Feet – not for the squeamish

Last week, I took over from a nurse who had been working for two hours in a consulting room in outpatients. I washed my hands, dried them on tissue paper and stepped on the pedal to open the normal waste bin. It was empty. I flipped open the clinical waste bin and found it was empty, too. I could think of three reasons – the bins had recently been emptied, the nurse hadn’t washed her hands or the nurse hadn’t needed to wash her hands because she hadn’t touched any patients.

I like touching patients. It’s a humane thing to do, reaching out and making contact. It demonstrates concern and compassion. But some health workers are concerned about contamination, especially in a clinic where there are many patients suffering from tuberculosis. I know one hospital doctor who wears an N95 surgical respirator all the time at work, no matter whom he is treating. In an MSF clinic, some nurses wanted to wear gloves when handling patients’ paperwork and medical records, out of fear of contamination.

I reminds me of reading Mary Douglas text on pollution and taboo while studying Social Psychology at Cambridge. In 1991 it was listed by the TLS as one of the 100 most influential non-fiction books published since the Second World War: http://en.wikipedia.org/wiki/Purity_and_Danger

Medical students learn that making a diagnosis involves three basic steps. Taking a history, examining the patient and carrying out special investigations. The history provides most of the information, with examination and investigation helping to support or refute your diagnostic hypotheses.

Given my non-existent communication skills in siSwati, my history taking is rudimentary. I don’t have access to a wide range of fancy laboratory investigations. So, the physical examination of the patient assumes greater importance for me. I use all my own high quality instruments, brought from UK – I need all the help I can get!

I’m trying to improve the care of our 200 diabetic patients. This means examining their eyes and feet. When I am checking feet, I sometimes sneak a peek at my translator who can’t hide her distaste. Occasionally, I have trouble, too.

This man could not feel this deep ulcer in the sole of his foot because he had lost all sensation of pain.

The patients in wheelchairs usually have the worst feet, mainly because they can’t walk on them. Last month I saw a man with one foot blackened rigid from gangrene. Last week I saw another patient who had been bed bound for four years at home following a stroke and vascular dementia, with pressure sores eroding his heel bones.

I called the local hospital about this lady’s gangrenous big toe. The SMO said it wasn’t an emergency and she should come to surgical outpatients next week.

Complete desquamation of the sole of the foot is rare. This happened two years ago in an Zambian cross country runner who did not use shoes at the Mfuwe Sports Day. The hard sole just sheared off from excessive friction.

The photograph below shows a man who has had bacterial cellulitis for two weeks before seeking medical care. The skin of his leg has already peeled off, with just the sole to go.

Sometimes I am amazed by the fragile condition of patients’ socks. They can look so worn out that there are more holes than material. It is a mystery how they manage to put their socks on without them falling to pieces…or perhaps it isn’t.

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