Depression complicates wound treatment in a diabetes patient
An off-label treatment gives a patient in pain a second chance.
Depression lowers efficacy of shingles vaccine
I had just become a nurse practitioner and had been working for about six months when I met Rosemary. She came in to see the doctor, but since he was so far backed up, she agreed to see me. As I took her history, I learned that her husband was ill and in a nursing home and that her grandson had just passed away. She seemed slightly down, but said her faith in God kept her going.
Rosemary had wounds on both legs from the knees down that she said just would not heal. She told me she was in constant pain. I did multiple tests and found out she was diabetic, which was why her wound healing was impaired, and sent her to a vascular specialist for evaluation.
Even though I began aggressively treating her diabetes, Rosemary reported that the pain in her legs seemed to worsen, and the wounds were still not healing. I sent her to our local wound center, but it seemed that she kept worsening instead of getting better.
After a three-day weekend, Rosemary came in without an appointment and demanded to be seen. She was clearly upset and tears were streaming down her face. Her legs were covered in dressings from the wound center. She told me she could not care for her husband, because she was in so much pain, and said it was so bad that if I could not make it stop she was going to end her life. As a woman of great faith, I knew that she meant what she said.
I was truly at a crossroads. I knew if I could not stop her pain, she was serious about ending her life. I had ordered new types of wound dressings, and at that time, a new medication had just been approved for depression that also had pain modulating properties. I took my time and slowly changed out all of Rosemary's dressings. I talked to her about the new medicine and told her she had to try it, because it would stop her pain and help her get through this.
I told her that if she started the medicine, it would ease the pain in her legs. I wanted to see her back within two days for a follow-up visit, and told her that I would call her the next day.
I prayed a lot that night, and hoped I had made the right decision in letting Rosemary go home. When I called her the next day, she said the pain was a little better, but she was still hurting.
The next day when she came in for appointment, Rosemary was smiling. She indicated the pain in her legs had improved more than 90%. We changed her dressings and made a plan for her wound care. It took more than two months for all of her leg wounds to fully heal, and we became very close during that time.
I have changed jobs and practiced in many offices since then, and Rosemary has followed me to each one. She says she is alive today because of me. I am thankful that I took a chance with medication that was off-label at that time, and listened to my patient.
Since then, Rosemary has referred many patients my way, including her sister. She is doing extremely well emotionally and physically. I truly feel my experience with her is one of the reasons I try so hard and spend so much time with my patients. I know I made a difference in Rosemary's life, and if I continue to provide care like that I will make a difference in others.
Tracey Richman, ARNP-C, practices internal medicine in Parkland, Florida.
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