When contrasting worlds collide

 

When two contrasting worlds collide, it leads to a lot of confusion. Mr. V is a 65 year old man with type 2 diabetes for more than 10 years. He belongs to a village located about 10 km from our clinic. He is a highly religious man with orthodox values and beliefs. He strongly believes in astrology and vouches by the fact that all humans are governed by their respective planetary alignments. “Doctor, what is your raasi? What is your lagnam?” he asked me a few years ago. In astrology raasi refer to the zodiac sign in which the moon was positioned at the time of one’s birth and lagnam is the rising sign which is the zodiac sign that was rising in the eastern horizon at the time of one’s birth. In astrology it is believed that raasi represents the inner mind and personality traits that govern the self, and lagnam represents the way a person interacts with the external world. An astrologer uses a person’s raasi and lagnam to determine their personality, success, failure, attitude to life and general approach to various situations in their life. I am not a major believer in astrology, neither do I have knowledge about it. But being born and brought up in an orthodox Hindu family, I know my raasi and lagnam and I told him. “You have a lot of karmic debt on your shoulders. Sani (Saturn) is the boss of your zodiac. You need to placate Sani. Go to a shiva temple every Saturday and light a lamp and pray to Sani. Also apply gingelly oil on your head every Saturday and bathe. All your karmic debt will reduce.” I laughed in my mind when he said this. I am certain I have a lot of karmic debt. According to the Hindu principle of Karma, Karmic debt refers to the accrual of consequences of good and bad deeds of this life and past lives, where there is an imbalance and so more negative consequences are present. I have probably hurt many people unintentionally and have accrued a lot of karma based on my actions. But if only lighting a lamp and taking oil bath could wash away all the karma, what does it say about religion as a means to ensure a moral life? But I smiled at him and acknowledged his suggestion and moved on. 

 

Mr. V is a good man, but his beliefs in astrology, traditional healing practices, rituals etc. are so strong, that I sometime feel frustrated having conversations with him in the clinic. For example, he will come to get his metformin refill only once in 3-4 months. He would go off the tablets in the interim period. “I take the tablets only when I feel tired. When I am feeling well, I just manage with diet modification, and walking. I soak fenugreek seeds overnight in water and chew them early in the morning. I also boil guava leaves in water and drink the stock. These treatments are sufficient for me” he would say. The most frustrating thing would be the way he would say these things with absolute conviction and in a tone that tries to convince me to adopt those practices myself. 

Two weeks ago, Mr. V came to the clinic with swelling of his right foot. I examined it and found that it was swollen, but not warm, not painful and there were no obvious cracks, wounds or injuries. The third toe had an old, dry ulcer that was healed completely and had a dry scab. There was no obvious evidence of an infection of the foot. One of the things I was most worried about was cellulitis of the foot, but there were no features indicating an active infection in the foot. I thought that it could be early stages of lymphatic filariasis transmitted by mosquito bite and caused due to a parasite. I treated him for it and asked him to keep the leg elevated. “No doctor, I am having transit of Sani this year. When Sani transits it leads to problems in the feet and bones. I just must go to temple and pray to Sani and this will become alright. I have to offer rice mixed with sesame seeds to Sani. Don’t worry about my foot.” he reassured me and left with the medicines. I was worried and hoped that he would care for his foot. 

He called me over the phone two days later. “Doctor, I am running a fever. The swelling has increased, and the leg has turned red. Still there is no pain. Should I come and see you, or can I continue the same tablets?” I asked him to come to see me. When I examined his foot, it looked a lot more inflamed now. The infection had become evident. The foot was warm and red. He still did not have any pain. Sometimes when people have long standing diabetes, they lose sensations over the feet and this numbs any pain. “I told you about Sani transit. That is why all this is happening. Yesterday I went to the temple and lit a lamp for Sani.” Summer has started and the days are quite hot. He told me he went to the temple. In temples people usually walk barefoot. I was wondering if there were any burns or blisters on his feet due to walking in the hot sun. There were no scalds, burns or blisters. The foot appeared clean. I examined the spaces between his toes, they were also clean. I put him on higher antibiotics, as there were obvious features of infection of the foot. “Mr. V, you must be careful. The foot is infected now. I am starting you on high antibiotics. Take them carefully. Don’t walk without slippers. Keep your foot elevated on a stool while seated. Don’t get your foot moist by walking in water. Keep your feet dry and clean” I gave him all instructions for care of his foot and sent him home. 

 

Mr. V came back yesterday. He usually comes on his own in a motorbike. But yesterday he was brought by his wife in an auto rickshaw. He did not look cheerful and even before he entered the clinic, the smell of rotting flesh permeated the room. I took him straight to the procedure room. When I asked him to lift his right foot and place it on the dressing table, the strong smell of rotting flesh came and hit me. He had covered the foot with a rag. I put on my gloves and opened the rag. The foot was looking bad. It was fully covered in white and grey dying flesh and was loaded with pus. There was barely any recognizable healthy foot left. I had seen this foot only one week ago and it was infected but still looked like a foot. In just one week it had gone from a healthy foot into rotten bag of pus. A strong sense of guilt hit me. I did not have time to think. I immediately opened a sterile dressing kit and poured saline on the foot and tried to wash it. As I washed and cleaned it, all the superficial skin peeled off revealing a tense foot. I needed to let out the pus collection. I took an artery forceps and opened the foot gently with it and the pus ejected like a fountain splashing all around. It started gushing out of the opening I had made. Within a few seconds the entire dressing table and floor were covered in pus and blood. I pressed the foot and removed all the remaining pus. The third toe which had a scar earlier, had now become black and lost life. It was barely hanging on to the foot. I was trying to clean up everything to see what is left and what should be done. All through this there was not a flinch of pain on Mr. V’s face. The staff nurse who was standing near me could not take the stench anymore and she walked away. It was just Mr. V and me standing there in the dressing room, my mind numb with fear, guilty and a sense of despair. 

