Case 153: Both Legs Preserved in Elderly Diabetic with Cerebral Atrophy and Bilateral Ischemic Decubiti

This 75 year old diabetic woman, who had cerebral atrophy from many strokes, had been sent to a nursing home with intact feet and pulses said to be present by Doppler. At the nursing home, she developed heel decubiti and secondarily cellulitis of her left lateral ankle. She had been eating poorly at the nursing home and ate little when hospitalized at Bryn Mawr. Her family chose not to permit the placement of a feeding tube but did want her feet treated and her dignity and comfort preserved. She received intravenous antibiotics and 5% glucose solutions. No attempt was made to treat her hypoalbumenemia.

She had a large black eschar on the back of her right heel and a smaller one under her right fifth metatarsal head. The lateral aspect of her left ankle was soft necrotic and odoriferous. The posterior lateral left heel was soft. Again, she had a area of focal necrosis under the left fifth metatarsal head. The possibility of amputating one or both legs was considered.

On the left are seen the vascular tests for her left (left three tracings) and right (2nd set of three tracings) legs on admission. The Doppler velocity writeouts for the dorsalis pedis is given on the top line and for the posterior tibial artery on the second line. The bottom line is a pulse volume measurement as gained from an electronic oscillometer. On the right, the same tests are shown after each leg had been treated in the hospital for one month with the Circulator Long-Boot. The height and shape of the Doppler curve in seen to improve especially in the posterior tibial arteries. The pressure rose in the left posterior tibial from <20 to 113 mm Hg. In the right leg, the posterior tibial had been faint and the pressure recorded at 128 mm Hg on admission; it became louder and the pressure rose to 134. The pulse volumes more than doubled at both ankles.

She was given Betadine-saline cleansing soaks prior to her boot treatments to rinse away loose material and pus. Gentamicin was injected into the sinus tracts in he left ankle and heel. She received a Long-Boot treatment to each leg daily. The cellulitis was quickly sterilized. The lateral ankle developed clean granulations. The soft area of her left lateral heel broke down as it proved difficult in her confusion to keep weight off her heel (no restraints were tried). The distal lesions of both feet went on to heal.

When her insurance coverage expired, she went home to her family for expectant care and died a few weeks later.

Comments: This is an old case that raises common issues. Here we had an elderly confused poorly nourished lady with cerebral atrophy and a very poor prognosis. Her mental deterioration had led to personal neglect that both contributed to the development of her lesions and made her therapy more difficult. Adequate tissue protein stores are necessary for wound healing. With no attempts to improve her nutrition, could one expect to heal her lesions? Should she be treated at all? Her foot lesions were painful for both her and her family. We relieved her pain and healed some of her lesions. She died with improved vascular tests and both of her legs intact. Had we made proper use of Medicare funds? Would an HMO today have allowed her care?.