The Cost

“Ok, you’re gonna feel a little pinch.”

What I feel is not a little pinch. A white-hot spear of memory and consequence slowly twists its way into the small of my back. A serpent, coiled around my spine, thrashes against the violation hissing it memory-filled outrage. The muscles across my back and down my legs jump, not at my command, but at those of the baleful creature twisting my body into painful knots. Punishment for my disobedience, my resistance to its tyrannical decay. Only the soft iron grip of the nurse holds me in place, that, and a lifetime of learned discipline.

I need all my concentration, all my willpower to hold back a flood of tears and curses. The unrelenting spear in my back pushes through the hardened fissures of my soul in search of the serpent who has made its home these past two years within those very cracks. The doctor thrusts deeper until her tool threatens to burst forth from my crotch in some hellish parody of birth.

The nurse holding my hand is trying to comfort me, to help me through the pain. She has been doing her very best to aid me since I arrived, countless hours ago. The serpent would not let me climb onto the examination table, slithering down into my legs and stiffening them against the intended procedure. So the fragile-seeming nurse had to lift me into position using strength her little body should not have. This young woman, little more than a girl and whose eyes carried far too much compassion for such an uncaring world, never wavered in her quiet words of encouragement and consolation in the long hours that followed. The serpent hated this nurse, and tried to force me into hating her.

“Ok, that’s one more in.”

I glance back at the pain-doc, the specialist that promised to free me from the serpent. I can only see the thin line of her eyes against all the protective gear. Her surgical gown shrouds her entire body, thick gloves shield her hands, a mask veils her face, and a plastic shield envelops her head. I had asked, jokingly, if she was worried about blood splatter, and though the pain-doc had tried to laugh at my feeble humor, her eyes confirmed my unintended truth. “There’s a cost,” they’d told us, all those years ago.

The pain-doc turns to a nearby table, returning with another spear.

“Here we go,” she breathes deeply. “Little pinch.”

❊

It’s three weeks ago, and we’re sitting in a borrowed office at the Veteran’s Affairs Pain Clinic. “It’s called radiofrequency ablation,” the pain-doc is telling me. There are no decorations or pictures on the walls, no personal touches of any kind in this tiny cubicle, since there is no funding for private offices at the Pain Clinic. She must share this space with a half-dozen other VA docs. There aren’t enough doctors at the VA either: few professionals can live on the sub-standard salary. There aren’t enough nurses for the same reason. There aren’t enough clinics or specialists or anything else. Except drugs, of course. There’s always plenty of drugs.

“We’ll insert a series of needles,” the pain-doc is saying, “probes actually, into your back, and then run an electric current through them. This will burn off the nerve endings and prevent you from feeling the pain.”

“Sounds like it’ll hurt,” I point out, shifting again in the uncomfortable plastic chair. The serpent in my back hates the ancient, unpadded VA chairs. Each time I sit down in one, it thrashes within my body, causing wrathful spasms across my torso and limbs.

The pain-doc tries to force a smile. Although she cannot be much past thirty, her face is already worn and lined, silent evidence of her constant and futile battle against the VA bureaucracy, the beast that tries its best to prevent the care she wants to provide. My pain-doc is cursed with compassion, and compassion is anathema at the VA. In a moment of weakness during our previous meeting, the doc admitted that she was unsure how much longer she could keep working here, keep seeing people forced to suffer because the great VA beast only reluctantly approves life-improving procedures because of that one, unforgivable sin: they cost money.

“It will hurt,” she admits. “Normally, in . . . other clinics, we would numb the whole spine and give you a few hours to recover after the procedure. Sometimes, we would even put you under and keep you overnight for observation. But . . . ”

“But not here,” I finished, glancing one again past the thin partitions that provided the closest the VA beast would provide for patient privacy.

“No, here, the best we can do is give you a light, local anesthetic, which should help with the initial insertion of the probes.”

“But you said they go deep,” I point out.

