Case 140: Gangrenous Instep Healed and Leg Salvaged in Elderly lady: Those Good Old Pre-HMO Days!

At age 84, this woman was admitted to the Bryn Mawr Hospital on October 7th, 1987 to avoid the leg amputation her physicians were recommending elsewhere.

She had a history of varicose veins and arteriosclerosis obliterans treated by bypass surgery (heel ulcer 1980) and over three hospitalizations earlier in 1987(February, July and September) with a sympathectomy, Uniboot applications and skin grafts. The latter did not heal and as various tendons became exposed, her physicians recommended leg amputation. She had atrial fibrillation and a New York Heart Class 3 designation.

At the time of discharge, she was advised her leg could accept a skin graft... which she refused in view of her previous failures.

Pseudomonas aeruginosa was cultured from her leg ulcer initially and frequently over the next few years whenever she relapsed. A common daily routine included an initial cleansing soak with dilute hydrogen peroxide in Sea Soaks followed by Mini-Boot treatments with her foot immersed in Sea Soaks containing gentamicin or neomycin. Ancef and later Ticar were given intravenously. A low vitamin B12 level documented the diagnosis of pernicious anemia. She was discharged November 27th, 1987 to our nursing facility, which was equipped with a treatment room for the Circulator Boot Systems.

She was readmitted to the Bryn Mawr Hospital from April 14th to April 28th with swelling of the other leg (right) of uncertain etiology. In spite of normal venous Doppler and PRG, she was heparinized and started cautiously on Mini-Boot therapy. Long-Boot therapy to the right leg was begun cautiously (first at low pressures and after the first treatment at full pressures). The leg returned to normal size and essentially remained normal thereafter. She continued with outpatient treatment of her left leg which was slow to close. Doppler studies showed her lower leg was largely supplied by collaterals from the lateral geniculate system which were easily occluded when she crossed her legs. She was readmitted to Bryn Mawr for three days in October 1988 to gain the proper paperwork to allow Medicare coverage of another admission to the nursing home where she continued her treatment while her family (her son) was away on business. Subsequently, she returned home where her son had installed a boot system and gave her booster treatments as necessary. She remained ambulatory and went to a center or senior citizens while her son was at work.

February 23, 1989.

May 18th, 1989.

November 9th, 1990, return visit for a stubbed big toe.

Comments:HMO's had no influence on our care in 1987. Today, we would likely fail to heal this lady. If she had had leg amputations and survived, she would have been an excessive burden on her son. With her legs, she had modest independence. Her son was surprised at her improvement in cardiac function. We advised him that the Long-Boot was a cardiac-assist device and patients like his mother commonly improve their heart function. Hers was a long course with small relapses from time to time. Her course would have been shortened if she had agreed to the skin grafting and stayed in the hospital. Had she had her leg amputated and become a nursing home resident for four or five years, her medical costs would have been much higher. For the HMO, the cheapest chronic patient, the cynics point out, is the one who dies.