Thursday, June 30, 2005

A Post-Surgical Complication

The patient initially presented with an antalgic gait, refusing to use the left leg. Almost no weight bearing at all. Agitated enough that sedation was required prior to x-ray, the diagnosis was a fractured metatarsal.

The recommendation was for ORIF, which was done the next morning. The report was good and the doctor predicted full return of function. The extremity was splinted and the doctor recommended no weight bearing if possible and very limited weight bearing at all.

However, after several days, the patient didn't seem to be improving. Another trip to the doctor, another set of x-rays. The verdict was satisfactory healing. Unfortunately, all was not as it seemed.

The next day, with the patient refusing to eat or drink and becoming gradually less interactive, there was need for a second opinion.

This is where I came in. As I entered the room, the most noticeable thing was that this was a very different patient from what I was used to. I knew the patient in her pre-morbid state and she was usually very active and personable. I couldn't help a slight wince at the odor, as well.

"I don't know what's causing the smell," her companion stated. "She saw her regular doctor yesterday and I was told everything was going well."

After greeting and reassuring the patient, I removed the dressing and examined the foot. It was somewhat swollen, but, overall, looked pretty good. However, there was a large ulcerated lesion over the lateral malleolus that was dripping pus.

Gasping, the patient's companion exclaimed, "I wasn't able to be there yesterday when they examined her and they didn't mention anything about this to me when I picked her up!" The doctor had apparently missed this wound, although I don't know how.

I prescribed Augmentin and pain meds. I taught the companion how to do wet to dry dressing changes and recommended them TID. I also told her I would like to see the patient again the next day.

For about a week, things were touch and go. I was gradually building a greater rapport with the patient and was able to examine her more easily. However, the skin surrounding the wound was very loose and showing signs of necrosis. The wet to dry dressings did seem to be working, though. I counseled her companion that if things didn't start to improve soon, we may have to consider referral for a skin graft. I could see underlying bone and tendon. The wound did not seem to extend to the joint.

The next few days showed improvement. However, the companion told me that she had left the patient at home alone the day before for only 40 minutes and returned to find a disaster. The Augmentin had caused a common side effect, diarrhea, and there was stool all over the living room and dining room. Code Brown, indeed!

I reassured her that this would be self-limited and advised proper care. It was apparent that the meds and dressing changes were working and that it was doubtful that the patient would require a skin graft.

It has now been three full weeks since the original surgery. I am happy to report that my wife's dog, Chatter, is doing very well. I know you are relieved. She is weight bearing and the wound is shrinking rapidly.