Wednesday, September 12, 2012

A different perspective

My service lately has been dominated by patients with serious wound issues.  

I think the general public would be horrified if they saw some of the chronic, non-healing wounds that people live with on a daily basis.  Hell, I see them on a frequent basis and even I'm horrified by them.  I just can't seem to get used to large, rotting, pus-filled wounds with visible chunks of muscle and occasionally bone.  

As an internist, thankfully I don't really have to actually be the one to deal with the wound.  I look at it once and then consult the wound care nurses.  If need be I call the surgeon to debride the wound.  But I rarely have to touch the wounds.  Frankly I don't really have anything to offer.  I'm not trained in wound care and I don't do surgery.  

Right now I have one patient who lost all of the skin on his lower leg from necrotizing fasciitis, one with a large abdominal surgical wound that has an enterocutaneous fistula that constantly oozes intestinal juices, and an extremely purulent non-healing skin wound from a skin cancer excision.  These are all pretty nasty, but they don't compare to the wounds of two patients I call 'the twins.'

The twins are not biologic twins, but rather twins of circumstance who happen to be the same ethnicity, have the same terrible wounds for the same terrible reason and ended up in being admitted to the hospital on the the same day.  They both ended up on my service and somehow they ended up in rooms right next to each other.  They don't share the room, and thus don't even know of each other's existence.  

Both were injured in motor vehicle accidents in their 20's.  Both have spinal cord injuries.  They both have stage 4 sacral decubitus ulcers with infections that have spread to the bone.  

One of the twins has probably the worse decubitus ulcer I've ever seen.  He has no skin over his entire sacrum, buttocks, or perineum.  All you can see is muscle and bone.  He got this from years of neglect - both by himself and his family caregivers.  He has a suprapubic urinary catheter that doesn't quite function properly - urine leaks around the catheter straight into the into the wound.  And when he defecates - you guessed it - stool inadvertently seeps into the wound as well.  

You wonder how anyone in this situation could go on living.  Both are partial quadriplegics and are primarily bed-bound.  Neither have a lot of money or family support and are thus limited in the quality of services that they can afford.  They don't get out much, if at all.  They aren't married and don't have children.  My heart goes out to them every time I see them, and deep down inside I feel guilty for having a body that works so well.  I wonder if they get jealous when they see me stroll in and out of their room.  I wonder if they secretly harbor anger towards those who have it better than them.

But I've noticed a curious thing about spinal cord patients.  Despite how terrible of a life I imagine them to have, they always seem quite content with their situation.  Decubitus ulcers and all, I've never heard one complain about being paralyzed.  

They are incredibly patient and take everything in stride.  Large infected decubitus ulcer?  No big deal, it's happened before.  UTI from chronic indwelling catheter?  Happens all the time.  Prolonged hospital or nursing home stay?  No problem.  They just go with the flow.  

I suppose you just get used to things and learn to deal with them.  

I've thought about the twins a lot this week.  Seeing them take their unbelievable misfortunes in stride is impressive.  They are much stronger that I would ever be in their situation.  Even in their misfortunes they have a better attitude about life than I do at times.

One of the selfish reasons that I like being an internist is because I get frequent reminders how fortunate I really am.  And yet at times the daily reminders still aren't enough to really make me appreciate what I have.  

Someone once told me that no matter how bad you think you have things, there is always someone who has it worse.  I think that's accurate.  

And thus after seeing the twins every day this week, I've recommitted (again) to being grateful for what I have.  I'm not hopeful that this feeling will last long, however, because it never does.  But that's okay, because fortunately for me there will always be another unfortunate patient on my list to remind me whenever I do forget.  I just hope I don't have to see his chronic wound.

Stay tuned.


  1. Great change-up post doc! As we pursue contentment and happiness in life, one of the few things we can actually control is our matter how much or little we have...

  2. Thanks for the reality check, it's welcome and appreciated.

    Looking forward to your next set of viewpoints, keep them coming.