Post Operative Treatment for Diabetic Amputee Patient

[LibbyO]

Calling all Orthapedic Surgeons/Students....Please read on. I am interested in obtaining some input from all of you bright minds. The details surrounding this case are true and are not fictious.

Patient:
Female
Diabetic
Age: 66 Years Old

1st Surgery:
Done one year prior to surgery in question. Both Great Toes amputated due to onstart of Gangrene. Stints placed in left leg to promote blood circulation.
Patient has PVD in both legs.
Pacemaker put in.
Patient has High Blood Pressure as well.
Dialysis Treatments administered.

Treatment During Following Year:
Patient receives in-home health care visits weekly basis (via registered nurse)/regular visits to primary physician.

One Year Later, Leg Amputation:
Admitted to hospital for one wet gangrene sore on bottom of left foot
Diseasae Control MD was to administer piggyback doses of antibiotics
(Medicine not administered until 8:30 p.m. that night)
Orthopedic Surgeon was going to let antibiotics kick in prior to performing any surgery.
Next a.m. Surgeon informs patient, will have to cut off both legs, then decides to only cut the left leg off. First it was below the knee, then decided to do a mid-thigh amputation.

Fun Part Now Boys & Girls:
Patient admitted to OR after one day in hospital.
Entire left leg amputated.
One hour after surgery, patient is placed in a semi-private room.
Patient never placed in ICU for monitoring purposes. (Keep in mind previous health conditions mentioned above)
No oxygen administered.
No heart monitor attached.
No catheter used.
Patient dies less than 12 hours later.

If you were the acting physician in this case...what would you have done differently?

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[hammena1]

It sound like it is the post op management that you take issue with. Without knowing the patient's OR couse (ie blood loss, intraoperative vitals), it is speculation to second guess the bed posting. This patient sounds like a terrible operative candidate, so any procedure of the magnatude of an AKA is huge surgery with huge risk to begin with.

 

[SOUNDMAN]

What the above said. Terrible risk really for surgery. But really more details are probably needed.

 

[moquito_17]

This is an interesting case. I always find discussion of bad outcomes helpful to understand the failures in the system and decision-making processes.

One could make the argument that this patient should have gone to a step-down unit, telemetry or some other cardiac-monitored unit, but the ICU would be inappropriate. We have lots of patients on the floor with HTN, on dialysis, with DM, etc. If we put everyone with these comorbidities in the unit, there would be no room for patients on vents, critically ill trauma patients, etc.

More information about the post-operative course would be helpful, but she should have been on DVT prophylaxis. Most institutions and departments have a protocol for this.

As far as dialysis, she probably should have been dialyzed the morning before surgery and possibly that evening depending on her parameters. I would want to know how much urine she makes as she is the type of patient that could get into trouble very quickly with her fluid status, especially coming from the OR. It would be important to stabilize her from a fluid status perspective before discharging her to the floor. Also, getting a post-operative BMP would probably have been reasonable.

As far as being 'a terrible risk for surgery' the original poster stated exactly why she needed the operation. Even thought she is a vasculopath, she had a gangrenous extremity which if untreated can lead to sepsis, shock and death. If she was in renal failure due to having a leg of dead muscle, then it was an emergent operation. Either way, this is not an elective operation, like doing an ACL or scoping a shoulder.

This patient obviously needed the operation and by placement of the stents preoperatively had maximization of her vascular status. Usually with these operations, there is an intraoperative decision as to whether to do a BKA or an AKA. If the stump of the BKA does not look favorable or viable, then an AKA should be performed. Presumably, this is what happened in the OR.

It sounds like she had a major vascular event that evening—probably a PE/MI/CVA. She could have been fluid underresuscitated and this can predispose to MI. If she was overloaded, she would probably have gotten short of breath in that intervening 12 hrs. An infections complication in this time period leading to sudden death is remote. Another possibility is hyperkalemia and a fatal arrythmia.

Unfortunately, the nature of CAD/PVD is such that those patients who need BKAs and AKAs are at risk for complications, and there are many, many vasculopathic diabetics with infected foot ulcers.

