08 October 2008

Never, not once. until yesteday

I am not proud. I am, in fact, rather ashamed. But the other emotions I feel are anger, distaste, and, quite frankly, dread.

I took the gentleman from this post to the OR last week... last Monday, to be exact. He was a mess. I have never seen anything like it. A grown man, mid-40s, strong (as far as looks--very muscular, fit), handsome, even... quivering uncontrollably at the sight of an IV needle. No joke. It took 5 of us to hold him down, after a lot of begging and bargaining, that is, to sssslide that little 20 into one of the hoses on his arm.

The surgery itself? I was so happy. I took off the distal phalanx routinely, looked at the middle phalanx--SOLID. No signs of infection. Surrounding skin? Healthy. Beautiful. The closure? I gotta tell you, I was so conscious of this man wanting to get back to work, I did not even allow a little dog ear. The whole surgery (minus starting the IV) went so smoothly, I was thrilled that he was coming for his first post op visit yesterday.

By the way, he called the day after surgery about some papers he needed to get filled out for work, but that was it. Smooth sailing. No calls about pain, nothing.

I explicitly ask all of my patients to leave their surgical dressing on until they see me at the first post-op visit. I tell them, reinforce it with their loved ones and write it in capital letters on the discharge papers. It is really, really rare that these orders are not followed. Seriously, my patients know I mean business.

So, I was almost confused when my friend came in with no dressing. Not even something he threw on at home, which some people try to fool me with. (Trust me, a surgeon ALWAYS knows their own dressing.) When I asked him what happened and when? He answered that the night of the surgery (!!!) the finger was itching him, so he took off the dressing so he could bite it (!). Then, over the past week, he remained with no dressing, going about his business (although he assured me he stayed in the house) changing his baby's diapers and the such, but NEVER ONCE WASHING HIS HAND!!!!

He complained (now, in my office, as he waved the swollen digit around) that the pain was tremendous. I asked him why he never called. I was calm, at first, when I reminded him that he called about his papers, but never mentioned any of this. My eyes were met with a blank stare.

I asked him to wash his hands now, in the office, with soap and water. As soon as he finished, he turned to me, "Why is there pus coming out?"

I looked in disbelief, at the same time realizing that it was the only explanation: he had a wound infection, which explained the tremendous pain and swelling. When he washed his hands, he dislodged some dirt and blood that was covering the wound, and now the pus was pouring out.

I told him that I would need to take out at least a few sutures and open the wound to let the pus drain. It was the only way to get rid of the pus and the pain. He started moaning and crying (crying, with tears streaming down his face). This is when the fiasco started. I called my medical assistant into the room. We are both small women. He is a tall, muscular, fit man. After wrestling with him for about 20 minutes, I asked my MA to call our administrator in. A man, pretty much the peace keeper, but not much larger than us. The amazing thing is that the whole problem was that this patient was truly, magnificently AFRAID. He was not aggressive to me or anyone else; he just would not allow me to do what I needed to. The whole procedure, on a cooperative patient, would take less than 1 minute. Really. Start to finish.

With this man, it took an hour and a half. Every five seconds, he was ready, and then he would freak out again. Taking out 3 sutures took 45 minutes. (I left the rest for another day.) He had on 5 layers of shirts, which he started taking off one by one. (I really kept thinking that he was going to be sitting in front of me nude.) He had on two hats (I am not joking). Once he finally let me do what I needed to do, it really did take exactly 2 seconds (scissors into wound, spread, done).

The thing that I find worst of all is my reaction. After the first 30 minutes of begging and cajoling, trying to mesmerize him into cooperating... I lost it. I really did. I was screaming at him. I have never done that. I feel awful. I was cursing, too. Not pretty, not professional. Really, really awful. I cannot stop thinking about it, replaying it in my brain. I cannot justify it. All I can say is that I really just wanted to do right for this man, and he would not let me. On top of that, I had patients piling up outside, so I felt pressured to get a move on. I even told him (and this I truly meant with all my heart) that if I had known that this was how things would go, I would have come in on my day off so I could spend as much time as necessary with him--even the whole day, if I had to. Unfortunately, that was not the case here.

The only good thing, well 2 good things: 1. When all was said and done and the dust settled, he thanked me. I mean, the man knows I really was trying to do good for him, NOT to hurt him. He understands he brought this on himself. 2. We called him today, and he said he is feeling much better with less pain. He is doing the wound care that I instructed him on.

No matter, I am seeing him again on Friday. He is one of the patients that I would move in with, if I could.


BBourgonjon said...

Nice story :)
And your reaction (cursing, yelling, ...) seems kinda normal!?
Sigh patients...

DrB said...

Except, you know, it's always good to have self-control, and my patients know that I mean business and am stern, but I have never lost it in front of any one of them.

Bongi said...

i must say i handle it all differently. i do not beg patients. it is his choice. if he doesn't want to be helped and is old enough to decide for himself, he can f#@k off.

DrB said...

Fair enough, Bongi, except that every 5 minutes, he was "ready." It was truly infuriating.

He's much, much better now, by the way. I saw him last Friday--smiling ear to ear. "It doesn't hurt at all anymore, doc." I wanted to strangle him.

DHS said...

It's a shame that in this day and age we can't admit these patients just to protect them from themselves.

DrB said...

DHS: That would be ideal; unfortunately, our group is under great pressure (as are most docs in the US, I believe) to not admit. I would be swiftly placed in front of a firing squad if I so much as thought of it!!

As for this patient, he ended up having to undergo a stump revision. I took out his sutures right before Christmas, and will see him again in early January. Keep your fingers crossed, people. So far, so good.

I think I have made myself clear to him, also, that I will not put up with his theatrics.