It Runs Deep

Boy-howdy, did you get lucky! When I sat down to start writing this post, I had decided to dive into the deepest, darkest waters of my life and tell you about the loss of my left foot. But as I settled my two fingers on my keyboard, (I'm a two-fingered typist), it occurred to me that a major topic would be missing from that story: Infection. Oh, I've mentioned how serious infections can be, but I haven't explained nearly as much as I can.

So buckle up, buttercup! We're going for a ride!

But fiiiiirst... Seriously, you Earthlings reading my ramblings, do you  really have nothing to say?! "Wow, Rob, I'm so glad you told this story! I had no idea this was even possible!" "Rob, for revealing the previously unmentioned and horrific truths about diabetes, I curse you and all who know you." "You write good." "I don't know who you are. I don't know what you want. If you're looking for money, I can tell you that I don't have money. But what I can tell you is that I have a very particular set of skills; skills I have acquired over a very long career. Skills that make me a nightmare for people like you. If you let my diabetes go, that'll be the end of it. I will not look for you. I will not pursue you. But if you don't, I will look for you; I will find you; and I will kill you." (Anyone catch what I did there?) Seriously, folks, I would appreciate the feedback. Heck, I'll even accept, "Show the scantily clad, beautiful young woman already!" (And give up on a running gag so easily? You'd have to comment to see if I'd actually do it.)

Back to our regularly scheduled blog post.

Infections are troublesome for Type 1 diabetics because we start off being immunocompromised. It means our immune systems don't function properly from the beginning. But then Type 1's and Type 2's experience overlap once diabetes has affected them at a microvascular level. It's important to remember that excessively high sugars alter the structure of blood vessels. The stranglehold in the smallest parts of your circulatory system means blood can't flow properly to wounds to heal them. As a result, we're more susceptible to infection.

Yes, I've mentioned the vascular disease before. And I'll mention it again whenever necessary so that you understand exactly how important it is. That applies to monitoring your blood sugars and communicating with your doctor.

Y'know what else I've mentioned that you may have forgotten? How deep an infection can get. An infection on your skin can wind up going down into your bones! And a bone infection is called osteomyelitis. 

I've had it twice.

The first time I had it was the result of an obnoxious ER doctor who didn't see me as a diabetic in pain. He viewed me as a drug-seeking lowlife.

Look, I can understand that he had probably encountered drug-seekers. They say they're in pain, but have nothing to show for it. I, in turn, had a lump in the middle of the ball of my foot. After getting an x-ray that showed nothing, he numbed me with a local anesthetic and used a scalpel on the lump.

The ER doctor... sliced open the underside of a foot... of a 38-year-old man... who'd been an insulin dependent diabetic... for 31 years. (Those are the numbers for the summer of 2005.)

Nothing but blood came out. The only things he had to go on were the facts that I said I was intense pain and that there was swelling. So he did two things. He flat out told me he wouldn't do ANYTHING for my pain and he discharged me. That's it. And he did these things as rudely as possible, making it very clear that he thought I was faking so I could get drugs.

Two weeks later, I was back in the ER with what seemed like the same complaint. Except this time the x-rays showed that the third metatarsal of my right foot, right at the point where the other doctor had cut me open, was infected. I was immediately admitted and kept for 27 days. Every day involved a twice daily bag of vancomycin, which is an antibiotic, and the occasional test. X-rays, bone density, MRIs. The x-rays were the best! Each showed more of that long bone in the middle of my foot slowly disintegrating. Eventually, there was so little of the bone left that I experienced a pathological fracture. That's officially defined as "a broken bone caused by disease." 

Once I was discharged from the hospital, I still had to administer the IV antibiotic. Getting that set up was its own form of fun. Their first two attempts were PICC lines. That's a Peripherally Inserted Central Catheter inserted in the forearm. The line was pushed all the way up my arm and into the chest region. They took an x-ray to ensure it was positioned correctly, and then the plan was to send me home with a two-week supply of vancomycin.

But by the time I returned from the x-ray, the skin covering my bicep was covered with a splotchy red rash and was tender to the touch. They'd never seen anything like it. I mean, it was obviously an allergic reaction, which they'd seen often enough, but the PICC line was made of the same materials as the IV lines they'd been putting in me for weeks, and I'd had no reaction to those in any way.

Those jerks at the hospital tried to get sneaky with me. They removed the first PICC line, inserted a new one in the opposite arm, and did their best to rush things along so they could have me out the door before I had another allergic reaction.

