Loose Ends
by Dana Deravin Carr, RNC, CCM

A long white envelope was on my desk. Inside there was a letter and a photograph. The letter read, “Dear Ms. Carr, Thank you for giving me the courage to run my own marathon. Check out my red shoes.” It was signed Ellen W. Accompanying the letter was a picture of Ellen. She was stunning, dressed in a red gown with a slight slit up the right seam partially exposing her leg and a red dancing shoe.

I let out a whoop and shouted, “You go girl!” My colleagues looked at me as if I were crazy, but they didn’t know Ellen. I had met her a year ago while covering the emergency department (ED). Ellen was a frequent flyer. She frustrated her providers and refused to adhere to her diabetes management program, stating she could manage her diabetes without any help. She was a regular in the ED, often presenting in diabetic ketoacidosis. She’d be admitted, started on an insulin drip, fine tuned and discharged. Ellen was a party girl. She’d eat and drink as much as she wanted and titrate her insulin accordingly. The team told her she was walking “a fine line,” but she’d just laugh.

During a pedicure, her right foot and toes were scalded. Thus began a prolonged course of failed self-management. She presented to the ED with a temperature of 104 degrees and inflamed, oozing, blackened toes. The cellulitis was spreading up her leg, her white blood count was rising and her blood sugars were in the high 300’s when she finally agreed to a right-below-the-knee amputation.

On post-op day four, Ellen was transferred to the rehabilitation unit. My colleague on the surgical floor had given me the “heads up” about her. Words like “stubborn,” “stoic” and “temperamental” peppered her report.

As a case manager, I have long since given up the ideal that my work could be tied up into a neat little package without loose ends; living life fully is about living with loose ends. Many of our patients enter the healthcare system running for their lives [em] their loose ends unraveling right before their eyes. Ellen was one of those people. As case managers, we often run beside our patients, as if in a relay race, passing the baton from one hand to the next so that no patient runs his or her marathon alone. Unbeknownst to Ellen, her training was about to begin.

I went to the rehab gym and introduced myself to Ellen. I explained my role and then I asked her if she was ready to start training for her marathon. She glanced at me sharply. “Are you for real? I only have one leg,” she said grimly. “I’ll never walk or run again.” I pointed to a neatly dressed woman standing nearby. “That’s what she said,” I responded as I motioned Helen S. to come over.

Later in our relationship, Ellen told me that I set her up. “No,” I said, “It was just a jumpstart.” We both laughed.