Maggot-Free Zone

A few days ago, a nurse friend from my ER days posted this meme on her Facebook page and asked for other “gross” stories/memories.

Immediately upon reading her request, I had the picture—and putrid smell—come to mind of—since 1998 I still remember her name—Bertha.

Although she probably had other housing available to her, Bertha lived under a bridge with a few homeless “friends” in a small Arizona town. Alcohol was part of their daily routine. One night, while deeply intoxicated, she fell into the group’s campfire and severely burned her foot. After calling an ambulance (it’s interesting that in almost any group of homeless folks, there’s almost always one who has a cell phone), she arrived at our ER with a 3-inch diameter, fairly-deep 2nd degree burn on the dorsum of her left foot. She reeked with a nose-searing mixed perfume of campfire smoke and body odor (sweat, alcohol, grime, and tinges of urine).

Our paramedic cleaned the ashes and debris from her wound—and the rest of her foot—with soap and water as much as he could—it was the only part of her body clean at that time. I suggested that she needed to be hospitalized for a day or two to be treated with IV antibiotics and be seen by the surgeon—she refused, so we slathered her burn with Silvadene, taped on a heavy gauze dressing and gave her strict instructions to follow-up at her free clinic the next day.

Exactly a week later on a Sunday evening she again arrived at our ER via ambulance complaining of pain in her burned foot. I glanced at her foot as her gurney rolled through the door, and, even at a distance it was clear that she still was wearing the original gauze dressing we’d placed the week before. One of our brave paramedics met his companions as they unloaded her onto a bed—he whipped out his bandage scissors, quickly cut through the dressing and threw it aside. Then, as I watched, he quickly turned and headed for the sink.

His unusual activity piqued my interest, so I immediately went to the bedside. The burn on her foot was not initially visible, because the whole top of her foot was covered with hundreds and hundreds of squirmy white maggots, which spilled out onto the table and floor on every side accompanied by the putrid stench of rotting flesh. The paramedic slammed his hand over his mouth and turned again to the sink—but to his credit, he didn’t lose his cookies.

Cleaning up the rolling, squirming maggots and clearing the stench from the room were the most difficult parts. After several days of “natural maggot debridement”, by now her burn was actually quite clean, and, surprisingly, looking healthy with early healing. I commended the maggots for saving the patient’s foot.

This time Bertha consented to hospitalization, but her reputation had preceded her (it’s funny how quickly news and unusual stories get around in small hospitals)—the medical floor nurses refused to take her unless I certified her to be maggot-free.

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Her story and condition reminded me of one I heard from a somewhat elderly neighbor, Les when I was a youth. It seems that in the early 1900s when he was a young adult, Les had been chopping wood with an ax—holding the chunk he was chopping with his left hand. The wood slipped as he swung his ax, he missed the piece and chopped the back of his left hand, lacerating the skin and transecting all the extensor tendons.

His family took him to town to Dr M, the old country doctor who painstakingly sewed together all the extensor tendons and the skin (I always identified with the “ol’ country doctor”, trying to do all he could with not a lot of conveniences).

A few days later the 4-inch laceration across the back of his Les’s hand was getting angry red and pus was bubbling out from the corners. Upon returning to Dr M, the experienced old gentleman just shook his head. This was the pre-antibiotic era and folks sometimes died from infected wounds like this. Les said that Dr M laid him down and stretched out his infected left hand. Then he opened the wound back up and removed all the sutures. After that from some unknown storage area in his office, Dr M retrieved a container of “sterilized maggots” (after hearing that story, I always wondered about the procedure for “sterilizing” maggots), and with a pair of thumb forceps, he gently removed “about 25 of them” and individually placed them inside Les’s infected hand wound. Then the doctor sutured the wound edges closed again, put on a clean dressing and sent him home with instructions to return in a week.

