Cath Lab Digest

  Everyone wants to practice good wound care and while knowledge about “advanced” wound care products and techniques is important, the elephant in the room may very well be related to a misdiagnosis of wounds. While many wounds clearly are related to arterial, venous, pressure or neuropathy/diabetes, others are clearly related to combinations of all the above. Of course, secondary diagnoses related to bacterial colonization or pathogenic infection can compromise healing, but attention to other diagnoses and the surrounding skin can go a long way toward achieving success and avoiding errors in medical care.

  I recently saw a patient with painful ulcers who for several months did not respond to multiple treatments. He had actually had biopsies done at another facility, yet they were not read by a dermatopathologist. The patient’s ulcers were atypical but probably represented some form of vasculitis, other vaso-occlusive etiology (eg— fibrin thrombi) or pyoderma gangrenosum. Rather than rebiopsy his lesions, I chose to call the pathologist, the doctor who biopsied the lesions, and the primary care physician, essentially attempting to sort things out. Further consultation with the pathologist identified fibrin thrombi, possibly related to a clotting disorder. In the meantime, however, the patient was admitted to a hospital (no one called me and it was a hospital in a nearby city where I am not credentialed) and was seen by a hospitalist who consulted an orthopedic surgeon, which resulted in the patient having his third toe amputated.

  The good news is that this patient had no complications yet as a result from his surgery; his leg continues to develop new lesions. The bad news is that his doctors think they did the right thing, but I believe that this man has a problem or problems related to a diagnosis that might have been treated medically. Still, the patient is a work in progress as I still try to connect with his primary physician (who does not see patients in the hospital anymore and is only using hospitalists!) and search out the pathology report from the toe amputation. I clearly recognize that the patient has some role in this, as he has not questioned any of his caregivers in ways that would help him, but as clinicians we have not helped him by communicating well with each other.

  While I will talk more about the need to get an accurate diagnosis more in my future blogs, I have found the diagnostic decision program, VisualDX (www.visualdx.com) to be exceptionally useful for teaching other physicians the value of a broader differential diagnosis. If you’ve never seen it, I highly recommend you take a look.

  Dr. Mostow indicated no financial conflict of interest.