Tuesday, November 29, 2011

The agony of de feet.

(This should be required reading for all future physicians.)

Wet foot, dry foot
Low foot, high foot
Front feet, back feet
Red feet, black feet
Left foot, right foot
Feet, feet, feet
How many, many feet you meet!
~ Dr. Seuss

I have this medical school classmate (that shall remain nameless) who hated feet when we were in school. Oh my goodness. Absolutely detested them. And touching them? Out of the question.

The funny thing about it is that this woman was and still is quite possibly one of my favorite medicine nerds and doctors of all time. Being friends with her made me a better medical student because I knew no one who valued their medical education more than she. Just being in her presence made you want to try harder and do better.

Anyways. Despite all that wonderful-ness, her Achilles heel (interesting proximity) was feet. Yes. Feet. Bigs ones, small ones, flaky ones, pedicured ones. It didn't matter. There was just something about them. . . . .all wiggly and sweaty and fresh off the ground that gave her the complete heebie jeebies. As a matter of fact, she used to even examine the toes of her diabetic patients using two tongue depressors! She had whatever is the complete polar opposite of a foot fetish.  More like a foot-a-phobia.

Which reminds me.

The closest I ever got to seeing her catch a case was the day I decided as a joke to put my bare foot on her. O.M. -expletive- G. I slid my foot out of my flip flop one day and touched her with my big toe during one of our big exam study marathons--and what did I do THAT for? Man. We were punch drunk from sitting in the library for twelve hours straight, so I thought my little prank would lighten things up. That's what I thought.


Seriously? We almost fell out for good over that. If I recall correctly, she froze and said, "B-word, did you just stick your bare FOOT on me?" And from the dead serious look on her face, my instinctive response was to run for my life. Fortunately, I've since learned to keep my feet to myself, and for this reason, we were in each other's weddings and remains tight like cornrows. Oh--and yes, she is now an amazing clinician who does, for the sake of her patients, occasionally touch their feet when medically indicated.


Tonight I was judging yet another stinky feet contest between Isaiah and Zachary and remembered my classmate. I sent her a text about the foot anti-fetish which made us both LOL.

But then. . .that got me to thinking.  I started reflecting on . . .well. . . .my clinical experiences through the years with feet. And you know?  My buddy might have been on to something. . . . .

I started to torture y'all with the top ten terribly, horrible no good very bad feet stories but quickly realized that would be cruel.  But that doesn't mean I won't share a few of the best foot horrors I've had. You know. . .the ones that have made me have fleeting thoughts of choosing a new line of work.

Caution to those who have a foot anti-fetish. . . .


Horror #1: What's in a word?

Okay. So I was in my third year of residency and was running a ward team. We were busy as I don't know what, but we were having loads of fun and taking good care of patients so it was all good.  One day we were rounding post call and the overnight intern was presenting his patient to me.  Back then, one of the interns was on call with a cross cover senior each night. As the ward team leader, I learned about the patients early the following morning unless I was that person supervising the night before.

On this day, I hadn't been in house overnight so this patient was new to me. I remember it like it was yesterday. The intern presented this extremely straightforward patient with a case of community acquired pneumonia. He had an oxygen requirement and involvement in more than one lobe, so this had gotten him hospitalized. In addition to that, he was unstably housed, so had lots of social issues to boot.

So I hear all about this gentleman and his respiratory issues. The intern was all over it, and had all the management wrapped up tight.  We prepared to walk into the patient's room when she stopped me and added, "Oh yeah. . .I forgot to mention that he has this funky, serpiginous rash on his foot."


"What do you mean by a 'funky, serpiginous rash'?" I immediately demanded of her.

My intern wrinkled her nose and shrugged. "I don't know. Some kind of parasitic thing or something fungal? I'm not sure. I put in a consult to Derm already."

And in she walked ahead of me like it was no big deal.

But it was a big deal. It was a big deal because of that word she used: "serpiginous."

ser·pig·i·nous (sr-pj-ns)adj.:  creeping from part to part; having a wavy border.

The thought of anything awaiting me that would be described as "serpiginous" made the hairs on my neck stand up.  And especially a serpiginous foot? Creeping. . .worm like. . . wavy. . . lawd. I was terrified.

And rightfully so.  Those feet. Good heavens to mergatroid. It looked like the patient had stepped on some tangled web of hot yarn and branded the sole of his foot with it.  It literally was worse than smelling chitlins cooking. I was so grossed out that I had to remove myself from the room.

