Death by Ankle Sprain

A recent and unfortunate death is being highlighted due to the inability of medical officials to capture a life threatening condition. A 29 year old woman was in and out the Emergency room for several days complaining of leg pain. The patient originally suffered from an ankle sprain but the pain continued to persist and worsen. Appropriate tests were done with no definitive answers found to suggest a problem. The patient refused to leave the hospital. She was arrested for trespassing. Fifteen minutes after being incarcerated, the woman was found dead in her jail cell. What went wrong?

An autopsy revealed the young woman died of a pulmonary embolism, a blood clot in the lungs. The woman’s leg pain was likely due to blood clots in the legs also known as deep vein thrombosis (DVT) that eventually traveled to her lungs and resulted in her death. Blood clots are uncommon and complicate less than 1% of foot and ankle injuries. The risk factors are trauma, recent surgery, prolonged inactivity, hospitalization, smoking, obesity, and birth control. Pain or discomfort in the calf is typically the preceding symptom through many DVTs can be silent. Many patients who are at high risk are typically treated prophylactically with blooding thinning medication such as aspirin or heparin.

When a patient complains of such leg pain, it is the standard of care to screen for a DVT. Though hospital records are still being reviewed, Medicare and Medicaid reviewers have not found a deficiency in the patient’s care. So why did she die? Could it have been prevented? I was not there and I can only speculate the course of events but some reports are describing the patient as having drug seeking behaviors. The patient was known to be homeless, combative and uncooperative with healthcare professionals during her hospital visit. Once the appropriate tests were performed and were negative, her continued complaints were disregarded and many assumed she was falsifying her symptoms. The emergency room is well known to drug seekers and it is a daily, hourly occurrence to encounter a patient who’s complaints cannot be supported by medical reasoning. It is often very difficult and challenging to identify those patients with serious and legitimate complaints and those who have ulterior motives.

For this young lady, it is hard to speculate if further evaluation and persistence of medical health care workers in diagnosing her leg pain would have ultimately saved her life. By protocol, they did their job, they could not find a problem and diagnosed her with a muscle strain/cramping. It was not necessarily a misdiagnosis because they tested her for DVTs but did not find enough clinical evidence to diagnose her. Could an intervention have saved her life… maybe? This is the grey are of medicine and there wasn’t one big thing that was missed. Is there fault? I don’t know if one person can be blamed. It’s an unfortunate loss and when caught, a DVT can be treated and pulmonary embolisms can be avoided.

My Toes are Always Cold!

When a patients comes to my office complaining of cold or numb toes there a three things that instantly pop into my head; diabetes, vascular disease, or Raynaud’s phenomenon. Now before you get all excited and start self diagnosing, many people just have cold feet because it is cold! We may think it is a new problem or it has gotten worse, but we must also take note that the temperature is dropping, our floors are colder and it has been months since our feet have seen this weather. Still, persistent coldness, numbness, or pain is not normal.

Why do diabetics have cold feet? Diabetes cause many changes in your body over time. One such change happens in the nerves. The elevated sugar levels in the blood damage the nerves and inhibit their ability to function properly. This is called peripheral neuropathy. Neuropathy can affect the foot in two ways. First it changes our perception of sensations and eventually progresses to loss of sensation. Most patients describe the process as burning and tingling that eventually leads to numbness, but I have heard many different descriptions. Just yesterday a gentlemen with neuropathy said, “It felt like was standing in ice cold water and my toes eventually froze with no feeling.” Secondly, neuropathy changes the way nerves reacts to stimuli. The nerves in the feet do not communicate well with the rest of the body. For example when we are warm the blood vessels dilate, this explains why we get rosy cheeks. But with diabetes the nerves in the foot don’t always get the message and the vessels stay constricted and less warm blood is getting the toes.

Are cold feet a sign of vascular disease? Our body produces heat in many different ways but a major facilitator to maintain body temperature is our blood. Blood vessels enlarge when we are warm and get smaller when we are cold. It is more important to keep our organs at a certain temperature than our hands, so our body naturally adjusts blood flow to facilitate the demands. With vascular disease, our vessels are damaged or clogged and either blood is not traveling where it needs to be fast enough or it is has trouble getting back to the heart to get re-warmed and refilled with oxygen. In the most simplistic terms: less blood moving means less warmth moving through our hands and feet.

Are cold feet a disease in itself? Actually, there is a disease that causes cold, numb feet! Raynaud’s disease is a condition in which your body over-reacts to cold stimuli. As I mentioned before, our blood vessels get smaller when we are cold. They can also get small when we are stressed or excited so our heart and brain get the most blood in demanding situations. With Raynaud’s our body blows the situation out of proportion and the vessels go into vasospasms. The toe(s) and or finger(s) will turn white due to the lack of blood flow, and then purple due to the increase in venous blood flow, finally when the toe is re-warmed it will turn red due to the return of blood flow. More often Raynaud’s occurs with other conditions such as Lupus, rheumatoid arthritis, or many other systemic diseases.

I cannot count the number of times I have heard the complaint about having cold feet. We have all had them and know the pure agony of freezing toes. Occasional coldness with changes in weather is normal. Struggling every day with cold feet is not normal.