Dm Ii And Vascular Disease

[harleyman]

Does anyone have referenes or experience in getting vascular disease of the lower limbs service connected as secondary to DM II?

Veteran is s/c for DMII and PN with loss of use of one of the lower extremity ( 2 K awards one for loss and the other for ED),and also s/c for IHD. But recent claim for DVT (blood clot and infection in lower leg secondary to DMII ,VA has denied stating the leg condition is not related to the DMII.

Might the veteran get the DVT (clot and or infection)s/c as secondary to IHD?

Thanks!

Edited July 27, 2013 by harleyman

[free_spirit_etc]

http://www.sciencedirect.com/science/article/pii/S0732889399000280

Abstract

We conducted a prospective study among 62 hospitalized adults, to evaluate the factors that contribute to the development of cellulitis. The majority of patients had multiple possible predisposing factors, and the most common were: diabetes mellitus (31/62), history of cellulitis (30/62), edema (28/62), peripheral vascular disease (25/62), and skin changes suggestive of tinea pedis (20/62). A significant number of patients reported and were clinically noted to have dry skin (42/62). Large controlled studies are needed to evaluate whether aggressive control of possible risk factors can reduce the incidence of cellulitis.

[free_spirit_etc]

Wow! I am having trouble getting my brain kicked into full gear today -- but it certainly looks like you have several things going - with both the VA and the private hospital.

1. Failure to diagnose

2. Even worse - Misdiagnosis - which led to

3. Improper treatment that worsened his condition.

The fact that the veteran went from fully ambulatory to unable to ambulate - without an adequate diagnoses - while under the care of the VA is horrid!

And -- I don't even think this is done playing out yet. Secondary conditions that can arise from the long-term use of antibiotics might not be pleasant. The fact that he is still on antibiotics would lead me to believe the infection is not safely all the way gone (so there still might be a possible risk of him losing the leg).

As for standard of care - My gosh! ANY suspicion of ANY type of infection in the lower limbs of diabetics should be taken as a serious matter! He went to the VA with a diagnosis of suspected infection and they didn't check him for infection?

Back in the day, when I was a CNA, CNAs were not even allowed to cut toenails on diabetic patients because of the risk of going from a simple nick of the skin to losing an entire leg - because of circulation issues and impaired healing abilities.

ANY suspected infection in the foot or leg of a diabetic patient should be considered potentially serious.

[free_spirit_etc]

I think, as far as malpractice goes, the VA and the first private hospital (besides saying that they did not cause harm) would try to point the finger at each other.

I am not real familiar with VA malpractice claims, and so I am not sure if the VA just had to contribute, or if they had to be the sole responsible party. But even with that - the VA and private hospital each kept passing the buck for the other one to do something, while the veteran became worse. What is telling is that the veteran had to take himself out from under the care of the VA before he received appropriate treatment.

So I am not clear, but when you are under the care of the VA, and they send you somewhere else for part of the treatment - shouldn't they still be putting it all together and overseeing your overall care?

As far as malpractice - You would generally have to show two things (and I am not investigating this fully yet - just throwing out some ideas to think about)

1. That the provider was negligent in the standard of care they provided. (I think you got this).

2. That the patient was harmed by that negligence.

So you would have to show that the VA's failure to diagnose, misdiagnosis, improper treatment, etc. led to "harm" to the patient. Is he is a worse condition / position than he would have been if it would not have been for their breech in standard of care?

If a doctor says he suffers disability that he would not have suffered if the VA would have discovered the infection in the first place and given him appropriate treatment from the start - that would be great!

[free_spirit_etc]

http://www.medscape.com/viewarticle/749290

Abstract and Introduction Introduction

Patients with diabetes have a 30-fold higher risk of lower-extremity amputation due to infection compared with patients without diabetes.^[1,2] Diabetic foot infections that are not appropriately treated because of delayed diagnosis or that are inadequately treated lead to lower-extremity amputation in approximately 10% of patients.^[3,4] Lower-extremity amputations may be debilitating and can dramatically affect the patient's quality of life. Successful outcome depends upon prompt identification of the infection, followed by appropriate antibiotic therapy in conjunction with good wound care and judicious use of surgical procedures when warranted.^[4,5]

Community pharmacists can play an integral role in educating patients about foot care and in recognizing ulcers that can lead to skin infections such as cellulitis, which involves the epidermis, dermis, and—in more complicated cases—subcutaneous tissue.^[6] Resulting from a cut, abrasion, trauma, or puncture, cellulitis may lead to diabetic foot infection. The presence of a foot wound does not necessarily signify infection; however, an existing infection must be treated. Infection is indicated by the presence of purulent secretions or at least two of the following symptoms: erythema, warmth, tenderness, pain, and induration. The clinician should also be alert for friable tissue, wound tenderness, and/or foul odor.^[3]

[free_spirit_etc]

C&P exam "There is no indication in the medical literature that

diabetes is a risk factor for cellulitis. "

That is complete and utter BS. It is hard to find medical literature that states diabetes is NOT a risk factor.

