What does it mean to be hopeful? Can I die and yet live??

“Who do we have next,” my preceptor, (we’d call him Dr. F) asked as he finished dictating notes on a patient we had just seen a few moments earlier. As is the norm, I looked through our next patient’s chart and took note of the important details, while Dr. F dictated notes on previous patients. I was supposed to do this in order to have an idea of what problems the patient came to the hospital for, and be ready to answer any questions just in case Dr. F decided to quiz me on anything before going in to see the patient.

“This is (Let’s call him Mr. T)” I started. “Mr. T is a 54 year-old male, presenting with symptoms of lower limb pain and a history of Lower Extremity Arterial Disease. His recent lab report shows a CTA ordered by Dr. M, who is considering a possible above-knee amputation of his left leg. (Side note: A CTA stands for Computerized Tomographic Angiography and is a radiological test that combines the technology of a conventional CT scan with that of traditional angiography to create detailed images of the blood vessels in the body.)

Dr. F then grabbed the chart and asked “anything else we should know?” “Not quite,” I answered. He flipped through the patient’s chart and took out his latest scan results. After going over the detailed report, Dr. F decided to draw out a detailed picture of what exactly the report said, as he always does for all his patients with blood vessels that are occluded. He took out the paper that had a picture of the different arteries and veins found in the abdominal and pelvic regions. We began, as Dr. F marked out the picture with as much detail as possible. “Partial occlusion of right common iliac artery. Complete occlusion of left common iliac artery. Patent left-to-right femoral-femoral bypass. Occlusion of right internal iliac artery. Complete occlusion of left internal iliac artery.” At this point, I thought “we are in for some trouble. This is going to be an interesting patient.” Dr. F continued “occluded left femoral-popliteal bypass, occluded superior and inferior gluteal arteries” and on, and on, and on…..Basically all other blood vessels in our patient’s lower limb were either partially occluded or worst still completely occluded. At this point, Dr. F sighed, and then said “This patient is in bad shape. Let’s go see him.”

As we approached the patient’s room, I imagined a young, at least healthy looking 54 year old man who unfortunately just had to face this unfortunate misfortune of having his leg cut off. To my surprise, as we knocked and entered, I did not see a patient sitting on the hospital bed. I looked around, and there he was, sitting in a wheelchair, by himself, completely covered in thick blanket with nothing but just his legs sticking out. Immediately, I learned my first lesson: EXPECT TO BE DISAPPOINTED!

As he noticed that someone had entered, he slowly uncovered his face. His facial expression could explain how much pain Mr. T was going through. He definitely looked sick; his thin, pale face was covered with an indescriptive expression. One that melted my heart as I thought how obvious it was that he was in so much pain, but was trying very hard to smile back at me. His moustache and beard had outgrown and covered his mouth, and all I could see was his frail-looking eyes which tried very hard to convey his emotions.
After introducing himself and me, Dr. F asked “so who referred you to come see me, Mr. T?” As slowly as he could, I heard our patient talk for the first time. “I do not know, doctor,” he replied in a voice as weak as an almost dying patient, gasping for breath. At this point, my heart missed a beat as numerous questions began to go through my already confused mind. “Does this patient know he’s really sick? Does he know he’s about to lose a leg? Does he know why he’s here? Hell…..does he even know where he is? Does he have a family? Anyone care about him?” As I looked back at him, he carefully and slowly covered himself with his blanket and appeared to have gone back to what seems to be ‘deep sleep.’ Lesson 2 : RELAXXX
Dr. F proceeded to listen to his lungs and heart, checked his temporal, carotid, radial, ulnar and popliteal pulses and then finally sat on a stool to examine our patient’s lower extremeties. Dr. F asked “Are you able to walk any?” Mr. T. J answered “No, doctor.” Both of his legs looked very tiny and small in size, his left leg considerably smaller than the right. This was definitely a classical example of disuse atrophy. When Dr. F asked when the last time was when he last walked, Mr. T answered in what seemed to have been the voice of a toddler “not after my stroke about a year ago.” What???? I thought to myself. He’s had a stroke too?! Lesson 3: ALWAYS read the patient’s past medical history IN DETAIL!!!
Aha!! That explains his physical appearance and his general health condition.

