Physician's Assistant

Jacksonville, Florida. October, 2019.

"Aiden? You ready to go?"

"Hold on, Mom! I just gotta grab my glove."

"We're going to the base hospital, honey, not a ball field."

She knew there was no reason to say that. Her eight-year old son never went anywhere without his baseball glove, so it didn't really matter where they were going. The glove was coming along with them.

"Okay. Just please hurry!"

Seconds later, the boy came scampering down the stairs holding the glove and said he was ready to go.

"You know what?" his mom said as she tried not to smile.

"No. What?"

"I'm gonna find a doctor and see if he can remove that glove from your hand."

"Huh?" her son replied as they got in the car.

"It's surgically attached to your hand, right? So I want to find out if it can be removed."

Aiden was exceptionally bright for his age, and while most kids still wouldn't have understood, he laughed. Unfortunately, he was taller than most kids his age, not very coordinated yet, and wore thick glasses due to severe near-sightedness and astigmatism, something for which he was often teased.

"Ha-ha. Very funny, Mom!" he told her as he climbed in and buckled his seat belt.

When his mom got in and started the car, she looked over and said, "I wish I was good enough to teach you how to play."

"You're good," her son said supportively even though she couldn't hit, throw, or catch to save her life. But she tried, and that's all that mattered to her baseball-crazed son.

Tori Bell was 38, the mother of an eight-year old boy, and had been widowed for three years after her husband, a Navy SEAL, had been killed in a training accident. She hadn't been required to leave base housing as soon as she did, but after two months in which she couldn't tell up from down, she moved back home to Orange Park, Florida, where she'd grown up.

Tori met her late husband, Mike Bell, at a Jacksonville bar one night when a friend convinced her to go clubbing with her. He was the first, last, and only guy she'd ever slept with the day she met him, but she'd never regretted it for even a moment. He'd called her the next day, she saw him again that night, and every day for the rest of the two weeks he was in town coordinating with one of the squadrons on base that would take part in a joint operation Mike's team would also be involved in.

A whirlwind, distance romance took place after that, and just six months later she married the guy his buddies called 'the gentle giant'.

Mike had been to Iraq once and Afghanistan twice and never so much as suffered a scratch. But back home in Little Creek, Virginia, he and his fellow SEALs routinely participated in very realistic training, and it was during one such event that he'd been killed.

She'd heard the explanation of how he'd been accidentally shot during a nighttime, live-fire exercise several times and had no reason to believe the Navy captain, himself a SEAL for 23 years, who came to her home wasn't telling her the truth. But in the end, how, or even the reason why didn't matter. What did matter was that he was gone; and not just from her life but from her son's who'd worshipped his dad, as well.

Tori often recalled the way Aiden clung to his father, a tall, strong man who was as calm and easygoing as anyone she'd ever met. He either held his father's hand or sat in his lap or let his dad drag him around on one of his feet while Aiden clung to a leg.

Mike was quiet and also very intelligent, but most of all, he was a man who loved being married, and Tori and Aiden were everything to him. They'd both hugged him and kissed him goodbye before that fateful night, and then, in the blink of an eye, he was gone.

Mike was also a pretty decent athlete who'd played three sports in high school, baseball being one of them. He bought Aiden a tiny glove when he was just three, and the two of them would play for as long as the little boy stayed interested. Initially it was just catch with the game being more 'drop' than catch as Mike would gently toss a tennis ball underhanded from just a couple of feet away to let Aiden start learning to judge how a ball moved. Later on, Mike rolled ground balls to his son or tossed little pop flies to him.

By the time he was four, they were using a real baseball. When he turned five, Mike started throwing overhand during batting practice but the throws were very easy. Aiden had also been hitting off of a Tee for over a year, and Mike began actually pitching to him just before he died. It was still a gentle toss, but Aiden would have played all day, every day, if his dad was willing.

Tori did her best to keep the game alive, but she was like a dancer with two left feet, and that was on her good days.

"Besides," Aiden continued. "I get to play in the T-ball league."

"Yes. Yes, you do," his mother agreed as she backed out of the driveway, grateful that he had other boys and a coach to help try and fill some of the void in his life.

