Max Kepler's Blog
July 7, 2017
Consumption
I smelled William before I actually met him, the foul odor startling me as I entered the emergency department. I could not immediately identify the smell as human, despite the myriad of patient odors I’ve encountered while working in several inner city emergency rooms over the years.
“What happened?” I asked the ER charge nurse.
She gave me a quizzical look.
“The smell,” I said, waving my hand in front of my nose.
“Oh, that’s your next admission,” she replied, a wry smile creasing her face.
William had been wheeled into the back of the emergency room and into a respiratory isolation room, which was separated from the rest of the department by two locking glass doors divided by an anteroom. The room itself was well-ventilated by a specialized reverse air-flow system. Four firemen were standing around chatting outside the outer door, incredulous looks on their faces. I asked them about William. One of the men, who appeared to be the head honcho, answered first. He hesitated initially, unable to put the story into words, a far-way look on his face. After a pause of half a minute, he drew a deep breath and began to speak.
The paramedic division of the fire department had received a call from William requesting transport to the county hospital for a “bad leg” that prevented him from seeking medical attention on his own. The two paramedics that arrived at William’s home found the front door locked and were thus forced to break it open. Upon entering the house, they encountered a terrible smell that suggested the presence of a dead body. As they considered the possibilities, suddenly they heard William calling to them, telling them he was in the back bedroom, and they needed to come get him. Gathering their strength and holding their breath, they walked through the surprisingly expensive home and into a large bedroom where they found William, a massively large man at four hundred and fifty pounds, lying on his side watching a blaring television. A documentary on World War II was showing, the sounds of battle echoing against the bedroom walls.
The paramedics put on surgical masks to stifle the smell, and stood there contemplating possible solutions to the obvious transport problem. Realizing help was needed, they called the fire department and within thirty minutes, four burly firemen showed up with a large tarp. With significant difficulty, the tarp was placed under William and the six men, grunting and shouting instructions to each other, manhandled William onto a reinforced gurney, whereby they proceeded to transport him to the hospital. Task complete, they were now recounting the events to each other in the ER, a war story of sorts.
I thanked them for the information and excused myself to attend to William. Before entering his room, I stood outside momentarily, peering through the two glass doors separating me from William, mustering courage for the task ahead. The nurse offered me a menthol ointment to place under my nose to neutralize the smell, which by that point permeated every pore of my body. I gladly accepted the offer, drew a deep menthol-tinged breath, opened the two doors and entered the room.
I introduced myself to William and he greeted me with a warm smile. He had a kind, gentle face that evoked Santa Claus with his cherubic cheeks and grey-flecked beard. His brown eyes darted around the room, making only fleeting contact with mine. The top of his head was devoid of hair, and I noted white, even teeth when he smiled at me. It seemed ironic that such fastidious dental hygiene would continue in the presence of such poor overall self-care. He spoke in deep tones with perfect diction, carefully measuring each word as he conversed. His large body framed the rectangular gurney almost perfectly, with a hospital gown and bed sheet covering him. He had pulled his blanket, now lying on the floor, off of his body because he felt hot. Despite that, he was still perspiring, beads of sweat covering his forehead and brow.
In those initial several minutes, I struggled to clear the fog of the smell from my brain. But it knocked repeatedly on my consciousness and I blinked my eyes long and hard and bowed my head to prevent William from seeing the grimace on my face. His humanity demanded dignity. When I lowered my head, I noticed a large bowl of coffee grounds sitting next to the bed, which the ER staff had placed there to cut the edge of the smell.
As I stared at the coffee grounds, William began telling me he first suspected his leg was infected one month ago but had waited before coming in because, he explained, he disliked hospitals. Surprised by the delay in seeking treatment, I asked gently if he understood there was a bad odor around him. He acknowledged this with a quick, expressionless nod, which was followed my quietness. I waited for him in silence, waited for an explanation, waited for what seemed like a long time. Then slowly and in a barely audible voice, William admitted that he suffered from social anxiety disorder and agoraphobia, which is defined as a morbid fear of having a panic-attack in a situation that is perceived to be embarrassing or difficult from which to escape. His employment history had been shaped by these psychological issues, such that his work as a computer programmer allowed him to work from home and thus avoid situations that provoked his anxiety.
