Hands-on Care Requires More Boots on the Ground

Although I’ve already written about toenails, I’m compelled to write about them again. Or maybe feet in general. There’re all different types of toenails-ingrown  ones, dirty ones, painted ones, tan ones, small nubbins. People do all sorts of things to either display their toes, or cover them up. Some are very conscious of their toes, others pay them hardly any mind. But the choices an individual makes on footwear and how they display their feet are often reflections of their personalities, or the extent of their extroversion within the confines of Western culture. Kids attending private schools wear multicolored socks to demonstrate their individuality. I remember, during middle school, having a near-pathological infatuation with shoes. Fortunately, it’s faded for the most part, but inevitably resides somewhere in my first impressions of a person.

Consequently, taking shoes off is almost akin to becoming naked-baring that which isn’t normally seen by others. Physically, there’s the added sensation of the ground around you and a connection to your place. If you’re in a doctor’s office, the cool tile of the exam room or rough carpet becomes suddenly apparent. On a plane the other day, I saw a guy walking down the aisle barefooted and thought of an opening scene in Die Hard where Bruce Willis’ character, anxious with plane flights, is given advice to take off his shoes and make fists with his toes to help relax.  

This may have been why one of my recent encounters with a patient from our local severe mental illness outreach team in our primary care clinic was so powerful. The team had arranged the appointment to specifically address foot-care issues, and had noted he was hobbling about lately. They had informed me ahead of time that they thought his toenails needed to be clipped-in fact,  that was the reason for his visit. We found a pair of nice, unused toenail clippers (the kind that look like handheld pruning shears for gardening) and set them up on a paper pad in preparation for his visit.

When he arrived, he appeared ambivalent about taking his shoes off, or even reluctant, and so started with just one foot. The team had recently arranged for him to get a new pair of tennis shoes, which he was sporting at the visit. White and bright, they masked the clawed and mangled appearance of his toes once unveiled. Some of the nails had worn ulcerations on the knuckles of adjacent toes, dirt and grime was rolling up in balls and falling off onto his socks on the ground, and his big toenail was so thick and curled I couldn’t see how I could get the foot pruners around it. The opposite foot was identical. I’d never cut another adult’s nails before-where do you start? Toenails are hard, and become dangerous projectiles unless you direct your trimming appropriately. As I proceeded, his toes offered ample opportunity for discussion, and a window into his life.

Q: Was he concerned about his feet?  Did they bother him? 
A: A little when they hurt, otherwise, not really.
Q: What did he think about his new shoes? 
A: OK, I guess.
Q: Why did he come in to clinic today? 
A: To walk better, I really like to walk.

His medical team later helped me read between the lines-he frequently goes on long walks and in the past has been known to be gone for several days at a time, sometimes ending up in nearby counties-in the past resulting in hospitalization. Lately his walking has been more appropriate.

When people need support, and have no family and friends to help them with this, it often falls to the healthcare system to provide instrumental care such as clipping toenails. We often take for granted the enormous amounts of work and the resulting depth of interpersonal awareness caregivers of our patients have. It’s this knowledge and understanding that can most ultimately affect their lives. For patients with complex mental illness or substance use issues, they rarely get this crucial connection with others.

Sometimes I feel there’s an entire world of lost citizens needing their toenails clipped. Maybe what we need in medicine is a matching assortment of toenail clippers, and warm bodies to be there to clip toenails--and then to understand. In any case, to develop relationships that can affect lives, we need more than a few more boots on the ground.