If this was my patient, I’m not sure that there was be anything else to do differently. It sounds like there was room to improve regarding the level of communication between the surgeon and patient/family, and I would make sure I had a handle on her fluids and DVT prophylaxis. Also, I think that obtaining an autopsy would be very helpful in this case as the cause of death is unknown (at least to me), thus any discussion on whether or not it was preventable is premature.

Of course, this is all academic speculation as we don't know a lot of the details of her disease and care. Take all of this with a grain of salt.

 

[LibbyO]

I wanted to thank you Mosquito, for your detailed and responsive insight as well as everyone else for their responses. I think the facts surrounding this case are disturbing due to two factors: 1. the patient in question was my Mother, and 2. the fact that she lay dead in her semi-private hospital bed for two hours prior to the next shift of nurses coming in to check the patients (information verified w/ other patient in the room). This patient was ill. As such, I found it disheartening after her surgery, when I asked the orthopedic surgeon in question why she wasn’t being admitted to ICU, was because “there is nothing wrong with her”. Quote Unquote.

I had the arduous task of having to find an independent pathologist to do the autopsy. We tried several venues, but to no avail. We were told by the coroner’s office as well as numerous independent pathologists, that it would create a conflict of interest if they did the autopsy. We were forced to use the Pathologist there at the hospital.

I can remark on some of the more substantial findings, which I feel are relevant:

Patient had severe right lower extremity cellulites, history of congestive heart failure and has a pacemaker, plus history of renal failure. Abdominal cavity shows organs which are generally normal in position and relationship. There is no ascitic fluid. Following removal of the abdominal organs, there appears to be 100 ccs of tan pleural fluid in each of the right and left pleural cavities. (Please note that throughout the report, it is noted that this tan fluid is located throughout her body – I guess she drowned in her own fluids.) Lungs otherwise appear normal. The pericardial sack appears free of fluid. There are no epicardial adhesions. Heart – the bicuspid and tricuspid valves show no focal lesions. The aortic valve shows atherosclerosis and just above the valve leaflets there are extensive nodules of atheromatous material ranging up to .5cm in diameter. The chamber are all of normal size and shape. The left atrium contains the pacemaker wire which extends normally through the right atrium into the right ventricle. The tope of the wire is adherent to the wall of the endocardium. There is a slight rubbery pink clot adherent to the wire within the right atrium and extending slightly into the right ventricle measuring 3 x 1. .5 cm There is severe coronary atherosclerosis with approximately 50% narrowing of the left common coronary arthery and what appears t be complete occlusion of the left anterior descending coronary artery beginning about .5 cm form the bifurcation. The left circumflex appears narrowed by about 50%. The right coronary artery shows 50% narrowing with what appears to be almost complete occlusion distally. Bladder contains 200 cc of urine.

Pathologist’s Summarization:
Severe generalized and coronary atherosclerosis
Focal myocardial fibrosis, heart
Pacemaker intact
Congestion in Lung, Liver, Adrenals and Spleen
Pleural adhesions, Left Lung
Chronic Cholelithiasis
Arteriolar nephrosclerosis, Kidneys
Clinical history of diabetes mellitus
Clinical history of renal failure
Post left above the knee amputations, recent, intact
Status post amputation right great toe, remote
Blood clot, right atrium adjacent to pacemaker lead

I guess after reading this, you will understand my frustration. I can only relate to the first surgery where they amputated her great toes. She had a surgeon that actually did some of the pre-op steps that you mentioned before. She was put on dialysis, antibiotic, the works (approximately a 3 week tenure) prior to her having the one surgery for the stints and for the toe removal. The surgeon she had for this second surgery went into this blindly almost. Her vitals were good the day she was admitted to the hospital, with no signs of infection in her blood, etc. I guess with so many health issues wrong for one person, one would question the surgeon’s comment of “There’s nothing wrong with her…..”

 

[dry dre]

Sorry about your loss, and sorry that I won't join the hunt against the physician.

Diabetes is a terrible disease. This case is proof.

If we put every diabetic in a monitored bed, half the hospital would need monitored beds to keep up with transient demand.