He had also hired a delivery service to provide him endless amounts of food and a trustworthy home health aide to take away his body wastes, which he collected himself while lying in bed, and this assistance served to protect him even further from interacting with the world. He could afford such services because his parents had passed away ten years earlier when he was forty-eight, and he had inherited both their large sum of money and expensive home, where he was now living.
I then asked William if I could perform a physical examination, and after he consented, I slowly pulled off the gown and sheet covering him. My eyes went immediately to his right leg, which from the knee down and extending to the foot, looked like the tissue had been removed with a large ice cream scoop, revealing a continuous deep ulcer along the outside. The wound was particularly deep on the foot such that one third of it was essentially missing. I could not immediately determine the wound’s cause.
I then moved to examine the abdomen, which was impossible large with a pannus-the fat that hangs down below the belly button-extending halfway down the thighs. The texture of the abdominal skin was rough and bumpy with an appearance that resembled cauliflower, except that it was stained greenish-black due to the exuberant growth of mold on the surface.
Progressively more startled, I asked William to roll to one side so that I could assess his backside. The right buttock looked as though a grenade had exploded therein. There was a massive, necrotic hole that was large enough to accommodate a large grapefruit. The wound had black, dead tissue and greenish pus oozing out. In that moment, I realized that William’s foul smell was produced by the ungodly combination of dead, infected human flesh on the leg and buttock and mold-infested skin on the abdomen.
I placed the gown and sheet back on William and returned to gathering more clinical history. William told me that he had been bed-bound for three months and that he tended to spend most of the time lying on his right side. This positioning allowed him a better view of the television, which was on throughout most of the day. I realized then the wounds on his right leg and foot and buttock were decubitus ulcers-skin breakdown caused by continuous pressure on one area of the body.
In a sequence of events precipitated and maintained by anxiety, William’s inexorable decline had started with self-confinement in his own home and ended with physical erosion of parts of his body. His obsessive eating and resulting massive weight gain had made simple side-to-side repositioning in bed nearly impossible. Unable to contain his anxiety, William’s life had become one of consumption; both his unrelenting consumption of food and the consumption of his body by infection and ulceration.
I called for a surgical consultation. The surgeon laughed haughtily when I warned him of the smell and the alarming nature of the wounds. He had been around the block and had seen it all, or so he thought. I remember the look of disgust when he exited William’s room. When I asked for his plan, he stammered and hesitated as he struggled to control his obvious emotional response to William’s condition. When he gathered himself, he told me William would require extensive debridement of the buttock wound and an amputation of the right leg above the knee. The wounds were so severe he wondered aloud whether William would survive.
The first order of business was to amputate the right leg, as it had started to develop gangrene, which could spread if not treated quickly. The operation went well and the surgeon was hopeful that with proper care the wound would heal adequately. Next, the buttock infection needed surgical debridement. Given the extent of the wound, the debridement would need to occur in the operating room. When the surgeon was finished removing the dead and infected tissue, the wound was fifty percent larger. He openly doubted that a wound that size would ever heal and figured it would eventually lead to William’s demise. During that same operation, the surgeon spent fifteen minutes scrubbing William’s abdomen with a surgical brush, and he was able to clear away most of the tightly adherent mold growing there.
Finished with his surgeries, William would require a long period of recovery, which included diligent wound care, a weight loss program and daily physical therapy. It was an arduous experience for him. The dressing changes of the buttock wound were especially tedious, time-consuming and painful. But William tolerated them without ever complaining or even requesting pain medication. In fact, he was genuinely relieved when I offered him pain medication to ease the experience.
