Treating the chronic diabetic foot ulcer of a patient with multiple physical and emotional health challenges requires compassion and understanding.
Mr. Sunshine had a standing appointment at 10:30 a.m. every Wednesday. He earned this nickname by being consistently the most crabby, rude, non-compliant, foul-mouthed veteran in my wound clinic at the VA. His reputation for negative verbal assaults to all medical staff had permanently exiled him, by mutual agreement, from surgery, plastics, physical therapy, and dermatology clinics. We were his last chance for the treatment of his chronic diabetic foot ulcer. So, after burning all those past bridges, he was all mine.
During podiatry school clinics, the other students and staff would send me the emotionally demanding patients that required more time and patience due to cognitive issues and/or their lack of cooperation. I enjoyed the challenge of getting the difficult patient to be engaged, calm, and agreeable to my treatment plan by the end of the visit. Sometimes it took more than one visit, but just like approaching a scared animal, I took baby steps to get them to trust me with their care and eventually win them over. It is a personal skill that I have enjoyed and perfected in the subsequent 26 years since leaving Ohio College of Podiatric Medicine.
Learning about the patient
So, back to my Wednesdays at the clinic. Around 10:25 am, all the nurses seemed to be busy in other treatment rooms or “had to urgently attend to” something on another floor. They learned that it was better to leave just the two of us in the treatment room so I could “work my magic” on the most disliked patients. Mr. Sunshine did have a miserable life, exacerbated by a car accident that left him with a right above-the-knee amputation and confined to an electric wheelchair that he was constantly complaining about.
Once, when the wheelchair controls went out, he showed up in the prosthetic department wielding a knife he kept under his seat cushion and threatened the staff if they didn’t immediately fix the broken part. This earned him a visit from the VA police who promptly issued him a $175 fine for bringing a weapon on federal property and threatening staff with physical harm. But as you might guess, this incident did nothing to improve his reputation in the hospital nor did it improve his contemptuous attitude.
During my clinic visits with this gentleman, I tried to talk to him not just about his medical conditions, but about life in general. My goal was to have a true conversation that didn’t end in him shouting or making threats. I was curious about how he had developed into this fireball of emotional negativity with a persistent need to cause conflict wherever he went. He had no family nearby, and being unable to live by himself, he was in a nursing home with patients who were much older than his 68 years. In the three years he was in my clinic, he was kicked out of two nursing facilities and three home health agencies for, as you can probably guess, verbally and physically assaulting the staff and other patients. So much of his energy was spent fighting and in conflict, I believe he didn’t know any other way of dealing with others.
His wound was on the bottom of his left foot. During our visits, he remained in his wheelchair and I took a seat on the floor, so he looked down at me while we spoke. This positioning was critical in building our relationship. Being confined to the wheelchair, people were always looking down at him, and this placement disadvantage made him feel more vulnerable and weaker, thereby invoking his need to be louder and more aggressive to make up for this inadequacy.
We talked about his wound care treatment, but also about life in general, and I got him to share some stories about his past. It was during these times that I got a small glimpse of the man that was once there. His dysfunctional family life, unmanaged medical conditions, and poor life choices had landed him in his current situation, and his only way to deal with the disappointment was to lash out at others. Mr. Sunshine was still very stubborn and didn’t do everything I recommended, but he appeared to listen to my ideas and was compliant in keeping his clinic appointments. He did admit that I was the only physician that had taken the time to get to know him and not just dictate orders.
One of our biggest conflicts was over his shoe wear. He insisted he didn’t need a shoe or post-op sandal since he didn’t walk, while I insisted it was important in protecting his foot as well as keeping the wound dressing clean. Once he came in with his foot and ankle wrapped in silver duct tape; this was during one of the times he was between home health agencies and was doing his own dressings. He was quite proud of his handy work, and I believe it was the only time I saw him smile.
We continued our weekly visits, with his wound improving when he was compliant but worsening when he was on his own. I believe he looked forward to our visits and chats. Despite the tough outer exterior, there was a small, soft part of him that needed this emotional connection. On our last visit, he informed me that he was moving to Florida where he had family who was going to “take care of him.” I must admit that my first thought was that this family doesn’t know what they have agreed to, but I quickly reprimanded myself and prayed that this was his opportunity for a better life. He could have a fresh start and hopefully be open to developing true positive emotional connections with his family.
An enlightening proverb that dates back to the Cherokee tribe of Native Americans warned: “Don’t judge a man until you have walked a mile in his shoes.” As podiatrists, this seems especially relevant. Developing compassion, forgiveness, empathy, and the ability to think yourself into another person’s shoes is very important as a health provider. In our profession, we are certain to interact with people of different viewpoints or complex personalities. Then there are some that just rub us the wrong way from the first meeting. It is easy to dismiss or judge others against our own values and past experiences. Responding with understanding and compassion instead of the primal response of anger or conflict, will help you become a better physician and ultimately help your patient. Just ask Mr. Sunshine.