A Nursing Story: Cover Your Sores

Nick,  a thin, 58-year-old homeless man, was sitting quietly at a bus stop, contemplating the trees across the street, when a stranger approached and happened to glance over at him. He took in Nick’s thin face, his small frame under the old flannel shirt…and Nick’s legs. They seemed awfully big for his body size.

In fact… his dirty jeans were stretched tight, all the way down to his boots. Were his legs swollen? His calves were as big around as his thighs. It didn’t seem right.

And then the stranger saw it.

Movement, under the jeans. The stranger peered closer. The jeans were subtly undulating, the tightly-stretched fabric rippling almost imperceptibly, like muscles being flexed under a taut T-shirt.

Except we don’t have muscles like that on our shins.

The stranger glanced sharply at Nick. Nick sat there unconcernedly while the fabric of his jeans shifted and crawled.

The stranger pulled out his cell phone and called 911. Nick was whisked to the local Emergency Room, where the doctors cut his jeans off to get a good look at his legs.

They discovered that Nick’s legs had sores on them.

Lots of sores.

And sores attract flies. Given that Nick lived outdoors: lots of flies.

And flies, of course, lay eggs.

Nick’s legs were crawling with thousands – maybe tens of thousands – of maggots. The white larvae formed a thick coating over his legs, wriggling and writhing as they all fought their way downward, competing with each other to get to Nick’s soft pink flesh below.

The doctors and nurses began stripping the maggots off. They encircled Nick’s legs with their gloved hands and pulled briskly downward. The maggots cascaded off Nick in great soft globs. Over and over, they skimmed his legs, and the pile of squirming maggots grew at their feet.

Tip to new nurses: Prepare to see some crazy shit.

Nick was my patient the next morning. We had orders for twice-daily dressing changes to his legs. With some apprehension, I removed the gauze bandages. What would I find?

His legs looked like pieces of driftwood you might see washed up at the beach. Scrawny whiteish-pink logs, they looked worm-eaten, riddled with tunnels and holes. The outer layer of skin was gone, devoured, exposing the raw dermis beneath. Worm-tracks cut across the surface, the twisting channels crisscrossing his legs. Worm holes, like you’d find in an apple, dotted the surface, each one diving down into the soft flesh.

A few stray maggots struggled from their burrows. I mopped them up with gauze.

The good news about maggots is that they do a great job of cleaning wounds. In fact, sometimes we deliberately place maggots into a wound so they can eat the dead areas, get everything nicely cleaned up.

Nick’s skin was sparkling clean.

Except, you know, for those leftover maggots.

Nick spent two weeks in the hospital while we worked hard to heal his legs, treating his skin as if it had been burned. Like many homeless people, Nick had a touch of mental illness: every time we changed his dressings, he loudly objected to the replacement bandages. He was much more concerned about letting his legs “breathe” than about the maggots crawling out of his flesh.

Hospital staff – nurses, case managers, social workers and physical therapists – discussed Nick’s discharge plan during our daily rounds. I worried about where he would he go. How could he properly care for his legs, living outdoors? But hospitals exist to solve medical problems, not social ones. He came from the street; he would be returned to the street.

On discharge day, we wheeled Nick to the front of the hospital. I urged him to keep the dressings clean and change them as soon as they got soiled, but he cheerfully announced he intended to remove them. Immediately.

His legs had to breathe!

I watched him amble down the street, happily swinging his hospital belongings bag. He disappeared around a corner, returning home to the trees and the dirt.

And the flies.

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