Later on that morning when we were rounding with the attending he asked me to "do some teaching on that foot lesion" since he "knew how much I liked dermatologic manifestations of medical illnesses."

"Sir, this is actually not medical-manifestation related. It's a purely an infectious Derm thing. Let's just see what they say."

My interns snickered because they knew I was trying hard not to have anyone expose those feet again. And that's when my attending insisted. "Oh, don't be silly, Kim."  And with that he pulled off a sock. And worse--he said this:

"Hmmm. . . .this is serpiginous." He leaned in closely. "Dr. Draper, step over here with your pen light."

But that was not happening. Dr. Draper was in the hallway leaning over a water fountain.  Dude. He lost me at "serpiginous."

I googled "serpiginous rash" and decided it would give you nightmares to post a photo. Instead, I took a picture of the goose flesh I keep getting every time I type the word "serpiginous."

If you want to make me run from you just say "serpiginous" three times fast.

Up until that day, I used to have thoughts about being a dermatologist instead of an internist. This was the day it became very clear that the thought of having to see someone repeatedly for their serpiginous eruption would cause me post traumatic stress for real.


The point was feet, wasn't it? Oh hell. It was on a foot and yes, it was super-duper gross so that counts.  Sure does. Oh, and for you medicine nerds? The diagnosis of that funky s-word rash was "cutaneous larva migrans" which I hope and pray I never, ever, ever see staring me in the face again. 


Horror #2:  Winter boots.

The worst possible smell I ever smelled in a hospital was that of feet coming out of heavy snow boots during Cleveland winters.  I mean it.  At least once per week, one of my clinic patients would need their annual Pap/pelvic exam.  No big deal in the summer. But the winters? Another story.

Picture this: Two really, really, REALLY sweaty, bare feet propped approximately four inches away from your face on some stirrups.


(That was me passing out from remembering it.)

The good news is that I do think it has adequately made me an appropriate authority for judging the stinky feet contests at my house.  My point of reference is quite extreme, man. Our frontrunner is Zachary, however, he has nothing on the snowboot feet. At. All.

Horror #3:  Admit to Medicine? Not.

I was eight and three fourths months pregnant with Isaiah and rounding at Grady one day.  The ER was hopping with patients and we were getting bombed with new admission after new admission. The patients were great as always, but I was so, so tired. This day I was trying to keep up with the team but finally had to sit down in a chair on the ward.

Until I got this page:

"Hey Dr. M. There's a patient who is getting admitted to us who I think may be a surgical admission. He needs an amputation but is refusing so the default is us. Can you come down to the ER?"


Pregnant, tired, and not in the mood for a fight.  But I had no idea what we would do for a patient warranting something that could only be corrected by surgeons. Especially considering we aren't surgeons.

So down I go.

"What's the deal?" I ask the resident while looking for yet another chair to sit down in.

"This man has a necrotic foot and no palpable pulse. It's really bad, too. He needs an amputation but is reluctant so they can't consent him. Surgery won't take him if he won't consent."

"Well, getting your foot cut off is something to be reluctant about, don't you think." I twisted my mouth for a minute and asked more questions. "Why is his foot necrotic? Is he a diabetic or does he have peripheral arterial disease?"

"Actually, no."

"That's weird. Why is his foot necrotic to the point of amputation then?"

My resident just looked down and sighed.  This was puzzling.  I was tired and my feet were hurting. My hip was hurting, my back was hurting and now my head was hurting from not understanding what this dude was doing with a dead foot and no good reason for it.

"Let me go see it." I shook my head and set out for the room. My resident grabbed my arm and stopped me.

"Uuuuhh. . . Dr. M? Listen, it's no big deal. Let's just admit him. Besides, he's a nice guy and has a lot of social issues that we can help with. Don't go in there. It's okay."

I looked at him suspiciously.  "What's up with his foot?"

That's when the ER resident walked up and asked me, "Hey Dr. Manning. I'm sorry about that admission. I mean, it's totally surgical, you know, but he won't consent to the surgery. I have never seen anything like that! Maggots?"



"Ex-squeeze me??"

"Oh, you didn't know? Mr. Parker has had on the same pair of socks and shoes for almost nine months. The left foot can probably just be debrided and cleaned up but that right one had some kind of sore on it that got infested with maggots.  They've pretty much eaten up his toes."

Aw. Hell. No.

I swallowed hard and searched for that seat again. All the color sank from my face, I'm sure, as I plopped down and asked, "So what am I supposed to do?"