“Yes. I’m afraid we just can’t do anything about the deep-tissue . . . discomfort you’ll experience. Especially once we get to your spine itself.” She shuffled a few papers, outlining the mandatorily-cheap procedures. “We have to do it out-patient,” she continued. “You won’t be able to walk very well afterwards, and there’s a risk of sudden muscle failure. You’ll need someone to drive you home.”

“The shuttle . . . ?”

The pain-doc shook her head, her long ponytail mirroring her resignation. All the programs that did so much for veterans and really required so little, they were all food for the VA beast, whose ravenous greed for funding and hope was as all-consuming as it was pitilessly insatiable. “We’ve had to cut the shuttle program.”

“Well,” I stretched against the pain and the problems, “I’ll figure something out.”

❊

“Ok, that’s the next one.” I vaguely hear the pain-doc say. I take a second to wipe away the rising tide from my eyes and glance about the tiny, cramped procedure room. I look for some distraction or, better, some target for my resentment. The bitter injustice of having to suffer through this, a procedure normally reserved for geriatrics, when I’m still supposed to be in the prime of my thirties, is a bitter pill that keeps forcing its burning way back up my throat.

Like the pain-doc’s office, the examination room has almost no humanizing touches. There are no desks or chairs, no cabinets or closets. There is only the unpadded table coldly pressing against my chest and a collection of machinery huddled around to observe my humiliating pain. The machines are the only sound. The medical instruments hum and beep, they groan and breathe. They are almost more alive than I am, since they cannot suffer the indignities of being old before their time.

“This isn’t an operating room, is it?” I ask the nurse.

She shakes her head. “Converted supply closet,” she answers through her surgical mask, wiping my forehead with a gloved hand. “Best we could do.”

“There’s a cost,” they told us, before the years, before the miles, before the missions.

I hear the pain-doc turning her attention back to me. “Ok, another pinch.”

❊

It’s three months ago, and I’m sitting with my primary care doctor. His office is a little more permanent than the pain-doc’s will be, since he only works out of here instead of having to rotate among a half-dozen different clinics. There are pictures of himself and his partner on vacation somewhere, not fancy—he probably couldn’t afford fancy.

We’re discussing possible treatments for my chronic pain. We’ve had this same discussion, on and off, for the past two years. To his credit, my doc is patient and genuinely trying to help; like the pain-doc, my primary care doc has spent the past years fighting his own battle against the VA beast, the unconquerable monster made up of political hypocrisy, bureaucratic incompetence, and social indifference. He’s been many veterans’ great champion in our endless battle against the beast. Like us, the doc is old before his time, greying temples and a creased face betraying the futility of caring.

“How about physical therapy?” he suggests filled with forced optimism. The doc is scrolling through the available options on his twenty-year-old office computer.

“Fourth time might be the charm.” Although I mean for the comment to sound optimistic and playful, my gritted teeth and heaving breathing betray my growing impatience. PT is cheap and easy, and many veterans find themselves going back time and again, regardless of benefit or lack of it.

“There’s aquathereapy.”

“Did it,” I remind the doc, trying not to scream as the serpent in my back thrashes against the uncomfortable VA chair. “Feels great while I’m in the pool and sucks the second I step out. Besides,” I try to joke, “I’m not ready for bikini season.”

The doc keeps scrolling. “How about a chiropractor? We just got access to a local clinic.”

“Tried it,” I grunt against another bite from the serpent. “Worked for about thirty minutes.”

Doc sighs and keeps scrolling. He’ll admit to me on our next visit that he knew on my first examination what I needed, but couldn’t get approval for the cost. So, instead, he spent months trying to wrestle with the VA beast and failing as inevitably as he knew he would. “We could try deep tissue massage . . . ?” His tone and slightly-rolled eyes say louder than his mouth ever could what he thinks of that idea.

“You mean another session with Boris?” I almost spit my response.

“Alex is a nice guy and he tries hard to help.”

I don’t even try to stop the snort of derision. “He’s still fighting the Cold War, one veteran at a time. We can probably hear the screams of his most recent customer.”

“Well, there’s always drugs.”

