When Foot And Ankle Conditions Result From Abuse
Doctors are required to report abuse in most states. We first think of child abuse and all of its signs, but there are other forms of abuse that occur and we must report them.
A few weeks before I retired, I received a call from a discount walk-in clinic with a request that I evaluate a seriously ill woman. I told them to send her immediately.
The patient was a well-dressed, pleasant 65-year-old woman. Her husband, who was well dressed and articulate, accompanied her. The woman’s right foot was bandaged and smelled bad.
She winced in pain as I carefully removed the bandage to reveal wet gangrene involving most of the first ray. The husband told me she had diabetes and was well controlled.
I asked about her primary caregiver. The husband interjected that he was her primary caregiver and he controlled her diabetes with so-called alternative therapy. He saw no need for tests for glucose blood levels since they just enriched the medical establishment. I asked the husband to leave the room for a minute, which he reluctantly did.
The woman started crying and begged me not to send her home. This was evolving into a difficult dilemma and one that I did not welcome with retirement looming in a few weeks.
I brought the husband back and explained to them that she needed to be hospitalized to prevent the gangrene from spreading, which could be deadly. I also explained that I was going to order consults with a vascular surgeon and an internist. The husband calmly informed me that hospitalization was not an option nor was the vascular consult. “They will just want to amputate her leg,” he said. “That’s what they do and her diabetes is in perfect control.”
I spent nearly an hour trying to explain the danger of not treating the gangrene and the husband finally agreed to take her to the hospital. It was too late to call Adult Protective Services but I planned to make the call the next day.
The internal medicine evaluation showed that her diabetes was seriously out of control. The vascular surgeon recommended immediate amputation of the first ray and subsequent vascular reconstruction to salvage the leg. All this led to another hour of dialogue, mostly with the husband. She gave consent for amputation of the first ray, which happened the following morning.
The woman did well postoperatively and got her diabetes under control.
We made discharge arrangements with the husband’s agreement that they would follow up with the vascular specialist and me since we were in the same office building. They never showed up and did not respond to phone messages that I left.
I called Adult Protective Services and was informed that I must report abuse when I suspect it. I was also informed that a physician is protected by the state from legal repercussion from the patient. I filed the report.
A social worker interviewed the couple and determined that they were within their rights to choose the manner of care. She told me they planned to follow up with chelation therapy.
I heard from the vascular surgeon after my retirement that the woman had been hospitalized under his care for further debridement but the husband continued to insist on alternative therapy.
The outcome of this case wasn’t what I would have chosen but I rest easy knowing I did what I was obligated to do.
Signs of abuse are vague and often well covered. My threat to report has motivated the parents and spouses of patients to follow through with needed care and seek counseling when needed.
Another challenging case was the wife of a respected business leader who presented to my office, stating that she tripped on the carpet and sprained her ankle. Examination and X-rays showed a Lisfranc’s fracture dislocation. I showed the X-ray to the patient and her husband, and asked what really happened. She pointed to him and said, “He did it.” The husband nodded in agreement.
In this case, I gave the option of immediate counseling or I would have to report it. I contacted a counselor who specialized in domestic violence who agreed to see them that day.
They chose a different doctor to treat the fracture, for which I was grateful. They came to my home a week later with a delicious desert pastry and a thank you note for sending them to the counselor.