The Chronicles of Valentina - Cephas
Cephas Picker is 62. He has a number of significant health problems that he pays little to no attention, but there was one that was a problem that should have been solved years ago. As far as the initial issue was concerned, the problem was solved. He had a craniotomy in 1999 to remove a meningioma. That surgery was simple and recovery was routine. No biggie.
Until he developed an obsessive disorder that led him to pick at the scalp incision. This is psychiatric disorder in the same category as people who pull on their eyebrows or pull out their hair. A couple weeks ago, he fainted on one of the few occasions he left his home, and some well-meaning person called EMS (he wasn’t pleased).
He fainted because of the infection related to the picking obsession. The area that he worried at with his fingers became infected and the corruption spread into his bloodstream. We are taught not to lose our composure in front of patients. No one has succeeded with this guy. He was all we could talk about in the doctor’s lounge. How could such a problem be allowed to go on for years?
He’s picked away skin and muscle from the side of his head down to the skull, starting at his eye and extending back behind his ear, up to the vertex of the skull. This is bigger than his hand. The infection involved all of the surrounding skin, extending into the eye socket (I can’t bring myself to describe the condition of what’s left of the eye) and the sinuses, as well as the skull. The fascia covering the skull should be shiny and a pearlescent pink. It is boggy and exuding pus. The smell is impressive. The osteomyelitis - the skull infection - looked to be full-thickness, meaning that the infection was a few deep breaths away from entering the brain. Frankly, he could have been an extra on ‘The Walking Dead’ with no makeup.
This whole scene generated consultations by the Hospitalist to Infectious Disease, Neurosurgery, Plastic Surgery, Ophthalmology, ENT, and Maxillofacial Surgery. That’s seven kinds of doctors seeing him. Once - IF - the antibiotics take hold, then treatment would involve:
1: enucleation (removal) of the eye by Ophthalmology,
2. removal of the facial bones to evacuate the necrotic tissue from the sinuses by ENT, with facial reconstruction by Maxillofacial,
3. removal of the infected skull by Neurosurgery, to be replaced with a plate at some other time,
4. The placement of a muscle flap and later, a skin graft, over the open area as a scalp replacement by Plastic Surgery.
That’s for starters.
Before that, Plastic Surgery biopsied the edges of the scalp that’s left. Every bit of it has become cancerous. So another centimeter or two of scalp would have to excised all around before anything else started. And the presence of the cancer means that all of the above would not be curative at all, but just a temporary management of a problem that will never go away.
Without all that, the infection, if killed off, will have to return. No way anyone can prevent that. He will die. Surgery would postpone all that for an unpredictable length of time. We hoped it would be longer than recovery from such radical surgery would take. Regardless, he’s going to die of this.
The big ironic part is that treatment for the picking compulsion is dreadfully easy, with a low dose of medicine that would have worked very quickly and permanently. This could have been stopped 15 years ago, in a matter of days.
One would assume that this man lived alone. He doesn’t. He has a wife. A wife who sat by and did nothing to stop any of this. She would remonstrate with him, he told her to leave him alone, and she did as she was told. She asked him to see a doctor, he refused, she made no further effort. When he got too freakish to go out in public, he stopped work, and they lived hand-to-mouth until their preacher gave her a job in the church office for far less than minimum wage. He pays her out of petty cash.
I try to understand this. I’ve never figured out how a woman could stick to the rule of a Good Wife Does As She’s Told, not if the nitwit she married is doing himself hideous harm and bringing the family down with him. What kind of helpmeet is that? I try to envision suffering in silence while my husband peels away his own skin and bleeds and smells and is ill for years. Years. Send me to whatever circle of Hell Dante described for wives who insist that their husbands do the right thing, but so help me, my man would get treated and live to a ripe old age while I earned that place in Hell.
So how did I get caught up in all this? Well, it seems that on top of all of the above, years ago, Cephas had to have a heart valve replaced. The replacement valve is the type that will allow blood to form clots on its surface unless the patient takes a blood thinner. This is a subject of extensive conversation before the replacement surgery is done. If you don’t take the blood thinner, clots will form and perhaps break free and travel to clog up arteries all over the body, and depending on what body part loses blood flow and dies inside you, you can wind up rather painfully dead or crippled. Or the valve itself with clot shut and you’re rather abruptly and painfully dead. You don’t agree to this without agreeing to lifelong medication.
Guess who wouldn’t take the blood thinner? In order to determine the thickness of the skull infection, they had to get an MRI of the head. He just so happened to have 12 (twelve) strokes. An ECHO showed rags of clot flapping in the current around the valve. So I was consultant #8, Cardiology was consultant #9. My job was easy: yes, he’s had a horrible number of strokes. PT/OT will help him get his mobility back. Prevention of more strokes is easy: use the blood thinner.
Consultant #10 was Palliative Care. Confronted with complicated surgeries, months of recovery and no chance of a real cure for the cancer, Cephas opted to do nothing. He went home. He will die. His wife didn’t say a word.