I enjoyed seeing William each morning, as did the rest of the hospital staff. He was always pleasant, sometimes even cheerful and very appreciate of the care provided him. He spent most days reading, thus consuming a prodigious volume of books during his hospitalization. We often talked about the books he was reading and discussed various other issues, as he was a well-informed, intelligent man. More personal discussions tended to be disjointed and guarded, with William deftly switching the topic of conversation each time. The psychiatrist who followed him in the hospital had similar experiences. Introspection did not come easily for William.
Eventually, William’s wounds healed to the point that he could be transferred to a skilled nursing facility for lower level care. On his day of discharge, he was clearly anxious about the impending change in his environment. He was worried about the uncertainty and had many questions regarding small details of the nursing facility. He kept organizing and re-organanizing his collection of books resting on his bedside tray table as we talked.
Done answering his logistical questions, I inquired about his anxiety regarding the transfer. With a wave of his hand and a forced chuckle, he said it was nothing to worry about and that he would deal with it. Switching focus, he asked offhandedly if I would visit him in the nursing home, and I assented to that with a nod of my head, but he did not see the gesture, as he had already turned to watch the television. I stood there watching him watch television, and I don’t believe he noticed when, after a brief time, I walked out of the room. In that moment, I felt the full impact of the formidable emotional fortress created by his anxiety and the resulting incompleteness of our connection. The painful physical challenges experienced over the preceding two months paled in comparison to the psychological ones William faces in the coming years.
“What happened?” I asked the ER charge nurse.
She gave me a quizzical look.
“The smell,” I said, waving my hand in front of my nose.
“Oh, that’s your next admission,” she replied, a wry smile creasing her face.
William had been wheeled into the back of the emergency room and into a respiratory isolation room, which was separated from the rest of the department by two locking glass doors divided by an anteroom. The room itself was well-ventilated by a specialized reverse air-flow system. Four firemen were standing around chatting outside the outer door, incredulous looks on their faces. I asked them about William. One of the men, who appeared to be the head honcho, answered first. He hesitated initially, unable to put the story into words, a far-way look on his face. After a pause of half a minute, he drew a deep breath and began to speak.
The paramedic division of the fire department had received a call from William requesting transport to the county hospital for a “bad leg” that prevented him from seeking medical attention on his own. The two paramedics that arrived at William’s home found the front door locked and were thus forced to break it open. Upon entering the house, they encountered a terrible smell that suggested the presence of a dead body. As they considered the possibilities, suddenly they heard William calling to them, telling them he was in the back bedroom, and they needed to come get him. Gathering their strength and holding their breath, they walked through the surprisingly expensive home and into a large bedroom where they found William, a massively large man at four hundred and fifty pounds, lying on his side watching a blaring television. A documentary on World War II was showing, the sounds of battle echoing against the bedroom walls.
The paramedics put on surgical masks to stifle the smell, and stood there contemplating possible solutions to the obvious transport problem. Realizing help was needed, they called the fire department and within thirty minutes, four burly firemen showed up with a large tarp. With significant difficulty, the tarp was placed under William and the six men, grunting and shouting instructions to each other, manhandled William onto a reinforced gurney, whereby they proceeded to transport him to the hospital. Task complete, they were now recounting the events to each other in the ER, a war story of sorts.
I thanked them for the information and excused myself to attend to William. Before entering his room, I stood outside momentarily, peering through the two glass doors separating me from William, mustering courage for the task ahead. The nurse offered me a menthol ointment to place under my nose to neutralize the smell, which by that point permeated every pore of my body. I gladly accepted the offer, drew a deep menthol-tinged breath, opened the two doors and entered the room.
I introduced myself to William and he greeted me with a warm smile. He had a kind, gentle face that evoked Santa Claus with his cherubic cheeks and grey-flecked beard. His brown eyes darted around the room, making only fleeting contact with mine. The top of his head was devoid of hair, and I noted white, even teeth when he smiled at me. It seemed ironic that such fastidious dental hygiene would continue in the presence of such poor overall self-care. He spoke in deep tones with perfect diction, carefully measuring each word as he conversed. His large body framed the rectangular gurney almost perfectly, with a hospital gown and bed sheet covering him. He had pulled his blanket, now lying on the floor, off of his body because he felt hot. Despite that, he was still perspiring, beads of sweat covering his forehead and brow.