A week later, Les went back, Dr M again cut and removed the sutures and removed the—now fatter—maggots. The inside of the wound was now clean and healthy appearing. Then, for the 3rd time, Dr M resutured Les’s hand laceration. Les then came back again for removing the sutures—for the final time—two weeks later, leaving Les with a functional left hand. When I saw the hand 50 years after that incident, Les had a barely-visible straight threadlike scar across the back of his perfectly-functional left hand.

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The wonders of maggot-ism! I had an older patient once who told me that as a kid he’d had a ruptured eardrum with constant pus draining from it, perpetual crustiness on the outside of his ear and pus on his pillow. Finally (again pre-antibiotics), they took him to the old family doctor who retrieved some maggots (apparently, in those days, doctors just had maggots lying [actually squirming] around in a container somewhere in their offices—maybe they got them from their medical supply reps?). My patient said the old doctor just put a bunch of them (maybe 10 or more?) in his ear canal with tweezers and put a piece of tape over the ear opening. He was instructed to remove the tape in about a week and as the maggots finished their work, they’d crawl to the outside and drop off. Apparently, they all came out—he never had problems with the ear infection after that, and when I examined him dozens of years later, he had no maggots—nor flies—in the ear canal, and the eardrum was healed.

While it all sounds gross, maggots only eat dead tissue and pus and other wound debris, so, after they’re done, all that’s left is healthy tissue—at least in this series of three maggot-related stories. Maybe, in this era of antibiotic resistance, we should more generally revisit the value of maggot therapy.

Russian Roulette Hastens One’s Mortal Departure—Medical Examiner

Nothing in medical school or interneship—except for the tiny part of actually learning how to officially “pronounce” someone “dead”—had prepared me for taking on the role of County Medical Examiner—the ways people find themselves dead are as varied as the personalities they were in life. Being the Medical Examiner required me to physically go to each scene in the county where a dead body had been discovered—as close as possible to the time of the discovery—to make a determination that the person was 1) actually dead, 2) to do a preliminary exam of the body and scene to try to find out why they were dead, and 3) to collaborate with the police agencies and pathologists for a final official report and death certificate.

In the Spring of 1982, for a bit of family change of routine and venue, my wife and I and all our kids decided to get together with friends—another couple who also had several children. At their house, the other Dad, Dave, presented a short spiritual message to the combined families, then handed everyone a treat as the kids all tornadoed off to play throughout their house while we four adults anticipated a relaxing chat at the kitchen table.

Instantly, as the kids dispersed, my pager beeped six shrill chirps—I borrowed the phone to call the number—it was police dispatch—she said I was immediately needed for a Medical Examiner case. Rolling my eyes, I explained the intrusion to my wife and friends. The case was only a couple of miles from our present location, so I stood to leave, knowing that ME cases usually didn’t require much time on the front-end exam.

ME calls were always attached to a bit of urgency, however, since there were usually several investigating police officers standing around waiting for the Medical Examiner to arrive to “pronounce” the body (dead) so they could release it to the on-call mortuary and get off-scene and back to routine. Most police officers, even though they confront it often, are not very comfortable with death—especially babysitting a dead body till the ME arrives.

In this case, that was especially poignant, since the victim was a 16-year-old who had been shot in the head.

As I got up to leave for the call, knowing I’d be back soon, turned and asked Dave if he wanted to go along. “Sure!” This was outside anything he’d ever been involved with before, and it sounded lots more interesting than staying behind listening to the mothers brag about their kids.

The flashing red-and-blue lights from a half-dozen city police cruisers made it easy to spot the location in an older fairly-dark neighborhood—I had trouble finding a place to park—there were cars everywhere—weeping and distressed friends, neighbors, and every family member from a ten-mile radius had already converged, filling the house and spilling out the front door and down the sidewalk. I didn’t relish the idea of trying to joggle my way between the nearly-hysterical mourning folks outside the front of the house, but I didn’t see other options. Recognizing my car and anticipating the dilemma as I exited my door, one of the police officers came up to us and told us that the easiest approach was through the back door, since the victim was in a back room anyway. He offered to lead the way.

