Toenail nest

You wouldn't guess my podiatry month could get any more exciting than long toenails.  But it has.

This week we had an add-on emergency visit.  It was hard to imagine what a podiatry emergency could possibly be.  An elderly gentlemen in poor health was brought in by his caregiver wife.  He weighed about 350 lbs and had portable oxygen on.  The wife's story was that he had stubbed his toe this morning stumbling upstairs.  She could tell it was oozing a bit, small blood there. She had him sit so she could clean it up.  AS she bent closer to clean it, she was alarmed to see small white wormy things moving around under the nail.

You may have guessed it- he had maggots under his nail.  Our job was to clean these guys out, one by one...ultimately taking off about half the nail to get to them all.

How could this have happened?  The wife explained that with their several cats, they often leave the door open when weather is nice.  This does allow a multitude of flies into the house...which they have grown accustomed to. The older gentleman likes to sleep with his feet exposed from under the covers- creating the perfect egg laying spot for a pregnant fly.

The wife understandably was a bit hysterical at her find.  I felt like being hysterical assisting in plucking out the maggots. 

In case you needed a reason not to let flies in your house-  beware the toenails!!

P.S= was going to post a maggot pic, but just looking up the images was making me sick....will spare everyone

Personal tragedy

I'm now back on the inpatient side for a few weeks.  The stories I encounter are often hard to believe, if not tragic. 

One case I can't get out of my mind is a young man we saw recently.  25 years old and already with 4 very young children. He had been in Iraq for a 1 year tour, and has been home for just a few months.  I suppose the adjustment, and stresses of life were just too much.  He choose to end his life, taking a gun to his chin and pointing upwards.

The tragedy, besides the act of suicide, is that it failed-  he was brought to our hospital, with the bullet passing through his nasal passages and eyes.  Unable to swallow or talk from the injury they placed a trach tube - that thing people can breath with under the adam's apple. Severe damage to the eyes made it necessary for now to sew the lids closed.

Can you imagine? Already the perception of his life was too much - now he's woken up to a black sightless reality, unable to talk.  He communicates with a notepad and pen- often, because he can't see, he invariably writes over words already there, making communication very difficult.  As you can imagine, he can't be alone- he'd be unable to call for help, or see to find a button to alert the nursing staff.  

I'm not sure how he's going to make it, but he scribbles on his notebook, "I want to go on, to get better, to be here for my kids"

Unintended closure

Emotionally she was worn down. Just weeks earlier, and very unexpectedly, her father, who lived continents away had died. She made the trek to mourn, but being so far away missed the official funeral ceremonies.  She returned to the states to continue her duties as a resident in my residency program. It was evident she was hurting, feeling guilt for not being by her father's bedside in death.  As a Hindu, her faith gave her no hope for closure.  And yet, how mysteriously God works...

She was working in the ICU after her return.  A tough month regardless, but compounded by her emotional instability.  Mr. J was an elderly lung cancer patient in her care. All knew he was close to his end. On this particular night, all signs pointed to this being the time. All day he had been inquiring about the arrival of his only son. He made it clear he wanted to tell him goodbye.  Sunitha, my friend, knew all to well how important it was for both of them.  His son arrived mid afternoon, and was by his bedside constantly.

Around 8 o'clock Sunitha came again to check on her patient, Mr. J's son decided to head to the vending machines to grab a snack and something to drink. He walked from the room and Sunitha inquired about those medical things like pain and anxiety.  Suddenly as the two talked, Mr. J looked at Sunitha and said, "The time is now, I'm dying." Sunitha in a panic looked for the son, wanting to escape and get him back in the room.  Mr J, however, looked Suintha in the eyes and quietly asked, "Please don't leave. Will you just hold my hand and say a prayer for me".

In that moment, Sunitha the Hindu, took this dying man's hand and though not clear on what kind of prayer this man wanted, she opened her heart to God on his behalf. She tells me that it became her father's hand that she held. She wept and told her father goodbye.  Such a profound peace and closure came over her as Mr J slipped away.

The timing of his death, though seeming to be at the worst time - in those minutes his son had stepped away, was perhaps perfect in a grander sense.

Abuse

I don't mean for all of my tales to be sad, but it's the extremes that have stuck out these first few weeks. Here's another psychosocial dilemma.  What do you do if you're dying at home on hospice and your spouse is abusive? It's hard to "leave" as we encourage in other situations, when you are trapped in your bed dying of cancer.  This was the predicament of a woman I admitted yesterday.  In her case, coming to the "house" was a safety issue.  So now, he's not allowed to come and visit, and she hopes to end her days not being threatened or abused.  

Things to do

I had a bit of a shock yesterday with one of my patients.  He is a 41 year old who had a very swollen left leg.  His upper thigh was tight, red and very painful.  Without my prompting he said he had noticed it was hard to breath the last few days.  The combination of these complaints will send off warning flags in any medical provider. His leg and breathing shouted blood clot.  Worse than that, he could have a piece of the clot sitting in his lungs.

I calmly told him my suspicions, and the plan to admit  him to the hospital to do the tests we needed to see if this was indeed a clot. I was shocked then, when his blank stare ended and he shook his head and said "nah" like he was turning down a request for an extra slice of cake.