This is where I'll bring up The Patient's Bill of Rights for the first time. Here are the basics:

1. The right to be treated with respect and without discrimination.
2. The right to obtain your medical records. (Keep in mind that many doctors' offices will charge you for the resources used to make copies.)
3. The right to privacy of your medical records. This is compliance with HIPAA. 
4. The right to make a treatment choice. As long as you're of sound mind, YOU decide what can and can't be done to you. Which leads neatly into...
5. The right to informed consent. You need to have tests and procedures explained to you in a way that you understand. This is why you'll find yourself signing a form saying that you consent for a doctor to treat you.
6. The right to refuse treatment. Again, as long as you're of sound mind and understand the consequences, you can refuse tests, treatments, and medications.
7. The right to make decisions about end-of-life care.

The attempt to rush me out of the hospital brought 4 and 6 of those rights into play. After racing to insert the PICC line, get their x-ray, and shoo me out the door, I availed myself of my rights and refused to be discharged. I insisted that we wait to be sure I didn't have the same allergic reaction, and I was glad I did! About an hour after refusing to let them release me back into the wild, the splotchy red patch and tenderness appeared on my arm.

So it was that I underwent a minor surgical procedure to install a Hickman catheter. This was put in my chest and anchored in my jugular vein. Same materials as the PICC lines. No allergic reaction. Don't ask me. I never received an explanation of how or why my body reacted like that.

Come the next day, which was the 27th day of my visit, I was sent home.

When the bone eventually healed completely, there was a visible deformity at the end of the bone that even I, without medical training, could pick out. But thanks to Charcot foot, all of the bones look deformed.

I was lucky. Very lucky. The treatments for osteomyelitis are:

1. IV antibiotics.
2. Surgical resection of the infected bone and IV antibiotics. This means that in addition to medication, they surgically cut away necrotic or infected bone. ("Necrotic" tissue means it's dead.)
3. Amputation.

It all depends on a number of factors. Patient age, medical history, severity of the infection, etc. If ever faced with this fairly scary illness, be sure to have an in-depth conversation with your healthcare team. There may be tight time constraints if the infection is endangering your life, but if you can be afforded the time, write down any questions you might have so you can remember everything that has come to mind about the literal loss of a limb. "Informed consent," remember? 😉

Okay... We'll start my second osteomyelitis story with some audience participation. Extend a finger, then use your other hand to move the finger in a circular motion by its tip. You'll notice that the entire finger moves. This is because of the tendons running the entire length of all of your fingers. This simple principle applies to your toes, too. There are no muscles in your fingers and toes. It's basically held together with skin and tendons.

What happened to the second toe of my left foot remains a mystery. I couldn't recall ever injuring it. For whatever the reason, I had what could best be described as a "volcanic wound." It looked like pressure built up inside and it blew its top, leaving a small hole at the tip of the toe.

Two things stood out from the examination by my podiatrist. (A podiatrist is a foot doctor.) The first was that he was able to get the wooden tip of an applicator into the hole and slide it down to the bone without any obstructions. The other thing was his ability to move the tip of my toe independently of the rest of the toe. Because there are no muscles in toes, it meant that the tip of my toe was basically being held in place by skin, and only skin. Oh, maybe some other tissues exist in there, but I couldn't tell you for sure. (I know it's been a few posts, but in that time I STILL HAVEN'T BECOME A DOCTOR!) Whatever the infection was that had gotten into my toe had eaten away the tendon. It was well within the realm of possibility that I could bang my foot into something, remove my sock to inspect the possible damage, and have the end of my toe fall out of the sock.

A second opinion wasn't necessary. I could see that the toe was done for. An x-ray was taken, but it revealed nothing because... Okay, this is going to be hard to grasp, but an x-ray of an infected bone is always two weeks behind what can actually be seen on film. The only way to get an up-to-the-minute status of osteomyelitis is to open the patient up and examine the bone visually. And that seemed like a lot for a toe that was obviously on its way out.

That particular podiatrist was a very likeable guy, and he often preferred to understand a patient's illness to some extent than dismiss it once it had been addressed. So after my toe was removed, it was sent off for a pathology report. I've already revealed that it turned out to be osteomyelitis, but the lab labeled it "site specific osteomyelitis." What does that mean? No idea. Even the doctor didn't know. His takeaway was that it was a bone infection, so the mystery was as solved as it could be.

I would like, however, to note that I tried to look up "site specific osteomyelitis" so I could give you all some kind of definition. This proved to be a monumental mistake. Pictures of diabetic feet with advanced infections are worthy of nausea. And when I get to my own foot amputation tale, you'll get an eyeful of nightmare fuel.

Thus, my lengthy post about osteomyelitis comes to an and. I would go through my shtick about the young woman, but I'm going to see if I can coerce you people into commenting. And to that end...

I'm all ears.