It Takes A Village To Save A Leg
My favorite writing project is to produce a “return to work” document for a patient who has recovered from a serious foot or ankle problem. I had that pleasure last week on behalf of a 53-year-old gentleman whom I first met six months ago during a hospital consult.
His primary physician requested a consult regarding a diabetic ulcer with cellulitus involving the fourth and fifth toes of the left foot. The primary doc also let me know that he was beginning his vacation that day so I could manage the patient until he was ready for discharge. It all seemed like a convenient “dump” to me.
The patient was a heavy equipment operator for a local lumberyard. He noticed but did not feel discoloration of his toes, and also noticed a bad odor. His primary doc tried some topical medication for a week and then hospitalized him. One look at the patient’s foot told me there was a serious risk of leg loss. The toes were dark gray and the odor was that of rotting flesh.
The patient had a history of coronary bypass surgery and his diabetes was clearly out of control. He was a non-smoker and had blood flow down to the demarcation of the necrotic ulcer. I knew I needed help with this guy.
I arranged for a well trained young internist to manage the medical issues. A general surgeon with good vascular training evaluated the patient and concluded that there was occlusion at the site of the ulcer. Wound care experts and physical therapy joined the team. The patient’s toes and then part of his foot continued to deteriorate.
I talked to the patient about the high risk of leg loss and he accepted it philosophically but let me know that losing a leg would not work too well for him since he lived alone and had animals to care for. I promised that I, along with the rest of the team, would do the best we could. He thanked me, which he did every time I visited him. I found that he thanked every caregiver or housekeeping person who came into his room. Most patients in his state of health are angry and depressed.
After a week, the diabetes and heart issues were under better control. The primary care doc returned to town but wanted nothing more to do with the patient because of the high liability risk. The internist happily took over. The lateral aspect of the forefoot was by that time black with findings consistent with wet gangrene. It was time for surgical debridement to save the leg.
Bone scan and X-rays showed involvement of the fourth and fifth metatarsals. I explained to the patient that after I removed the necrotic flesh and bones, there would not be enough skin to close the wound so skin grafts would be needed later. He thanked me and told me he knew I would do my best.
After the operation, there was a gaping wound with no hope of primary closure. The wound care experts debrided and dressed the wound daily. It remained open but not infected for another two weeks. The patient continued to thank everybody for doing their best.
I met with the wound care team and we decided to try a vacuum device to shrink the wound to a size where a graft would possibly take. In one month, the wound was one-third of its original size. We decided to forego the graft idea and the wound healed.
A pedorthist joined our team and provided the patient with special work boots with a prosthetic insole. He will return to his job as a crane operator tomorrow.
Sen. Hillary Clinton wrote a book called It Takes a Village to Raise a Child. The title was borrowed from an old African proverb. I have learned over and over during the past 32 years of being a podiatrist that it often takes a village to save a leg. The team of internists, surgeons, physical therapists, pedorthists and me the podiatrist did not have time to get into turf battles. Our collective focus was our patient’s leg and life.
I am blessed to work in a medical community that embraces the teamwork approach. Podiatrists are respected and welcome members of the team. It is the way things should be everywhere. I just got lucky 32 years ago in picking this community.
Dr. McCord is a Diplomate with the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.