This author navigates the complex issues in treating an elderly patient with a heavily exudative diabetic foot ulcer, which has recurred over an 11-year period.
This case is compelling for several reasons. It illustrates the importance of the team approach to limb salvage in a complex case. It illustrates the importance of thorough vascular assessment, the need to biopsy and the utilization of advanced technologies. It also illustrates the disconnect in wound management between the home health industry and ordering physicians who do not closely follow their patients in the home setting and who typically have minimal expertise in wound care.
Lastly, it is a case that illustrates the impact of social dynamics in the home and how effective networking can positively affect outcomes. It is certainly not the most complicated case in the clinical sense but there are powerful and enduring lessons that one can take away from this case.
The patient is an 82-year-old male with a left foot ulcer, which was marked by healing and recurrence over an 11-year period. The initial evaluation of the ulcer occurred in the patient’s home June 13, 2006. His past history included heavy tobacco use of greater than 60 years and a recently diagnosed onset of type 2 diabetes.
The Director of Nursing (DON) for a home health agency went to the home of this patient to perform a final evaluation before discharging him. It was her first encounter with the patient although her agency had been following him for several months. Upon evaluating the patient, the DON found a patient who was not appropriate for the home care setting. The DON subsequently referred the patient to our practice.
Upon the initial examination in the patient’s home, our nurse practitioner noted a heavily exudative ulcer on the dorsum of his right foot. The patient was in exquisite pain and this pain became worse upon elevation of his lower extremity, which was cool to the touch. Maggots had infested the ulcer and there was an odor to the ulcer as well. The wound edges were irregular and there was obvious depth to the ulcer although one could not determine the full depth of the ulcer due to extensive debris and pain. The patient was afebrile.
The patient’s primary caretaker was his son, a Vietnam-era veteran who suffered from post-traumatic stress disorder. He told our nurse practitioner: “All they (the home health nurses) do is tell my father to elevate his legs but he can’t because he has too much pain.”
We admitted the patient to Specialty Hospital of Jacksonville on June 13, 2006. During the patient’s subsequent hospitalization, magnetic resonance imaging (MRI) and X-rays did not reveal bone marrow edema, osteolysis or deep abscess. Cultures revealed multiple bacterial organisms and infectious disease physicians prescribed IV antibiotics including vancomycin and Zosyn (piperacillin/tazobactam).
The medical management of the patient was under the direction of an internist. A biopsy of the ulcer revealed initial pathology, which triggered concern for a possible angiosarcoma. A pathologist recommended a second opinion to further assess the biopsy specimen.
When Revascularization Is The Keystone For Improved Healing
A vascular evaluation of the patient revealed multi-segmental occlusions of multiple arteries of the lower extremity, both proximal and distal to the popliteal artery. An interventional cardiologist performed subsequent revascularization using several endovascular methods including angioplasty, atherectomy, stent placement and cold laser.
The patient began showing rapid improvement after revascularization. This improvement started to happen while further evaluation of the biopsy specimen was occurring. The patient’s pain level decreased significantly after endovascular intervention and the ulcer responded to initial management that focused solely on regular cleaning. While awaiting the second assessment of the biopsy assessment, intensive wound care included daily pulsed lavage, IV antibiotics and an alginate dressing saturated with Dakin’s solution.
After approximately two weeks, the results of the biopsy ruled out angiosarcoma on July 5, 2006 in favor of a diagnosis of hypergranulation tissue.
With the wound now revealing an overall improvement marked by decreases in depth, pain, odor and an increase in granulation, we decided to apply Apligraf on July 7, 2006. The patient was discharged from the hospital to home on July 19, 2006.
Through home health care and our nurse practitioner’s home visits, the patient’s progress was followed after the hospital discharge. On October 25, 2006, the ulcer was resolved. We discharged the patient from our service.
The patient’s son began questioning the ethics of the interventional cardiologist, who had also found occlusions on the contralateral lower extremity and recommended further endovascular interventions as well as periodic monitoring of the left lower extremity. The patient’s son did not bring the patient to follow-up visits with the cardiologist as he verbalized the opinion that the cardiologist was only looking to “make money off” his father.
Eventually, the patient developed ischemic gangrene in his right lower extremity, which resulted in a below-knee amputation. The patient was admitted to a long-term care facility, where he has been residing since 2007. His left foot remains healed at the time of this writing.
Dr. Bell is a board certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.