Month: May 2017

Patient Reflection: Internal Medicine

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“You’re not cutting it off, I don’t care if I die…”

Ms. Marrow lay tired, her facial expression sullied with fatigue, left arm gnarled tubes bringing her tainted scarlet tinged blood into the machine keeping her alive. Ms. Marrow, another victim of the end stage complications associated with poorly controlled diabetes: end-stage renal disease with dialysis dependence, stocking distribution neuropathy (loss of proprioception, touch, and intermittent sharp searing pain), and previous strokes. Angry at her disease, frustrated at her seemingly inexplicable decent in health, and now uncertain of her fate. Recalcitrant towards healthcare system, askance towards medical explanations, her own illness and experience left her skeptical of our “good intentions.” As a patient, she was said to be difficult and infamously inapproachable. Deep down, she was scared and understandably so, for in her body lay a harbinger of doom. And for several days, I would try to work to earn her trust so I could convince her to let us sever off her foot.

Her foot was dying, skin peeling, from sole to heel her violaceous flesh split in two to drain her festering infection from multiple organisms. Though, obscuring the seriousness of Ms. Marrow’s medical risk was her unremarkable temperature, heart rate, and blood pressure. From her own gestalt, she had drawn the conclusion that she’d be fine. But, it was all a subterfuge. Ms. Marrow’s had “diabetic foot”, an etiologic triad of ischemia, neuropathy, and infection. Yet alas, the most difficult person to save is the one who thinks everything is fine.

Our fear as a medical team, though appeared fine on the outside, she’d eventually reach a tipping point and slip into a point of no return – this year, I’ve seen people come back from the brink, but it’s always been at an incalculable price.

She required an amputation, without the procedure she would likely not only lose the foot but also her life but a life-saving surgery that she adamantly refused. Against medical advice, Ms. Marrows decided that she would only be amenable to medical treatment, there was to be no amputation. No doubt, her stable vitals signs only served to obstinate the problem of ridding her of her poisonous limb. So, we gave her our best drugs and we gave her broad antibiotic coverage (including MRSA), and then we waited. It was a bad plan, a route fraught we pitfalls, but we the patient our captain we temporarily sailed on into the abyss. Like a roll of a loaded cosmic dice, her life would play out in three scenarios 1) by a miracle the foot would heal enough to use, 2) the foot would undergo unlikely innocuous necrosis 3) her infection from her decaying foot would spread to her blood and kill her. The longer we tried antibiotics and bided our time, the likely the bacteria could spread into her bone, and into her blood. The more it the infection creeps, the more flesh should be sacrificed, but at some point, there’s a limit of how much you take to fix the problem of inevitable death.

I spent a few days getting to know Ms. Marrow and she weren’t always in this situation. In fact, this whole situation started as nothing more than a trivial accident. Two weeks prior her arrival to the hospital, she had been in her normal state of health. She was at home, enjoying her independence at the age of 70, where she lives alone. When mentioning her children, she beams with proudness as she recounts how she raised them to be self-sufficient. She has no plans of dying, indeed she plans on getting married to a high school crush in July, loves going to the casino, laments on her recent loss of her “curves”, and recounts how she gets bored of “country people” when visiting her home town in Virginia. She mourns the days where she used to be able to drive, a couple of years ago she gave up driving because she could no longer feel the pedals. Each time we’d meet, she’d share another part of her life with me, sometimes when prompted I’d share some of my life, and each day I would slowly gain her trust. She hated her diabetes, how it changed her, how it aged her, and how it took away who she was. Diabetes had been a scourge to nearly her whole family. Her grandparents had it, as did her parents, as did her brothers and sisters. Two of her brothers with diabetes left a notable impact on her. One brother on dialysis died abruptly, of what the patient said was conditions related to his dialysis. Another brother, he started with toe amputations, which lead to a trans metatarsal amputation, which subsequently leads to a below the knee amputation, and this finally leads to an above the knee amputation. After seeing her brothers, Ms. Marrow distrusted doctors. Her terse talk and cantankerous tone with the medical staff wasn’t borne of ill will or spite but instead came forth from fear and inadequate health literacy. There was a constellation of reasons why Ms. Marrow’s said to use, “You’re not cutting it off, I don’t care if I die if I die it’s the will of God and only he knows what’s supposed to happen.”

While at home, she stepped on something; at the time she didn’t know what it was. But, before she could sit down and inspect her foot a knock on a door lead to a conversation, the conversation lead to laughs, laughs lead to distractions, and distractions lead Ms. Marrow to forget about her foot. After that day, her foot ached, but foot pain is nothing new and her “new” pain was ignored. Eventually, someone noticed Ms. Marrow’s foot and urged her to go the hospital and eventual removal of a sewing needle that was embedded within her.

The source of her brush with demise lay in a tiny metal rod. One morning, a blood result came back that indicated our worse fears. This tiny rod as it plunged into her flesh brought with it the bacteria to where it ought not to be, into her blood despite our optimal antibiotic treatment. The microscopic invaders were no longer a hypothetical threat to her life, instead, now the infection was a tangible assassin laying in wait to take her life. Our attending physician decided to round up the team for a last ditch intervention to convince Ms. Marrow of her perilous situation. She was indifferent towards others so I volunteered, albeit hesitantly, to lead the conversation to be had with Ms. Marrow. That is, a conversation with a definite goal: talk Ms. Marrow into cutting off her foot, and inform her of the possibility that we may need to take more as we’ve waited so long. We let her eat her lunch, when the scrounged up several chairs for us to sit down in while we talked to her. Though I had a chair, I decided to stand by her bedside. It probably appeared as an act of confidence on my part, but in actuality I just wanted to be close to her because I knew soon I would hurt her. I knew soon I would use all that she had trusted me with, the details of her life and goals, and the relationship that we formed to convince her to try to fight to live. From our perspective it would appear noble, from her perspective we were no less vile than her very disease. I stood next to her both to comfort her and to assuage my own concerns of how my word would dig at her soul.

For what felt like an eternity, we talked, debated, she argued, we listened to each, and when she became silent we became silent. The conservation hit what seemed like an unrecoverable dead in several times, each dead end avenue lead to a refusal to even consider surgery. I suppose, in the last act of betrayal of her friendship, I used the last bit of information I knew about Ms. Marrow. I said to her, “I know you don’t like asking for help, but what we are asking is to let us help you.” She broke eye contact with me, and though emotional, never allowed herself to outwardly weep. She said to us, “This is something I’d need to think about.” We all agreed to that as a viable solution for the time being. Angry with us, angry with me, she told us all to leave and not return that day. Ms. Marrow imagined death would be better than becoming dependent on others, she thought death as a tidy way to be done with things. This fly in defiance against her plans to keep living a full live. I often struggled to reconcile how she could both retire herself to death and make concrete near term plans.

A day later, she decided to get the amputation, I hope one day I can update this ending and tell you that she went to her wedding. And I hope that one day I can tell you that I wasn’t wrong, after all there was some truth in Ms. Marrow’s belief that we don’t know everything.


Thank you for reading. This piece was a writing assignment that I submitted during my rotation.