Case 112: Pain Relief and Stabilization of Ischemic Foot until Death in Elderly Man

This man had a 60 pack-year history of smoking and was admitted because of increasing dypsnea attributed to his known bronchitis and emphysema. His left leg was noted to be painful and cyanotic on admission. When further attention was finally called to his leg, it was found that he had no femoral or popliteal pulses. Noninvasive vascular testing revealed a blood prssure of 60 mm Hg in the mid-thigh and 40 in the calf and above the ankle. The readings were taken in the anterior tibial as the peroneal and posterior tibial arteries were not detectable by Doppler. His pulse volume determinations at the calf and ankle were zero. A decision was made not to have an arteriogram and not to consider surgery. A boot consultation was called. His leg was found to be cold below the knee and somewhat ruborous on dependency.

Areas of necrosis were found on his 1st, 2nd and 5th toes, on the side of his foot and over the lateral malleolus. His big toenail was dark and the toe very painful. He had scabs and excoriations on his shin and calf.

The medial view of the foot showed a large black eschar on the heel and numerous small black spots in a line from the medial malleolus to the big toe. His name is inked out in his mid-arch.

He was booted several times over the next few days while his family and doctors debated as to how much care this old confused man should really have. His pain disappeared. He was discharged back to the nursing home in anticipation of death from his emphysema, heart disease and cerebrovascular disease. A few weeks after discharge he did die. His leg had caused no further difficulty.

When boot therapy was discontinued, his foot was pain-free and his lesions were healing.

Comments: As opposed to the previous case, pain and leg deterioration were reversed in this man. Hmm... Successful palliative therapy... Do HMO's pay for such a thing today? More of a question for those of us in the boot world is the delay in recognizing the man's vascular problem and then the inclination of the physicians to consider boot therapy only after invasive procedures were ruled out. The average physician is poorly trained in peripheral vascular medicine... and, sorry to say, most "vascular physicians" do not know one boot from another.