The Medico-Legal Advisor ®
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It has become very clear to us through the past few years' experience of reviewing malpractice claims that treatment of the diabetic foot brings patients to lawyers about as often as does the bad baby or the anesthetic mishap. There is usually plenty of negligence too, so much so that one wonders what the standard of care in this area of medicine really is (if one considers average care to represent the standard). Yet, you say, "I don't see that many successful cases involving the diabetic foot". You are correct, not because of lack of negligence but because of the problems with causation and sorting out damages. Here is one typical scenario involving the diabetic foot: The patient, and adult diabetic with peripheral neuropathy and ischemia, goes to a podiatrist to have his corns trimmed. The area ulcerates and is debrided. The patient seeks the help of his family practitioner and is put on soaks and oral antibiotics. The ulcer grows and by the time he is referred to a surgeon he has a large infected ulcer and osteomyelitis. He loses a couple of toes or a foot or a leg. The acts of negligence are easily defined. First off, the foot of the diabetic requires exquisite care. Corns or other lesions should be removed very cautiously and superficially. Surgery on the diabetic foot should only be done after it is established by vascular studies that the patient has reasonable vascular supply and prophylactic antibiotics are considered. Once an infected ulcer develops the treatment needs to be vigorous. Hospitalization, whirlpool, frequent meticulous debridement and IV antibiotics are in order if the ulcer is to heal. Hyperbaric oxygenation may be helpful. Diabetics invariably have diminished host defenses and are prone to a polymicrobial infection. Lack of sensation in the foot means that the ulcer can be walked on without pain; and the pressure from walking will cause the ulcer to enlarge. Since the diabetic often denies his disease and is casual about getting medical attention it is imperative to have him in a setting where his activity and his treatment can be closely monitored. If the negligence is so clear cut, why doesn't the diabetic often get to court or win his claim? 1) Because it is well know that diabetics lose their extremities; 2) Because juries understand that a diabetic may lose his extremity or a part thereof even with the best of care; 3) Because even if treatment were better, it is difficult to prove that the loss would not have occurred anyway; 4) Finally, diabetics often contribute substantially to their own problems. They often sit and watch an ulcer grow before seeking medical attention; and detailed warnings rarely change this behavior pattern. The treatment of the diabetic foot is one of the areas where average treatment needs to improve dramatically! The loss to the nation of productivity, hospitalization costs, medical costs, and decrease in the quality of life is enormous and it is increasing yearly. It is plain that too few doctors and other health professionals understand the diabetic foot! SCOPE OF THE PROBLEM Of the nearly 4 million diabetics in our country, about 17 percent will have some sort of amputation. Nearly 70 percent of all non-traumatic amputations occur in diabetics, most after the person is over 60 years of age. Most of the amputations will result from foot lesions. As life expectancy of the diabetic increases, (as it does proportionately to the rest of the population) one can anticipate that this problem will also increase. Although it is probably true that the severe insulin-dependent diabetic suffers the greatest incidence of amputation, often this complication of diabetes is unrelated to severity of disease. Since most amputations occur in the over-sixty group, one can infer that the etiology is multifactorial with diabetes enhancing the effects of atherosclerosis and aging. Smoking diabetics often are at greatest risk. Once a diabetic sustains a foot infection or ulceration, medical care is likely to be a prolonged affair. Hospitalization is often required and a prolonged course of expensive treatment often ends in failure to save a portion of the extremity ... amputation. PREVENTION
Several studies have shown that in medical centers which instituted
prophylactic foot care programs for diabetics the rate of major
amputation decreased merely 50 percent. Here are some common
precautionary measures of these programs which seem to work: 1) The patient is examined with particular attention to the vascular tree. Doppler pulses and pressures are measured and if ischemia is apparent, the vascular investigation includes consultation with a vascular surgeon. Revascularization procedures may be indicated. 2) Adequate footwear is prescribed. Particular attention to this one single aspect which is such an important preventative is made the more important because of the likelihood of non-compliance. Diabetics do not wish to think of themselves as having special health problems and it is common to find them wearing stylish ill-fitting shoes despite previous serious foot problems and instruction on proper footwear. 