I made a cursory introduction between the officer and Dave as we threaded our way toward the dimly-lit back door amongst police cars with flashing lights and crackling radios—passing through the wooden gate barely-hanging by its hinges into the backyard. The gauntlet continued down a dark dusty path from the gate to the door—I gingerly followed the uniformed officer, Dave following my footsteps. Three large German Shepherd dogs stood just off the shadowy path—one on the right, two on the left—this was THEIR domain, it was clear. None of them appeared overtly-aggressive, but with the numbers of agitated people and all their weeping and wailing, with the flashing police lights, and the enveloping pervasive spirit of gloom, the hair was bristling on the dogs’ necks. I was thinking that I sure hoped we could get past them unchomped. The policeman indicated that the dogs had—up till then—been docile. One second later, however, as Dave was passing by the last of the three, the dog’s head and neck shot out, his teeth grabbing Dave’s pantleg and thigh. The officer jumped, the dog retreated.

It was too dark on the path to examine Dave’s bite, even with the officer’s police-issue flashlight —Dave assured us he didn’t think it was serious, so we pressed on. Once the dog had established his position with his teeth, he retired off the path a few feet. Why he picked Dave to demonstrate that position was an unanswerable question.

The wooden back steps were barely illuminated by a single, dim, bare light bulb hanging over the door frame of the clapboard-covered back porch. The officer and his light led us through a narrow walkway between stacks of cardboard boxes, turning left into a bedroom near the back of the house—the hallways, living room, and kitchen were filled with sorrowing, grieving family and friends—many openly sobbing for this dead child—the wailing volume diminished a bit as they saw us enter the back of the house.

Seeing this young man sprawled lifelessly across the blood-spattered bed immediately forced my thoughts to my own daughter near his age, and I momentarily empathized a twinge of the agony his parents must be experiencing at that moment, knowing how I’d feel if circumstances were reversed. The officer filled in the details he had been given: this 16 year/old boy was hanging out with his friends; someone produced an “unloaded” pistol; he began spinning the cylinder, playing Russian Roulette—and LOST—when the .38 discharged into his left temple.

Because of my strong religious background, and having been raised on a ranch witnessing numerous animal deaths, I have never had much of a problem viewing deceased individuals and doing the ME investigations. However, children’s deaths have always been harder for me than adults’. And the proximity of the multitude of nearby grieving grownups and youth made this one even more difficult.

Even though it had already been over an hour since the incident, in the dim room I obligatorily checked for signs of life—carotid pulses (none), skin pale—no capillary refill, apical heart sounds (likewise none), and pupillary reflexes—both pupils dilated and fixed, the corneas now dryish. Trying to take it all in and make sense of the whole circumstance, I stood for a few moments and just gazed at the lifeless body that an hour before had been full of vitality and happiness—now joy was not to be found anywhere in this place. Gloom was oppressive. Dave was also lost in thought.

Another police officer entered the room and told us the mortician had arrived. We stayed to help them load and zip the body into the heavy black plastic body bag, covering it with a red fuzzy velour funeral blanket on the gurney for the return trip through the back porch-door/backyard gauntlet. Dave, the officers and I wordlessly plodded behind. The dogs were nowhere to be seen.

As we drove in silence back to Dave’s house, he interrupted the quiet asking, “I hope you’re writing these things down, Carlin?”

“No”, I said matter-of-factly, “This is an everyday occurrence for me.”

“But it’s not for folks like me. You should write these experiences down.”

I’d never entertained that perspective before, so I told him I would.

Back with our own healthy, happy, vibrant families, Dave and I were still somber—the contrast to the scene we’d just left was humbling and filled me with gratitude as our families prayed together before our return home. We prayed for the mourning folks we’d just left. Dave’s leg was contused, but the skin unbroken—the pants were torn.