"I mean we can't send him back to the street like this. He's homeless, Dr. Manning."

I looked at the resident and then down at my ginormous pregnant belly and wanted to cry. Now this? This was up there with the serpiginous foot. I took a deep breath with closed eyes.  "I'm going in there to talk to him."

My resident and the ER guy looked at each other and realized there was no point in trying to stop me.  I was going in. 

And so I did. Alone. I could see people looking and pointing at me through the glass window separating the patient's room from the rest of the ER. They seemed worried that I would faint. But all I knew was that I had no magic treatment for a maggot infested foot. So I needed to try to speak to him myself.

So I take a history and learn his story. Homeless for five years. Lives outdoors, under bridges, and all over. Had been given a pair of steel toe boots a year back by an outreach group and also some socks. So yes. I confirmed that he had been wearing those shoes and those socks for almost nine months. And yes, he pulled off that dressing and I am not kidding or exaggerating one single bit--it looked like his toes had already been amputated and the stump was alive with wiggling maggots.

Alive. With. Maggots.

I leaned on the bed rail to brace myself. Thank goodness for the pregnant stuffy nose--at least I couldn't smell anything.  "Mr. Parker, sir? Have you actually seen your foot?"

I'm not sure why but I decided I'd ask this before anything else.  And guess what his answer was? No.  No! He had come in because he was having pain in the foot and people around him on the streets were complaining about the smell. He had never actually seen what the commotion was under that sock, though.

And so. I showed him his foot. I pointed out the larvae and the denuded metatarsals. And those maggots seemed to wake up and wiggle extra just for him. He looked as aghast as I did and asked, "So now what can they do about it?" So I told him that it was surgical. Surgical debridement or amputation or something that was beyond my expertise. Honestly? Probably an amputation under the knee. But if he waits, more.

And just like that he said he wanted surgery. No arm-twisting just a simple mirror on his foot. So out I walked with my big ol' basketball belly and personally called surgery myself.  And yes, they graciously accepted Mr. Parker to the surgery service.


I know it sounds crazy to have not taken your shoes off in nine months. But he said that those steel-toe boots were good, sturdy shoes and he was scared they'd get stolen if he removed them. So he didn't.


Now that patient? He was super sweet. But that foot of his? Literally it was like some mini-Medusa head with writhing appendages. Yes. And if that description makes you throw up in your mouth a little bit--or just throw up period--then that means I have accurately painted the picture for you.

Medusa Head: Peter Paul Rubens - Oil on Canvas

That? Now that was the worst of all the feet horrors. Whooo-weeeee.


Damn, it's late. Wait, what was the point of me telling you all of this? Hmmm. Oh well. I'm pretty sure there isn't one.


Here's one:  If any aspiring medical doctor reading this thinks that blood and bodily excrement are the only considerations you must get cool with before entering the field of medicine--honey, think again! Contrary to what they might show you on Grey's Anatomy, a world of funky, serpiginous, sweaty, and maggot-infested feet await you just behind the curtain in Room 2.

Up feet, down feet

Here come the clown feet.

Small feet, big feet

Here come the pig feet.

His feet, her feet

Fuzzy fur feet

In the house and on the street,

How many, many feet you meet!
~ Dr. Seuss

Happy Hump-day all you medicine nerds.


  1. Hell yeah on the maggots - our veterinary patients are sometimes full of them. Occasionally they do an okay job of debridement, too. But all the wriggling...ugh!

  2. Whew, I smell your pain! Nothing like removing the boots from a person who works in a chicken killin' factory and doesn't see the need to take a bath until his week is over...

  3. This is pretty much the most disgusting post I have ever read. I started reading it while eating supper, and I was gagging by the time I read the word "serpiginous". Ugh. It reminds me of a patient I admitted with sepsis secondary to wet gangrene from an infected diabetic foot ulcer. /shudder

    I may have nightmares from this.

  4. Just when I was thinking about Hem/Onc, I think maybe I'll stick with Path...........oh wait, they got maggots there too except the patients with the maggots don't talk back!

    I got NO problem with anything gross, including maggots. The ONLY exception is yellow/green nasal material, LOL!!!

  5. Oh, yuck, yuck, yuck. At least you have good work stories, I suppose.

  6. Reminds me of the docs who do the foot service at the men's shelter at the Immaculate Conception church downtown. Now I realize how necessary that is.

    And, BTW, EWWWW.

    Allison in ATL


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