Say it’s true that life’s worth all the dying we do, sings Matthew Perryman-Jones.
There is a lady who comes whose diabetic foot wounds our clinic doctors in Tripoli, Lebanon, and I debride and dress. She is in her late 70s, with the saddest, grateful eyes and warmest smile. She came to us taking intramuscular amikacin, an aminoglycoside antibiotic. A wound swab sent to the laboratory from another clinic suggested the organism growing in this lady’s wounds was most sensitive to this particular antibiotic. Not a drug in my regular armory, either here or at home. I was grateful this lady came already taking the medication, and on it described improvement.
There were two wounds, between the great and second toe—one about 5mm deep, the other at least 10mm. Gently, we explored the wound, releasing exudate and feeling to assess if we touched bone. “Probe to bone” is an old-school test for osteomyelitis, one I learned as a student in the Indigenous Australian communities of the Torres Strait and the Cape York Peninsula twelve years ago. Osteomyelitis is infection of the bone.
Osteomyelitis is awful in any setting, but it is a potential disaster here. There are challenges accessing hospitals, and, in the event of access, the likelihood of major financial problems. If she needed to be admitted for intravenous antibiotics, would we be able to convince her? Would it be enough of an emergency for UNHCR to pay the bulk of the bill? Would the family be able to pay the rest? Would the hospital even agree with me if I believed it to be a necessary course of action? Would she be charged and discharged? Ultimately, if the treatment did not occur or it failed, would she lose her foot? And if the foot needed to go, would someone do that operation? Again, who would pay? Would there be a physiotherapist to help her walk again? Would there be walking aids? Would her mobility be compromised, and with it her independence? Would infection spread to the rest of her body?
Contemplating these standard questions of consequences, imagine my gratitude that I could not probe bone, and that the family were committed to locating and buying the continued intramuscular antibiotics while the wound healed.
Consider then that amikacin is an aminoglycoside and our patient is an elderly diabetic. Diabetes and aminoglycosides are not a great combination with potentially impaired kidneys in a setting where serial renal function measurements are problematic. Learning how to work with what you have, press for what you need, and through it all cross your fingers and bank on your clinical judgment and experience.
Photo: © Amy Neilson/MSF
She was so grateful. Huge smiles and wet cheek kisses. Every dab of betadine, the debriding of the wound, the dressing, the concern, the conversation. There was much thanking us, and thanking Allah.
Five days later our patient returned for review. The smaller ulcer was close to healed; the surrounding skin was not red, the wounds were healing as desired from the inside out, and maybe only 2mm deep. The larger wound was equally improved, persisting at about 5mm deep. I knelt at her feet to again debride the edges and dress the foot. She tapped me on the head when it hurt too much. I don’t want to cause her pain, but I was happy that this meant there was persisting sensation.
There are no words for how small your efforts seem taking the time to care for an elderly lady’s foot. A little enough task to me, but life impacting for her. Of course, it’s not small for us as an organisation. It’s an example of the complexity of secondary care services we are trying to deliver in a poor region not far from the border of Syria. Behind that act of sitting at the feet of an elderly lady is a huge team of logistics, supply, nursing, pharmacy, doctors, coordination, security, finances, and, of course ultimately, donors investing in taking outpatient care beyond primary care and into chronic non-communicable disease care. My immense privilege is to be the person sitting at her feet; the privilege of being at the front line.
I am nervous by now though about the duration of aminoglycoside treatment. I hesitated to continue, but was reticent to stop. We’d reduced the dose already but we decide then to cease for three days and test her kidney and liver function. Tossing up between the infection and her kidneys; the risks of permanent foot injury or even sepsis, versus renal failure.
Thirty-five this year, our patient’s son was next to be seen in our chronic disease clinic. He was diagnosed with diabetes three years ago. His diabetes is markedly uncontrolled, and we discuss at length to obtain a measure of the issues.