I reflected on Dave’s admonition and resolved to do better—in recording my unusual life and at being a Dad

Pap Smears and Tools of the Trade—Dr-Patient Relationship

Subtitle: Blurry Bottoms—Hand Me a Screwdriver (1987)

For two years Maryann, an attractive mid-30s brunette, had been putting off getting a Pap smear because she didn’t particularly like the OB/GYN doctor she had seen in the past—he was somewhat cold and distant—made her feel uncomfortable, so she put off going. Finally, fear and guilt took over, so she asked her friend for a new doctor recommendation.

Over the years, because of my wife’s hypersensitivity (at least from a male’s standpoint) to being over-exposed “in the position” for a pelvic exam, I had become very conscious of and sensitive to the feelings that most women harbor about being “in the position” with a man doing the examining (notwithstanding Jane, my nurse always standing nearby). Because of my kindly and non-patronizing demeanor and my gift to be able to assist women in feeling a bit of security in an uncomfortable situation, I had gained a reputation as a safe, caring gynecologist. However, my personal or family female friends either came to see me BECAUSE I was gentle and sensitive, OR, they would NEVER in a thousand years come to me for a pelvic exam, because they imagined that if I run into them at the store or church, I’d remember what their bottom looked like (in actuality, for medical providers all the bottoms become sort of a blur, anyway).

So, following her friend’s recommendation, Maryann sheepishly presented at our office. Taking a brief new-patient history, Jane showed her into the exam room and handed her a folded paper (“maximum exposure/minimal coverage”) gown with instructions to take off all her clothes, don the gown with the opening in the front and sit on the end of the table. Moments later, I joined them.

I glanced at the history form—Maryann was essentially healthy, although it was apparent that because of “new doctor/Pap smear” complex—she was understandably jittery, so we made some small talk to help her be more comfortable for the assessment, and with Jane holding her hand, I began with a breast exam—all went well.

Then, with my back to them, I slid on my latex gloves while Jane assisted Maryann to lie down and put her legs up in the stirrups. Over the years, I found that if the patient can’t see my face because of the drapes and position, they are less uncomfortable—kinda like “if I can’t see you, you can’t see me” sort of disconnect. I sat on a stool facing the bottom end (no pun intended) of the exam table, where, just in front of my knees, were two instrument drawers storing the exam speculae (the “duckbill exam thingies” as they were known to many female patients). Maryann was fully-positioned ready for the instrument exam. I applied KY gel to her and reached to open the drawer to pull out a sterile speculum. The chrome drawer handle fell off in my hand! I was unable to open the drawer to get the exam instrument!

Then, in one of those moments you’d like to go back and relive so you can phrase something differently, I unconsciously said, “Jane, hand me a screwdriver!”

I’ll never know exactly what went on in Maryann’s mind that moment, but instantaneously she was sitting straight up on the table with one arm covering her breasts and her thighs pressed together—I just barely got out of the way of flying feet as she screeched, “What are you going to do with THAT?”

Too late to rethink my phrasing, I immediately realized that I had done a massive faux pas, worsening an already bad situation.

Jane promptly grasped Maryann’s hand again and patted it as I displayed the errant loose drawer handle, apologizing for my poor choice of wording/timing. After a short, very quiet pause, we all had a hearty laugh—it broke the ice and the remainder of the exam was quickly completed without incident.

Maryann ended up coming back for her Pap smear year-after-year, but each year before she’d lie down on the exam table, she made me prove the drawer handle was functioning and that no screwdriver would be needed.

Surprise Delivery

Often in the “practice” of medicine, we have help…

I was at home assisting the kids with chores on a 1983 Spring Saturday afternoon when the phone rang—since it was my weekend on call, I’d already fielded about two dozen calls from our Family Practice clinic. Hoping it was for her, one of my teenage daughters answered it but frowned and immediately handed off to me. Dr. Rogers, the ER doctor on the other end of the line got right to the point, “Hey Doc, I’ve got a pregnant 16-year-old here that is absolutely insistent that she couldn’t be pregnant—says she has never been with a guy—so, no prenatal care, obviously. Belly looks like she’s about 20 weeks or so—can’t tell for sure, because the on-call ultrasound tech is not answering his phone. She’s having a lot of pain—appears to be in labor. I sent her over to OB.”

