what Dr. Dobkin said. This is the chance to get you out of the wheelchair.

How about after the Christmas holidays, in a week or so? I’ve got a load of people coming in.

Jerry smiled at me. See what I go through? He rubbed his cheek a few times and swung back to Drimmer. We do the study in the morning. Mr. Drimmer folded his hands and nodded yes.

The next day, I was with the neuroradiologist as he hung the film from Mr. Drimmer’s myelogram against a backlighted board. Jerry joined us. I leaned in as each successive film showed in greater detail the emergence of a shadowy mass the size of an apricot pit. It filled half the spinal canal just above the first lumbar vertebra.

From the looks of it, we suspected a meningioma, a tumor that arises from the overgrowth of cells that line the covering around the spinal cord. If so, Mr. Drimmer was especially lucky. Such tumors are not malignant and can easily be pcut away, usually without doing further damage to the cord and nerves. I called a neurosurgeon whom I had already put on notice about the case.

Lying on a gurney, wrapped in a hospital gown that fit like a bib, Mr. Drimmer listened to us describe the results with no emotion. He then insisted that he needed to go home; he could return for the surgery after New Year’s Day. I could see he was still negotiating, still convinced he could bend the world to his will. I performed a brief exam and found that his legs were weaker and, for the first time, the nature of his reflexes pointed to compression of the spinal cord itself. The myelogram had altered the fluid pressure within the canal and caused the tumor to collapse against the stalk of the cord.

I started him on medication that would lessen any swelling of the cord. Mr. Drimmer had to be operated on immediately. I told him any further deterioration could cost him the use of his legs.

I’m admitting you now, Jerry concurred. I’ll talk to the family.

In the operating room, the neurosurgeon cut into Mr. Drimmer’s spinal canal and delicately removed a gritty, rubbery meningioma. The oval sphere of tumor had a thinner tongue that extended several inches down the horse’s tail. Together, they had compressed both the stalk of the cord and its tail.

The next morning, surrounded by his wife and children and dozens of flower arrangements, Mr. Drimmer easily lifted his legs off the bed a good six inches and pumped his feet. The anxiety on the faces of his family vanished.

Mr. Drimmer did not remain in the hospital for his rehabilitation therapy. He set up a staff of nurses and therapists in his home, and I visited him several times. The first of these mansion calls took me past security gates with guards, into a center hall in which my two-story home would have fit like a postage stamp on an envelope. By the time I reached Mr. Drimmer, ensconced in his master bedroom and attended by his wife and staff, I realized how easy it would be to get too caught up in the aura of glitz and power to do decent doctoring.

All too often I have seen how vips--people with fame, fortune, and worldwide connections--come to receive less than optimal medical care. When ill, they jump from one doctor to another as well-placed friends suggest who the best doctor in the country would be for their problem. They will fly in a doctor for an opinion or stop by to see one during their travels. Unfortunately, that sometimes means there is no personal physician who grasps the course of their illness and their response to a treatment. And that’s what had happened to Mr. Drimmer. Sometimes, however, the doctors have to shoulder the blame. When treating a patient who is accustomed to wielding power, physicians can become overly cautious in their efforts to avoid any confrontation.

Eight weeks after surgery, Mr. Drimmer’s leg strength had returned nearly to normal. Diabetes-related damage had not been a factor after all. When knee pain and other medical complications flared up, Jerry managed them. I faded into the background, giving advice to the physical therapist I’d put on the case and trading notes with the neurosurgeon and Jerry. By the start of summer, Mr. Drimmer walked without so much as a limp. That was our medical center’s gift to the vip and his family.
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