In those initial several minutes, I struggled to clear the fog of the smell from my brain. But it knocked repeatedly on my consciousness and I blinked my eyes long and hard and bowed my head to prevent William from seeing the grimace on my face. His humanity demanded dignity. When I lowered my head, I noticed a large bowl of coffee grounds sitting next to the bed, which the ER staff had placed there to cut the edge of the smell.
As I stared at the coffee grounds, William began telling me he first suspected his leg was infected one month ago but had waited before coming in because, he explained, he disliked hospitals. Surprised by the delay in seeking treatment, I asked gently if he understood there was a bad odor around him. He acknowledged this with a quick, expressionless nod, which was followed my quietness. I waited for him in silence, waited for an explanation, waited for what seemed like a long time. Then slowly and in a barely audible voice, William admitted that he suffered from social anxiety disorder and agoraphobia, which is defined as a morbid fear of having a panic-attack in a situation that is perceived to be embarrassing or difficult from which to escape. His employment history had been shaped by these psychological issues, such that his work as a computer programmer allowed him to work from home and thus avoid situations that provoked his anxiety.
He had also hired a delivery service to provide him endless amounts of food and a trustworthy home health aide to take away his body wastes, which he collected himself while lying in bed, and this assistance served to protect him even further from interacting with the world. He could afford such services because his parents had passed away ten years earlier when he was forty-eight, and he had inherited both their large sum of money and expensive home, where he was now living.
I then asked William if I could perform a physical examination, and after he consented, I slowly pulled off the gown and sheet covering him. My eyes went immediately to his right leg, which from the knee down and extending to the foot, looked like the tissue had been removed with a large ice cream scoop, revealing a continuous deep ulcer along the outside. The wound was particularly deep on the foot such that one third of it was essentially missing. I could not immediately determine the wound’s cause.
I then moved to examine the abdomen, which was impossible large with a pannus-the fat that hangs down below the belly button-extending halfway down the thighs. The texture of the abdominal skin was rough and bumpy with an appearance that resembled cauliflower, except that it was stained greenish-black due to the exuberant growth of mold on the surface.
Progressively more startled, I asked William to roll to one side so that I could assess his backside. The right buttock looked as though a grenade had exploded therein. There was a massive, necrotic hole that was large enough to accommodate a large grapefruit. The wound had black, dead tissue and greenish pus oozing out. In that moment, I realized that William’s foul smell was produced by the ungodly combination of dead, infected human flesh on the leg and buttock and mold-infested skin on the abdomen.
I placed the gown and sheet back on William and returned to gathering more clinical history. William told me that he had been bed-bound for three months and that he tended to spend most of the time lying on his right side. This positioning allowed him a better view of the television, which was on throughout most of the day. I realized then the wounds on his right leg and foot and buttock were decubitus ulcers-skin breakdown caused by continuous pressure on one area of the body.
In a sequence of events precipitated and maintained by anxiety, William’s inexorable decline had started with self-confinement in his own home and ended with physical erosion of parts of his body. His obsessive eating and resulting massive weight gain had made simple side-to-side repositioning in bed nearly impossible. Unable to contain his anxiety, William’s life had become one of consumption; both his unrelenting consumption of food and the consumption of his body by infection and ulceration.
I called for a surgical consultation. The surgeon laughed haughtily when I warned him of the smell and the alarming nature of the wounds. He had been around the block and had seen it all, or so he thought. I remember the look of disgust when he exited William’s room. When I asked for his plan, he stammered and hesitated as he struggled to control his obvious emotional response to William’s condition. When he gathered himself, he told me William would require extensive debridement of the buttock wound and an amputation of the right leg above the knee. The wounds were so severe he wondered aloud whether William would survive.
