The case of the foot

It was a corn in her foot. That was what the doctor found on 6th May. They planned to do an excision and she would go home. Plain and simple. They cut it out, stiched it with blue thread that they would need to remove with time, doused the foot in iodine. We thought the corn looked bigger than what we thought a corn should be. We were thankful. The pain in the foot would go, within a week or two, she would be on her feet. Tell me why it is September and the pain is still there. There is a whole thread of history. In between pictures of tiles, trees and house discussions, there are pictures I cannot delete from my phone, this wound in all its forms. First as a surgical wound, then stitched, then wide open, then yellow but closing - then pictures of her foot, now dark - signs of gangrine. We had been told that we need to get her to India within two weeks or there would be a high risk of losing her leg. Leg, not foot, and in fact, it appeared as though both feet were affected and not getting enough blood supply, so it could be two legs she would lose. Let me tell the story in the order of things. Let's go back to May. On 16th May, another hospital. My mother is lying on a hospital bed in pain. We have driven directly from the previous hospital because the doctor there was more concerned about how he did a marvelous job than the fact it had not worked - the excision. We had wheeled her in for the review because the pain was so great, she could not walk. I stared at the man as he knelt, touched the floor then touched my mothers clearly infected foot - not touched, pressed, indifferent to her screams and pained twists on the hospital bed. We had to find somewhere else. He said, he was sure he had done a good job and what he was looking at was a healing wound. No, it was not. It was infected. So yes, another hospital. We left him and drove to the city, met with a surgeon who immediately confirmed what our naked non medical eyes were telling us, the wound was infected and needed proper management. They removed some of the stitches, cleaned out the pus, more dressing and a plan for monitoring visits. He listened to her, that was important. He asked her how she was, where the pain was strongest, how she felt the pain, when it was strongest and so on. He saw her, he heard her, he wanted to help. A couple of weeks later, no change. He referred us to a plastic surgeon somewhere in Old Kampala, this was now something he was not confident he could address. At least it was not infected anymore. The biggest problem was the extreme pain. The plastic surgeon in Kampala said this was a simple problem. We just had to pay 1.5m for his services and whatever fee whichever hospital we decided to do the surgery from asked of us. He did not acknowldege the patient, ask her any questions or care for the history. He was just ready to cut as soon as he was paid. We met with another doctor for another opinion. He said, this looked pretty easy, he had seen and treated this many times. In his experience, the first doctor had not fully removed the corn. The corn had regrown. It needed to be burnt. Pay one million shillings and come have the procedure done on Monday. She would need spinal anasthesia. For an 80 year old, there were reservations. We had been asked to checkout another hospital and they too said we ought to have surgery, but, the doctor said, there was no gaurantee that this excruciating pain would go away even with another procedure. My mother had endured such a terribly painful experience with the first procedure and the relentless pain all these months, that anymention of surgery caused her great anxiety. Of all the things she was keenly aware of, was the fact that she would not have her foot touched with another sharp object. There was heavy trauma there. We had a function in Nairobi at about this time so while there, we had her visit a doctor for another opinion. In Kampala, the doctors gave us conflicting thoughts about the pain. Some thought a nerve had been damaged, others thought a bone, others thought it was just the corn. In Nairobi, they asked us to do an MRI and CT scan. We did those back in Kampala with her physician. The results painted such an urgent picture that we were called and told on phone that she needed to travel to India immediately. India because he was confident that even Nairobi would not be able to do the surgery and would also suggest amputation. Only india would save her leg/s. A referral letter was sent by whatsapp within the hour. We were instructed to keep her from walking and using the foot and in fact, but crutches so that no weight would be put on that leg. We immediately had a family meeting to discuss logistics and so on. I spoke to a colleague from India, she called a doctor in India, he listened, read the report, wondered if my mother, at her age with a history of alzheimers, would manage the trip. On Monday, we saw the cadiothoracic surgeon that my mothers physician had asked us to see before we could concretise plans for india. The surgeon looked at the report, the scans, then physically examined her. He saw no need for India. He explained that for her age, the overall blood-flow pattern was not unusual. She had been active over the years, so she has developed collateral vessels (extra pathways) that had now helped her adapt. The foot was receiving adequate blood even though the flow was somewhat reduced. He saw some narrowing, some clots but did not recommend surgery. What he saw was that there was a lot of sensitivity around the scar — he described this as likely nerve entrapment, not a wound that needs to be opened or massaged. At this point, she was on a fentanyl patch for the pain but because of it, he could not fully judge her pain while he took her through exercises. He also mentioned that bones in her back may be compressing a nerve. He advised that she should walk, walk as much as possible! Confused but somewhat relieved, we walked to the Physicians office and explained that contrary to his advice, we were told by the surgeon he sent us to that India was not necessary - in fact, not recommended. He asked us to get a deciding opinion, made a call, got us an appointment with a top surgeon at a big hospital. The surgeon at the next hospital agreed. He could see that there was a real problem with the foot - what he called peripheral arterial disease, but he did not recommend the surgery. He wanted to focus on managing the pain. He gave a cream for the wound and some new tablets. He advised that she walk, walk, and walk some more. This was early September. The pain did not subside. One Friday, the pain was more than usual and the foot appeared to be darkening even more. A friend recommended another doctor who she said always had a way of figuring out complicated stuff. I called him. He was patient, listened, encouraged me to explain some more on phone, asked for pictures, then explained that he was away in Arua and what I was explaining and showing him needed immediate care. He asked that I call a doctor he trusted to sort this. Shared a number. I called. That doctor was at a burial. I called him back, he shared another number. That doctor too was at a burial. The same burial. I remembered that in that week, a doctor had died. They must all be at this burial. The second doctor took my call anyway and when I mentioned that the doctor in Arua had asked me to call him, he stepped away and listened. He would be back in Kampala the next day, could I bring my mother to the hospital? Of course. We sat in the small room at the hospital and explained the history. He physically checked the foot. There was still a corn, that build up of dead skin on a pressure point. He explained it, explained causes and explained that she might in fact develop another corn on the heel of her foot because she had beeen putting pressure on it to reduce the pressure on the wound. He figured that the pain - some of it was neuropathic and that some of it could be from the expectation of pain after having suffered it for so long. He advised that we change shoes, dress the wound twice a day, soak it with half a pack of salt and warm water twice a day, apply a cream. Since surgery was out of the question, we would have to approach this differently. Heal the offending persistent wound, then deal with the corn. Once the wound was healed, he would then start dealing with the corn. He warned us of the many antibiotics, at her age, we had to consider her liver and kidneys. He advised on corn tape, but we explained that we had tried it before and it had not worked. He explained that we had stopped it because it made her feel more pain but that pain was an indicator that it was doing what it needed to be doing. We are at the tail end of October now, the wound is healing, the pain is less, significantly less. She shuffles around the house non stop. The gaping hole in the foot left by the surgery in May has closed to the size of a needle. Seven months of excruciating pain. Seven months of restriction from the things she loves with her entire being - going to the neighbouring church, walking about in her own house taking care of her people, etc...seven good months. I am so glad that we are at the end of this particular pain point - pun intended.