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AFARR
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Posted: 5/18/2012 1:50:15 PM
Patient gave permission to share pics and some info to the public.

Patient was seen in the ER for 'cellulitis'. I was consulted. This is about 2 months ago.
Started as a callus on the bottom of the foot, used 'Ped Egg', a few days later noticed redness and treated with peroxide.
Didn't feel better 2 weeks later...redness on foot going to ankle, soreness to foot, started to get fever/chills....so they went to the ER.
Blood sugars about 400 (and the patient had never been diagnosed diabetic). White count about 16.

Click To View Spoiler



Click To View Spoiler




Wounds tracked from bottom to top. Puriulence under the necrotic tissue on the top, tracking towards the ankle and towards the big toe.

Did bedside surface debridement, flushed wound with betadine 'solution' (mix of saline/betadine)...took them to the OR the next day, debrided, flushed it well, dressed it.
The wound tracked about the length of my little finger towards the ankle and towards the big toe (under the edge).

Put a wound vac on the wound the next day.

I told the patient that we're going to try everything to save the foot, but you have a high likelyhood of losing a part of, or all of the foot.

This is the patient a few days later at the wound center:

Click To View Spoiler




(Yes, that's a tendon you're seeing...and with the 'purplish' color to the little toe, it didn't look like it was going to make it)

Regular wound care, hyperbaric Oxygen treatments (supervised by one of the guys in our practice who is at the wound center regularly)

Today (almost healed...I probably won't see them again). Patient very happy to have an intact foot.

Click To View Spoiler


“We live in a society of excuses, pleading for second chances, and unwillingness to take responsibility for our actions,”
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Posted: 5/18/2012 1:52:16 PM
Wow.
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Posted: 5/18/2012 1:52:26 PM
In before Flesh eating bacteria!
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Posted: 5/18/2012 1:54:25 PM
That is incredible.
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Posted: 5/18/2012 1:54:46 PM
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Posted: 5/18/2012 1:55:56 PM
Beware the diabetic foot.
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Posted: 5/18/2012 1:56:09 PM
I'd rather watch the chain saw beheading video thatn look at those pictures again...
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Posted: 5/18/2012 1:56:36 PM
I didn't look at the pics...

I once lived on the 21st floor of an apt building in Canuckistan. There was a man who lost both legs and had nurses with him all the time, living in the building. I would see him in the lobby, but never said anything more than a hello.
One day I got on the elevator and his nurse wheeled him into the same elevator... the smell. He had gangrene and was being treated outpatient. I will never forget that smell. Poor nurses, it was bad enough being trapped in the elevator for a few floors, but to be around that all day...

Do you ever encounter patients who have that "smell"?
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Posted: 5/18/2012 1:58:40 PM
Ughhh. I have a neighbor that's probably in the 400 lb range. I rarely see him outside since they started chopping his legs off, starting at the feet.
HighStrung1
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Posted: 5/18/2012 1:59:59 PM
Bad Fucking Ass!!!!

BRB, gotta pick up my 10 year old from school, she'll love these pics!!!
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Posted: 5/18/2012 2:00:24 PM
glad they were able to keep the foot at least.
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Posted: 5/18/2012 2:01:37 PM
so was this a problem due to him being diabetic and not knowing it or did he just get dealt a bad hand after scuffing away the bottom of his foot with a stone?

scary shite there
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Posted: 5/18/2012 2:01:43 PM
Damn good work.
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Posted: 5/18/2012 2:02:55 PM
I'm calling BS on this. I used a Ped Egg to shave off a calloused part of my hoof the other night. You have to be a fucking contortionist to use those things. There is no way this patient had the range of motion to use a Ped Egg on herself at that wound site.

Which of course means that someone had to do it for her...Which is the only part about this that makes me want to throw up.


Originally Posted By AFARR:

Started as a callus on the bottom of the foot, used 'Ped Egg',
Originally Posted By SWIRE:

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Posted: 5/18/2012 2:03:35 PM
Well fuck.
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Posted: 5/18/2012 2:04:59 PM
What caused it?
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Posted: 5/18/2012 2:07:32 PM
Originally Posted By Spade:
What caused it?