If you need to cut off a necrotic body part, you have to cut it off, or you need to suggest the end is near to the patient and let them call the family for last goodbyes if they do not wish to undergo the risk of surgery.

In my institution we see between 1 and 5 of these cases per week. The average lower extremity amputation is done on a patient with CAD, PVD, systemic atherosclerosis, HTN, often CRF, usually poor compliance with home treatment/monitoring of blood glucose, often with current tobacco use, often with alcohol use, on and on. I can't recall the last time that someone walked in with normal labs was sent to a monitored bed post-operatively. They get q4 glucose, q8 vitals, and an AM CBC/BMP.

Since we are talking turkey, what were the home sugars running? What did you do to help the disease process at home? What was the diet like? Excercise program? Smoking/drinking? How frequent were primary care visits undertaken? How many visits missed? How many family members assisted in care? What questions were unanswered (i.e. how many questions were asked that did not receive satisfactory answers BEFORE the fact)? What was home wound care compliance? What was home medication compliance? What makes you think that a very sick person is not at great risk to health at every moment (i.e. even before surgery) with all of the known health conditions?

There won't be any surgeons left if you get rid of/sue every surgeon who has a sick patient die post-operatively. What is the ethical basis for your search here?

 

[LibbyO]

Since we are talking turkey, what were the home sugars running?
* On average 120 – 130 Insulin was administered if sugar levels went out of range.

What did you do to help the disease process at home?
* I work full-time (and then some). She had a tenet home health nurse that would come out twice a week for about a GRAND TOTAL of 5 minutes or so, plus a physical therapist only came out two or three times after the initial toe removal. The nurse would come and monitor the status of her wounds (the amputation of the toes never really healed well. I was there every morning and every night for 3 – 4 hours when I got off of work. Home helpers - myself, my Grandmother & a personal friend. I would change her bandages in the morning before I went to work and when I came home. I would empty her potty chair and cook breakfast and dinner upon arrival, plus fill insulin shots for the day. Medicines were filled two weeks out w/ pill dispensers marked Breakfast/Lunch/Dinner. Yes – I had a system.

What was the diet like?
* Diet was good. We monitored what she ate. She would order out for Chinese every now and then. Maybe twice a month. When I saw the takeout boxes in the trash – I would raise hell (in a nice way  ) We were well versed though on what she could eat and not eat.

Exercise program?
* After the amputation of her toes, walking and mobility was limited. Bandages on her feet and discomfort kept her inside most of the time. She would walk on average 5 – 6 times up and down the hallway every day, plus I put a chart in her room on exercises that she could do in the bed and in a chair. Exercise would have to be the downfall here.

Smoking/drinking?
* She never touched either.

How frequent were primary care visits undertaken? How many visits missed?
* My friend and I would coordinate between the two of us to take her to her monthly visits to the Doctors office. The Tenet nurses were filing reports to with the Doctor’s office every time they came out.

How many family members assisted in care?
*Just myself, my 90 year old grandmother, and a friend of mine that would come most every day from 9 – 3 to bring meals, run errands, etc.

What questions were unanswered (i.e. how many questions were asked that did not receive satisfactory answers BEFORE the fact)?
* All I can say is too many. The physician said that if I don’t cut her leg off she is going to die. He also said she will be up and walking around in about 10 days after the surgery. Sorry – but what a crock of C_ _ P. He didn’t even show me one X-Ray of her leg. Not one. Nothing w/ regards to blood workups, etc.

What was home wound care compliance?
* Cleaned wounds & applied medicated ointments & wrapped feet w/ bandages. This was done every morning & every night. My wrappings could rival that of any seasoned nurse. When the Tenet nurses came in, they would change them too, because they had to check the wounds.

What was home medication compliance?
*Answered above.

