A diabetic foot dilemma resolved through the use of the diabetic foot MDT
K F Styles, C M Burns, H Shaikh & J Turner
A 63-year-old type 2 diabetic gentleman with paranoid schizophrenia presented in October 2008 with systemic sepsis arising from multiple neuropathic foot ulcers. Foot MRI confirmed extensive osteomyelitic change. This admission followed two previous similar episodes which culminated in surgical debridement of the ulcers and amputation of the second and third toe of his left foot. Post-operatively, as his condition improved he was unable to comply with IV antibiotics, VAC dressings and off-loading of his feet due to his schizophrenic delusions re-emerging.
On his admission, he tolerated IV antibiotics fleetingly during the acute phase of his illness. However as IV access became problematic, he was subsequently switched to oral Ciprofloxacin and Clindamycin. He was discussed at the Diabetic Foot MDT. It was felt that bilateral below knee amputations would be an option which, given our patients lack of capacity, would need further discussion with the next of kin and his psychiatrist to ascertain the patients best interest. In the interim, we continued with oral antibiotics and closely monitored his clinical state. His condition deteriorated and he was discussed in further MDT and case conference settings with a Consultant Diabetologist, Vascular Surgeon, Microbiologist, Psychiatrist, Next of Kin, Community Psychiatric Nurse and Nursing Home Manager present. It was concluded that due to this patients inability to tolerate IV antibiotics and his poor rehabilitation potential combined with his poor quality of life and prognosis, it was in his best interest to be treated palliatively. To this end we withdrew antibiotics and discharged him to his nursing home with community palliative support.
This case highlights the vital importance of regular diabetic foot multidisciplinary meetings in tailoring management to meet individual patient needs.