His ever-alert mother listens as we consider the history of his illness and treatment trials. She listens, and then interrupts to tell her story of his diagnosis. He watched his two brothers die, she said. He collapsed, and was taken to hospital. Following this great stress, he was diagnosed with diabetes. Not knowing what to say, I leaned over and put her stray shoe back on her foot. She kissed me again. So many kisses. No wonder she was hanging intently to his every word.
Say it’s true that life’s worth all the dying we do.
The elderly are inspiring me, teaching me, and pummeling my heart in this particular emergency. Old and unwell, with new grief and years of displacement, previously as ordinary or middle class as you and I and now markedly reliant on the support of non-government organisations and on the family that remains. And their families likewise reliant upon them. Some place their hope in UNHCR and the consideration of journeys to a new life. Some explain that it is enough to stay and live day-to-day, hoping fervently that the opportunity to return home will arise.
When I hear reporting on the news, ‘women and children’ are persistently touted as a vulnerable group. But consider the elderly. The elderly are a sizeable and often vulnerable group that deserves consideration and investment.
I first gave this group thought while listening to a talk by a lady from Help Age International in London at the Extreme Medicine Expo in December 2014. Amidst an event of excitement and grandeur, with many fascinating people, this talk struck me. The elderly in complex humanitarian emergencies. Epidemiologically, do we consider them? Do we count them?
It is important to consider how the elderly access medical and other services, their mobility, their family pressures and expectations, their grief, their literacy, their income capacity, their adaptability. They are the caregivers for their families. Taking the responsibility for grandchildren when fighting-age children have been lost to war. The elderly are culturally important for rebuilding a nation post-war. We should invest in them.
The following day one of our GPs [family doctors] called me when I was at the office. An elderly patient had had a fall. In the past few weeks we have given a lot of thought to how we are managing two key complications experienced by our cohort of hypertensive and diabetic patients. Considerations of possibilities for how we can approach chest pain and new renal impairment in this context has preoccupied my thoughts, words, spreadsheets, and research.
Falls. I hadn’t thought yet about falls. Significant, because it’s not going to be an isolated event. Knowing the cohort, I expect that seeing one we will see more. Mobility. Falls in the elderly are a common presentation in Australian emergency departments—my pre-MSF stomping ground. Was injury sustained? Was there a mechanical reason for the fall? Was it what we call non-mechanical in that it was preceded by such symptoms as chest pain, shortness of breath, or dizziness? Is he stable? Does he need walking aids? What is accessible to him? What resources are available to us? What actions can we take now to assist this man in preserving his mobility? Just as osteomyelitis in a complex humanitarian emergency would be startlingly unwelcome, so too would a fractured neck or femur.
Investing in the elderly. Considering their dizziness, neuropathic pain, falls, heart disease, wounds, and arthritis.
A fifty-one-year-old woman cried when I returned to the GP’s consult with a glucometer. She was a very poor lady who travelled a long way to our clinic for free diabetic medications. She had owned a glucometer in Syria and used it assiduously. She was struggling with the cost of disposable strips for analysis here. Persisting where she could, she nonetheless was not winning. Our strips did not fit her machine so replacing the whole system was the solution. A number of our patients travel quite a distance despite financial and health limitations. Certainly fifty-one is young to me, but you would say in Australia “she didn’t look a day over seventy.” More kisses. More tears. More thanks.
Then, at the close of my week of considering all the more my older patients, there was the one. The one who, for quite a few more breaths than normal, was the undoing of my heart. Eighty-five years of age with tears in her eyes and a slight facial droop. Her four sons were killed in front of her in the war. Their throats cut. Elderly, quite deaf, and accompanied by her daughter; her only surviving child.
How do you live after watching your four sons killed? How do you place one foot in front of the next? Outside, after the consult and with her unfazed consent, I photographed her and her daughter. Love and sorrow mingled in her daughter’s eyes as she looked upon her mother.
“If I die there is a photo to show,” our patient said to me.
Yes there is, but I will give it to you before you die.
Treating chronic non-communicable disease amongst Syrian refugees in Lebanon is an exercise in humanity, humility, and resilience—for us all.
Say it’s true that life’s worth all the dying we do.