"I don't think you understand what I'm saying" I explained. "If you walk out of this clinic, that clot could dislodge and go to your lungs and instantly you'd be unable to breath, and could die"  I say this trying not to sound condemning.  He again just shook his head and said "we all have to die sometime".

There's not much else to do in these situations. I tried exploring the reason WHY he didn't want to come in- but no real reason was apparent besides "I've got things to do at home" He did add, "I guess I could come in some other day" Sure, I thought, when it's convenient for you to save your life, we'll talk.

I ended up having him sign something called an AMA paper.  It's a document protecting me in case he dose drop dead once he gets home. He signed this document that says he knew he was leaving against my advice.

What keeps playing in my mind is the eerie similarity of this encounter to one I had when I worked a month in Papua New Guinea 3 years ago. A man about his age had come to our hospital in the highlands of new guinea with what seemed to be clearly a blood clot.  I recall having a similar conversation with this man about coming into our meager hospital for treatment and having him refuse.  He had things to do at his village.  Death was a real possibility, and just like my patient, he made some comment about the time to die coming for everyone.  At the time I attributed his insolence to the ignorance of the new guinea people.  I was shocked at the carelessness of his attitude.  Now I know, it's not something immune to a developing country.

I know we do all have to die sometime, but it seems irresponsible to play rush and roulette with that life!

"Goodbye Doc"

My colleague told me a great story today from her years of experience. 

An 80 year old spunky female patient of hers had made a sudden appointment to see her.  When Dr. C entered the room, this kind old lady let her know she had taken 3 different buses to get to her appointment.  “And why have you come to see me today?” Dr. C asked.

“I came to tell you good bye.” Dr. C’s brow furrowed, and she waited in silence for more of the story.  “I just know I’m going to die soon. I don’t feel sick, or have any pain…I just know it’s coming.  I’ve pressed my husband’s nicest suit that I want him to wear for the funeral, and I’ve written him a note of the order of service, and now I’ve come to see you."

Dr. C still thought there must be something else to this, and dug deeper into medical symptoms.  She finally got this elder lady to say that perhaps her back was hurting a little more than usual.  In Dr. C’s adeptness she asked another question, “I have a feeling the pain you are feeling is your heart, do you want me to do anything about it?"

To this the patient, well known to Dr. C over the years, replied with a knowing twinkle in her eyes, “No. I know it’s almost time, Dr. C ,I just wanted to come all this way to tell you goodbye, not for you to do anything” 

So, honoring her wishes Dr. C said goodbye, but added, “I’m not going to let you take those 3 buses home!”  Dr. C stepped out and arranged for her medical assistant to drive the patient home – she helped her into the car, cane and all, and hugged goodbye.

The old woman of course died, right in the medical assistant's car on that drive home. Not exactly what the med assistant bargained for in volunteering for the lift home (and as you can guess a little traumatic).

I had to smile at this story, sometimes you just KNOW it's time!

Cynicism in the ER

You get pretty cynical when you work in large ER centers.  Intermixed with the real emergencies, comes a variety of complaints that belong simply with “Ask a Nurse”.  Instead, I am amazed at how long people wait to be seen (often 3-4 hours) to ask about a swollen lip, or a mild case of diarrhea.  It’s 2 in the morning, why in the world would you care about a tick bite right now?!!   But, still they come, for whatever reasons, clogging our hallways and rooms and giving those of us who work shifts in the ER a dismal outlook on humanity’s judgment of the term emergency room. 

The problem is, you can’t let the cynicism encase you.  I was reminded of this last night during one of my weekend ER shifts.  The young woman I came to see said her complaint was “bumps in skin”.  I felt the wheels of “oh brother” starting to turn in my brain.  Still, with utmost respect in my voice I asked about these 2 bumps just noticed that day.  They caused no pain, had no redness surrounding.  One was on her lower belly, about a ½ inch felt just below a small fat layer.  The other, on her back thigh was a similar size, and also soft and movable.  It felt very similar to a lipoma, or small fatty blob we all get sometimes.

I told her they were nothing- internally rolling my eyes, that she had felt this was of such importance that it would be an emergency.  Before I walked away tho, I asked her about the cough she had been exhibiting throughout the exam.  “oh that”, the young 25 year old said, “ I was just diagnosed with cancer last week, it’s in my lungs, but they aren’t sure where it came from, maybe my uterus or cervix”

Just like that, grace abounded.  Her unreasonable medical “emergency” didn’t matter any more.  This poor girl was dying.  I found out she had had a CT scan last week, so went to see if these bumps were there last week.  The blobs were there on the scans, and more likely little cancer mets in her skin than fat collections. I glanced at her xray, showing the diffuse metastatic cancer riddling her lungs.  While still not emergency material, I realized now why this patient was in our ER.  She was afraid. She had cancer spreading and chewing it’s way thru her body, and she had every right to worry about bumps in her skin.

The lesson of course is to give everyone the right for their silly complaints.  I might disagree with how emergent their reason is for walking thru our doors, but I’m still their doctor, and it’s still my job to help heal- even if it’s just respectful reassurance.