The first order of business was to amputate the right leg, as it had started to develop gangrene, which could spread if not treated quickly. The operation went well and the surgeon was hopeful that with proper care the wound would heal adequately. Next, the buttock infection needed surgical debridement. Given the extent of the wound, the debridement would need to occur in the operating room. When the surgeon was finished removing the dead and infected tissue, the wound was fifty percent larger. He openly doubted that a wound that size would ever heal and figured it would eventually lead to William’s demise. During that same operation, the surgeon spent fifteen minutes scrubbing William’s abdomen with a surgical brush, and he was able to clear away most of the tightly adherent mold growing there.
Finished with his surgeries, William would require a long period of recovery, which included diligent wound care, a weight loss program and daily physical therapy. It was an arduous experience for him. The dressing changes of the buttock wound were especially tedious, time-consuming and painful. But William tolerated them without ever complaining or even requesting pain medication. In fact, he was genuinely relieved when I offered him pain medication to ease the experience.
I enjoyed seeing William each morning, as did the rest of the hospital staff. He was always pleasant, sometimes even cheerful and very appreciate of the care provided him. He spent most days reading, thus consuming a prodigious volume of books during his hospitalization. We often talked about the books he was reading and discussed various other issues, as he was a well-informed, intelligent man. More personal discussions tended to be disjointed and guarded, with William deftly switching the topic of conversation each time. The psychiatrist who followed him in the hospital had similar experiences. Introspection did not come easily for William.
Eventually, William’s wounds healed to the point that he could be transferred to a skilled nursing facility for lower level care. On his day of discharge, he was clearly anxious about the impending change in his environment. He was worried about the uncertainty and had many questions regarding small details of the nursing facility. He kept organizing and re-organanizing his collection of books resting on his bedside tray table as we talked.
Done answering his logistical questions, I inquired about his anxiety regarding the transfer. With a wave of his hand and a forced chuckle, he said it was nothing to worry about and that he would deal with it. Switching focus, he asked offhandedly if I would visit him in the nursing home, and I assented to that with a nod of my head, but he did not see the gesture, as he had already turned to watch the television. I stood there watching him watch television, and I don’t believe he noticed when, after a brief time, I walked out of the room. In that moment, I felt the full impact of the formidable emotional fortress created by his anxiety and the resulting incompleteness of our connection. The painful physical challenges experienced over the preceding two months paled in comparison to the psychological ones William faces in the coming years.
June 11, 2017
"Jessica" today
A number of readers have sent me messages inquiring about my daughter, "Jessica." Thank you for wondering.
Jessica is now 15, but thinks she's much older than that. She's tall, too, about 5'8', and athletic. She's funny and creative and a handful. She's also a great writer, and I wish we could write something together, but she has other interests (boys) right now. Maybe someday...
And, yes, she knows what I've done in the past. It was not an easy conversation, but I wanted her to hear it straight from me, instead of from Google. It confused her quite a bit at first, but we've had a number of conversations about it by now. The initial conversation was a big low point, but it seems my sharing with her has brought us even closer.
She doesn't want to be a doctor, not because of my behavior, but because she wants to do something more creative. Like all parents, I just want her to be happy.
She's the greatest gift I've been given.
Max
Jessica is now 15, but thinks she's much older than that. She's tall, too, about 5'8', and athletic. She's funny and creative and a handful. She's also a great writer, and I wish we could write something together, but she has other interests (boys) right now. Maybe someday...
And, yes, she knows what I've done in the past. It was not an easy conversation, but I wanted her to hear it straight from me, instead of from Google. It confused her quite a bit at first, but we've had a number of conversations about it by now. The initial conversation was a big low point, but it seems my sharing with her has brought us even closer.
She doesn't want to be a doctor, not because of my behavior, but because she wants to do something more creative. Like all parents, I just want her to be happy.
She's the greatest gift I've been given.
Max