Diabetes.
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Posted: 5/18/2012 2:08:15 PM
Well damn, good job saving a foot. I bet that makes you feel as good as they do
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Posted: 5/18/2012 2:09:19 PM
All the sudden, my Indian food doesn't taste so good.
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AFARR
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Posted: 5/18/2012 2:09:21 PM
Originally Posted By maleante:
I didn't look at the pics...

I once lived on the 21st floor of an apt building in Canuckistan. There was a man who lost both legs and had nurses with him all the time, living in the building. I would see him in the lobby, but never said anything more than a hello.
One day I got on the elevator and his nurse wheeled him into the same elevator... the smell. He had gangrene and was being treated outpatient. I will never forget that smell. Poor nurses, it was bad enough being trapped in the elevator for a few floors, but to be around that all day...

Do you ever encounter patients who have that "smell"?


All the time. An Attending at my first year of residency called it the 'rotten pumpkin' smell.....
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AFARR
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Posted: 5/18/2012 2:10:58 PM
Originally Posted By Notched:
so was this a problem due to him being diabetic and not knowing it or did he just get dealt a bad hand after scuffing away the bottom of his foot with a stone?

scary shite there


Combination of both. High sugars for (presumably....I think the A1C was about 9 or 10) a while, 'other' issues (taking care of a very ill family member...so they weren't paying attention to themselves), and the self treatment.

AFARR
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Posted: 5/18/2012 2:11:52 PM
wow, just wow...
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AFARR
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Posted: 5/18/2012 2:12:15 PM
Originally Posted By SevenMaryThree:
I'm calling BS on this. I used a Ped Egg to shave off a calloused part of my hoof the other night. You have to be a fucking contortionist to use those things. There is no way this patient had the range of motion to use a Ped Egg on herself at that wound site.

Which of course means that someone had to do it for her...Which is the only part about this that makes me want to throw up.


Originally Posted By AFARR:

Started as a callus on the bottom of the foot, used 'Ped Egg',


Oh, they could reach the bottom of their foot...couldn't SEE what they were doing down there, but could reach it.

“We live in a society of excuses, pleading for second chances, and unwillingness to take responsibility for our actions,”
AFARR
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Posted: 5/18/2012 2:13:39 PM
Originally Posted By badfish274:
Damn good work.


I did the inital prep, got them to the wound care center....who did the bulk of the work, so I can't take too much credit....it's just nice to see one that does that well.

AFARR
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Posted: 5/18/2012 2:14:24 PM
Had a diabetic foot come in the other day. They were already missing half the foot, probably going to lose the rest of it. I spent about an hour in the room trying to find IV access until giving up.

I really need to start smoking again, just so I can kill my sense of smell.
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Posted: 5/18/2012 2:14:34 PM
Wow that looks painful. What does it smell like?
Over there.
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Posted: 5/18/2012 2:18:00 PM
Originally Posted By badfish274:
Damn good work.


+1. Good job OP
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Posted: 5/18/2012 2:19:04 PM
Wow
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Posted: 5/18/2012 2:20:39 PM
Originally Posted By SKSLVR:
Originally Posted By Spade:
What caused it?


Diabetes.


Obligatory.

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Posted: 5/18/2012 2:20:43 PM
nice job for helping him keep his foot

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Posted: 5/18/2012 2:20:50 PM
[Last Edit: 5/18/2012 2:22:42 PM by TheGrayMan]
The bulk of your cases of wet gangrene in a modern ER will be in diabetic feet.

Peripheral-Arterial-Disease patients make up the remainder.

The smell is fairly unmistakable.

ETA: now that I think about it, the same could be said of dry gangrene... and the last case of gas gangrene I saw was also in a diabetic.
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Posted: 5/18/2012 2:42:13 PM
Originally Posted By SevenMaryThree:
I'm calling BS on this. I used a Ped Egg to shave off a calloused part of my hoof the other night. You have to be a fucking contortionist to use those things. There is no way this patient had the range of motion to use a Ped Egg on herself at that wound site.

Which of course means that someone had to do it for her...Which is the only part about this that makes me want to throw up.