“And,” he paused and sounded relieved to dump the responsibility, “You’re on call for drop-in OB.”

I hung up the phone and while trying to assimilate the information I had just been handed, sheepishly mumbled an apology to my angel wife and busy children for leaving them—yet again—to do the work around the house without me.

We lived out in the country near an Arizona town of about 50-60,000, and at the very best of times (the middle of the night) our house was exactly 12 minutes from the hospital delivery room, but on Saturday afternoon it might be more like 20. I hopped in my small truck and took off down our lane, still attempting to formulate complete ideas from the cursory details Rogers had given me: very high-risk pregnant girl in denial with no prenatal care; probably in labor; markedly premature baby possibly too small to salvage; no neonatologist; no neo-ICU; 3-hr by ground ambulance from us to the nearest neonatologist/neonatology unit; most of the OB specialists in town would not be readily available for consultation in case this young mother had serious maternal complications—I did not want to do this.

Of three Family Practice docs in town who delivered babies, I was obstetrically the busiest (averaging about 30 deliveries a month)—there were 7 or 8 Board Certified Obstetricians. All of us who did obstetrics took an equal number of OB calls for drop-in deliveries (no prenatal care, or from out of town—we averaged about one-a-day). For us Family docs, in case we had an emergency C-Section or severe maternal complications, we had to try to track down one of the specialists. But I was on my way to the hospital and I had no way of contacting anyone else until I arrived there and I first had to assess the situation.

I slammed to a stop at the hospital back door and still in my street clothes sprinted down the hall to the OB Dept and entered. I had hoped we could give some IV terbutaline to slow her labor for long enough to get her transferred by ambulance to Phoenix, but by the time I arrived, the pregnant “child”, Sylvia, had already been moved into the Delivery Room and been put her up in stirrups—the experienced, astute OB nurses had assessed her and found that delivery was imminent.

I rushed into the Doctors Lounge and—as I had done before hundreds of times—yanked off my shirt and pants and jumped into green scrubs, stretching disposable shoe covers over my penny-loafers. In the delivery room I grabbed and jammed my hands into a pair of sterile latex gloves so I could check her.

“Oh crap!” I thought as I inserted my right middle finger and forefinger into the birth canal and immediately encountered the baby’s head—completely dilated—NO cervix remaining—head engaged! No time to stop labor! No time to call the backup OB! Nothing to do but stand there and deliver her!

Sylvia was writhing all over the place and screaming with each contraction—there was little time between them. Mrs. T, my stalwart delivery RN, was desperately trying to use the doppler to hear the baby’s heart—initially, it had been good at about 160/minute, but with everything else going on, including Sylvia’s mother standing by the bedside, crying with anxiety and fear, while her daughter was squeezing Mom’s knuckles white with each contraction—the fetal heart  was now not heard .

Mrs. W, my other nurse called the newborn nursery to find out where the on-call Pediatrician was—he happened to be right there examining babies—”Great! Send him in!” Dr. Cranston rushed through the door that connected the Delivery Room to the Nursery and between Sylvia’s screams I filled him in. I watched his countenance drop—he was only out of training for a couple of months—“Carlin, you KNOW we don’t have a neonatologist!”

“Cran, she’s going to deliver any second! We are just going to have to do our best! I didn’t choose this!” He just stood beside the stirrup shaking his head.

Then, with an ear-piercing, mighty, long, loud yell, Sylvia began pushing the baby’s head out as I grabbed some sterile towels and did my best to not drop the slippery newborn. Because the baby was so small, Sylvia only had to push once, and I was suddenly gripping the smallest baby I had ever delivered! She couldn’t have been more than about 3 pounds! My heart sunk and the Pediatrician just stood there. They usually weren’t yet saving babies this small even under the best circumstances with Neonatologists in Neonatal ICUs in the big cities! And this tiny peanut of a baby here in rural Arizona was not breathing, was not moving—she just lay limp and purple on the green surgical towels I held in front of me—apparently dead. Sylvia and her mother looked at us in fearful anticipation. Cranston silently shook his head back and forth in a sign that this was beyond anything we could handle—this baby was NOT resuscitatable—she was too small, too dead! My experienced nurses standing by knew it, too.

