Not her job -- not that it matters

The man’s deep voice was bright and happy until he realized that I wasn’t a podiatrist. I had phoned to introduce myself as his new primary care doctor. The social worker and I wanted to visit him at home the next day, I told him.

He’d been referred to our hospital’s home-care team because he hadn’t left his apartment in more than a year. The problem, the man explained on the phone, was that he weighed almost 400 pounds and had bad feet. He couldn’t walk up the 12 stairs to get outside; the last time he’d tried he’d fallen, and two firefighters had barely gotten him back into his kitchen chair.

But he insisted he didn’t need a primary care doctor: His diabetes was fine. What he needed was for someone to cut his toenails.

Doctors, in my experience, don’t do personal hygiene -- we don’t change diapers or bedpans. I’m not sure we’d even clean out earwax if we couldn’t call it “cerumen disimpaction.”

Though I’d started making house calls a few months earlier, nail-cutting was not something I planned to add to my repertoire. People cut their own toenails. If they’re obese or blind or arthritic, a family member is usually willing to do it. If they’re diabetic, thick-nailed or completely alone, there’s always a podiatrist.

The social worker and I discussed the options as we drove toward his inner-city apartment. If he weren’t homebound, we could have arranged for transportation to a podiatrist’s office. There was also a traveling podiatrist who made house calls for $80. But I didn’t want the social worker to get the notion I was planning to do it myself.

We parked in front of his building and studied the list of faded names on the buzzer. “Down here!” a voice shouted. We walked down the 12 stairs to the basement apartment. A short, gray-haired man whose round shape filled the door frame smiled broadly at us and waved us in.

Leaning heavily on his walker, he took a few awkward steps on the sides of his feet, dropping with a breathy grunt onto a sagging plastic kitchen chair.

The social worker and I sat down at the kitchen table, its orange Formica surface cluttered with bills and newspapers and several plastic shopping bags filled with cans of Campbell’s soup. The kitchen was dark and musty and there was a faint chemical odor of roach spray. A microwave oven sat on the counter next to the refrigerator, which was decorated with old photos.

The social worker asked him about his income and benefits and whether he had family members who helped him. He didn’t have much, he told her. One relative shopped for him every week and another called to check on him every couple of days.

I chatted with him about his diabetes and his weight. I took his blood pressure and examined him, then told him I wanted to look at his feet to check the circulation and nerve function.

“But what about my nails?” he asked, motioning over a mountain of belly toward his feet. He sounded desperate. “My toenails, nobody’s cut them in over a year. They hurt!”

He kicked off his foam slippers and asked me to remove his socks, which dug into his thick ankles. I jammed two fingers under the edge of one worn sock and with some effort worked it down and off. A cloud of dried skin flecks floated into the air.

“I told you they were bad,” he said, shaking his head.

I nodded and pressed my lips together, suppressing the urge to tell him that I’d seen thick nails, nails roughened by fungus, but I’d never, ever seen nails this long and this bad. The second and third toenails had grown out so far -- more than an inch -- that the sharp tips had curled sideways and pressed into each other, splaying the toes apart.

I imagined the man cringing the moment his feet hit the ground in the morning, wincing as he hobbled to the bathroom. Every painful step must have put more strain on his hip. And the more stationary he became, the heavier he got, and the greater the chance he’d never get up the stairs.

The social worker was telling him about the traveling podiatrist. The man said he would pay anything at this point. But I thought paying $80 for a nail trimming seemed exorbitant.

The only other option, of course, was for me to do it. I really didn’t want to.

For one thing, cutting his nails would take a big chunk of time out of the visit. For another, internists aren’t trained on the proper way to cut toenails that look like party-sized corn chips. With some patients, such as diabetics, a botched nail trimming can trigger a nasty cascade of infection, gangrene and amputation. And what if the news that I cut toenails got back to the home-care team -- and I became its unofficial podiatrist?

So I was as surprised as the social worker and the patient when I heard myself say, “I’ll cut these for you.” There was simply no alternative. He was in distress and there was something I could do about it. The social worker grinned. The man’s mouth dropped open, then he laughed with delight and astonishment.

I told him I couldn’t do it immediately, but I promised to come back the following week. Meanwhile, I could hunt down a wire cutter-type nail clipper. And I’d be able to prepare myself mentally.

But, it turned out, the man had a good clipper in the other room. No more procrastinating, I said to myself. This is it. You’re here to do what your patient needs.

I got a towel from his bathroom, pulled my chair across from his, and hoisted what felt like a 30-pound weight onto my lap. Holding my breath, I leaned in close. Even with the kitchen light on, it was a little dim. I grasped the big toenail, lined up the clipper and pressed the blades together. I felt it bite through the first few irregular layers of fungus-covered nail and squeezed harder, launching a pellet of nail across the room.

“Whoa!” I said. The social worker backed up a couple of steps and winked at me.

I peeled off five translucent layers from the same nail that were brittle yet separating, like a rotten oyster shell. The next nail seemed like a petrified piece of wood, the wavy surface smooth and solid. I inspected it from a few angles and, both hands together on the clipper, squeezed with all my strength. A piece of hard nail pinged on a cupboard; the next hit me in the chest. I’d have to bring a pair of goggles and some protective clothing next time. Another piece landed on the social worker. The three of us giggled like a bunch of school kids.

There wasn’t much I could do about the overwhelming problem: his morbid obesity. Sure, we’d talked about diet and exercise, but that was all abstract. With his nails, I’d found a concrete and immediate way to help him. Though it hadn’t been easy to step beyond my usual job description, now I was as happy as he was.

I stopped for a moment to survey my work. It wasn’t very good: at best, a hack job, rough and awkward, because I didn’t want to risk cutting too close to the skin. And yet there was something intimate, even beautiful, about the moment, as if we were subjects in a Rembrandt painting: the dim room, the man’s foot on my lap, a serene smile on his face, the social worker leaning against the refrigerator, beaming, the two of us helping him with what he needed most.

--

Reisman is a general internist in Connecticut.

Are you a doctor, nurse or someone else in a healthcare profession? Do you have a personal story to tell about your work and lessons it has taught you? Send “In Practice” submissions to health@latimes.com. Offerings will be edited for space and content.