Little Things Matter

Yes, the little things really do matter. I’m referring to a patient I had in years past. He was pretty typical for one of my patients. He was an elderly somewhat demented noncompliant diabetic (as if there is any other type) who had congestive heart failure (CHF) which caused his lower legs to be horribly swollen most of the time because he absolutely refused to elevate them, even going so far as to sleep in his wheelchair. He had bad peripheral vascular disease (PVD) causing stasis ulcers to form on his lower extremities. What I mean by bad PVD is that his arteries were so clogged with atherosclerotic plaques from uncontrolled cholesterol levels and damage from uncontrolled blood sugar levels that the red blood cells were probably in single file and moving along about as well as a guest at Club Gitmo.

He also suffered from chronic obstructive pulmonary disease (COPD) from years of smoking. Add in some high blood pressure (HTN), emphysema, diabetic retinopathy and neuropathy, chronic renal failure, gastric reflux, chronic pain, and constipation one starts to get the picture that he was not the healthiest chap on the planet, but he was doing ok considering.

His family would come to visit almost everyday and his wife who lived in assisted living across the street would come over about every other day. Stan’s life was not great but what more can you ask than to have loving family at your side.

As time went on we worked very hard to get Stan’s wounds on his lower extremities to heal. We were successful in that endeavor except for one small area on the top of his toes on his left foot. Try as I might I could not find the right combination of medications to get his toes to heal up. The wounds were not getting worse so I was not concerned but we had to continue to document that we were trying to get them healed or the state would consider him a deficiency and possibly fine the owners of the Long Term Care Facility. The wounds probably would not have healed because Stan had no circulation of blood in his feet. His toes were mildly cyanotic (blue) and cold to the touch. I ordered that bacitracin be applied to the top of his toes twice daily and the Podiatrist agreed that there was nothing else I should worry about for the moment.

Stan’s circulation and diabetic neuropathy was so bad that he had no feeling in his feet. One night the “nurse” (as I’ll call her because the building hid who did the deed) applied ointment to his toes. The next morning I was called by the daytime LPN to come and look at Stan’s toes. Immediately I knew something was very wrong. The remaining ointment on his toes was a deep green, and no it was not pus from an infection. The “nurse” the night before put the wrong ointment on his toes either by ignorance, mistake, or practicing medicine on her own. The result was that the enzymatic ointment she had applied ate the skin off the top of his toes down to the bone.

I was mortified and immediately called the Podiatrist and he came over right away to examine and treat Stan, who was in no discomfort and was annoyed at the attention.

I continued to monitor the treatment the Podiatrist was providing and discussed with him the appearance of gangrene, first in the toes and then in Stan’s foot. It was apparent Stan’s wounds were not doing well and that drastic measures might have to be instituted.

As the gangrene marched it’s way up Stan’s leg the vascular surgeon I sent Stan to recommended that the leg be amputated. The family agreed and I arranged for the pulmonary and cardiac consults Stan needed prior to surgery. All were apprehensive about surgery. Stan would die if his leg was not surgically removed but how long he would live if it was not done no one could say.

I said goodbye to Stan as he left the facility and headed for surgery across the street at the hospital. I called two days later to see how Stan had done in surgery. I was told that he had a severe stroke on the operating table and never regained consciousness. His family had him transferred to a Hospice where he died the following day. I felt terrible. A patient who should never have had to go to surgery died and a father and husband was gone because a “nurse” applied the wrong ointment to his toes. I complained but the “nurse” was never identified by the powers that be.

When asked about patient treatment I always think of Stan.

Yes, the little things really do matter.

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