We stood helplessly looking, hoping for breathing, for movement—nothing—it had been two or three minutes since she had popped out of the birth canal—I clamped and cut the cord and carried the limp, lifeless,  purplish baby girl to the bare stainless-steel surgical table beside us and gently laid her there, still partly-wrapped in the towels.

As I placed her there, I said a silent prayer, “Heavenly Father, if you want this baby to live, you’re going to have to please do something, because we are in WAY over our heads here.” Then, leaving her alone on the cold table, I started to rotate back to deliver the placenta. But, just as I finished my silent entreaty to Heaven and began to turn around, abruptly the baby spontaneously took a big deep gasp of air and let out a cry that, moments before, would’ve rivaled her young mother’s yells. Cranston’s eyes got huge and immediately he lunged for her, folding the slimy green towels over her now animated body—he bolted for the nursery with her in his arms, placed her in an infant warmer and gave her generous amounts of oxygen.

With deep, sincere “Thank-You, Father” prayer in my heart, I again turned back to Sylvia and uneventfully delivered the placenta. The new grandma was still crying—only for a different reason.

The baby girl, who they named Emily, was 3 ½ pounds. Once she instantly began spontaneously breathing and got into an isolette on oxygen, she never turned back. She went home at 3 weeks of age and was healthy and happy. I saw again her with her mother when Emily was 3 years old, and I couldn’t tell she’d had such a rocky start. Sylvia was gushing gratitude for what she thought I had done 3 years earlier. I reminded her that Emily was there only through divine intervention—certainly NOTHING that I could take credit for.

PS—A couple of days after her delivery, I interviewed Sylvia when she was alone. She had known that not having periods was not a good thing but, in her immaturity, had been in denial that she could be PG, even when she began to show and was successful in covering it up.

There wasn’t much Grandma could do about any of this under the circumstances, so she just enjoyed being the Grandma.

Dr Carlin Intro

Once a prison inmate presented to my ER with a five-inch “shank” (homemade knife) jammed into his right temple to the hilt—and he lived to tell about it.

That caused me to later reflect: “Carlin, you’ve seen things that almost no-one else in the world has ever seen. Maybe others would be interested in hearing some of the unusual—or even the not-so-unusual—cases, and in relating and sharing some of their own.

So, the idea of this blog was born—a place where an Old Timer like me can relate and share medical “war stories”—mine and others’; a place for posting practical, common-sense remedies, and a source of medical edutainment and humor. A doctor can learn a lot by simply observing and being aware of what is going on—actually examining the patients—including having the “stethoscope in the ears” (hence the title of this blog).

“Doctor Carlin” was a Family Practice doctor (also doing OB) in a medium-sized Arizona community for 15 years, then switched to Emergency Medicine in mostly-rural hospitals all over South Texas for 4 years and afterward continuing in central Arizona until retirement.

A colleague once told me, “Yeah, I wanted to be a doctor from the time I was a little kid.”

Not me. Dr Carlin had not considered becoming a physician.

My Dad was a cattle and sheep rancher. I grew up knowing that he had had a dream and passion for Bridge Engineering and that he’d completed a year and a half of Engineering at a university. Then the Pearl Harbor attack, December 7, 1941. Since his background was farming/ranching, while everyone else was rushing to enlist to return the fight and exact revenge on the perpetrators, Dad was mandated to leave college and go home to the ranch to help raise food for the troops and the rest of the country. He never got back to college. I grew up wanting to go into Engineering, so I could fulfill his dream.

As I neared High School graduation, it seemed that all of my closest friends had college scholarships for one course of study/college or another. But not me. I’d already been accepted to a university—of course into their College of Engineering. But somebody forgot to tell me that if you want a scholarship for college, you have to actually apply for one. I hadn’t—I was without. Then, two days before graduation, I found out that the local Mothers’ March of Dimes organization had offered a scholarship for $150—but it was only for a Pre-Med student who was actually registered in Pre-Med, taking Pre-Med classes and everything!