Also, this went past cellulitis - to be cellulitis with abscess.

In fact, it is probably necrotic cellutitis:

Did they just drain the leg? Or did they have to clean out the necrotic tissue?

The article talks about how it can cause blot clots, drops in blood pressure (sign of the individual becoming septic) and other symptoms you reported.

http://cellulitisinfections.blogspot.com/2005/11/necrotizing-cellulitis.html

Necrotizing Cellulitis

Necrotizing Skin Infections

Necrotizing skin infections, including necrotizing cellulitis and necrotizing fasciitis, are severe forms of cellulitis characterized by death of infected tissue (necrosis).

Most skin infections do not result in death of skin and nearby tissues. Sometimes, however, bacterial infection can cause small blood vessels in the infected area to clot. This clotting causes the tissue fed by these vessels to die from lack of blood. Because the body's immune defenses that travel through the bloodstream (such as white blood cells and antibodies) can no longer reach this area, the infection spreads rapidly and may be difficult to control. Death is not uncommon, even with appropriate treatment.

Some necrotizing skin infections spread deep in the skin along the surface of the muscle (fascia) and are termed necrotizing fasciitis. Other necrotizing skin infections spread on the outer layers of skin and are termed necrotizing cellulitis. Several different bacteria, such as Streptococcus and Clostridia, may cause necrotizing skin infections, although in many people the infection is caused by a combination of bacteria. The streptococcal infection in particular has been termed "flesh-eating disease" by the lay press, although it differs little from the others.

Some necrotizing skin infections begin at puncture wounds or lacerations, particularly wounds contaminated with dirt and debris. Other infections begin in surgical incisions or even healthy skin. Sometimes people with diverticulitis, intestinal perforation, or tumors of the intestine develop necrotizing infections of the abdominal wall, genital area, or thighs. These infections occur when certain bacteria escape from the intestine and spread to the skin. The bacteria may initially create an abscess in the abdominal cavity and spread directly outward to the skin, or they may spread through the bloodstream to the skin and other organs.

Symptoms and Diagnosis

Symptoms often begin just as for cellulitis (see Bacterial Skin Infections: Cellulitis). The skin may look pale at first, but quickly becomes red or bronze and warm to the touch, and sometimes becomes swollen. Later, the skin turns violet, often with the development of large fluid-filled blisters (bullae). The fluid from these blisters is brown, watery, and sometimes foul smelling.

Areas of dead skin (gangrene) turn black. Some types of infection, including those produced by Clostridia and mixed bacteria, produce gas (see Bacterial Infections: Gas Gangrene). The gas creates bubbles under the skin and sometimes in the blisters themselves, causing the skin to feel crackly when pressed. Initially the infected area is painful, but as the skin dies, the nerves stop working and the area loses sensation.

The person usually feels very ill and has a fever, a rapid heart rate, and mental deterioration ranging from confusion to unconsciousness. Blood pressure may fall because of toxins secreted by the bacteria and the body's response to the infection (septic shock (see Bacteremia, Sepsis, and Septic Shock: Septic Shock).

A doctor makes a diagnosis of necrotizing skin infection based on its appearance, particularly the presence of gas bubbles under the skin. X-rays may show gas under the skin as well. The specific bacteria involved are identified by laboratory analysis of infected fluid and tissue samples. However, treatment must begin before a doctor can be certain which bacteria are causing the infection.

Treatment and Prognosis

The treatment for necrotizing fasciitis is intravenous antibiotic therapy and surgical removal of the dead tissue. Large amounts of skin, tissue, and muscle must often be removed, and in some cases, an affected arm or leg may have to be amputated. People with necrotizing infections caused by anaerobic bacteria (for example, Clostridium perfringens (see What Are Clostridia?) may benefit from treatment in a high-pressure (hyperbaric) oxygen chamber.
The overall death rate is about 30%. Older people, those who have other medical disorders, and those in whom the disease has reached an advanced stage have a poorer outcome.
Last reviewed/revised February 1, 2003

[harleyman]

This is really good information, as the non-diagnosis of the infection and treatment with blood thinners as opposed to anti-biotic treatment caused a life threathenting situation, and the infection of the entire leg up into the thigh. Most of the medical studies states even with anti-biotic treatment it is not enough and usually requires very strong IV antibiotics to save the Veteran from amputation. I am amazed at the examiner. He did give a diagnosis, but the VA denied based on no diagnosis. I don't get it. The VA completly disregarded the C&P exam. Maybe they knew the examiner was full of SH**. I am having a hard time figuring this out.- H

Edited October 6, 2013 by harleyman