Ischemia

When a patient presents with signs and symptoms of an ischemic limb – that is, an arm or leg which is slowly dying from lack of adequate blood flow – there are a number of simple observations we can make to grade the severity of the disease process. The patient will develop pain and a loss of muscle function; the limb will become pale and cold, and eventually pulseless and avascular. Death. The very first thing to go, however, is sensation. The webbed areas between the fingers and toes will grow numb, and the palms or hands will lose what’s called “two-point discrimination.” That is, if I undo a paperclip and bend it in a “U,” the patient will not be able to tell whether one or both points of the “U” are touching their skin at a given time.

Sensation, we must conclude, is pretty important, because when our bodies are facing anoxia and are threatened, it’s the first thing to go. And failing to process what’s going on can mean serious consequences – like the loss of a limb.

But as important as it is for the doctor to evaluate the sensory capabilities of the patient, the simple act of doing so can be nearly just as important. The osteopathic medical profession places a lot of importance on physical contact – that is, assuring that the patient positively senses us. One of the most common complaints raised against physicians is “he never even touched me.”

I’ve never been a particularly touchy-feely sort of guy. I’ll give anyone I meet a handshake, but when it comes to hugs and long embraces or even a gentle rub of the back – it just doesn’t come that natural to me. I go out of my way to do so, however, because I realize it is important to most people. What I never realized was truly how important it is to me.

Yesterday I was having a terrible day. I just was. I was working with a colleague and apologized to her for how useless I had been over the past few days. She smiled, said not to worry, and very innocently and honestly gave me a gentle rub behind my shoulder. It was the strangest thing in the world – it was totally asexual, yet her hand on my back felt like white lightning. I realized that her touch was the first from a women – other than my mother or sister – that I’d experienced in a long time. I had no idea that that sort of physical contact was important to me.

It seemed I had lost sensation, and after months of gut-wrenching pain had become simply numb. Like an arm whose blood supply was cut off, I was going through the stages of ischemia, starting with the loss of sensation which would have ended ultimately in death. And this gentle touch on my back was the lightning bolt of revelation to the process at hand. It snapped me back to reality, like a rush of oxygen to my brain.

When we re-vascularize a limb – when we do surgery to make sure more blood gets to the arm or leg – it nearly instantly gets more pink and warm. But the sensation is slow to return in full. In fact, where the patient once felt numbness or maybe even nothing at all, he will now actually feel pain. That pain will eventually go away, and morph into normal sensation.

My personal ischemia left me completely numb. Now I am back to feeling pain. I only hope it is on the way towards normal sensation.