The great golden key that unlocks every veteran, at least according to the VA beast. Feelin’ hurt? Here’s some drugs. Feelin’ down? Here’s drugs. Bleedin’ rectally while frothing at the mouth and uncontrollably singing showtunes? Drugs. “Pass,” is my only response.

“Just because your friend . . . ” But I hold up my hand against the sales pitch the doc is required to make. I had told him about what happened to Jessie, my last surviving friend from the Service. We’d become close while fighting for our lives, and then became closer when we had to fight the VA beast. I told the doc about Jessie’s broken back and the unending pain that turned into an opiate addiction. I told him about the VA beast prescribing more and more drugs, and Jessie’s lost family, failed career, and ruined life that, just two weeks ago, ended with a rope, gently swinging from a backyard shed. All of that because the VA beast would not pay for anything except Vicodin.

A sigh and a return to the too-bright screen brings, “Well, there’s always the Pain Clinic.”

❊

“You’re doing great,” the pain-doc’s lie briefly encourages me before being crushed against the empowered waves of hellish terror and rage. Her siren melody receives only a torrent of screeching roars in response, promising bloody vengeance on the world. The serene fog that had, at first, enshrouded my mind let me pity the cursing, crying thing writhing against the unyielding grip of the nurse. But now the fog has been torn away by a pitiless storm, sundering what little remains of my will.

The minor surface-anesthetic, the only pain-killer the VA beast would authorize for this procedure, has long since worn off. The serpent in my back, twisting against each probe’s penetration, is now biting my spine, again and again. It’s rage travels down my arms and legs, forcing unwanted spasms like an angry goddess shaking the earth. The paper gown scrapes across my chest and stomach, offering no protection against the freezing burn of the metal table, and dragging jagged talons across my flesh. Even the pathetic draft from the ancient air conditioner, sputtering its way ever-closer to death, attacks me, grabbing hold of all the tiny hairs on my back and legs, jerking at each and sending insidious sparks arcing from one to the other. I lose track of all the endless eternities.

“There’s a cost,” they’d said. Back before . . . before the killing and the lies and the regret.

“Ok,” the pain-doc says from behind the safety of her mask, “little pinch.”

❊

It’s nine months ago, and I’m sitting in the waiting room of my orthopedic surgeon’s office, the back-doctor that is latest in a string of specialists. After months of tests, prods, samples, theories, and half-assed guesses, I’m at last here, in another VA clinic that looks like all the others. Generic patriotic posters dot the walls. Plastic plants decorate plywood furniture. Uncomfortable chairs line beige walls. Veterans like me, in various stages of living-decay, wait for an end to come at last.

This is the meeting in which I’ll finally get a clear diagnosis. Osteoarthritis: degenerative arthritis in the lower back. Normally a problem that affects the elderly, combat veterans are also at risk because of high-impact lives with little or no recovery time between deployments. The back doctor will look up from the variety of MRIs, CT-Scans, and X-rays as he gives me the news. The older man, grey and balding but still in good physical shape, will not frown or smile, not try to be gentle and kind, nor overly harsh. He will just give me the facts of the rest of my life.

“Pain, obviously, is the biggest symptom,” the back-doctor will say as I shift in my chair. “The severity and specific location of the pain will vary from day to day, sometimes based on physical activity, but often randomly. Some days, you’ll be almost pain-free, able to function normally for short periods. Some days, you’ll be in so much pain you won’t be able to stand.”

I will say nothing in response, just listen, muted by the back-doctor’s damnation. Even the serpent will go briefly still. They taught us how to accept reality and force down any emotion that might try to assert itself in response to a crisis. In that moment, I will be forcing down a large response. I will wrestle down a throbbing, chocking void of wailing despair that will try to force itself up into the cheap florescent light of the back-doctor’s office. I will not let it, though; I will breathe deeply and accept what will be.

“You’ll suffer decreasing mobility over time,” the back-doctor will continue. “Again, there will be fluctuations in severity. Some days, you’ll only have a minor limp, others your legs will be effectively paralyzed. You’ll tire much more easily, and have a general sense of weakness as you are less able to move and your muscles begin to atrophy.”

