Osteomyelitis Patient Gets Inadequate Treatment – Who’s to blame?

There was an elderly diabetic patient who was admitted to the Endocrinology department of Central Hospital. He had come in with a “diabetic foot“, he was febrile, there was a large ulcer/abscess on the medial surface of his lower limb, stretching from the proximal foot to distal leg. Why Endocrinology instead of Orthopaedic Surgery? Well, he’s diabetic, ain’t he?

The Endocrinology team tweaked his diabetic control with subcutaneous insulin, sent off blood and wound cultures, ordered X-rays of the offending area and fired off a blue letter to the Orthopods. The man’s diabetic neuropathy was so bad that even though the abscess looked positively nasty, he didn’t feel an ounce of pain.

The Orthopaedic Surgeons came. They looked at the wound. Looks bad. They prodded it with an instrument to gauge the depth of the abscess (if the bottom is soft-tissue, it’s good, if the bottom is bone, high chance of osteomyelitis)… there was the crunching of weakened bone even on gentle prodding. They looked at the X-ray pictures – “consistent with osteomyelitis”. Furthermore, just as they had expected from the physical examination, the infection had pervaded most of the bone in the area.

Osteomyelitis is infection of the bone. It is a dreaded condition/post-operative complication because it’s very hard to treat as most antibiotics don’t reach the site of infection very well.

For this man, they cultured Methicillin-Resistant Staphylococcus Aureus (MRSA). It’s nasty stuff. It eats away at tissue, causes lots of pus and pain, and worse of all is resistant to commonly used forms of antibiotics.

Given his immune-compromised status (due to long-term poorly-controlled diabetes mellitus), and poor blood supply in the area (due to long-term poorly-controlled diabetes mellitus) and the danger of his condition (due to… no, wait, it’s a serious infection, that’s all), the best clinical decision the orthopaedic surgeons and endocrinologists came to was: amputation, especially since the man wasn’t walking prior to admission anyway.

The man refused. His family refused.

Could they be blamed? After all, losing a body part is a very serious issue. And like family who refuse to pull the plug of a brain-dead man on life support, they fail to understand that what appears to be alive/viable is actually dead/non-viable. Worse still, in this case, this decision could have a major impact on whether the man lives or dies.

They fail to understand the gambling concept of cutting your losses. Money that’s put on the table is no longer yours, and there’s no point in throwing more money after it if the odds are against you. Similarly, he’s already gotten into this severe situation. Get out safely while you can.

The family were well within their rights to seek a second opinion. Rather than seeking a second opinion from an orthopaedic surgeon or similarly trained specialist, they opted to see a General Practitioner. The Endocrinology team at Central Hospital, respecting his wishes, did not keep him against his will and allowed him to be discharged against medical advice. They sent off a memo to the GP repeating in no uncertain terms: “This is osteomyelitis!”, pointing out X-ray findings and the culture results.

What is mindboggling is that the GP actually chose to treat the man himself with an Incision & Drainage (I&D) and antibiotics. This is the type of treatment you would give to a normal abscess, not an MRSA osteomyelitis in a diabetic patient.

What. The. Hell. In J.’s opinion, the humble GP’s response would have been to assess the information laid before him and yield to the superior experience and surgical talents of the specialists. The knowledgeable GP would see the severity of the condition, know that it was beyond his field of expertise to treat and refer the patient to another specialist for the second opinion or say, “Yes, the Central Hospital doctors are correct.” What kind of monkey treatment is that?

In this case, he lays the blame at the feet of the GP, who unlikely the trusting family, was armed with the information and failed to use it.

J. doesn’t know what happened to the man. He speculates that he’s probably not cured and will lose the leg still, if not his life.

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One response to this post.

  1. I noticed that this is not the first time at all that you write about this topic. Why have you decided to write about it again?

    Reply

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