What makes you think that a very sick person is not at great risk to health at every moment (i.e. even before surgery) with all of the known health conditions?
* First off, I don’t take life for granted. I never have. I was the one that when I saw her toes the first time told her to get to the hospital a.s.a.p. I was there to bring her there, was there when they amputated her toes, almost lost my job because I was always there to bring her and my grandmother to the hospital, and had to take off so much time from work. I’m trying to point out the fact that:
•A. She should have been given antibiotics for a couple of days prior to the surgery to see what effect that would have had on the sore on the bottom of her foot.
•B. She should have been placed in a monitoring unit of some kind so that the nurses could have seen if she was under duress or had trouble breathing.
•C. The fact that she was dead in her bed for two hours before the nurse came to check – let’s just say – that is inhumane by any culture’s standards.
•D. As I pointed out above regarding her Post-Operative care. Sorry – but that is not what I call proper care for someone that was elderly, diabetic, and with pacemaker.
•E. For your personal information, I’m not suing any Doctor. I am however asking that a Medical Review Board review the information surrounding this case. Maybe I can help some other poor soul from winding up on an autopsy table.

You also mentioned that why should we assume that anyone as sick as she was, could not be in danger of death, etc. My question to you is then why did this Doctor assume she wouldn't?

The Turkey is now served.

 

[dry dre]

You want to see x-rays? For what? Are you a surgeon or radiologist who can interpret the findings?

•A. She should have been given antibiotics for a couple of days prior to the surgery to see what effect that would have had on the sore on the bottom of her foot.

--Violating terms of use here, in the spirit of your post, this in all likelihood would not work. Wounds at minimum need blood to heal. PVD, DM, CHF, et al, works against this. In all likelihood, the underlying problem here was not one of infection.

•B. She should have been placed in a monitoring unit of some kind so that the nurses could have seen if she was under duress or had trouble breathing.

--It is unreasonable (in a system with limited resources) to place every patient in a monitored bed post-operatively. It's also clinically unjustified.

•C. The fact that she was dead in her bed for two hours before the nurse came to check – let’s just say – that is inhumane by any culture’s standards.

--This is dramatic. I've volunteered in three other cultures' health "systems" and have lived in two others. Nurses in the US, like every other country, do not sit at the end of every hospital bed. In other countries, and less often in the US, family members are constantly with the patient. In other cultures physicians are usually not the culprit in death of sick people. Ask any foreign physician.

--Inhumane is dragging a well-meaning and good practicing physician through the courts, review panels, etc. Fact is, under the circumstances you provided, this case was reviewed already by a physician panel in the hospital to determine if someone was done wrong. Enter the "white coat wall" conspiracy theory here.

•D. As I pointed out above regarding her Post-Operative care. Sorry – but that is not what I call proper care for someone that was elderly, diabetic, and with pacemaker.

--Are you seriously suggesting that all elderly diabetics with pacemakers and a relatively normal work-up be placed in the ICU when they enter the hospital and/or post-operatively? To be a rule, this is nonsense.

•E. For your personal information, I’m not suing any Doctor. I am however asking that a Medical Review Board review the information surrounding this case. Maybe I can help some other poor soul from winding up on an autopsy table.

You also mentioned that why should we assume that anyone as sick as she was, could not be in danger of death, etc. My question to you is then why did this Doctor assume she wouldn't?

Everyone is at risk of death. Being so sick as to be in a hospital increases this risk. Worse yet is being so sick as to have multiple medical problems necessitating amputation. All this being said, clinical judgement determines care.

Only clinicians intimately family with the circumstances here can determine if the standard of care was attempted. A review committee is such a group. Your clinical sense, while heartfelt and well meant, seems off the mark here. Accordingly, you'll tie up the time (societal resources) looking into what doesn't sound to be malpractice. In the end, you'll help other people not sleep, you'll waste society's resources, you won't change the outcome, and you won't change the standard of care.

Fact is, everyone in America doesn't get "presidential" treatment when they enter the hospital. Systems like Mayo offer these services, at a premium (i.e. money).

What you have presented here does not sound like malpractice. IF the patient was in a monitored bed, certainly there would have been alarm of a problem. Such an alarm may not have altered the final result. If you want to talk humane and other medical systems, other systems don't spend every effort in treating end-stages of disease, as we do; instead they front-load primary and preventative medicine in attempt to reduce the percentage of patients who end up in end-stage circumstances. If you believe WHO etc numbers, other industrialized societies do a relatively good job of this.