Originally Posted By AFARR:

Started as a callus on the bottom of the foot, used 'Ped Egg',


Just want to say that I enjoy your posts.
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Posted: 5/18/2012 2:45:07 PM
Thats amazing!
Glad that they saved the foot.
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Posted: 5/18/2012 2:45:39 PM
Originally Posted By AFARR:
Patient gave permission to share pics and some info to the public.

Patient was seen in the ER for 'cellulitis'. I was consulted. This is about 2 months ago.
Started as a callus on the bottom of the foot, used 'Ped Egg', a few days later noticed redness and treated with peroxide.
Didn't feel better 2 weeks later...redness on foot going to ankle, soreness to foot, started to get fever/chills....so they went to the ER.
Blood sugars about 400 (and the patient had never been diagnosed diabetic). White count about 16.

Click To View Spoiler



Click To View Spoiler




Wounds tracked from bottom to top. Puriulence under the necrotic tissue on the top, tracking towards the ankle and towards the big toe.

Did bedside surface debridement, flushed wound with betadine 'solution' (mix of saline/betadine)...took them to the OR the next day, debrided, flushed it well, dressed it.
The wound tracked about the length of my little finger towards the ankle and towards the big toe (under the edge).

Put a wound vac on the wound the next day.

I told the patient that we're going to try everything to save the foot, but you have a high likelyhood of losing a part of, or all of the foot.

This is the patient a few days later at the wound center:

Click To View Spoiler




(Yes, that's a tendon you're seeing...and with the 'purplish' color to the little toe, it didn't look like it was going to make it)

Regular wound care, hyperbaric Oxygen treatments (supervised by one of the guys in our practice who is at the wound center regularly)

Today (almost healed...I probably won't see them again). Patient very happy to have an intact foot.

Click To View Spoiler




Holy shit! Good job doc!
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AFARR
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Posted: 5/18/2012 2:48:05 PM
Originally Posted By TheGrayMan:
The bulk of your cases of wet gangrene in a modern ER will be in diabetic feet.

Peripheral-Arterial-Disease patients make up the remainder.

The smell is fairly unmistakable.

ETA: now that I think about it, the same could be said of dry gangrene... and the last case of gas gangrene I saw was also in a diabetic.


I've gotten used to the tissue necrosis smell...but Gas Gangrene really stinks.

Dry's not too bad (I just got done treating a 90+ year old guy with dry gangrene in the 5th toe.....just wound care (betadine dressings around the base to ensure it didn't get 'soupy') until it fell off).

AFARR
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Posted: 5/18/2012 2:49:10 PM
In before "fat people are disgusting" comments.
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Posted: 5/18/2012 2:51:37 PM
Originally Posted By davisac:
Wow.


They are lucky
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Posted: 5/18/2012 2:58:22 PM
[Last Edit: 5/18/2012 2:59:17 PM by toekneeg]
My wife is a type 1 diabetic on an insulin pump. Stories like this scare the hell out of me.

My buddies look at me funny when I spend 30 minutes cleaning up broken glass at a party. I should show them this thread to show them why i do so.

ETA - No she is not a 300 lbs whale. I've posted pics before
MYAH!!
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Posted: 5/18/2012 2:59:20 PM
[Last Edit: 5/18/2012 2:59:52 PM by TrojanMan]
Originally Posted By diehippy:
In before "fat people are disgusting" comments.


I'm sure they'll be along soon enough.

But holy crap, if you ever needed motivation to get off the couch...
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Posted: 5/18/2012 3:01:12 PM
HELL of a job, Doc!
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Posted: 5/18/2012 3:01:38 PM

Originally Posted By Tweek218:
I'd rather watch the chain saw beheading video thatn look at those pictures again...

It wasn't even that close to graphic.


It was amazing to see how the foot looked after treatment though, wow.
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Posted: 5/18/2012 3:02:11 PM
Originally Posted By AFARR:
Originally Posted By TheGrayMan:
The bulk of your cases of wet gangrene in a modern ER will be in diabetic feet.

Peripheral-Arterial-Disease patients make up the remainder.

The smell is fairly unmistakable.

ETA: now that I think about it, the same could be said of dry gangrene... and the last case of gas gangrene I saw was also in a diabetic.


