Friday, January 4, 2008

what do you say? part II

Another patient on my service is also in that proverbial place between the rock and the hard place. He's young as far as our patients go -- only 51. But he has the body and face of a septuagenarian. Through a constellation of events, some self-induced, some self-neglect, some medical neglect, he is facing an above knee amputation.

He was trasnferred to our facility for a "higher level of care," which sounds like the transferring facility has reached the limits of what they can do, either with expertise or equipment. More often than not, however, this term just means that they don't want to be bothered with the difficult work up, or they have done a "wallet biopsy," determined that the patient doesn't have insurance and don't want to do something for which they will not be compesated. But I digress.

We accepted this transfer because he had a huge saddle embolus from new-onset atrial fibrillation. The thrombus was occluding his common iliac arteries that eventually give blood supply to the legs, which meant that he was not receiving much blood supply to his legs. Superimpose this condition on pre-existing peripheral vascular disease caused by years of smoking and hypertension, and he has experienced necrosis of most of the toes on one of his feet. And this was all before we got him.

When he arrived, we were able to remove the clot from his arteries and restore the inflow, but much of the damage had already been done. In addition to the necrotic toes, he has a wound on his heel that extends to the bone and Achilles tendon as well as a large wound with exposed tendons on the lateral aspect of his leg. We could try to re-vascularize his leg and try to restore some blood supply to try to heal his leg wound, but he has a large vegetation on his mitral valve causing a large degree of mitral regurgitation and congestive heart failure. Simply put, he simply would not survive the major surgery needed to restore blood flow to his feet.

And this is how I received him when I arrived on the service. He was slowly getting his mind around the fact that he was going to lose his toes. Everyone but the patient and his family knew that the heel wound would not close and he would lose that, too. But so far, everyone was dancing around the idea of a bigger amputation and not talking to him or his family about it. That's easier, isn't it? I took down the dressings on the leg in question and knew immediately that a standard below knee amputation would not even be enough. The leg wound is on the posterior flap that we would create to close the stump with. He needs an above knee.

I tried as best I could to bring up the idea to him gently. I used words like "you should start thinking about the possiblity that we are going to need to amputate your leg" and other things to that effect, but no matter what or how I said it, he bawled and his daughter was hostile. Not that I'm offended in any way, but we don't have a magic scalpel.

Exactly how do you tell a relatively young man that one of his legs needs to be removed? And that after he recovers from that, he'll need open heart surgery? And after that, he may need major revascularization procedures?


Kellie said...

Basically you just keep telling him what you've already told him. Sometimes they just need time. Hostility is normal and with time, time and more time, they will understand. Sometimes it is "it's either your leg or your life" and most people "get it" after that.

BTW, not every referral is done because of a "wallet biopsy" or becuase the outlying hospital doesn't want to do the work up. I now practice in a small hospital even though I have the skills to do vascular, I only do the minor stuff now (dialysis access).

Good luck and I enjoy reliving my residency days!

lights n steel said...

Oh, I completely agree that there are some facilities that simply don't have the ability to do some things. I've recently interviewed at a place that doesn't have in-house radionuclide imaging for breast lesions!