This case involves an overweight, elderly female patient with a history of poor circulation and diabetes. She presented to her podiatrist with non-healing foot ulcers and was referred to vascular surgery for revascularization. The patient received angioplasty and stent treatment as well as antibiotics and was discharged. The patient returned to the hospital several days later and was found to have gangrene and infection around the tissue of her nails. Podiatry obtained cultures which grew multi-drug-resistant bacteria. The patient underwent surgical intervention to amputate her right foot and was discharged. The patient returned to the hospital a week later with a high fever and a rash on her legs and was diagnosed with atypical measles syndrome. The patient deteriorated significantly during this stay. Non-healing at the amputation sites mandated bilateral below the knee amputation but the patient succumbed to pneumonia shortly after the amputation. An expert in podiatry was sought to review the facts and discuss the standard of care in this case.
Question(s) For Expert Witness
- 1. Please describe your background as it relates to this case. How often do you care for patients with similar health profiles?
- 2. What is the standard of care in terms of consulting an infectious disease specialist?
- 3. How often does dry gangrene progress to wet after revascularization?
- 4. What is the standard surgical procedure to manage a patient requiring toe amputation and revascularization of the lower extremity?
Expert Witness Response E-054072
I have worked in a wound care center for 8+ years. I also do hospital consults on similar patients with similar conditions. It is common to have patients with wounds that also have several systemic and co-morbid conditions. The standard is to assess the severity of the infection and weight the benefits of early vs. delayed intervention. For an infectious disease specialist to become involved, cultures must be obtained to determine the correct antibiotic usage. The patient would have likely been placed on empiric antibiotics prior to the culture results regardless of health status. The key is for appropriate management when infection occurs. If the limb becomes ischemic, even if re-vascularization is performed, an infection can set in quickly, especially in a patient with multiple co-morbid conditions. There are several scenarios that can determine when amputation is appropriate before re-vascularization and vice versa. If there is a severe limb or life-threatening infection, the tissue must be removed regardless of circulatory status. If the patient is stable and/or the gangrene is dry, then re-vasculariztion should be performed prior to amputation. Even then, the blood flow should be re-assessed to determine the proper level of amputation to maximize the chances of healing. This patient obviously had numerous health issues that complicated the outcomes. It is not uncommon for vessels to become re-occluded. Total occlusions can quickly cause distal gangrenous changes. The question is these cases, when there are several sources of infection, is what ultimately caused the patient’s demise; the infections in the extremity or pneumonia?