As she drove to the base hospital, where she still had privileges, Tori kept thinking about something her younger sister, Amanda, had said to her a couple of days earlier after mentioning she needed more Tramadol.

"I'm wondering if the base is going to continue prescribing it," Amanda mentioned.

"Why? What have you heard?"

Amanda was a registered nurse, and when it came to such things, she was almost always correct. She was also married to a fellow RN named Jeremy, a guy Tori loved like the brother she'd never had. Sadly, they were unable to have children of their own, and Aiden was the boy they loved like their own son.

"Well, they made it a 'scheduled drug' back in 2015, and with the opioid epidemic, I see problems on the horizon. Our hospital is already cracking down hard, so just be aware, okay."

"But Tramadol isn't an opioid. It's a synthetic, right?" Tori countered.

"Yes, but that won't matter when the federal government reaches out with a blanket regulation and its wide net. Tramadol, and people who actually need it, and especially Oxycodone, are going to get hit hard."

Tori had been diagnosed with rheumatoid arthritis or RA not long before Mike's death. When she told him why her hands were so sore, he laughed and started teasing her about being old and falling apart. The truth was, people of any age could get RA, and Tori was one of those who got it in her 30s.

Initially, she'd taken Naproxen which seemed to work just fine. But within months it wasn't getting the job done, so her doctor prescribed Celebrex, and that had worked wonders for the next two years or so.

But a year ago, he added in 50mg of Tramadol, and six months ago, another 50mg tablet. So she was now taking 200mg of Celecobix, the generic form of Celebrex, and 100mg of Tramadol to keep the pain at bay. Were she to be cut off, she could live with it, but she knew her fingers, wrists, and elbows would start hurting again, and without some other medication to reduce the inflammation, her RA could get worse.

So she stayed optimistic as she checked in, and hoped against hope she could get another six-months worth of the medication she needed.

But when her doctor, a Navy lieutenant commander, came in and sat down, she knew something was wrong.

"Tori? I have a list of all of the patients at this hospital who are regularly prescribed opioid medications, and your name is on it."

Feeling queasy, she quietly asked, "What does that mean?"

"I'm afraid it puts you on the radar as being a potential abuser."

"What? An abuser? You can't be serious!" she said, hardly able to believe what she'd just hear.

"No. I know you're not abusing it. But we have a new policy, and unfortunately, we can't prescribe more than 10 days worth of any opioid, to include Tramadol, to anyone for any reason. We have an exception for active duty personnel, but there's only one pain specialist at the hospital so all dependents and retirees will have to go elsewhere."

"So...what does that mean for me?" she quietly asked.

"The good news is we can, and will, refer you out in town to one of the several pain clinics. The bad news is I can't guarantee you that any specific clinic will agree to continue prescribing Tramadol. I've heard good and bad things about two clinics, but there's one that seems to really work with the patients we've sent their way."

The doctor paused then said, "And believe me, there are a lot of them."

"Okay. So...what should I do?"

"I can't tell you which clinic to use. However, I can give you the name of the clinic my patients, who still see me for other reasons, have said has been really good about working with them."

He wrote the name down on a sticky note, handed it to her, then asked her if there was anything else she needed to discuss then walked her out front.

"I'm really sorry, but this is how these things tend to work."

Tori forced herself to smile then said, "Right. Wide nets and all that."

"Indeed," the internist said before wishing her a good day.

"Mom? What did all that mean?" Aiden asked, knowing his mother was upset but not understanding why.

"Oh. It's nothing, honey. I'm just going to need to see a different doctor for one of my medications. So no worries."

"Okay," her son said, satisfied with the simple answer.

Tori had never heard of the First Coast Pain and Spine Clinic, but she knew exactly where it was based on the address. Kingsley Avenue in her hometown of Orange Park was home to a first-rate hospital and dozens of professional medical and dental clinics.

It took three days for the referral to arrive by mail, but once she had it in hand, Tori gave the clinic a call even as she remembered her doctor's words about there being no guarantee.