You seem to be unrealistic in appreciating the resources (i.e. capabilities) of a hospital. Moreover, you seem to be interested in stamping your feet in effort to find fault in something/someone other than accepting that what has occured as part of the consequences of a terrible disease (and not a terrible clinician).

 

[LibbyO]

The end result is, she is gone. My final statement is....she could have had a few more days or weeks if they hadn't amputated her leg. We could have had time to fly my brother in from out of state to tell her goodbye. I'm not saying that it wasn't her time to go. She could have had a few more precious moments, hours, days possibly.

I'm not a Doctor, I never proclaimed to be one. When I said he didn't show me any X-rays or let me know of any test results, etc. I was uninformed....about everything. This was my Mother. I was taking care of her for the past three years up until her death. I was lead to believe that she would die, if we didn't cut her leg off. Possibly so. But she should have been given a choice. It's a choice she should have had time to make and not at the urgency of an HMO plan or hospital schedule requiring another empty bed. You said it yourself....limited resources. That's what our health care system has come down to...limited resources. Where we take our elderly and our sick and shuttle them in and out as quickly as we can. To nursing homes, etc. where their quality of life is mediocre at best.

Sorry, but this was my Mom. I wasn't going to let her down then, and I'm not going to let her down now. Remember my words....one day you will be on the other side of that table. I only hope that you have someone fighting for you in your corner....like I fought for my Mom. A Presidential candidate no, but a kind and decent woman, Yes. You have your opinions and I have mine, and I will keep it at that.

 

[bugmenot]

did you send for autopsy

 

[LibbyO]

Hi Bugmenot,

Yes, we did follow-up with an autopsy report. They think she died of cardiac arrest. She also had a blood clot by her pacemaker, could have been a PE, but not sure. In addition, they didn't give her any pain medication for that full 12 hours after surgery. I can't even imagine the amount of pain she was in. That could have caused her heart to go in arrest too. I mean her entire leg was removed up to a little above mid thigh. I guess that is why I'm finding this all very difficult.

 

[moquito_17]

LibbyO,

I'm sorry for your loss. This must be a tough time for you.

You stated that you wanted to get to the bottom of this so that no one else has to go through this. That is an admirable thing to do--a very common sentiment among those who have suffered loss. You ought to continue with this.

So this is what was in the report: "complete occlusion of the left anterior descending coronary artery beginning about .5 cm form the bifurcation." It sounds like your mother had a massive LAD infarct. Given the suddenness of her passing, she probably had a fatal arrhythmia or precipitous drop in blood pressure.

Unfortunately, the risk for post-operative MI increases with any physiological stress (infection, trauma, surgery, etc), especially so in people who have numerous predisposing risk factors (DM, CAD, HTN). You mother may have had this MI even without the surgery given that she had an infected ulcer/leg. I doubt that there is anything else that could have been done for her. Antibiotics would probably not have helped. It doesn’t sound like she had a CHF exacerbation, so her fluid status was probably optimized.

Prevention of perioperative MI is a challenging task. There is a lot of debate about the use of stress tests, cardiac cath, aspirin, etc. The details of this are beyond my area of knowledge. I do know that there is some evidence that routine beta-blockers postoperatively lower the incidence of post-op MI—I don’t know if she was on one. But this is only risk reduction, not risk removal. I’m not a cardiologist, but I have heard that of all-comers, anywhere from 8-15% of patients with CAD will have a post-operative cardiac event. If we could find a way to lower this number, it would be a great thing for medicine.

As far as the other things go, communication, x-rays, what was said, etc., I’m not going to comment. I wasn’t there and neither was DryDre, so I don’t know where the breakdown was.

I wish you the best in managing your mother’s affairs, and I hope that you are able to assist others like her.

 

[LibbyO]

Hi Mosquito,

The death certificate says she died of natural causes for manner of death. Then it has a little caption below that says complications brought on by Atherosclerotic Heart Disease. That's all they had on there. They didn't even metion her diabetes, which I thought was strange seeing that is what caused the deterioration of her leg, overall health, etc.