Why We Need To Be More Judicious With Diagnostic Testing

As an extension of last month's magnetic resonance imaging (MRI) blog, I had an interesting case in our local hospital, which I wanted to share with the readership. This is about a female who presented to the emergency room with a toe ulcer and the roundabout way we were able to “save” her toe.

A female patient in her mid-30s presented to the local ER with a long history of medical issues and an ulceration on her dorsal left hallux. She said she had hit her toe and has had an ulcer in this area for some time. It had recently gotten more red and swollen after hitting it several nights prior. She thought she may have broken the toe after hitting it and since it was red and swollen, she wanted to get it checked out.
 
She went on to tell the ER physicians she had a previous heart attack due to a combination of diet pills and oral birth control (among other things), and had mini-strokes due to the heart attack (so she says). These “mini-strokes” had apparently caused multiple lower extremity issues that required arterial bypass and the placement of a stent in her left leg. According to her, she also had a clot that traveled to her spine and caused a drop foot on her left side, for which she wears a brace. At night, she does not wear the brace and developed an acute ulceration on the dorsum of the hallux from dragging her foot while traveling to the bathroom.

In the ER, her toe was marginally swollen. She had some serous drainage and no odor from the small ulcerated spot on her dorsal hallux. The ER doc wasted no time getting a radiograph, which the radiologist then read as potential osteomyelitis. The patient was admitted by the Medicine Department. The hospitalist proceeded to order a Tc99m bone scan, which showed increased uptake to the hallux in all three phases. The hospitalist subsequently ordered the patient NPO in expectation of our taking this young lady to the operating room for a hallux amputation. This all occurred before even consulting us to take a look at the foot. How fortuitous.

When we finally consulted on the patient, she had no cardinal signs of an infective process to her toe, the ulcer was dry and clean with no odor, and the patient was concerned because someone told her she was about to lose her toe.
 
After scrutinizing her radiographs and conferring with one of the docs in our group with much more experience than I, it seemed to us that she had sustained a fracture in the proximal phalanx of said hallux and the testing may have been falsely positive due to trauma. I decided to call radiology to ask for an opinion on whether it was possible to have all three phases “light up” with a fracture. Unfortunately, no radiologists were available to talk (it was too early in the morning for them). Even though I left a message, sadly, no one called me back, even three days later.

Despite all these tests pointing to the potential infective process in her toe, I said I would be willing to give it some time and see her in the wound care center for follow-up. If the area inflames again, then I would consider an amputation. The patient was overjoyed.
 
The other doctors were not overjoyed. I got a flood of calls about why I wasn't taking this patient to the OR stat and whether I thought she needed long-term antibiotics. They started talking about bone biopsies, ulcer biopsies, etc. Ultimately, we decided that she would get a peripherally inserted central catheter line and long-term antibiotics, and we would release her for infusion therapy as she was not a candidate for home health. Medicine kept her in the hospital for the weekend, as the infusion centers were closed for new patients on the weekend, and we had hoped to get her out of the hospital on Monday.
 
Monday comes around and I get a frantic call from the infectious diseases fellow asking me if I was sure I didn't want a MRI to see if there was osteomyelitis. She also wondered whether I could spare my poor patient the long-term IV antibiotics and just have her go home on oral antiobiotics. I left that decision up the infectious disease guys and gals, and asked to make sure I could follow up with the patient in the wound care center.
 

How A More Systematic Approach To Testing Could Have Helped This Patient

It seems to me this was a mad dash to get the patient in and out. Use every test possible, see if one sticks and hope everyone is on the same page. I was sincerely dumbfounded by the whole situation. How could the system not be considered broken in these types of situations? Compound that with a patient who really didn't have much investment in her own health and well being, and you have a crash course for serious disaster.
 
Who cares? It's just one toe, right? Wrong. We should all care. “First do no harm,” right?

What would I have done differently? How about admitting the patient for suspected fracture with an Ulcer and then letting us sort through the mess? I would have likely ordered a computed tomography scan to evaluate the fracture a little better and taken it from there.
 
Say it's a fracture. Have the patient go home with a controlled ankle motion (CAM) boot and follow up in the office. Subsequently, one manage the patient's ulcer either at the office or in the wound care center.
 
What if it's not a fracture? Hmm. Have the patient go home and follow up at the wound care center for ulcer management. Again, the toe isn't red, swollen or painful (okay, she has neuropathy). The patient denies fever, chills, nausea, vomiting or night sweats. She also doesn't have an elevated white blood cell count and has an appetite.
 
That could have saved everyone time and money. If the toe with the ulcer blows up later, re-evaluate her. Since we are following her closely, we have a handle on it, assuming she shows for her appointments. (In this case, is it wise to do surgery on her given her history?)

Is it just me or has this gotten just a little out of control? I can't be the only one who is seeing this type of thing. What's the solution?