Indexing Title: DCHUA’s Medical Anecdotal Report [04-6]

MAR Title: Lost Causes and Effective Finds

 Date of Medical Observation: August 2004

 Narration:

A forty-six-year-old diabetic was brought to the hospital for an uncontrolled infection from a rotting right foot.  He had neglected a wound sustained three months ago and was similarly non-compliant to the care of his illness since its diagnosis eight years ago.

Quick work-ups revealed co-existent basal pneumonia, pulmonary tuberculosis and urinary tract infection, together with a profound anemia.  On my ward rounds, I talked with the family who together with the patient, were refusing consent for operation.  Explaining the dire consequences of such a decision, I required them to sign a refusal.  They thought twice and soon agreed to the amputation.

It was then the anesthesiologist’s turn to refuse involvement with the operation, returning the patient to the wards after surgeons directed him to the operating room.  Three bags of blood were subsequently transfused in an attempt to optimize his condition.  Limited-spectrum intravenous antibiotics were maintained inconsistently.

I received the patient with his foot still reeking, with swollen redness affecting the leg, and with persistent fever in spite of sustained doses of antipyretics.  I loaded him with what antibiotics I could scavenge, and went about with the planned above the knee amputation.  The high level of amputation practically condemned the patient from ever walking again.  If his limb could be traded for his life, I would be more than happy.  This time however, Fate was not offering a barter, but a gamble.

I applied a distal tourniquet as tightly as I could manage on the strung leg in the hopes of minimizing loss of sequestered blood.  After tolerating some minor breaks in asepsis, I started my incisions and dissections towards isolating, carefully ligating, and cutting the largest femoral blood vessels.  I resisted the urge to use cautery instead of the knife to minimize bleeding, and was therefore certain of the good circulation to the resultant stump.

The slow pace of ligating every small bleeder, even from the venous end of the leg with the tourniquet prompted me to just do the cutting in one fell swoop.  Swooping I did to just above my ligated major vessels!  I re-ligated the vessels, wasted an additional unit of blood, and ended up with a femoral length less than the ten inches I had planned for.  I closed the muscular fascia over a rubber drain, and then the skin to prevent further contamination in this clean-contaminated wound.

On the third day after the operation, the patient lapsed back into fever.  The stump showed no signs of infection, with clear fluid from the drain in the setting of generalized edema.  I ordered for shifting the antibiotics to a second generation cephalosporin to cover for a suspected worsening of the pneumonia.  This was applied to and approved by the hospital Infectious Control Committee (ICC).

Chest x-ray suggested that the edema had also congested the lungs.  Developing a sudden difficulty of breathing, aggressive diuresis for the congestion was ordered.  I did a venous cutdown to measure his central venous pressure since the unequal chest auscultation findings predicted that high-dose furosemide was not necessary, and may even  be harmful.

The next day, ICC shifted the antibiotics to a semisynthetic penicillin as part of dual coverage for hospital bugs, giving me a great and false sense of comfort.  Another day later, I investigated for the reason why both sequences of ICC meds were not given as approved after all.

The nurses explained that the cefuroxime was not given because it had been changed soon after its order, and that the subsequent piperacillin was not given because the availment form had just been recovered from misplacement by the patient’s relatives.  They promised that the latter had been procured and would be given that evening.

Patient’s fever returned.  I was exasperated to learn that the hospital had withheld all prescriptions to all patients, that ICC was still making rounds like the medications were being given, and that my patient who was dying from infection had virtually not been given any antibiotics for four days straight, or effective antibiotics since the operation seven days ago.

I stopped all the orders for intravenous drugs and started the patient on broad-spectrum oral antibiotics after making carefully certain that the relatives could afford and sustain such treatment.

That night, a clerk referred the patient for a sudden deterioration of sensorium/ consciousness without a corresponding deterioration of vital signs.  The patient was unresponsive, had a blank stare, and occasional jerky eyeball movements.  Thinking that the nystagmus might indicate a seizure, I asked the nurses to secure anticonvulsants while we checked for the blood glucose level.  True enough, a hypoglycemia of 40mg/dL was documented without the prodrome of cold sweats, nervousness and hunger.  The patient promptly responded to 50ml of 50% dextrose.  Subcutaneous boluses of insulin were shifted to an insulin-dextrose intravenous drip.

Two days later, much of the respiratory symptoms abated.  Chest x-ray also showed improvement.  The stump eventually infected and I had to pack and do debridement.  The fever has gone, the edema seems controlled by the high-protein diet and low dose diuretic, and the patient is able to sit.

The patient dips in and out of trouble.  I remain hopeful that he may somehow transcend his broken body.  With his more recent roommates dropping like flies, perhaps the Grim Reaper has found him unsuitable for harvesting.  Perhaps not.