Case 77: Recurrent Stasis Ulcers in Retarded Patient

Born in June 1924, this lady was mildly retarded and dependent on others all of her life. She married a likewise mildly retarded man. Both were poor historians and poor at following their medical programs. She had a replacement of her left knee in 1985 that left her unable to bend her knee and relieve pressure on the back of her calf. A sedentary smoker for many years, she found pleasure in the company of many tick-infected cats. She presented at Bryn Mawr March 4th, 1991, on the service of a general surgeon with excoriations from her mid-thighs to her calves along with large odoriferous leg ulcers of uncertain duration. They had not responded to the surgeon's outpatient treatments. Her leukocyte then numbered 14,200 and her albumen and cholesterol were reduced to 3.1/gm/dl and 157mg/dl pointing to poor nutrition. She was referred for boot therapy. As the legs improved, she was transferred to our nursing-boot facility for further treatment. Her progress there was slowed by her wetting her legs with urine and her inability to unweight the back of her calves. Eventually, a removable cast was made to unweight the calf and protect it from scratching. Her legs healed and she was sent home. Several days later she was admitted to another hospital with seizures and coma that proved to be secondary to hyponatremia (Na+ 112mEq/L) associated with excessive water drinking. A CAT scan showed an old parietal stroke and cerebral atrophy. Her leg ulcers recurred in the summer of 1991 bringing her back to the office for boot therapy when she could find transportation. Her ulcers improved and she disappeared for a year and returned in July 1992 with a large leg ulcer. She again improved and attended other medical problems (breast calcifications and urethral stenosis) with other doctors. Her husband in the meantime had developed leukemia and had stasis ulcers of his own; he required hospitalization in April 1993. Unable to care for herself, she too was hospitalized.

March 25th,1993: Her ulcer had recurred and Enterobacter cloacae and Pseudomonas aeruginosa were cultured.

Again once they were stable, both she and her husband were transferred to our boot-nursing facility where they had a lengthy stay, her slowness to heal related to her inability to cooperate and adhere to her program. Booting with antibiotic-Sea Soaks compresses, frequent dressing changes, casting to unweight her ulcer, various ointments and elevation were all tried

Her ulcer slowly filled in and she was discharged.

She returned but a few weeks later claiming to have collided with a rolling cart. She again began office boot treatments. Transcutaneous PO2 measurements were low pointing to local ischemia likely due to small thrombi associated with stasis.

The TcPO2 near the ulcer on the lateral leg was 0 mmHg. (Lesions associated with values under 20mmHg presumably will not heal)

The TcPO2 near the ulcer on the medial aspect of the leg was 3 mmHg.

With regular booting her leg was healed again. She was evaluated for long term placement in a nursing facility in June 1994.

Comments: This lady represents a vary difficult kind of patient: those unable to care for themselves and susceptible to advanced skin lesions that call for treatment even by the more hard hearted souls. The care for this lady was difficult enough. Added to it, however, were concerns about Medicare regulations. With regular visits to the office she could be healed and kept pretty much intact. The office visits involved transportation costs. Routine visits could be interpreted as maintenance care and the latter is not permitted by Medicare. Hence, efforts must be made to discharge the patient even though it may be obvious the lesions may relapse. The recurrent lesions in turn then require considerably more effort to heal. Commonly, the efforts to discharge the patient are poorly received by both patient and family. HMO's and other insurance carriers also like discharge dates and allow limited treatment periods. Leg amputation is agreed an extreme answer.... and an answer that results in more nursing care needs and costs in many of these patients.