He’ll give me a few minutes to process the news, the effective end of my life as I knew it. We were warned, all those years ago; there would be consequences for the life and the Service. Not the blood-and-guts consequences, though there would be those as well. We were warned by the old-timers that there would be consequences for all the high-speed, low-drag badassery we’d spend a few short years enjoying. Some of us can’t accept the cost, that’s what they warned us; some of us won’t be able to pay. Those will seek a quick end to the slow death of living decay.

“So, what now?” I will ask through a voice of dried-out clay.

“Well,” the back-doctor will say, removing his reading glasses and fixing me with steady brown eyes. “There are a number of treatments with which your primary care doctor can try to manage the lack of mobility—physical therapy being the most obvious. There will need to be some lifestyle changes to reduce inflammation—give up smoking, change your diet, being less physically active. The main purpose of all of this, however, will only be to buy you more time.”

“More time . . . ?”

“The problem is degenerative,” he’ll say. “Think of your back as a battery with a finite charge and no ability to be re-charged. As you use up the power, the strength your back has left, the battery gets weaker and weaker.”

“So, there’s nothing to do except endure?” Or just give up, is the part I won’t say.

This will be the only time the back-doctor looks uncomfortable. “There is a surgery, a spinal fusion. I would join together several of the bones in your spinal column. It has a fair degree of success in permanently relieving the pain and degeneration of motor function.

“But . . . ?” A brief twist by the serpent is unneeded in reminding me of Ed’s surgery and the VA’s failed promise of being free of the pain.

“Well, along with the normal risks in surgery, blood clots, infection, things like that, there’s one big risk to the procedure. Nerve damage. You’ll permanently lose a degree of mobility and flexibility, but there’s a… not-insignificant risk of permanent nerve damage.”

“Which would do what?” My voice will seem mechanical, unfeeling and uncaring. My voice will seem to be that.

“Numbness, partial paralysis. Many of the same symptoms you see in stroke victims, but located below the waist.” The back-doctor will then lean forward. “It’s a quality of life question,” he’ll say. “We send you through treatments for the pain until those don’t work anymore, or they just don’t work enough. The pain will keep getting worse, with greater and greater need for temporary relief. Eventually, the treatments just won’t do anything. That’s when you decide to risk the surgery.”

But all of that has yet to happen. Right now, I’m in the waiting room, chatting with Jessie. My old friend is here to support me, despite how painful it is to go outside. Jessie has a serpent as well, though in the liver as opposed to the serpent in my back. Jessie’s hates the outdoors and punishes Jessie anytime they leave the house. Right now, my friend is looking at me and trying to hide a deep resignation. Jessie had a surgery as well, but it didn’t fix the pain. Jessie’s serpent is growing and my friend’s resolve is shrinking. The VA beast will only give my friend more and more Vicodin for the ever-increasing pain. Eventually, they say, the pain will get so bad that Jessie will have to be tied down to a hospital bed, where my friend will die screaming. There has been talk about a new shed in the backyard. Jessie’s been working on it for over a year, as best the serpent will allow. It’s almost done. It’s almost ready.

❊

“Alright, we’re almost done.”

The pain-doc is taking a deep breath. Her hands and her voice are stone: solid and steady.

“Now, these last couple of probes are a little bigger.”

There’s a cost. Those were the prophetic words that I’d shrugged off, like all the other recruits too new, too young, and too ignorant to understand.

The pain-doc picks up another spear, larger than its brothers. “Little pinch.”

❊

It’s two years ago and I’m lying on the floor of my kitchen. It’s Thanksgiving, and Mom is visiting. Jessie is there, of course, the surgery scheduled for next week. My friend was optimistic for the first time in years; the VA docs have promised freedom from the serpent. The failure of the surgery will be a terrible blow.

We’ve already finished Thanksgiving dinner and Mom and I are cleaning the kitchen. I’d just finished loading the dishwasher when the serpent strikes for the first time. It tears open a hole in the small of my back and forces its way in, burrowing deeper and deeper, into the very root of my soul and the base of my body. It wraps itself around the core of my being, squeezing, biting, dripping venom. I must have lost my balance, but I don’t remember that.

