Soldiers: The Silent Underserved

I loved my elective rotation in a family practice in Orange County. The office was decorated nicely, the exam rooms had winged armchairs instead of standard-issue medical office chairs, the office staff was a close-knit group, and the temp was a cool 67 degrees. It was exactly the kind of practice I'd like to have in the future. I saw many patients there, ranging from newborn to elderly, and enjoyed the various presentations of illness unique to a diverse family practice. One patient in particular was memorable, a young man serving in the Army.

The first thing I noticed about this guy was that he called me "Ma'am." It almost made me giggle- he was about my same age, maybe a few years younger, and I wasn't even the real doctor. He was clean-cut, polite, and respectful, wearing a t-shirt that I recognized as military fabric, similar to the ones my husband wears that are leftover from his years in the Air Force. I asked him what brought him in, and he held up his pointer finger, which was an ominous black color with red marks streaking up his forearm. He said a black widow had bitten it five days prior, and he had tried to lance the bite to relieve some of the pus, but it was getting worse. I asked him what he used to try to drain the area, and he replied "a steak knife, ma'am." Ouch.

I called in the doctor I was working for (clearly this was over my head), and she told me she had never seen a black widow bite before. Unfortunately (or fortunately?) I had already seen many, because in the community I serve, grape-pickers come in after a full-day's work with several bites on their fingers and back from the spiders falling down their shirts from the tall grape arbors. I had seen this because I work with underserved pickers. I never expected this active-duty military member to be more medically underserved than the illegal farmworkers.

The best idea was to refer him urgently over to the orthopedic clinic, given the likely systemic manifestations of the bite and the underperfused finger, but he couldn't go over there due to insurance limits. (When telling this story to my husband, he stopped me here and said, "TriCare" and rolled his eyes). Apparently the military insurance, TriCare, denies unapproved specialist/emergency visits, unless there is an "impending loss of limb, sight, or life." This was getting close enough to loss of limb that the doctor was uncomfortable, but couldn't get the visit approved. He had only come to the office today under direct order from his sergeant.

We gave him antibiotics, and she let me drain the pus using a scalpel (not a steak knife). He was a tough guy, but I knew it was hurting him. He left with strict instructions to come back in the morning to have it looked at again (Yes, Ma'am).

I was appalled. Here was this young man, putting his life on the line, and he was in danger of sepsis and loss of a finger because of insurance regulations? He should have absolutely the best insurance available, able to show his military ID card at any medical facility and receive care, no questions asked. Antivenom should have been given on day one, not palliative care on day six. This doesn't seem to be a topic civilians know much about, but I believe that if a feature article was run about it in a prominent newspaper, taxpayers would demand better medical care of our military personnel. I think this system compromises the medical well-being of the thousands of people that are responsible for protecting our country's safety. My own husband cites it as the main reason that he chose to leave the Air Force and reenter society as a civilian.

I don't know what happened to this guy. I wasn't in the office the following day (another doctor was on call), but I still wonder about him, and hope that everything healed well with no loss of function. Especially since the affected finger was his trigger finger- important for an Army man. I hope everything is okay, but I'm doubtful. If it did heal, it's because of his staff sergeant's orders and his own immune system, not because of care provided by the military. And that's a shame.