 

Mr. V brought his hand to the infected foot and pressed and prodded the areas that still had the skin intact. “Looks like all the pus is gone and the foot has become soft. Thank you doctor. Now we can dress it up and I can leave right?” It did not seem like Mr. V had understood the seriousness of the situation. The foot had been ravaged by the infection and it was almost destroyed. Mr. V did not have any pain because of the loss of sensations due to diabetes. So, he had not grasped the seriousness of the situation. He probably was also not able to smell all the stench due to loss of ability to smell. 

“Mr. V, the foot is seriously infected. I have only let out the pus. Do you see all this white and grey tissue all over. These are all dead and rotten tissue, they need to be cut and removed. You require surgical treatment.” 

“What? No no. I don’t require surgery. I will never allow anyone to put a knife to the foot. I came here only because you will do dressing and send me home. Do that. No surgery.”

I requested our housekeeping staff to bring some water and give him to drink. After he took a drink, I spoke again, “No sir. It is not so simple. The foot is seriously infected. You need to go to the Chengalpet Government Hospital and get admitted immediately.”

We were in the dressing room for more than half an hour already. The other patients who were waiting outside were becoming impatient. Mr V’s wife walked into the room. She held a handkerchief covering her nose and mouth. She was crying. 

“Doctor, a few days ago I was cleaning the foot as you had suggested, and I pulled out a piece of broken glass from the foot. The day before that we had gone to the temple to worship Sani and offer our prayers. It must have entered his foot on that day. I told him that it is a bad sign, and we had to inform you. But he said we need not tell you. Is this because of that glass piece injury?” she was crying uncontrollably. 

I turned to Mr. V, “Why did you not tell me? We could have taken a closer look at the foot then and done something.” I was really upset at the condition of the foot. 

“You sound upset Doctor. Don’t worry, didn’t I tell you, this is how Sani plays with our leg before it transits out. Everything will be fine.” 

His words were making me angrier. I ignored what he said and continued debriding the dead tissue and cleaning the foot. Suddenly I hit another pocket of pus, and it burst out and oozed with force. Along with it the wound started bleeding. I tried to control the bleeding, but there was a continuous trickle. We do not have the capacity to handle any major bleeds or complications in our centre. So, I urgently packed the bleeding wound and called the ambulance and referred him to the emergency department at Chengalpet GH. Mr. V was very upset and disappointed with me and kept insisting that I should treat him at our centre and should not refer him. Any amount of explanation and reasoning would not convince him. I literally forced him into the ambulance and sent him and his wife to the hospital with a referral letter. 

 

This episode happened yesterday afternoon in the clinic. It is more than 20 hours since it happened. I still have the lingering stench of the rotten flesh in my nose. I slept fitfully last night with my mind ridden with guilt and a sense of immense failure in losing a foot to diabetes complication. When he came back with a cellulitis, should I have examined more closely to find the small, punctured wounds of the broken glass piece on his feet? Should I have probed the history better to ask for injuries? Did I miss out on warning him adequately against walking barefoot. Should I have called him over phone and closely followed up on the status of the foot? Should I have admitted him on the day that he came back with frank cellulitis? Did I trust his self-management skills too much to take care of his feet? Was I too polite? Maybe a harsh and stern reprimand would have communicated the message strongly? I was asking all these questions all last night. I am still unable to wrap my head around the fact that a potentially salvageable foot is gone in just under a week’s time. One of the biggest challenges of working solo in a small remote rural clinic is that things get extremely lonely at times. If it had been a hospital, I would have had other doctors to fall back on. I would have had at least people whom I could talk to and vent my frustrations. Writing this blog is my venting mechanism. I started writing this around 6 AM this morning. It is almost 10.20 AM now. After writing every few sentences, my thoughts are drifting off to that scene in the dressing room of our clinic, me standing in a pool of pus and blood, poor Mr. V staring at the wound without any clue and me guilt ridden and perplexed about what I should do next. 

 

When two contrasting world views collide, confusion is inevitable. My world view is one of science. I am aware of the potential risk of losing the foot in a patient with diabetes who has lost sensations over the feet. My perspectives come from working for many years in hospitals and clinics dressing foot ulcers, assisting amputations of feet and seeing horrible consequences of foot infections. Mr V’s world view is one of traditional, religious and astrological beliefs and faith. He believes that there is a religious and ritualistic solution to every major problem caused by alignment of the planets. Even when I warned him about care of his foot, he perceived it as a risk to the foot due to transit of Sani, which needs to be appeased by offering prayers in a temple in barefoot. I am now not so sure if I was objective in the way I examined his foot when he came back with the cellulitis. Was my mind clouded by frustration of having to deal with his beliefs and value systems which were against my treatment? My rational brain knows however hard we try and however thorough we are in our treatment, sometimes things like this happen. But my emotional brain fails to accept this. My take home from this episode is that I should maintain value neutrality in the face of patients’ beliefs and preferences which go against my own.