Tour of Pain

It is projected that by 2020 the U.S. will spend $685 billion a year in direct medical costs for persons with chronic diseases, and by 2050–$906 billion.

Hoffman, Catherine and Dorothy P. Rice. Chronic Care in America: A 21st century challenge. San Francisco, CA: The Institute for Health and Aging, University of California. 1996. [ Permalink ]

It’s a sobering thought – $685 billion a year in direct costs, which doesn’t even begin to address indirect costs.  As a friend would say, “That’s shit-ton of money!”  We all know that early intervention in chronic diseases, like COPD, heart failure and diabetes can curb and reduce the effect of these diseases over the long term.  Sometimes though, getting the message through in words alone just doesn’t work.

Even though programs like “Scared Straight” where convicts are unleashed upon juvenile offenders in an effort to make them come correct have been shown not to work (and in some cases do more harm than good), the idea is sound.  Imagine if you can show a patient with the beginnings of these chronic diseases the ravages they face.  Maybe putting a visual, a face on the horrors could make them start making better choices.

We had the perfect storm scenario for this a couple of weeks ago.  Our census was more than representative of what diseases like diabetes, COPD and heart failure can do.  These patients, while nice, every last one of them, they are were what many call gomers – the chronically ill.  We all know them, they get admitted and never leave.  Ravaged by their diseases their life is pretty much a never-ending cycle of meds, dialysis, fingersticks, lab work, scans, pneumonia, renal failure, decubitus ulcers and other skin issues, trips to the hospital and back to the skilled nursing facility.  You know them by name, family, diagnosis, code status and how many times they’ve gone to the Unit.  So imagine if we were to expose folks in the beginning of the journey to them.  Sure it’s a HIPAA nightmare, but maybe some good could come of it.

So back to the other night.  The patient I have in mind is a young man, has Type 1 diabetes and has been admitted with a blood glucose of 600mg/dl.  After a bout with osteomyelitis, he’s already lost a finger, thanks in part to being unable to heal well with elevated blood glucose.  His A1C, when last checked was over 11% (normal for good control is around 7%), so obviously he’s not doing well in managing his disease.  So I wanted to take him on a tour of pain, what could happen if he continues this path.

“So how old do you think this patient is?”  I ask as we walk into the room.

“Uh, dunno, 70 something…” he replies.

“Yeah, try 55.  See where her legs should be?  Not there right?  See that tubing under the skin of her stump?  That’s a dialysis graft where she’s hooked up to a machine 3 times a week that cleans her blood because her kidneys can’t.”

Diabetes continues to be the leading cause of kidney failure, nontraumatic lower-extremity amputations, and blindness among adults, aged 20-74.  CDC – Chronic Diseases and Health Promotion.

And we’re walking…

“And over here is a gentleman with a tracheostomy, otherwise known as a hole in his windpipe so he can breathe because he had pneumonia so bad he was on a machine to help him breathe for 2 months.  The other day he blew eggs right out of it as he aspirated them and instead of going into his lungs they flew out the hole.  He pretty much just lies there.  He’s had at least 3 heart attacks, that we know of, he craps the bed as he has no control – which you did this morning as well I heard, and spends more time in the hospital than home.  Oh yeah, he also has an implanted penis pump to get that to work because his vascular disease is so bad.”

“Diabetes can cause nerve and artery damage that can make achieving an erection difficult. Between 35% and 50% of men with diabetes experience ED, according the National Institutes of Health. Some estimates are higher, stating that up to 75% of men with diabetes will experience at least some degree of ED during their lifetime and the risk increases with age.” WebMD

Continuing on…

“See those funny looking scars on this guy’s face?  That’s where he melted his oxygen cannula to his face when he caught it on fire while smoking with oxygen on.  He smoked 3 packs a day for 3 years and now can’t go anywhere without his oxygen, or as he says, ‘It’s my lifeline man!’ as he clutches the tank like Gollum and Precious.”

We all know the issues with smoking, there’s even a warning on the bloody pack.  “Nuff said.

And last but not least…

“This guy looks pretty young right?”

“Yeah, I guess, I mean I can’t tell.”

“Yup, he’s barely 40.  See how he can’t move his left side and that arm is all twisted?  He had a stroke 5 years ago.  Y’know why?  He’s a Type 1 diabetic, just like you.  He didn’t take care of himself, figured he’d be fine.  Now he too gets dialysis 3 days a week, has had a stroke and is barely into his 40’s.  You could be him in 15 years – or less.”

“…results indicate that incident dialysis patients are at five to ten times the risk of hospitalized stroke when compared to patients without renal failure. Although this high rate of stroke may not be unexpected given the accelerated risk of atherosclerosis among ESRD patients, previous public health initiatives have focused primarily on controlling cardiac disease among dialysis patients34; our results suggest that similar initiatives are needed to control the high risk of stroke in this population.”   Elevated risk of stroke among patients with end-stage renal disease.  Stephen L Seliger, Daniel L Gillen, W T Longstreth Jr, Bryan Kestenbaum and Catherine O Stehman-Breen.  Kidney International (2003) 64, 603–609; doi:10.1046/j.1523-1755.2003.00101.

Of course in an ideal world he would swear on a stack of Bibles that he would change, but it ain’t a perfect world.  I expect to see him soon.



  1. ok, I stumbled onto your postings while trying to find a national average for telemetry floor ADT rate. Too frickin funny. Totally made my morning. I absolutely love your take and attitude on nursing.


  2. Awesome post. I am an orthotist – so deal with a lot of diabetic feet and loss of limbs. I totally wish you could do as you just described. But really, it would maybe only help a few, folks are still idiots about their health.


  3. Aw, come on…you know it could never happen to him. Denial is a very strong defense mechanism. Until he figures out why he’s noncompliant, he’ll remain noncompliant. It’s like an addiction. Everyone has their ghosts that need released. Unfortunately, there’s no money for psych for these folks.


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