Milt’s Rule

It was a Tuesday, late morning, a pretty day. I was going to try to see one more patient before going to lunch. This would mean my afternoon would be fairly light. I always tried to get most of my patients assessed before I ate my lunch. This way if I ate too much lunch and was sluggish or sleepy after lunch, I wouldn’t be sitting across from my patient desperately trying to keep my eyes from closing while asking the patient questions about their diabetes history.

One time I glanced at my watch while in the middle of assessing a patient. The patient immediately stopped what he was saying mid word and asked me if I needed to go, was he keeping me from something? I was so embarrassed. I should have known better. Over the years I have learned more subtle methods for determining the time of day when I am with a patient, looking at my watch is not one of them.

Anyway, I grabbed the forms I needed and went into the patient’s room to assess why he was in the hospital and how diabetes was involved. Back in the mid 1990’s, doctors could admit their patients to the hospital for a 3-4 day stay for having uncontrolled blood sugar levels. I believe that was the case with this 60+ year-old gentleman.

Unexplained blood sugar excursions ranging from less than 100mg/dl. to over 300mg/dl., warranted admitting the patient to the hospital. During the three to four days the patient was hospitalized frequent blood sugar testing would be performed in hopes that upon the doctor’s review, a cause or causes, for the patients fluctuating blood sugar levels would be found.

 I positioned a chair near the foot of the patient’s chair and sat down to conduct my assessment. An initial patient assessment is required of all diabetes patients that we teach.

 I explained to the patient who I was and why I was there. The patient was good-natured and answered the questions I asked the best he could and matter of factly.

Over the course of the next thirty to forty minutes I asked the patient numerous questions to help me get a better feel for my patient's knowledge about diabetes self care.

Typically, my assessment of the patient will yield information that determines what I need to teach the patient, areas of diabetes self care that either the patient is not doing or not doing very well.

For the most part it was a routine assessment, nothing significantly outside the range of what I typically hear, until I got to his feet. Shortly after taking a seat and getting started, I glanced casually to my left and got my first good glimpse of the patient’s feet. If my jaw dropped I don’t think the patient saw it, at least he didn’t say anything if it did. I think it did, though. Anyway, it was really good that the rest of the assessment didn’t take too long because I was definitely going to need some extra time to discuss this patient's feet.

With all else having been discussed, it was time for me to address the feet.

The patient was semi-sitting up in bed with his legs stretched out in front of him, crossed at the ankles. His feet were not covered. They were okay feet, as far as feet go. They were long, pale and dry, particularly around the heels, not unusual for someone with diabetes. The skin was unremarkable with no splotches, discoloration or subsurface evidence of broken capillaries so often present in older patients.

Hardly unremarkable, however, were his toenails, undoubtedly, some of the thickest nails I have ever seen and unkempt to say the least. When you see toenails like this, you think,

“Man, don’t you ever take a look at your feet?”

“So, how are your feet?” I asked.

Before he responds, he rearranges the position of his feet slightly, rubbing them together gently and wiggling a few of his ten unsightly toes.

“They’re okay, “he responded.

I’m sitting there, looking at his feet, thinking, “Are you kidding me, you think this is okay?”

This is what I am thinking; mind you, not what I am saying.

“Yeah, they’re doin' pretty good now. My toenails are kind of thick and I used to have a hard time cuttin' em.”

“Yeah, I can see that. So what do you do now, how do you get them trimmed?”

“Well, I’ll tell ya. Regular toenail clippers, you know, the same ones you use to trim your fingernails, and those don’t work at all. They just break,” he told me.

“I tell you what I did,” the man starts to explain as he looks down the length of the bed at his feet the same way a newly engaged lady admires her engagement ring.

“You know, I’m retired, and I spend a lot of my time now, out taking care of my roses.

One day I was out pruning my rose plants and I got to thinkin; I bet these rose clippers would work on my toe nails. So after I was finished with my roses I went in and tried em. They trimmed em right up. I mean they worked great. You can see em. I haven’t had a problem with em ever since.”

The man looked proud, as if he had just made a great discovery. I got out of my chair and bent over the bed to take a closer look at the toe nails, pruned by the pruning shears, meant to be used on the thorny rose bush. Truly amazing, I thought.

I found my nose to be about a foot away from his feet, hands on my knees, staring, the same way you would stare at the destructive path a deadly tornado might make as it cuts through a town or city.

As I returned to my chair and sat back down, I remember thinking, how do I break it to this man that using pruning shears to trim his toenails is really a bad idea? I could have said, “What, are you, nuts?” but my better judgment got the best of me, thank goodness, and it never came out.

“Eventually, in a calm voice, I tried to diplomatically, compassionately, explain the potential problems with what he had done. The patient, obviously a bit deflated when he learned that his toe trimming method was not the great idea he thought it was, agreed to let a podiatrist look at his toes soon to see if he could assist the patient with proper foot care.

Before I left the patient's bedside that day, I reviewed some of the topics we had discussed during my visit. When it came to foot care, I told the patient to remember the following and he should be alright: If your toenails ever become so long, or thickened, that you cannot trim them with regular toenail clippers, never, ever, go to the shed and pick out some gardening tools to use on your feet. Instead, go see a podiatrist.

Although some folks may think using rose pruning shears is innocent enough, this may eventually lead to the use of electric hedge trimmers and even gas powered chain saws. As I am sure you can see now, the use of garden tools for the purpose of trimming body parts that grow, is inappropriate and should be discouraged.

Just as Dr. Heimlich named the maneuver for relieving a choking victim after himself, I have taken it upon myself to name the above-mentioned rule, Milt’s Rule.

As yet not a well known rule, but give it time.