As we proceeded to examine his left leg, I noticed that our patient’s 3rd, 4th and 5th toes were missing. The nails on his remaining 2 toes were discolored, disorganized and looked as though they will fall off if one should exert even very little pressure. His entire foot looked cyanosed, which confirmed his history of lower extremity arterial disease and the extensive occlusions present in his blood vessels that supplied blood to his left leg. In an attempt to further examine his foot, Dr. F tried to raise our patient’s foot, as he moaned and groaned in pain. As I looked back up at his face, I could see the pain and discomfort illuminated in his eyes. “Does anyone care about this poor man? Does his wife not realize his pain? Does she not know that she needed to be here to comfort and provide support to his seriously ill husband? Lesson 4: Before we get married, future wifey must be put to a test to prove beyond reasonable doubt that she will be there for me, no matter what….” #Just saying. :)
By now, we counted up to 5 huge ulcers on Mr. T’s foot. Ulcers that were covered with bandages but were obviously not healing. These ulcers could only be managed and kept clean as nothing else could be done to make them heal due to the poor blood supply to his legs and feet. We redressed his ulcers and the big moment came; discussing options and see what could be done. Mr. T was very sick and obviously in so much pain, Dr. F could not even explain the diagram he had prepared earlier to help him understand his situation better. It was obvious: our patient needed help, no matter what the underlying cause of the disease was.
As Dr. F explained to him what his options were, our patient looked very attentively and seemed to be understanding every single detail. His options? Well, they could continue to watch and manage his leg just like they are now, OR they could amputate the leg above the knee, as it is impossible for the area below the knee to heal if the amputation should be done below the knee. After what seemed to have been 10 long seconds of silence, our patient attempted to talk. He sighed heavily, and then said softly, “I have something to tell you, doctor.” At this point, I realized that Dr. F was ready to do anything, even if it was beyond his means to help this poor man. I could see it in his eyes as he responded “Yes, go ahead and talk to me. I am here for you and take as much time as you need. I will be here waiting patiently.” Lesson 5: TRULY CARING, LOVING AND COMPASSIONATE PHYSICIANS DO EXIST!
Again after a period of long silence, our patient whose breathing appeared to get shallower each second began to speak. While trying to catch as much breath as he possibly could, he said “Doctor” and paused….”I am very confident that I will be able to walk again one day. I know I’ve had a stroke and will possibly not be able to walk again, but I know that I can.” He then paused again, eager to say something next but couldn’t. I could feel the tears build up in my eye, ready to get loose!!! As the pressure continued to build up in the room, he broke the silence again saying “but I know that you are a doctor, and I trust you enough to decide what is right for me.” Our patient just taught and reminded me of this very important virtue and lesson; Lesson 6: NEVER, EVER LOSE HOPE, NO MATTER WHAT!!!!
Even after having been told by numerous people and doctors alike about his inability to ever walk again, this utterly sick patient remained hopeful. He believed that even in the midst of all the problems, his 3 already lost toes, his unrepairable feet and a completely “dead limb,” there was still HOPE that he could potentially be able to walk some day. At this point I could feel the pressure and buildup of sympathy and sadness in the room. I held myself tight, trying my best to not let a tear drop! Lesson 7: HOLD YOURSELF TOGETHER. DO NOT LET YOUR EMOTIONS OVERCOME YOU.
When Dr. F asked our patient if there was any family member or guardian he could call and talk to about the situation, Mr. T answered NO! Although his medical records and chart said he was married, our patient said No?! Wow……Hell, make that lesson 8: BE VERY CAREFUL IN THE WIFEY SELECTION PROCESS. Not all that glitters is gold!!!

Dr. F, looking as dismayed as myself then asked Mr. T if he was married, to which he answered in the affirmative. When Dr. F asked if he could call his wife to ask of her opinion and/or permission to amputate, our patient remained speechless for a while, thought for a few seconds and then said “Okay. Just do what you have to do, in order to help me, doctor.” Clearly, Mr. T had his faith and remained hopeful that his leg could be salvaged. Thus, he wanted to continue to manage his leg, in hopes of being able to walk again someday. Medically, however, there was nothing that could be done to help salvage his leg from further damage. Thus, an amputation above the knee was necessary and the only way to help this patient. Lesson 9: ETHICAL SITUATIONS ABOUND!!

This ‘conflict of interest,’ if you will, especially in the absence of a family member to make a decision on behalf of the patient leaves physicians in this mind and nerve-wracking bout of ethical decision making.
I can only hope that Mr. T’s wife will be willing to help in the decision-making process when she is contacted, as her husband was sent to his rehabilitation home in pain, agony and the unending thoughts that no one, yes absolutely no one cares about him, not even the woman who promised on that fateful day to “have and to hold from this day forward...in sickness and in health, to love and to cherish, till death do us part, according to God's holy ordinance.” Lesson 10: Even when people fail you, remember that LIFE GOES ON…KEEP ON KEEPING ON.

If there’s anything I have learned that I hope to remind myself of and hope to carry with me for as long as I live, it is this. That LIFE is indeed a journey. Expect to be disappointed. But when you do, just RELAX. Keep on keeping on….be hopeful that your present location will NOT determine your future destination. Ask for help when you need it and take on the journey, an inch at a time.

Thank you, Mr. T!!!!