I've gotten used to the tissue necrosis smell...but Gas Gangrene really stinks.

Dry's not too bad (I just got done treating a 90+ year old guy with dry gangrene in the 5th toe.....just wound care (betadine dressings around the base to ensure it didn't get 'soupy') until it fell off).

AFARR


I don't mind dry gangrene either... you can just snap those toes right off.
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Posted: 5/18/2012 3:05:32 PM
[Last Edit: 5/18/2012 3:06:30 PM by DriftPunch]
I'm not learned in this area...

What is the ultimate cause, poor circulation from diabetes leading to an inability to fight as simple infection? Or was this an infection that would have hit anybody hard, but truly spanked a diabetic?
AFARR
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Posted: 5/18/2012 3:06:00 PM
Originally Posted By toekneeg:
My wife is a type 1 diabetic on an insulin pump. Stories like this scare the hell out of me.

My buddies look at me funny when I spend 30 minutes cleaning up broken glass at a party. I should show them this thread to show them why i do so.

ETA - No she is not a 300 lbs whale. I've posted pics before


Another patient today.....probably won't do quite so well (didn't get permission for pics, so none of those)...

Insulin Dependent Diabetic.

Numb below the knees. Ulcer for more than 6 months on one foot....

Healed that foot.

Walked on a nail in his boot (the other foot), opened an ulcer. Multiple areas of infection, osteomyelitis....pathologic separation of the achillies tendon on that side. Surgical debridement took about 20% of his foot.



He has a slim chance of keeping that foot....but the Wound Center is trying.

I see a LOT of Diabetic patients with problems from broken glass, nails, etc....in addition to the normal pressure breakdown and calluses they get in their feet (areas that frequently ulcerate).

Good job on the
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Posted: 5/18/2012 3:08:14 PM
My wife's a triple certified WOC nurse. She lives for that shit.
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Posted: 5/18/2012 3:09:23 PM
Originally Posted By YoungGOP:
That is incredible.


That's nothing.
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Posted: 5/18/2012 3:11:07 PM
Originally Posted By Tweek218:
I'd rather watch the chain saw beheading video thatn look at those pictures again...


This.
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Posted: 5/18/2012 3:12:56 PM
Can I avoid this by simply not being a fat ass? If so I'm going to head around the block an extra time tonight.
AFARR
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Posted: 5/18/2012 3:18:54 PM
Originally Posted By DriftPunch:
I'm not learned in this area...

What is the ultimate cause, poor circulation from diabetes leading to an inability to fight as simple infection? Or was this an infection that would have hit anybody hard, but truly spanked a diabetic?


More the latter. The patient's circulation was not bad at all. The Diabetes can mask an infection early (so it gets worse before they get treatment), and is often polymicrobial....(many different bugs), and with high sugars (over 200) makes it VERY hard to fight the infection and heal a wound. Any numbness (from neuropathy...this patient didn't have any clinical signs of it) makes it hard for them to notice problems and get them treated quickly. You can pull nails, splinters, glass out of a neuropathic patient's foot and they never felt them....I've debrided to the heel bone without them feeling me so much as scraping the surface of the bone.

Diabetics do get poor circulation (and calicification of the vessels) very quickly...so that leads to many issues also (just not in this case).

AFARR
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Posted: 5/18/2012 3:19:23 PM
[Last Edit: 5/18/2012 3:19:59 PM by toekneeg]
Originally Posted By killingmachine123:
Can I avoid this by simply not being a fat ass? If so I'm going to head around the block an extra time tonight.


Not really. Most of the cases of diabetes is brought on by poor diet and lack of exercise. My wife, for example, was diagnosed when she was 17 out of no where. Regular diet, was in numerous sports programs. One day she passed out at school. She woke up and docs diagnosed her with diabetes. Been on pumps and needles ever since.

MYAH!!
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Posted: 5/18/2012 3:22:32 PM
Damn.

My uncle died after infection due to a diabetes related ulcer. He was stupid, didn't take care of himself, got an ulcer and didn't get assistance for it and it progressively got worse and they cut his foot off, then his leg. After that he wound up passing away. He wasn't the best man in the world, but I can't imagine going through that.
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