The receptionist was friendly enough, and after less than a minute on the phone, Tori had an appointment two days later at 3pm. That would allow her to go from the school where she worked as a classroom assistant and where her son attended, straight to the clinic.

The weather had finally cooled off, and for the first time since April, the morning low was under 60 degrees. It would hit 84 by the time of her appointment, but the cool, crisp, dry air was a pleasant change from the relentless heat and humidity that engulfed northeast Florida from around mid-April or early May through mid-to-late October.

Aiden had no idea what his mom went through to keep her pain in check, but he loved her dearly, and the thought of her being hurting in any way hurt him, so when she told him they were going to see a new doctor, he told her that was fine.

That afternoon, as they walked into the clinic, Tori had this sick feeling in her stomach. The waiting room was filled with people, most of whom looked like they were in desperate shape. She wasn't a snob, she'd never thought she was better than anyone else, and she genuinely felt sorry for anyone who was poor due to no fault of their own.

But there was something about the folks in the waiting room that made her feel...out of place. She didn't have time to really look as she needed to check in, but she still felt uneasy.

"Ms. Bell," the receptionist said. "Your co-pay is $30, and we'll need a urine sample from you each time you see us."

The woman wasn't rude, she was just...brusque. And as far as urine samples went, that was something the base hospital had never asked her to do. But arguing wasn't in her DNA, and it wouldn't have changed anything even if it was, so she handed the woman her credit card, signed the receipt, then told Aiden to wait right outside one of the two restrooms.

She breathed a sigh of relief when the bathroom looked to be reasonably clean. Even so, she hated dealing with all of the hassle any woman dealt with just to provide a sample, but if she wanted to have any chance of getting her pain medication, this was the price of admission.

When she was finished, she washed her hands then covered the sample with a paper towel, slung her purse over her shoulder, then stepped outside. There was a location for urine samples, and there were at least a dozen of them in the large tray where she set hers as she 'willied' from the thought of where all that pee had come from.

"Okay. Let's go sit down until they call us," she told her son, who was now seeing for himself what his mother had already noticed.

"Mom. Is everybody here poor?" Aiden asked very quietly.

"Shhh," she told him anyway.

But once they sat down she looked around again and what she saw reminded her of the kinds of photos people posted about shoppers at WalMart. It was cruel, but it was also often funny in a disgusting kind of way. These patients weren't that bad, but there were quite a few who easily made the honorable mention list.

It took about 15 minutes to call her name, but a cheerful, young black girl waited for her and told her who she was and what they'd be doing. Along with the standard height and weight measurements as well as taking her blood pressure, Tori was asked a long series of questions about her pain, the causes of it, how long she'd had it, what she'd been taking, and many other such things.

By the time the nurse left and told her the doctor would be right in, she felt even worse about being a suspected drug addict. Between the 'grilling', the urine sample, and the kind of people in the clinic, she couldn't help but wonder how many patients had gotten addicted to Oxycontin and the like and were now dependent on it. That, in turn, made her wonder if this and other clinics like it, made their money on feeding the addiction.

Her thoughts were interrupted when a very attractive female doctor about her age came in and introduced herself.

"Hi. I'm Doctor Zellner," she said as she offered Tori her hand.

"Hi. I'm Tori Bell and this is my son, Aiden."

The pleasantries out of the way, Dr. Zellner began asking Tori nearly the same questions her nurse had just asked not five minutes earlier. Again, arguing wasn't an issue, so she patiently answered each question a second time.

She watched the doctor make a series of notes as they talked, and at one point she looked up and said, "Okay. I don't see any problem with continuing the Tramadol. I'll give you a 30-day supply and we'll see you back in a month."

For the third time, Tori stifled the urge to say something. In this case, it was the timing. The base had always given her a 90-day supply with 3 refills. And there was no co-pay for the visit or the medications if she used the base pharmacy. Here she would be paying $30 per month and either go all the way back to the base and wait for an hour or have another co-pay on for the prescription.

She knew full well that her medical care was virtually free while many paid thousands of dollars per year just for their insurance. On top of that, they had to meet certain minimums before the insurance paid anything, and there were large co-pays on top of that. Still, it seemed excessive to make her come in every 30-days for a medication she'd been responsibly taking for quite some time without incident.

