“How do you want to be remembered?”
Julie was brought to the Emergency Room after an anonymous phone call to 911. She had been lying in her own waste for days, but all that mattered to her was getting her next fix.
She was 94 pounds and 28 years old, but you couldn’t tell her age by looking at her. She had the rotting teeth that come with using meth. But mostly, her drug of choice was heroin. Her blond hair was greasy, thin, graying and matted flat against her head. Her face was almost skeletal and she had dark circles under her eyes. Her eyes seemed big because of the loss of fat around them and they almost protruded from her eye sockets. All of her ribs were easily visible and I could actually see her heart beating against her bony chest.
Since she was lying in bed for days without moving, both buttocks were covered with a thick, black eschar. The tissue was dead and gangrenous, but instead of being soft, it was dry and hard and needed to be surgically removed under general anesthesia. We couldn’t start an IV on her because she had used up all of her veins shooting heroin. Her arms, hands and legs were solid tracks of scar tissue any place there used to be a vein visible. She had long since destroyed the veins and even had scars between her fingers and toes where she had found veins once the bigger ones were gone. She had started skin popping, which means shooting right under the skin. This had led to lots of skin infections, some old and scarred, but some actively infected when she came in.
In spite of her almost constant use of needles, she was deathly afraid of getting an IV started and screamed and fought when anyone even got close to her with one. Once she was in surgery and under anesthesia, the surgery resident put a central line in. This is a large bore IV into the jugular vein in her neck and was the only way we would be able to draw blood for labs and to give her the IV antibiotics she needed. Cutting away the dead, gangrenous tissue on her buttocks was a long and laborious process. She also had open ulcers and abscesses on her arms and legs that had to be opened, drained of pus and packed with gauze. One of the old sores on her right forearm had scarred over and a swab inserted into the hole in her wrist tracked through the muscle and came out just below her elbow.
Once out of surgery, she was in narcotic withdrawal for almost a week. She had constant abdominal pain, nausea and diarrhea and her arms and legs were writhing constantly. She would wake up in cold sweats thinking there were insects crawling through her blood vessels and would scratch and claw furiously at them. She had to be restrained so she wouldn’t cause any more wounds and needed a feeding tube for the first few days as her withdrawal made her too sick to eat anything.
Once she started to recover, a chemical dependency counselor was posted to see her and was working on getting her into a drug treatment program. She was also working with physical therapy on trying to walk more as the buttock muscles that she needed to walk had been debrided in surgery. She walked slowly and painfully in the hallways.
She was finally starting to walk on her own a little and one day she walked to the elevator with her IV pole and never came back. Her antibiotic course was almost done, but she still had her central IV line in her neck. Since she had no veins left, this was a perfect port for her to shoot heroin. The resident who put the central line in knew this and also knew that off antibiotics, the central line would quickly become infected and could easily spread an infection to her heart valves. This is called infective endocarditis and can be fatal if not treated.
Since she was homeless, there was no way of knowing where she was, especially in a city as big as Seattle.
Several days later, the resident who put the line in was driving through one of the rougher neighborhoods and saw Julie walking in an alley. She parked her car and followed her. This resulted in a chase on foot over a fence and through a park. They jumped over another fence and the resident caught her in another alley trying to climb into a dumpster. She pinned her down and peeled back her shirt and saw the central line she had put in. There was foul, creamy gray pus oozing from the site where it went into her neck and the single stitch holding it in place was encrusted in scabby, dried, bloody fluid. She had grabbed a handful of napkins from her car before the chase and held them over the site where the line went in. She took her fingernail clippers out of her pocket and cut the stitch and pulled the line out of her neck then held pressure over the site with the napkins until it stopped bleeding. She threw the dirty line and the fingernail clippers into the dumpster, helped Julie get up, went to her car and went home.
This came up in teaching rounds the next day. Some of the other residents were incredulous that she ran Julie down and pulled out the line in an alley. It does seem incredible, but the resident pointed out that the line was infected and was only going to get worse and clearly, Julie wasn’t going to come in and have it taken out.
That was easily fifteen years ago. I doubt Julie is still alive and would be surprised if she even made it to 30. She chose a hard path and there was really nothing the surgery resident or I could do to change that course. There is a science to medicine and there is an art.
I know how I would have felt if my central line was out there being used to shoot heroin and becoming infected. Would I have run her down in an alley? I’m not sure. It’s easy to question someone else’s actions from the comfort of any other vantage point.
There is no doubt in my mind the surgery resident added time to Julie’s short life by her actions. In the big scheme of things, maybe adding time is all we get to do as health care providers.
Using that time to choose how you want to be remembered is up to you.
Arne Vainio, M.D. is a Family Practice Physician at the Min-No-Aya-Win Human Services Clinic on the Fond du Lac Ojibwe Reservation in Northern Minnesota. He can be reached at email@example.com.