Case 85: Healing Toes and Improving Claudication

At age 77, this pipe smoker was referred by his cardiologist for sore toes and claudication. His family was worried lest gangrene was developing in his toes. His walking was limited to the degree that it required great effort for him just to get around his house. There had been a question of his having an abdominal aneurysm as a source of peripheral emboli but an ultrasound of the abdomen proved to be normal. He had no palpable pulses below his groins. PPG tracings of his toes were greatly diminished especially in his right 2nd, 4th and 5th toes. Coagulase-negative staphylococci were cultured from his toes and treated with oral Bactrim-Ds and appropriate antibiotics in his Mini-Boot fluids. He received 75 boot treatments from December 30th, 1992 to June 1993 as an outpatient. The pictures show his progress. His walking capacity improved to allow him to walk a block at average speed without any difficulty.

The plantar surfaces of the right 2nd to 5th toes had reddened areas that did not blanch on pressure.

Small areas of skin necrosis were found at the ends of both big.

The red color and pain receded in all of the affected toes.

The lesions on the big toes healed and the toenail began to grow again.

Comments: The need and benefit that this man had from his treatment is clear to most people. He had straight Medicare coverage. Such cases are covered by Medicare on an as needed basis. Periodically our cases are reviewed and if we have not appropriately documented the treatments and their need, we are potentially subject to a payback. This system is generally fair. It allows us to be the initial judge of the needs of our patients and to make haste in attempting to help them. Delay in initiating treatment in these patients not uncommonly results in extension of their lesions. As will be seen, patients with managed care insurance programs do not fare so well. Commonly, the initial reaction of the HMO is to deny care and require considerable paperwork. We have yet to find that there response has benefited either the patient or, in the long term, their own pocketbook.

Return to CBC Homepage
Return to Menu of Case Histories
Next Case