When the doctor stood up and told her she'd walk them to the front where she'd need to wait for the hardcopy of the prescription, Tori just smiled and thanked the doctor. On the way upfront, Dr. Zellner chatted with Aiden about school and that's when the subject of baseball came up.

"Oh. We have a PA on staff here who played high school and college baseball. Maybe you'll have a chance to meet him sometime," she told Aiden who was all ears at the mention of his favorite sport.

But the conversation was over as quickly as it started when she said, "Just have a seat here, and I'll be back with your paperwork. Mary will make your next appointment, too, so we'll see you again a month."

There was a large gray bench, and as Tori went to sit down, a man who looked to be at least a hundred pounds overweight plopped down right in the middle of it. He let out a loud groan as he sat, and when he looked up at Tori, he smiled revealing a missing front tooth with the ones that were remaining as yellow as any she'd ever seen.

She was doing her best not to judge, but it was taking all of her willpower to do so.

"You in here fer yer monthly fix, too, little lady?" the man asked with raspy voice.

"I'm sorry?" Tori said, as she did her best to not let her anxieties show through.

"I ain't seen you 'round here before, so I'z jus' wonderin' if you wuz new."

"Oh. Yes. This is my first time," she told him.

"Oxycontin?" the man asked.

"No. Tramadol," she replied.

"Oh. I ain't never heard a that," he told her. "They got me hooked on this stuff five years ago when I hurt mah back. Things wuz fine fer a good long while 'til them Feds done went an' changed the rules. Now I gotta run over here ever month, and all I got's Sosh S'curity, so it gits right expensive. But whatcha gonna do, right?"

"Yes. That's right," she said as she realized Aiden was holding onto her hand for the first time in ages.

"Ms. Bell?" she heard the woman behind the plexiglass say.

"Yes. That's me," Tori said, turning around to see her and stop seeing someone else.

"Okay. I have your prescription. Just let me know what day and time works for you, and we'll get your next appointment for you."

Tori looked at the Calendar app on her phone and picked the same day and time four weeks later. The woman handed her a reminder card along with her prescription, and that was that.

"Mom? Why does everyone look poor?" Aiden asked again once they got outside.

"I...I don't know, honey. Maybe they just are," was the best his mother could come up with as she didn't have the answer, either.

She dropped the script off at a drugstore near their house, and returned to pick it up the next day. On the positive side, she still had access to the medication she needed. On the negative side, a monthly doctor visit was now going to be a necessity.

As she signed for the prescription—twice, since it was a scheduled medication—she could hear Mike saying, "It could always be worse."

She couldn't help but smile when she thought of that, and by the time she got home, the entire 'ordeal' was out of her mind.

But as the day for her next appointment got closer, Tori began dreading having to go back in. She also felt extremely guilty about feeling the way the clinic made her feel. She knew there was a story behind every person in there, but even so, it was all she could do to force herself to go back when the day of her appointment came.

Aiden had his ball glove with him when they returned to First Coast Pain and Spine, and he already knew the routine when his mom took the plastic cup from the lady behind the receptionist window.

Just like the month before, Tori was amazed at the patients sitting in the waiting room with her. She wasn't wearing anything expensive, but she was by far the nicest-dressed person in the room with Aiden being a close second. She looked around and saw a man in bib overalls, a woman in baggy sweats, and someone else who was missing not one, but two, front teeth. Worst of all, a woman of about 50 was sneezing over and over and over, and not once did she so much as try to cover her nose.

By the time she was called to back and see the doctor, she'd made up her mind that there was no way on earth she was ever coming back there again as a different nurse took her to a different room but asked her the exact same set of questions as before; questions which Tori answered with a smile.

"Okay. The doctor will be right in," the new nurse told her.

After she left, Aiden looked up at her and said, "Mom? This place gives me the creeps!"

Her eyes opened wide and her hand shot up to cover her mouth as she tried as hard as she could not to laugh.

"Why is that funny?" her son laughed.

"I'm sorry, buddy. It's not funny. It's just..."

The door opened, and a male doctor walked in and said hello.