The Case I Can’t Forget is a weekly series that hears from the people working at the coalface of public service about the cases they have carried with them throughout their careers.
This time, cardiac nurse specialist Molly Case writes about Derrick, an independent amputee preparing to lose his second leg.
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Every year since qualifying as nurses, my friends and I host a Christmas dinner and talk about the patients we have looked after, the colleagues we have known, the stories we have heard, the cases that have have kept us up at night – on night shifts or simply awake in our own beds thinking about them.
We set the date months in advance and meet up weeks before the real Christmas day since we are all nursing in different places now; High Dependency Units, Intensive Cares, GP surgeries and outpatient settings, and our hours and rotas never match up. We all bring food and plenty of drink and sit around describing those shifts we never thought we would make it through, the ones that didn’t seem to end.
As the night goes on we all exclaim that we were the golden era of nurses, the dream team and we are always in firm agreement that that particular ward, where we met four years ago, has never been the same since we all left. This assurance becomes more passionate and fervent as the Christmas party goes on.
That evening, one of my colleagues and I reminisce about Derrick who we looked after in alternate shifts for about four weeks at the start of our careers. We worked on a vascular ward, it looked after the pipework, the veins and the arteries of people suffering from various plumbing problems: the circulation not working as well as it should due to blockages or bulges in the pipes.
Derrick was an amputee and had lost his right leg 10 years earlier due to the effects of smoking on his circulation, peripheral vascular disease and poorly managed diabetes. Over time, he had suffered from recurrent foot ulcers in that right leg, which had become de-sensitised – his pain receptors less able to tell him that there was a problem. This delayed wound healing and, in addition, Derrick’s high blood sugars increased the inflammation around the wound and prevented his immune system allowing it to heal. In the end the wound became gangrenous and his leg was amputated.
Since that operation, Derrick had remained active and his upper body strength was strong. This time, he arrived on the ward with a wound infection in his remaining leg, it had been bandaged at his GP surgery but it had already started seeping through the dressings and we could smell that it had become infected.
Derrick unpacked his belongings in the side room, he was able to wheel into the space and move from chair to bed and back again with the strength in his arms. He unpacked his football shirt, pyjamas and a wash bag. He was independent and despite losing the leg 10 years before, he felt he had continued to live his life without many restrictions.
As the week passed my colleague and I dressed the infected wound. We were both under a year qualified and felt hopeful that it might improve now that he was an inpatient with us, receiving regular intravenous antibiotics and dressings, honey and iodine, algae and silver – materials to help draw out the infection and allow the wound to heal. The vascular nurse specialist came and taught us how to soak the skin and clean away the dead tissue allowing fresh cells to form.
But the wound didn’t heal. Derrick watched us as we worked, crouched down patting the sore left leg dry and wrapping it with gauze and crepe bandage. He thanked us and told us in his youth he had been a semi-professional football player. He told us about the women he had dated and the children he had had, although none of them came to visit. In the evening, he would rub cocoa butter on his good skin, turn on his radio and lie there watching the moon rise over the railway line.
One morning on the ward round the vascular surgeons came to see Derrick. They told him that the left leg was not going to heal and that it had begun to die. He had a temperature and my colleague and I had noticed patches of dark, hardened skin that we knew as necrotic tissue. Much of the leg looked swollen and pale as if the blood circulation was no longer there.
Derrick turned his radio off and asked for the doctors to leave. Before they did they told him they advised him to prepare himself for surgery tomorrow, if the infection spread any further they feared he could die. Derrick closed the door behind them and asked to be left alone.
Before I finished my shift, I went to see him and asked if I could come in. He nodded and I sat on a footstool while he lay propped up in bed. He told me he couldn’t believe he wasn’t going to have any legs anymore, he couldn’t understand how he would never be able to stand again, to feel the ground beneath his foot, to be tall, to feel strong, that he would be confined to a wheelchair for the rest of his life.
I was a new nurse but I knew I simply needed to listen. Time passed and I sat there listening to Derrick talk about all the places he had played football, the feeling of hard dirt roads and leather balls, rain-sodden sponge footballs from school, astro-turf and freshly cut grass, bare feet and tight leather boots with new laces. He cried, and I tried not to.
In the morning, Derrick went for surgery to have his left leg removed above the knee. The operation went well and he recovered quickly. A couple of days later, my colleague and I were finally working the same shift together.
We offered to help him to wash that morning since he was not used to washing without the use of any legs to steady himself and this would be the first time. He agreed and at first did not say very much. We told him we would help him wash this morning but by the end of the week, he would no doubt be able to do a bit more for himself. He nodded.
The morning was bright and we pulled down the blinds so that the room was dim and occasionally there would be a flash of light as the sun glinted off the trains speeding past the hospital. The room smelt of bubble bath and antibacterial soap and soon all of us were laughing as the papier-mâché bowl leaked onto the bed linen. My colleague raced to cover the floor in towels and then to cover Derrick so he wouldn’t feel cold and exposed. I slipped on a bedsheet caught in the wet, just catching myself before I fell over completely. Derrick was holding his belly, the laughter was loud in the room and through the tears he thanked us for the hot water and washing his back and helping him to feel that maybe there was hope after all.
Molly Case is a nurse and was the first writer in residence for the Royal College of Nursing. Her book, ‘How to Treat People,’ will be published by Viking Penguin in April 2019.