Two weeks ago I was faced with a clinical dilemma, a patient of mine who was repeatedly eating, yes eating, the dressings that his carer kept applying to his non healing leg lesion and who was thus working his way steadily through a box of Elastoplast.
I sought the advice of my medical colleagues. What, I asked them, might I best do for my patient. Should I:
a) For fear of provoking an intestinal obstruction, counsel the carer to desist from applying the dressings and instead suffer the consequences of the lesion bleeding all over the carpet,
b) Seek a psychiatric opinion, or
c) Advise the carer to take a more authoritarian tone with the patient and threaten no further doggie chocs if the behaviour were to continue.
Their recommendations for action came back from all corners of the country. Had I considered pica, had I checked his ferritin levels and, from those more fully appreciating my patient’s four leggedness, had I tried a cone of shame. This last suggestion, however, despite its suitability and soundness, was not one that was possible for me to employ since all I had at my disposal was a cube of discontent and a cylinder of regret.
Of course the only real option open to me was to seek out a specialist opinion. But having done so and received the advice that a surgical solution was what the leg lesion required, the surgeon sought out my opinion as to whether the procedure should go ahead.
My initial reaction was an unqualified yes but, after reflecting on the matter, I realised that, in terms of quality adjusted life years, performing the operation on a nonagenarian patient made poor financial sense irrespective of how much the old fella was loved by those dear to him.
I sought the opinion of my esteemed colleagues once more in the hope that their collective wisdom would aid me in my ethical dilemma. I asked them whether, in these days of ever increasingly tight purse strings, I should
a) stick with my original advice and, as his allocated key worker, bear the cost of the surgery myself.
b) withdraw my support for the proposed intervention and advise instead that the patient be kept off the furniture for fear of him bleeding on the upholstery, or
c) remove, as it were, the patient from my list, and take on a younger, less arthritic patient who was likely to have better smelling breath.
The advice was universally in favour of proceeding with the proposed surgery, a decision which in truth was never in doubt.
And so, this morning, after a night during which the air was filled with the rancid smell of necrotic tissue, and the silence was disturbed only by the incessant sound of a wound being constantly licked and all too many Elastoplasts being declared lost, presumed missing in action, [does that still count as ‘nil by mouth’?], my elderly patient slipped into an acute confusional state on account of his carers refusing to give him his usual breakfast of cornflakes with milk. [I know, but I’m sorry, he really likes milky cornflakes!]
Transport was duly arranged and he was promptly conveyed to the surgical assessment unit from where he, soon after, was taken down to theatre.
A few hours later, after a brief spell in recovery, he was back home with nothing to show for his ordeal save for a bald patch on his leg, that long overdue cone of shame, and an anaesthetic induced propensity to stagger amusingly when he tried to walk. [Is it wrong to laugh at the afflicted?]
So today was a good day as a result of a job well done. Thank you to Eric, Glen, Jessie and everyone at The Mount Veterinary Hospital, Wellington for early diagnosis, prompt referral and timely surgical intervention all combining to ensure, for today at least, a happy outcome.
His breath still smells though!