Tuesday, April 21, 2009

Potong kaki?

" Mak cik tak nak kaki mak cik kena potong..bukannya senang dik..nak dapat kaki ni" Makcik Muniati shook her head

We all stared at her in disbelief..Her left leg was already necrotic, most of the muscles were devitalized. The stench of the odor from her leg was filling the whole ward.

" Makcik..makcik sayang nyawa ke, atau sayang kaki lebih? makcik boleh mati kalau biarkan macam ni." Mister Jacob was stern this time

" Apa ni doktor..nak paksa-paksa saya pulak!" She scoffed

My specialist was exasperated. The wound was open for her to see. Even with the extensive
wound that we did, and the muscles, bones and the internal structure being open, she was still adamant on keeping the lower limb..


During my 2nd call recently, I had to assist my medical officer perform a wound debridement of the left leg of this lady because she had necrotizing fasciitis of the affected limb. Her left leg was not in good condition, whereby it was swollen and there was already gangrene of the small toe.

She was initially counselled for below knee amputation, in which she repeatedly refused.

Thus, we offered her a less than optimum intervention which was wound debridement

Even with the extensive debridement that has been done, the prognosis for the limb was poor.

I was scared that she might be going into sepsis as clinically she was becoming febrile and the white blood counts were already raised.

That afternoon after the ward round, i encountered the family members.

" Puan..tentang mak puan ni..semalam kita dah buang tisu-tisu yang dah mati, tapi disebabkan luka nya sangat besar, kami tak mampu nak kesemuanya. Untuk kes sebegini, sebaiknya adalah untuk potong bahagian yang affected tu. Kalau puan tengok, sememangnya otot-ototnya dan juga sebahagian tulang pun dah mati. Saya risau sekiranya jangkita ni merebak keseluruhan badannnya. Sekarang pun dia dah mula demam."i tried to explain to them the seriousness of the issue.

" Tapi doktor..apa akan jadi kalau dibiarkan begitu sahaja?"

" Jangkitan sebegini boleh merebak ke seluruh badan - menyebabkan sepsis, di mana , keadaan ini boleh menyebabkan kematian" I continued

" Oh..hm..tapi mak saya sendiri yang tak nak..kami tak boleh buat apa-apa" The daughter answered.

# How to counsel patients in this kind of situation?



Gangrene is a complication of necrosis (i.e., cell death) characterized by the decay of body tissues, which become black (and/or green) and malodorous. It is caused by infection or ischemia, such as from thrombosis (blocked blood vessel). It is usually the result of critically insufficient blood supply (e.g., peripheral vascular disease) and is often associated with diabetes and long-term smoking.

Debridement is the process of removing dead (necrotic) tissue or foreign material from and around a wound to expose healthy tissue.

Purpose of wound debridement:
An open wound or ulcer can not be properly evaluated until the dead tissue or foreign matter is removed. Wounds that contain necrotic and ischemic (low oxygen content) tissue take longer to close and heal. This is because necrotic tissue provides an ideal growth medium for bacteria, especially for Bacteroides spp. and Clostridium perfringens that causes the gas gangrene so feared in military medical practice. Though a wound may not necessarily be infected, the bacteria can cause inflammation and strain the body's ability to fight infection. Debridement is also used to treat pockets of pus called abscesses. Abscesses can develop into a general infection that may invade the bloodstream (sepsis) and lead to amputation and even death


necrotizing fascitits is any necrotizing soft tissue infection spreading along fascial planes, with or without overlying cellulitis; - also called Meleney ulcer, NF is severe manifestation of lymphangitis that progresses in a frightening manner within a few hours; - tissue necrosis develops rapidly behind advancing wall of inflammation that limits penetration by antibiotics;

Below knee amputation
Amputation is the removal of a body extremity by trauma or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene

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