Us and Them

“Oh God,” groaned my senior resident, grimacing and hiding her nose in the crook of her elbow as she pulled off the patient’s soaked sticky bandage.

“We’re going to have to chop your foot off,” she said, turning toward the door, leaving no time for response.  I was left to redress his foot amidst the rotten pungence.

Mr. Schultz had arrived at the hospital with his left leg in a thick plastic garbage bag – still attached, but blackened and oozing up to the mid-calf.  Years of diabetes did it, along with homelessness and heroin.  He was upfront about it all.  

“I had a sore, and it got worse, and it started stinking, and I covered up with garbage bags,” he told me.  

Soon the smell could no longer be ignored – wet gangrene is an odor like no other.  He was admitted to the surgery service for potent antibiotics and removal of the dead leg above the knee.  As the third-year medical student on my general surgery rotation, I was instructed to follow his case.

Most avoided his end of the unit, so it quickly became desolate, the result of recurrent detours.  Those who needed to enter – the janitor emptying his trash can, the nurse replacing his IV, the technician taking X-rays of his limb – pinched their noses, twisted their faces and exclaimed “Oh, Lord” or “That’s disgusting” or “Why didn’t he come in sooner?” or “How could he let it get like that?”

There was one nurse who reliably cared for him without overt disgust.  She taught me her trick – a dab of peppermint oil under her nose, enough to mask the malodor.  

But even with his smell subdued, Mr. Schultz was still quite repellent.  Surly and sour, he snarled at all who approached.  And he repeatedly refused the amputation we insisted upon.

“You will die without this,” we told him.  

“I don’t think I need it,” he replied again and again.  “Let’s just let them antibiotics work a little longer.  I’ve been through worse than this.  I got shot four times – still got a few bullets in me.  The street made me strong.  And I don’t trust you docs any which way.”  

Dutifully, I read his entire chart.  It chronicled decades of rocketing blood pressures, leaping blood sugars and violent injuries, along with many unrequited referrals to substance abuse specialists and unfilled prescriptions for antihypertensives and insulin.  “Non-compliant,” “not invested in care,” “no-show,” “minimal self-efficacy,” and “denial” peppered the notes of the dozens of doctors, nurses and social workers who’d seen him over the years.  

Facilitated by peppermint oil, my visits to check his wound and vital signs became a bit longer, enough to listen to his stories of wild Brooklyn street life in the seventies – a time and place where one wrong move or angry glance could put your life at risk.  He prioritized immediate survival over all and wasn’t going to lose a leg without a long and scrappy fight.

Our lives were very different, but with these conversations, I began to appreciate his wry sense of humor and feisty wit.  We discovered our grandmothers shared amazing pie-baking abilities; he assured me his grandma’s peach pie would have won any contest.  He reminded me of a grumpy yet charming great-uncle.  And I understood his denial; I too had found denial to be a friend early in my own cancer treatment, though it proved to be a disloyal companion.  

The bacteria putrefying his leg continued to swirl throughout his bloodstream, impervious to his strong will.  Naked fear overtook his obstinance.  His fever spiked and chills rattled his bed; these, likely more than any of our conversations, convinced him to surrender to amputation.

The operation was messy but swift; his leg fell heavily in my arms as it was released from the last connecting bits of bone and tendon.  The malodor was now gone, enclosed in a biohazard bag. He returned to the ward, his blanket deflated on the left side of his lower half.  Some staff saw him now as a “disabled poorly-controlled diabetic homeless addict.”  His dead leg was severed, but the negative labels and snide remarks were still attached.

Mr. Schultz’s care had been infected by judgment for years.  Some may say he deserved it – he embraced risk, damaged his own body with drugs, flouted nearly every doctor’s recommendation.  But perhaps, as a man too often reduced to stereotypes, the judgment he felt fueled a vicious cycle.  The sicker he became and the more care he required, the more alienation and distrust he felt.  His amputation was one casualty of a self-fulfilling prophesy.

When we see others as irrevocably different from ourselves, prejudice can emerge.  When we create an “us” and a “them”, our shared humanity is lost. This division now plagues our nation’s politics, but a similar chasm can develop in the relationship between patients and doctors.

Many moments create the divide. It starts in the storied ritual of medical school’s first year, the anatomy lab, where the process of dissecting another human compels us to distance ourselves from the flesh we cut into.  We spend years learning to distinguish the well from the sick – determining when a person becomes a patient.  We become daily witnesses to disfigurement and death; detachment becomes one of our coping mechanisms.  Patients are reduced into abbreviations and numbers; Mr. Schultz, with all his wisecracks and peach pies and hopes for invincibility, becomes “Room 12, 56 y/o M, POD#2 s/p AKA secondary to DM and Gram positive gangrene.” (1)   

Others are the diseased; we are the healers.  But this is a false separation, and as a cancer patient and doctor intertwined, it is one that I have never been able to entirely achieve.  I have been both the “us” and the “them.”  I’ve felt frustrated when patients damage their health through neglect or denial, but then I remember all the times I wished I could just forget my cancer for awhile.  I’ve been frustrated when someone won’t take the medication I prescribe, yet I remember when I skipped days of my own pills.  I’ve resented patients for not being thankful or kind, but then I remember when my own fear, anger or pain took precedence over any amount of gratitude I felt toward my doctors.  So I try, despite my own biases, not to judge.      

Patients, it is up to us to remember our doctor is also human, full of foibles and imperfections.  Doctors, it is up to us to examine the roots of our judgment.

We can find our own peppermint oil and use it to see the person underneath the pathology.  We all can remember how our human vulnerability unites us.  

I ran into Mr. Schultz a few months later – literally.  He hit the back of my knees with his wheelchair as I rushed to catch the hospital elevator.  Stumbling and nearly dropping the blood samples I was carrying, I turned around angrily, only to see him grinning widely, the sparkle in his eyes glinting behind his dark shades.  He was there for the final fitting of his prosthesis.  

“Hey!  It’s my student doc!  How am I lookin?  Pretty smooth, yeah?”

“Sure thing,” I laughed.  

“You know I still gotta dig out my grandma’s peach pie recipe .  So delicious.  You would be blown away,” he taunted.

“I bet, Mr. Schulz, I bet I would.”

I could almost smell it baking.

 

 

*All names and identifying details of patients and their families have been changed to protect their privacy.

(1)  M = male. POD#2 = post-operative day 2. s/p = status post.  AKA = above the knee amputation. DM = diabetes mellitus.

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3 Comments

  1. Julia-
    I am blown away by your blog! Your words resonated throughout my being. I am so proud of you….reminiscing on when you were preparing for medical school and your mom’s concern when you were diagnosed. “Mr. Schultz ” needed you and so will countless others! God’s plan is unfolding in your life.

  2. Julia,
    You have a gift for writing and expressing real medical situations, while weaving in conversations.
    It’s interesting to hear your stories and point of view. Bravo, keep going!

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