3) The patient is given instruction on care of the feet: a. Stop smoking; b. Inspect feet twice daily; c. Bathe feet daily in tepid water and soap; d. Dry feet carefully without rubbing; e. Avoid extremes of heat and cold; f. Keep feet away from external sources of heat; g. Don't sit with legs crossed; h. Cut nails very carefully without cutting them into the nail grooves. If nails can't be filed or cut, let a physician do it; i. Do not cut or use chemical agents on calluses; j. Avoid circular garters, bandages and any source of pressure; k. Check shoes daily for foreign objects such as pebbles or nails protruding through the sole; 1. Obtain proper footwear (should be inspected by a physician); m. Come to the doctor quickly at the first sign of trouble, DO NOT WAIT!!! PHYSIOLOGIC PROBLEMS OF THE DIABETIC FOOT The diabetic foot suffers from some unique problems and from accentuation of others common to non-diabetics. The triad of neuropathy, ischemia and compromised tissue immunity combine to predispose the diabetic foot to non-healing ulcers. Diabetic neuropathy with partial loss of sensation to the feet is not only a cause of the diabetic foot but a complicating factor in its treatment. Many of the deformities of the feet of diabetics have as their origin the loss of sensation which occurs in diabetics. Continued weight bearing on tissue which is under intense pressure due to foreign bodies in the shoe or an abnormal boney growth is commonplace. The diabetic with neuropathy receives no "signals" of ischemia and breakdown. By the time treatment is sought, the lesion is far advanced and often much more extensive than it appears to an untrained observer. Loss of blood supply to the foot, while common in older patients with advanced atherosclerosis is much more common in diabetics and tends to occur at a much earlier age. Disease of the small vessels is common. In fact, while rare in the general population, it is not rare at all to find ischemia in diabetics with palpable pulses in the feet. Vascular examination must measure flow and to do this doppler pressures and plethysmography are necessary. Often the simple arm-ankle index of pressures obtained with a pocket doppler will give a reasonable indication of the extent of ischemia. Treatment of ischemia may require revascularization in the extremity before healing occurs. Since most diabetic foot problems involve sepsis, and the choice and timing of operation can prove challenging. Use of synthetic grafts often must be foregone because of the presence of infection and the potential for that infection to "seed" the graft. Sepsis in the diabetic foot is common and difficult to treat. Once the diabetic foot is infected, a host of organisms of various kinds will be found. Anaerobic and aerobic cultures are a must as are broad spectrum antibiotics. The treating physician is unlikely to over-estimate either the extent or the virulence of the process. Failure to aggressively treat the diabetic foot infection at the moment of its diagnosis is a frequent cause of disaster. A small innocent appearing infected ulcer today is tomorrow's gas gangrene. Antibiotics alone are usually insufficient even if coverage of both aerobes and anaerobes is adequate. Drainage of closed space infections and adequate debridement are essential for success. The innocent ulcer of the diabetic foot will often hide vast amounts of underlying tissue destruction which must be removed if healing is to occur. Choice of antibiotics should be based on cultures. Coverage before culture results are back should be broad spectrum, usually with two or three antibiotics in combination. Third generation cephalosporins may be adequate although many who treat diabetic feet still prefer a combination of a synthetic penicillin or caphalosporin with either clindamycin or metronidazole (Flagyl) for the anaerobes. SURGICAL TREATMENT OF THE DIABETIC FOOT The goal of surgery of the diabetic foot is to preserve as much as possible. Aggressive debridement, thorough drainage of infection and limited amputations are the essentials. Wishful thinking either on the part of the surgeon or the patient often results in disaster since devitalized tissue serves as a means for the infection to gain a foothold and propagate. Usually the chance for limited amputation is an early one which delay will foreclose. However, extensive and frequent debridement and patience may produce salvage of more of the foot than is expected. Guillotine amputations with the stump left open are often required in the presence of infection; and this technique is likely to salvage more of the foot. Radiographs of the affected foot should always be performed. Ostoomyelitis in the diabetic foot is frequent. Failure to discover the existence or extent of osteomyelitis can lead to disastrous long-term results. The amputation done may be too limited or the patient discharged from the hospital only to return in a few days with a sudden recurrence of infection. Non-weight bearing is essential since diabetics often do not feel pain in the foot. Close observation even after the patient leaves the hospital is essential to assure compliance. Even with superb surgical treatment, a large percentage of diabetic patients will undergo a major amputation. As in the initial treatment, it is important to preserve as much as possible since the diabetic is likely to have future problems in the other leg. The likelihood of a second major amputation within two years is about 50 percent. The recent years, below-the-knee amputations have gained in frequency, an encouraging trend since the below-the-knee amputation is much less disabling. COMMON MEDICO-LEGAL PROBLEMS WITH THE DIABETIC FOOT 1) Failure to assess the vascular status of the diabetic foot prior to even the most trivial operation; 2) Failure to recognize the seriousness of an infected diabetic ulcer; 3) Lack of sufficient drainage or debridement of the foot; 4) Failure to treat the polymicrobial (mixed) nature of the infection; 5) Failure to recognize the existence of boney infection; 6) Inappropriate amputation level... either too extensive or not extensive enough. Lack of blood flow studies is often the cause. SUMMARY The diabetic foot requires special knowledge and expertise which starts with an appreciation of the physiology of the diabetic that causes this frequent problem. Casual treatment of the diabetic foot often results in amputation which could have been avoided with vigorous initial treatment. The standard of care which diabetic foot problems receive is poor. While litigation in this area is not often successful, many claims are scrutinized. Perhaps no area in modern medicine cries out for increased patient and physician education more than does the treatment of the diabetic foot. |