Chapter 2

“I was covering my first wound care clinic without senior assistance”

During my second month of residency in my PGY1, I was covering my first wound care clinic without senior assistance. Toward the end of the clinic, a patient who had been under the care of my attending for about one year for the same ulcer presented for follow-up care.

The treatment had been largely the same, using a collagen dressing, absorbent foam, and total contact cast (TCC) throughout the majority of his treatment course. The attending was in a rush as he was leaving to catch a flight, and he briefly looked at the patient’s foot, told me it was stable, and ordered the same treatment (including a TCC).

I had never seen the patient before,

but I could tell something did not look right.

The attending insisted the ulcer was stable and I could modify the treatment if needed. He promptly left the facility after seeing this patient. During one of my first encounters as a resident in wound care clinic, I had to make a decision:

do I listen to my attending, or do I listen to my gut?

Without hesitation, I began examining a plantar ulcer that was mostly callus covered. After debriding the thick layer of callus, I noted a small ulcer, measuring 0.5cm x 0.5cm x 0.2cm, that was dusky-red in appearance at the level of the second metatarsal head. The patient was elderly and did not speak much that day. I asked the nurse to check his vitals: his blood pressure was 90/60 and his heart rate was 120 beats/min. I noticed he was diaphoretic, and I sensed he may be shivering. I did not know exactly what was going on at the time, but I knew something was going on.

I informed the wound care staff that I would like the patient to be admitted, and I called my attending to inform him. He did not seem happy as he was out of the state, and he told me to ask another attending if he could cover for him. The emergency department noted the patient’s vitals were unstable, so he was admitted with a diabetic foot infection with possible septicemia. His X-rays did not show any signs of any gas gangrene.

The next day was a weekend,

and I went to round early in the morning on the patient.

As I unwrapped the dressing, I noted a horrific appearing foot.

I gently introduced my finger at the plantar ulcer site and did not feel any resistance: my finger went directly through all fascial planes, and the seemingly liquified skin and soft tissue dripped out of the foot. There was about 10 mL of dishwater pus in the ulcer site, and my finger probed all the way through to the level of bone. I quickly sent a clinical picture and called the attending covering and told him I suspect necrotizing fasciitis, but he doubted my assessment.

“Give me an LRINEC score and let’s go from there. I do not think the OR wants to come in for a wound debridement on a Saturday”.

I went back into the patient’s room, and in the 20 minutes I was away, the foot was even worse, and the toes were turning purple, black with hemorrhagic blisters forming. I sent another clinical picture to my attending. This time, I sent the picture to the senior resident as well, who supported my assessment and contacted the OR and my attending to come for immediate surgical intervention. By the time everything was set up for surgery, the patient’s infection spread more proximal than the point where a trans-metatarsal amputation would be effective. We performed an immediate guillotine amputation.

At the conclusion of the surgery, the remaining bases of the metatarsals, dorsal and plantar tendons and neurovasculature remained exposed without adequate viable skin and soft tissue for wound coverage.

Shortly after surgery, I received a phone call from the patient’s original attending who said “good thing we didn’t send him home in a TCC doc; he had quite a scary infection.” Without a doubt, this patient would have likely passed away if he went home in a cast that day with flesh-eating bacteria in his foot.

Story by Dr. MJK