I thought about it for about three minutes. Then I lied: “Yes, I AM a Pre-Med student.” On the spot, I filled out the application—and since I was the only one applying—they awarded it, handed me a check made out to my college, and the scholarship was announced along with those of my friends on graduation night as I crossed the stage.

Three months later, March Of Dimes check in hand, I went in to officially register in college classes. Now, I had a dilemma—continue with the lie and my Engineering direction, or personal integrity—meaning I’d have to register in Pre-Med and actually take the classes (at least for a quarter, to keep up the façade while spending the tuition scholarship money). I chose the latter, intending to change majors back to Engineering at the beginning of my second quarter. So, in the company of 450 other new Pre-Med students, I began classes in the fall of 1966.

I soon found that the Pre-Med curriculum was challenging! But, notwithstanding my (typical Freshman) immaturity, I was keeping my head above water in my class/labwork. So, I decided to keep plugging away for a 2nd quarter. I began to notice that Pre-Med students were dropping out of the program like flies and switching to other, less demanding, majors. It became a challenge to me—by the end of my first year, I had decided, “I can DO this!” My lean towards engineering became less, then none at all. For the first time in my life, I began entertaining thoughts of actually being a doctor. I stuck it out. By the time I graduated (with a double major—Pre-Med and Journalism) in 1970, there were only 20 of the original Pre-Med students who graduated in Pre-Med—the rest went to other majors. And of those 20, only 5 had been accepted to Medical Schools, anywhere in the world. Of the 15 others, two had been accepted into Dental Schools and the rest graduated with a nearly-useless Pre-Med Zoology B.S. degree (many of them were accepted into advanced-degree programs and may have subsequently re-applied to medical schools). (to be continued)

Diabetic Foot; Gangrene

Diabetic Toe Gangrene

Charles was dumbfounded when I told him he had gangrene in his left big toe. He’d had pain in that toe for several days and earlier, some redness, but, being a lifelong stoic, he hadn’t come to the ER until the redness of that toe became blackish purple and the tip of the toe became rock-hard.

Unfortunately, that wasn’t all the bad news I had for Charles that night. Gangrene of a digit doesn’t usually happen spontaneously—so we must look for a cause. His cause was diabetes. He had never been diagnosed before—Charles hated going to the doctor—he’d had symptoms of frequent urination, severe thirst and ravishing appetite for several months—all pointing to elevated blood sugar—in the ER his was over 600 (normal is 70-100). At 62, because he had ignored the messages his body had given him before the toe gangrene began, Charles was relegated to living with and treating (or not) his diabetes the remainder of his life—however long that may be.

I spent a goodly time talking to Charles and trying my best to convince him—or at least scare him to take the problem seriously and become pro-active (healthcare buzzword) in learning how to give himself insulin shots and eating healthily (although, the healthy-diet talk loses something in the translation when it is being administered by an overweight doctor). I related horror stories like John, a diabetic fellow I knew in South Texas who had had both his hands and both his feet amputated and was on dialysis 3 times a week for 4 hours at a time (he was completely dependent on others for his every need).

I started Charles on insulin, began fluids and made arrangements for him to be admitted to the hospital that night. The next day his left great toe was amputated at the first joint.

What happened after that, I will never know. ER docs almost always lose follow-up with patients—that’s a good thing—and bad (if things go well and their health problems are taken care of or get resolved and we don’t see them back, it’s good, but if they become like John and have to often return to the ER [we used to call them “frequent flyers”], it’s bad). Hopefully, Charles followed up with his primary Dr and used his own agency to do his best to control his disease. I really hated being the bearer of such ominous news to Charles that night, but if he’d waited another week, his whole foot could have been his loss instead of just part of his toe.

ER Docs often get to bear bad news to patients and family—but that’s a topic for another time.