Monday, March 31, 2014

The Little Mallet
By Michael

Pelicans are cool, but they are so
numerous her in La Paz, that they
come to seem like sea gulls; we
shoo them off every chance we
get. See the giant white stain in
corner of our dinghy floor?
And I waved back, just to emphasize how happy I am, and how great this is.

I wrote that, just weeks ago. I was relishing the joy of doing laundry on the foredeck, basking in the warm air of paradise as I stomped on clothes in a bucket of cool soapy water.

The joy was short-lived.

A few days ago I was at it again, stomping, stomping. But then I reached into the bucket to pull a piece of clothing from the bottom and…I don’t know. It happened quickly, my pinky finger on my left hand caught something and I felt a small tweak or snap. When I pulled my hand up, it hurt a bit, but worse, my little finger just felt odd, a combined numbness and stretched feeling.

And it looked odd too. The very tip hung limp. I could easily lift it with my other hand, rotating that tiny joint so that my finger was straight, but as soon as I let go that tip would just fall down again. I played with it a bit and decided I must have ripped a tendon off the top of the little bone at the tip of my finger.

I went below to consult Dr. Google and right away it was clear that my diagnosis was spot-on: I had ripped the tendon off the top of the little bone at the tip of my finger. The injury is called mallet finger. Treatment rarely involves surgery, a splint for eight weeks is the indicated approach. I made a splint. That was the end of it.

Until it made me think about my healthcare decision-making process as an out-of-country cruiser. First, though we do carry international health insurance, our deductible is $10K per person; we are self-insured for the small stuff like mallet finger. Seeing a doctor for this injury would be easy and cheap, not even an appointment would be necessary. If indicated, an x-ray would be more of a hassle, probably a referral and more walking and waiting, but I wouldn't expect the total cost to exceed $40US.

So those were my options for care. I decided not to seek care. I think my decision is primarily due to the fact that the information I found online seems to align perfectly with my injury, the treatment approach seems universal, and I don't feel like taking the time to visit a clinic and then an x-ray lab.

But I want to contrast this with the approach I may have taken in our old life, complete with a steady income and employer-based health insurance coverage. Let's put me at home with this injury, it happens during a Saturday of yard work. Ice would have been so easy to get out of the freezer that I would have likely done that first. Then, without a thought to inquiring online, I'd have driven myself to nearby urgent care. I'd flash my insurance card, fill out forms, see a doctor or P.A., get in the queue for an x-ray, watch a nurse put a $25 splint on my finger, and then get sent home--with a prescription for pain medication I probably would not have filled.

All totally appropriate, and with a more certain diagnosis and a smaller risk that a rare complication went undiscovered. Old life or new, the out-of-pocket expenses would be about the same.

In our current, very-low-income life, every dollar spent moves us closer to the end of our travels, so maybe my decision making in this case is just a matter of $40US looming larger than it otherwise would. (Yet I know that if one of the girls suffered the same injury, I wouldn't think twice before bringing them in.) But whatever the reason, and whether it's foolish or prideful, I appreciate the self-sufficient approach, I embrace it.

Back in my Washington, DC professional life, I remember several times over a decade, returning to work after missing a day because a cold or flu had knocked me out. Invariably, throughout that first day back, one or two coworkers would ask if I'd been to the doctor. "No, of course not," I'd reply, "it's just a cold--maybe the flu--just had to wait for the fever to break."

"I had that last week, my doctor gave me an antibiotic that just knocked it out."

The whole over-proscribed-antibiotics issue aside, I couldn't understand the knee-jerk response to seek medical care for something minor. The last thing I want when feeling sick in bed is to leave the bed to visit a doctor's office. But I think that mentality is pervasive in a system in which there is an almost complete disconnect between health care seekers and the market that sets prices for that care.

But I digress. The worst part about my injury isn't the care, it's typing. I’m a writer, I type constantly. And my self-splinted left pinky finger can no longer manage its important job on the <SHIFT> key and the letter <a.> (It's in charge of the <q> too, but I’m not a big user of the letter <q.>) Fortunately, I’m not a quitter. I will quietly suck it up and learn to type quickly with my temporary disability. Damn, that was three q’s.


Here are Eleanor and Frances with the 256-foot yacht Venus.
It's owned by Laurene Powell, wife of the late Steve Jobs.
Jobs commissioned this boat, but it wasn't finished until
almost a year after he died. It cost $250 million. The
quality of the photo is terrible because I didn't have my
camera with me when we saw this, only a second-generation
iPhone from 2008, kind of appropriate actually.
This is Frances in her berth with Stella, a dog we sat for a couple
days while the owner was in Cabo. She is a nice dog, a former
La Paz stray they picked up a couple months back. But she must
have been beaten by some guy with a 35mm camera in her street
dog life because we couldn't get her to look at the camera
for anything.



  1. Great post Michael! If it is any consolation I can't hardly type and I have all of my fingers. :-) I can relate to your feeling on visiting the doctor; for us almost every time we have made the decision to go to the doctor we end up feeling embarrassed we went as it usually could have been handled on-board. May your pinky heal rapidly and be typing away in no time!

  2. Great post. I've been reading your blog for a long time, but don't think I've ever commented. I am an ER nurse, and totally on board with your thoughts about seeking healthcare. It drives me absolutely crazy for what some people will come into an ER and wait hours to see a doctor for (can't imagine what the clinics have to deal with). When did it become so difficult for people to sit at home and nurse themselves back to health for the small stuff???? Incredible the number of people who won't even go to a pharmacy to try an anti-nausea medication, or even a Tylenol/advil before immediately seeking care. Good on ya, Mike! Hope that finger heals quickly.

  3. Hi Michael, Tommy from Phambili here. Been enjoying your blog for the last few years. You've probably already read about this but in case you haven't it's important to keep the joint slightly hyperextended in a splint 100% of the time for 6-8 weeks. f you take the splint off for any reason make sure you keep the joint in the hyperextended position by pressing down on a hard surface as you take it off and keep it there till you replace the splint. If you don't the more powerful flexor muscle will pull the healing fibrous tissue apart and you start at the beginning again!

    1. Tommy, thank you very much for the comment (and the nice words). Intuitively, it makes sense to hyperextend it a bit, but my efforts to do so using the foam-filled, aluminum splits have failed. I see mallet-finger-specific splints online, but I can't find them here (and they are less bulky). I can keep the finger straight though, so I'm hoping that's adequate. Thoughts? Regarding the 100% thing, I've read that and have been very careful when switching splints (I have two and switch when one gets wet). Only once, on day three, did I screw up. I was in the shower and the splint slipped off and the fingertip fell down before I realized it. Thank you again, Michael

  4. Your post explains clearly the key reasons healthcare is so expensive in the U.S. and why does the U.S. expend disproportionally more of its national income on healthcare.

    1. Disconnect between the consumer of service and the payer
    2. Intermediaries (insurance co's) between the payer, the consumer, and the provider

    They solution, quite of course, is to no longer allow employers to deduct healthcare insurance from their tax liability, and instead to allow people to deduct healthcare costs from their income tax, and to allow people to buy insurance from anyone anywhere, or not to buy insurance at all.


  5. home made washer, one new(clean) 5 gal. bucket with a good fitting lid, one new never used plunger(the king with the red rubber cup on the end)drill a hole in the lid that fits the handle, fill with soap and water, put in laundry, put on the lid and use the plunger to work the laundry, you can use it to help rinse also, does small loads, but it does work.

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