I am lying on the floor, covered in the shards of Thanksgiving. The dishwasher is groaning and spraying us, violently objecting to this unwholesome incident. Its racks are broken and upturned. Pieces of dirty plates and glasses cover me and most of the kitchen floor. I am soaked in sweat and drool and my own urine. I am screaming. In a moment, I will vomit and Jessie will have to hold me down as Mom struggles to keep my airway clear.

I don’t remember if Mom has retired yet, or if that’s next Thanksgiving. She’s worked for decades as a VA nurse. I remember Mom coming home from work on so many nights, looking sad and tired; she cared a lot for the veterans, and suffered from being unable to help. She doesn’t want to retire, I remember that. She doesn’t want to give up her battle with the VA beast, but she will tell me that she just can’t fight anymore.

None of that has happened yet, though. Right now, Mom and Jessie are struggling to hold me down, to keep me from getting hurt worse amidst the jagged, broken pieces of Thanksgiving. Mom is shouting something about her bag, and Jessie is obeying. Strong hands are holding me down and time blurs until an ER doctor is injecting something into my back.

❊

Ok, last one,” the pain-doc says. She harpoons me like the beached whale I resemble. I try to curse through clenched teeth, but end up just growling as the nurse stares at me with her mixture of compassion and pity. Her inflexible grip doesn’t match her soft eyes. I don’t tear up anymore, and I don’t curse, no matter how much my soul rages against the injustice. I just accept what is.

There’s a cost. Words I’ve said myself to recruits, once I’d learned.

Doc’s hand goes, once again, to the small of my back. “Ok, little pinch.”

❊

I’m in the Army, years ago, back in the desert. Things are getting a little fuzzy; it’s hard to hold my mind together. Which desert am I in this time? Iraq? Kuwait? Somewhere else; somewhere the politicians say I’m not? Which mission is this? Am I patrolling a burned-out village or am I burning out a village? Am I guarding the International Zone or setting up the Green Zone, or guiding missiles into the capital? Am I running a training module on how to spot road-side bombs, emplaced by terrorists, or am I teaching local freedom fighters how to set up road-side bombs?

No, that’s right. I’m back in training, decades ago. I’m in Oklahoma, learning about how to fight the Cold War, though the Cold War is long over. I’m standing in formation with several other new recruits as the Drill Sergeant looks us up and down. “You all think you’re hot shit, don’t you?” he demands, not hiding his contempt. “You all think you’re going to go out there and just kick all kinds of ass?”

He walks with a barely-noticeable limp. He has no visible scars, but there will be moments during training when his eyes glaze over, when he stares into the distance. There will be moments when his stone-wall hardness cracks for just a moment, and a flicker of pain washes over his face.

“You think you all know what’s coming,” he continues, barely-limping up and down the formation to stare us each in the eye, one by one. He comes to me, sneering. “There’s a cost to being a hard-ass, you know.”

❊

“Alright,” the pain-doc says, her gentle voice betraying her relief. “That’s it.” She moves the red-soaked probes to a tray and switches off the machine that had been happily pumping electricity into my body. I cannot move, exhausted, violated, humiliated, and nearly broken. The nurse hasn’t removed her hands from mine; she is waiting.

“Well,” the pain-doc says. “You’ll need a few minutes, and then we’ll get you dressed and ready to go home.” She consults her notes on a nearby clipboard. “And then we’ll see you back here in a few months . . . or whenever you need another procedure.”

Once able to stand, I dress, with less help from the nurse than I needed to undress. I take my cane, though I find I can walk without it for now, and thank the two professionals for their help. The shadow of expectation hangs over us. We all know that I’ll see them again, far too soon. I then walk out to the waiting room, where Mom is pretending to read some three-year-old magazine. She sees me and gathers her things. We walk outside, but I’m not there, not really. I’m still standing in Ed’s backyard, looking into the open, completed shed where I found him. I’m looking into his peaceful eyes and wondering.

I whisper to myself, walking towards the bright light of day, and the parking lot where Mom will drive me home. “There’s a cost.”