March 24, 2015

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Ramblings of an Itinerant Wound Care Guy

Don’t Kid Yourself, Amputation Is Unquestionably A Failure

 by Dr. Michael Miller

I recently saw an ad for a pending lecture at a national conference that piqued my interest much like “deflate-gate”.  The title of this lecture horrifically touted that Amputation need not be considered failure.  As a full time wound care doc, I work to identify those conditions that place patients at risk of all consequences both limited and catastrophic.  We use the catchy title of “Limb Preservation”.  We start the process by engaging in the unusual behavior of making definitive diagnoses, then systematically address them in as comprehensive manner as possible.  I am proud to tell you that while there are occasions in which a terminally damaged digit is lost,  that we have rarely sacrificed the greater part of a foot and more, have had only 3 lower extremity amputations in the last 5 years on patients who’s care remained exclusively with us.  Of course, when a patient for whom we have created and implemented a “Limb Pres” care plan is taken out of our system (usually via a hospitalization for a reason other then the lower extremity problem), the facility forces that be unfortunately but infrequently demonstrate their inadequacy and paranoia by gang-harangueing the patient and family.  They are lambasted with lurid tales of the condition marching up the leg engulfing the foot, knee, torso, and brains much like a flesh-eating PacMan.   The patient’s confidence now neutered has little chance against this persistent onslaught of inadequacy and so, much like the Queen song, “Another One Bites The Dust”.

I do not know who will be presenting this attempt to mitigate abject failure of care nor do I really care.   The mere consideration that the performance of an elective amputation is acceptable an that all is right with the world seem to me to be an admission of technological impotence.  I am not talking about a traumatic event in which the extremity has become a high risk gam no more functional than a flesh colored Lego.  I am talking about the loss of a limb, a major, integral part of ones self taken blithely through what was unquestionably a series of unrecognized but correctible events; a perverse falling domino affect further amplifying the inadequacy of one or many to correct the aberrant conditions. The final curtain comes down culminating in extremity Gotterdammerung.

I cannot recall a patient with any condition coming to me and asking for a catastrophic outcome.  Rather, they come to me with that sword of Damocles hanging over their heads from far to many underconfident  wound care dabblers. The mantra of need for amputation is repeated ad nauseum in Hare Krishna fashion.   Never a mention of what they would or could to prevent it, rather a litany of proposed attempts, none of which presented with any conviction regarding the “If this fails, then…”

It is not so much that the occurrence of this tragic outcome is unacceptable, as there are things done wrong that have good outcomes and things done well that have undesirable endpoints.

The 54 year old diabetic with poor vascular supply escaped the “Hospital Wound Care Team” by signing out AMA.  They had apparently failed to convince him of the beneficial novelty of being a one-legged Homo Sapien.  He appeared at our clinic fresh from his great escape, terrified but hopeful.  His wife of 35 years had convinced him that even the smallest chance of salvation was worth the trip.  A quick evaluation and off he went to a colleague who quickly obtained a vascular intervention wherein, blood was soon discovered in areas previously barren of it.  Debridement skills reincarnated tissues declared post-mortem with healthy tissues now substituting for the previously surface.  Antibiotics soon floated leisurely to angry soft tissues which responded in kind.  Much like 1960’s action figures, he now talked and walked on two essentially identical legs .

Is Limb Salvage a miracle akin to manna from heaven or simple, logical evaluation and diagnoses smothered in a healthy dose of confidence and expertise?  Probably equal arts of both.  The medical notes we sent to his would be ampu-cutioners  will probably not make them happy but they may yet think differently the next time they are faced with what they perceive as a firm grasp of the obvious.  In the meantime, the patient has sworn to visit them all, doc by doc and nurse by nurse to demonstrate perhaps a little too proudly that what they willingly and knowingly were willing to abdicate, transported him back to them.

As far as that pending lecture, I lament the premise but more, the presenter who would knowingly and willingly bare their soul regarding their catharsis of inability.  Demonstration of expertise…I think not.

So let’s cut to the chase.  Amputations are never considered acceptable as an endpoint.   The emotional, psychological, financial, social, physical, circulatory, cardiac, musculoskeletal, neurologic, and human effects are so heinous, abhorrent, repulsive, vile, and execrable that the mere consideration of this as acceptable questions anyone’s humanity.   In short, the casual suggestion that lower extremity amputation is an acceptable outcome is simply unacceptable.

Until we ramble together next time.

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