I work on a unit that has a lot of so-called "frequent flyers". That is, patients that return multiple times because of relapses in their disease. Mostly, this is vascular and heart failure patients. I see quite a few patients who are current smokers that come in with peripheral vascular disease in unrelenting agony that end up getting their leg amputated, yet they refuse to stop smoking and end up returning later for the other leg. In the case of heart failure, patients slack on restricting their fluid intake and/or don't keep up with their diuretics and end up returning every few months swollen up like a balloon. We have this one internal medicine doctor in particular, Dr. S., who is known for being brutally honest with patients and scaring them into compliance. I remember him once telling a patient, "If you don't keep up with your meds, you'll be dead within a year." While some might call it insensitive, I think it's often necessary, and my next story is a super good example of why.
I had a patient once who was in for necrotizing fasciitis. It started as small as a cut on his right foot, but he didn't take care of it, and it became infected. But necrotizing fasciitis isn't your ordinary wound infection. It's a rare type of infection of a specific bacteria that literally eats your flesh at an incredibly fast pace, often faster than we can keep up. It is often fatal as a result. This patient, unfortunately, sought help too late, and his treatment was the surgeons trying to play catch-up to the infection. They started with surgeries trying to just clean out the infected tissue, but each attempt was in vain. They would find the infection already further up the leg. So, they moved on to a below-the-knee amputation. Again, the infection remained ahead of us, so they did an above-the-knee amputation. And, yep, you guessed it. We still hadn't caught up. At this point, the only option was a total hip disarticulation, which is an amputation through the hip joint. At this point, the patient refused. This confused me, because it was essentially either that or he would die when the infection spread through his body, and this guy was very young with a girlfriend. He had something to live for. He had come this far, why refuse now? Maybe he was tired of surgery? Was he really just ready to die? I wasn't around when the doctors told him he needed the surgery, but I assumed they explained that the alternative was death. Still, I felt like I wouldn't be doing my job if I didn't give it a shot. I spent a couple shifts building rapport with the patient, and then before leaving on my last shift of the week, I decided to talk to him about it.
"So... I heard you don't want to get the amputation at the hip. I can't help but wonder why after you've come so far. You're also very young. They have prosthetics and you are more likely to recover from it at your age. Can you tell me why don't want to do the surgery? Did the doctors explain to you that the alternative is pretty much sure death?" I struggled to get the last few words out, as I feared the bluntness might be a little off-putting. To my surprise, he looked at me like I was telling him something utterly shocking.
"What?? No! They didn't tell me that! They come in, say a few words, and leave so fast. I didn't know that was the alternative!"
I'll be honest, there's a good chance they did tell him, but he was too emotional or distracted or something and blocked it out. But at the same time, it wouldn't be the first time something like that was danced around. I deeply respect the doctors I work with, but occasionally they do tend to squirm out of the uncomfortable death talks. That's why I like Dr. S. so much.
"Okay well I'm sorry about that but I think you should know that's a likely alternative to the surgery. The surgery is hopefully going to cut the infection out of your body. Without that, the infection will spread to the rest of the body rapidly and will kill you. I really think you need to reconsider refusing it. You can still have a life. You can get a prosthetic and learn to walk with it. You don't have to let this infection win." I paused to let him reflect. He was upset, but he was also clearly realizing what needed to be done. He started crying and venting about how hard it all was but ultimately agreed to do the amputation. I felt my heart leap.
"I'm so glad to hear that... I really believe you can get through this and live a full life. I'll tell the doctors to come talk to you about the surgery."
I don't know anything about what happened after that, but I do know I got to go home feeling good about guiding him in the right direction. I meant what I said. I believe he could make it through that surgery and live a full life. He was otherwise young and healthy.
Moral of the story: Don't tip-toe around the real stuff. Sometimes, patients need to hear the ugly truth to make the right choices. Fear is a powerful emotion, and it can actually serve as a tool for us in healthcare when nothing else is getting through to a patient.
- Bella, RN
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