The Weight Of A Leg

Setting meaningful boundaries around behavior is one of the most important health decisions you can make. Choosing the right boundaries takes great wisdom. Actually living by and within those boundaries is one of the hardest things you are ever likely to do.

When I was a young surgeon in training I saw a case that taught me something about this issue of health boundaries. As you will have guessed, in the current vernacular, I am ‘old school.’ The old Stanford Medical Center had been designed by Edward Durell Stone. Geometrically textured, buff colored, concrete ’tiles’ defined the exterior and great effort had been made to make the patient rooms seem like they were an Oasis in a mythical desert; some with small courtyards, textured light filtered through the patterned tiles and even the artificial light had a yellowed hue. Warm, calm, the desert- Palo Alto is after all semi-arid- the desert air even in the patient rooms seemed real and unfiltered. Modern hospital architecture would never allow this almost organic experience of air and light; it might attempt to duplicate it in pattern and color but actual air and actual light? Never!

As the first year resident I had not admitted the patient we, our little gaggle of docs, were going to see. He was there to have a Syme’s amputation; his leg removed basically at the level of the ankle. He was a smoker. He also had Reynaud’s disease. The combination, and other more general ill health, meant that his foot was dead; inadequate blood flow. He was out on his little patio smoking. We called him back in and after examining him the attending told him that the Syme’s would no longer be possible because it appeared on clinical exam that there was not adequate blood flow to support so distal an amputation and that he would need, instead, a BKA; below the knee amputation. Again he was told he would need to stop smoking before surgery to help him tolerate the anesthesia. Everyone supposed it too late to admonish him to stop smoking to save his leg. He would be in the hospital for two days before the surgery for a tune up; antibiotics, lab work up and so on. We actually did things like that in the old days. No longer by the way; too costly.

The next day’s evening rounds found our man in his bed, we happened to be there when he had not smoked for most of the day and he bragged about it. On examination even his foot was pink and almost viable looking; the Syme’s was back on! He could keep his leg even if he would lose his foot. Now I can go on and on, there were a great many twists and turns to the story, but I will let it suffice for now to tell you that before he and we were done he wound up not with a Syme’s- lose the foot- nor with a BKA- lose the leg below the knee- but with an AKA; an above the knee amputation. And he barely kept that! What stuck with me about this episode was the waxing and waning, the ebb and flow, not just of his blood flow but of his will to change at each turn in his fate.

As I said this event stuck with me; vivid now more than 30 years later. One more little story to help make my point. When I was a little further down the training pike I had my own first case of an AKA. The only detail I will tell you, the only detail of the case I remember besides his diabetes, even this is unusual; the only thing I remember is the weight of that draped leg as I handed it off the operating table to the nurse. Left hand under the knee, right hand under the ankle; elbows flexed, gently handed off. I didn’t want anyone to drop the leg. Blue drapes and bloody stump.

The reason I brutalize you with this image, with my own memory is these two events dramatically shaped why I now do what I do. And I hope they will remind you why you want to take your health more seriously. Neither of these amputations need ever have happened.

But! You say. But, I don’t smoke, have Reynaud’s, eat badly, avoid exercise, drink to excess, sleep too little, play too hard, want bigger guns more than good health. No, I don’t do any of those bad things. Well I am here to tell you (don’t argue with me!) that you do. Perhaps less dramatic things but things that will nevertheless add up and will someday yield exactly the same result. How? How is it possible that you will wind up the same way? Because we must all die. We must all have a final agony, conscious or not, of knowing we could have done better, of seeing that our choices could have been bounded by a far sighted wisdom of goal and behavior. I’m not talking about regret or guilt. I’m telling you these things now in order to avoid the mistakes you know you make which will cost you then.

My Indian patients, those kind, wonderful, family loving and honoring Hindus and Christians and Buddhists from India; every day and family occasion marked by Gulab Jamon, Kulfi, Rasmalai. Of course they all have diabetes and premature heart attacks. But who would deprive them of their families and friendships and joy? For that is how it seems to them when I tell them I too love those things but cannot eat them.

My ‘superjocks’ who love to run and ride and climb and just don’t know when to quit or cut back or save or conserve. I love them because I was one of them. Perhaps I still am. But I know surely that here too overtraining, over work do harm; harm that will cut short their life, their sense of well-being.

I could easily give more categories. Rather, tell your own story of excess, foolish choices, of your struggle with healthy boundaries.

Inform yourself, steel yourself, be a Hero. Live well now so you can die well then.

Smile, Have Fun, God Speed,

Dr. Mike

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