Case 91: Managed Care and Smoking Contribute to Loss of Limb

This 55 year old diabetic heavy smoker was concerned he might lose his leg. His father had lost a leg. He himself had seen four other specialists in vascular medicine and vascular surgery in the Philadelphia area and, after an arteriogram and a sympathectomy were accomplished, had advised him there was nothing more to be done except stopping smoking and exercise..

He presented August 28th, 1987 with no palpable pulses below his groin. His temperature was 101 degrees F, pulse 104 sitting and leukocyte count 14.6. His 3rd toe was gangrenous and foot cellulitic to the ankle. Permission from his HMO to hospitalize him was denied.

His arteriogram showed no continuous tibial vessels in either leg.

This example of his subtraction films showed some small collateral arteries in the lower leg.

We recommend hospitalization in patients like this man for several reasons: (a) his fever and leukocytosis signify a serious infection capable of rapidly destroying tissue and capable of decompensating his diabetes; (b) the man had a lot of pain that would best have been treated with parenteral narcotics; (c) serious infection is at least initially best treated with parenteral antibiotics; (d) bedrest is desirable for a badly damaged foot; (e) he had only faint non-pulsatile arterial flow at the ankle signifying to us that he needed multiple boot treatments a day for a few weeks; (f) a hospital environment is helpful in interrupting his smoking addiction; and (g) we are able to readily consult other physicians and services that might be helpful in his care. These pleas fell on deaf ears. .

He was treated with oral (Duricef) and local antibiotics for one week. Initially, gentamicin was injected into the 3rd toe and distal foot and was added to his Sea Soaks in the Mini-Boot. Staphylococcus aureus, Citrobacter diversus and later in the week Pseudomonas maltophilia were grown form his foot. Then Clindamycin was injected into the foot. He received both Mini-boot and Long-Boot treatments daily. At the end of the week, his fever and pain were gone... and, unfortunately, so was the patient. His commute from the middle of New Jersey had lost its urgency. We supposed he was back under the care of his primary doctor.

Ten days later, we had a phonecall from our nursing home boot center. The HMO physician, without consulting us the treating physicians, had approved the admission of the patient there but not the hospital. His foot had deteriorated. He was given a boot treatments two days and transferred to the hospital for an arteriogram. The latter now showed a possibility for a distal bypass. The vascular surgeon, however, in viewing his foot destruction and persisting smoking habits did not recommend it. Again, while his advanced foot destruction might have been eventually cured with boot therapy, he was advised it would take many months of treatment and that he had to stop smoking. He had already been lost to therapy one time and amputation was recommended and accomplished at his home town hospital.

His anterior tibial was now visualized at the ankle and bypass was considered.

Comments: This man presented with advanced disease. If his leg were to be saved, he needed aggressive immediate care and he needed to cooperate in his therapy over many months. His initial response to therapy was gratifying and suggested there was indeed hope. His therapy, however, was orchestrated more by his insurance company than by us. Given this man's addiction to nicotine and his advanced disease, we might have failed to save his leg in the long run regardless what we did for him. The hassle over his insurance and hospitalization did make his treatment difficult and contributed to his early failure and leg amputation.