Jesus & Michael Jackson...and Star Wars

Good morning, All!!!

First, prayers go up to KB and her family as her Mom recovers from a recent heart attack. She is a living witness that what looks impossible to man is so easy for God.

2 Corinthians 5:17. That power right there can heal a broken spirit and the wounded flesh. Better get you some.

I got a call the other day about some health ministry business at the church back home. I am trying to decide how involved I am going to get into that situation at this point. Not because I don't want to get involved, but when I was fully involved, I experienced some of that church politickin' that I've heard so much about. Didn't like it. Not one little bit.

But don't get me started on that. This blog might get shut down.

Its cool, though. I finally realized that God has given me gifts that the people at home needed, but were not ready to accept from me. As much as I wanted to bring better things to my people at home, God had to move me out of that situation to show me that the work that He sent me here to do was not going to get done in that environment.  And I have been judged harshly for that.

The good thing is that harsh judgment is the proof that what I did was right. Otherwise, I'd be still pulling my hair out trying to please people who had already made up their minds that they were not going to be pleased. Especially not by me.

Chile. Boo.

God sent me here to save the world. I don't owe anyone an explanation of my purpose.

Plus, I don't know about you, but ain't nobody over here got time for that.

But I digress. Because only Jesus and Michael Jackson know what I mean.

I was talking to my supervising physician the other day about how I wanted to go into emergency medicine in my next life. That adrenaline rush is something else.

I told him how frustrated I get when a patient comes to me from the hospital or emergency room without complete care, like just enough was done to justify getting them out of there.

Its just seems like we need folks to change the culture of emergency medicine in this area. Especially for the poor and uninsured populations.

I have an elderly, male patient who is diabetic. He'd had a toe amputated a couple of weeks before the first time I say him. He said that he had seen the surgeon just a few days before that and had been released from care.  He had been being seen at a free clinic to have his diabetes managed. Obviously, though, the diabetes had not been under good control as witnessed by the fact that he had to have a toe amputated.

He was coming to see us to establish care and said that he was told by the surgeon to follow-up with a primary care provider for management of the amputation site. I took a complete health history that was only significant for a personal and familial history of diabetes. He had no history of drug, tobacco, or alcohol use. His blood pressure was excellent and his weight was appropriate for his height.

But when I asked him about his medications we hit a bump in the road.

He was wearing an old-school fanny pack. He unzipped it and started pulling out insulin pen after insulin pen after half-empty insulin pen. Lantus. Novolog. Regular and 70/30. Humalog. Levemir.

"Which ones are you supposed to be using?" I asked him.

His reply: "What's the difference?"

Among other things, he told me that he was using the insulin 3 times a day after meals and wasn't really sure what combinations of insulin he was using. What he did tell me was that he usually gave himself  2 - 6 units each time depending on what he ate and that he did not have a meter to check his blood sugar.

His finger stick blood sugar and rapid A1C in the office that day was 174 fasting and >13.0 respectively.We drew a complete metabolic panel to check his kidney and liver function and a lipid panel to assess his cholesterol.

His physical exam was essentially normal.

That is until we got to his feet.

Now I am no surgeon, but I was pretty sure that releasing this man from his care was probably not a good idea.

Where the "pinky" toe of the right foot had been was a open wound, oozing green and yellow pus with a gangrenous flap of skin hanging off. The other four toes were all blistering, bleeding, or oozing pus in some combination. It was obvious that he was going to have to lose at least part of that right foot. The left foot was in better shape, but not by much. If he did not have some intervention immediately, it would suffer the same fate as the right one.

 As I stood there examining his wounds, it suddenly hit me that he had not made a sound the entire time...because he had absolutely no feeling his feet at this point. The out of control diabetes had completely compromised his circulation.  There was no telling how long he had been walking around like that.

We were able to get in touch with the surgeon's office. It was Friday and he had left early, but I did speak to his nurse who gave me an appointment for first thing Monday morning. I told here that I would clean and dress his wounds and put him back on some antibiotics until then.

As I suspected, the surgeon decided to amputate his forefoot. The surgery was scheduled for Wednesday morning. I fully expected that we would not see him back at the shelter until at least late Thursday or Friday morning.

But I should have known better.

That same Wednesday afternoon, one of the shelter's staff came to the clinic area and asked KB and I if we had time to come check on a patient that was bleeding in the day room.

We followed him through the double doors to the day room and our eyes settled on a heavy trail of blood leading to a table near the front desk. When we finally spotted the source of the bloody scene, I realized it was my patient. He'd had his foot amputated that morning and was discharged back to the shelter just hours later.  The patient's story was that he stayed in recovery for about 2 hours before he was discharged. He had walked back to the shelter from the hospital.

No wheelchair. No crutches. Just a gauze dressing and a blue "shoe" with velcro straps.

His leg was propped up on a chair and underneath the chair was a widening pool of blood. His once white bandages were completely red and blood was actively pouring from the wound. The patient was sitting there like nothing had happened and I was actually grateful for the fact that he could not feel anything. I asked the shelter staff to call 911 because there was no way I would be able to stop that bleeding. KB and I gloved up and began to wrap his foot with layer upon layer of gauze. It only took the ambulance a few minutes to get to us, but by the time they did, there was a red spot growing on the wad of gauze we had just put in place.

Not long after the ambulance picked him up, he was back at the shelter. Apparently, on the walk back to the shelter, he'd busted open his stitches. At least this time, the hospital had given him a cab token for the ride back.

I saw him back a few days later. He'd been set up to be seen at a foot clinic for follow-up. We got him a new meter, ordered him some diabetic shoes and started him on Metformin, Lantus and 2.5 mg of Lisinopril for kidney prophylaxis. I thought about adding mealtime insulin, but felt that it would just complicate things for him at that point.

Plus, and I don't know if this can really be described as a good thing, but the good thing about many diabetic homeless patients is that most of the time, they have not been taking their medicine correctly, if at all. That means that even if their A1C is off the chart, there is great potential that you will have a marked improvement in the control of their blood sugar within the first few months of consistent therapy.

All of this happened a couple of months ago.  I've seen the patient back a couple of times. KB and I have taken a lot of time educating him on his diabetes and his treatment regimen. In the process of all this, we found out that he only has a 3rd grade education and can barely read.

He also told us that he actually had a meter at one time, but that he did not know how to use it. No one ever offered to show him how to use it, so he just didn't. We made sure that we got him a one touch meter with visual prompts to make it easier for him.

Sometimes, it just takes us to recognize that a patient's failure to take care of themselves may be based upon our failure to give them all the tools they need to do so. The patient-provider relationship is meant to be both altruistic and symbiotic. Responsibility for success and failure must be equally shared.

That patient is doing very well these days. He came into the clinic for labs earlier this week was ecstatic to show us his blood sugar diary. His fasting that morning was 96. I can't wait to see what his A1C looks like.

I am proud of and excited about the work that we do in the community. AF and HL are doing a great job at planning health education program planning for the residents at the shelter. We have our diabetes class coming up here soon and the turnout should be massive.

My work has got me giddy. Like a Star Wars geek at a Sci-Fi convention.

Towanna