Case+2+Discussion

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Ultrasound findings: -right femoral artery clot with full occlusion. Patent right femoral vein. -remember that veins are compressible, and though I was unable to show you, this patent femoral vein was also compressible. -visually arteries will be pulsatile, and thicker-walled than venous vessels due to high pressure system and associated musculature -Doppler flow should also be used to determine the following in this case: vein vs artery (arterial pulsatile flow vs constant venous flow), whether or not any flow exists or if arterial clot is fully occluded.

Discussion and Management:

The history and physical render this pathology an almost immediate diagnosis. Patient’s often present with sudden and dramatic onset of symptoms and typically can pinpoint the exact time of onset. Classically taught as the ‘6 P’s:’ paresthesia, pain (distal to proximal, increasing to severe, then decreasing), pallor (or cyanosis), pulselessness, poikilothermia (cool temp for you non-greek speakers), paralysis. Etiology most often embolus (from heart or aorta), though, like an MI, less commonly plaque rupture can occur at the site of thrombosis. The differential can include acute compartment syndrome (though a different history and exam), large DVT (associated with swelling), vasospasm (drug-induced most often). If diagnosis is still in question, vascular ultrasound with findings as outlined below should be definitive.

This is a challenging case to manage at the rural district level with the resources we have. Naturally, in our home institutions this is a medical emergency for which we call vascular surgery. The goal of PIH, as well as the medical school here in Malawi, is to model high quality care to the best of our resource limited abilities from primary care to the inpatient wards. Therefore, lets discuss the current aspects of high quality care for peripheral arterial occlusion.

Standard of care upon recognition is immediate anticoagulation with heparin bolus followed by drip to prevent further propagation of the clot. Subsequent treatment varies according to the severity of arterial occlusion. Termed ‘viable extremity’ with likely partial occlusion but with retained sensation and movement, options exist regarding surgery vs intra-arterial thrombolytic therapy. However patients with a threatened extremity with likely full occlusion but with significant pain and progressive symptoms (usually within the first 4-6 hrs from time of embolus) are to undergo surgical revascularization. Nonviable extremities, as in the case of our patient, are to undergo prompt amputation. Delays in amputation can result in the sequelae of infection, myoglobinuria and rhabdo (ARF), hyperkalemia, profound metabolic acidosis, and death. Increasing duration of limb ischemia of < 12, 12 to 24, and > 24 hrs were associated with increasing rates of amputation. This acuteness of this time frame underscores the urgency of the pathology.

Our pharmacy does carry heparin. However, in our case, we do not have access to aPTT lab, therefore the monitoring and adjustment of a heparin drip cannot be safely guaranteed. Though extensive trials have not been performed in arterial occlusion, venous thromboembolism trials summed up in a Cochrane review have showed no difference in outcome between heparin subcut compared to heparin drip or lovenox. Though this is not standard of care, 333 units/kg subcut bolus followed by 250 units/kg q12 hrs is a reasonable choice in our situation.

At the time of diagnosis in our case, the clot had been in place likely 6 days duration. For any chance of survival patient necessitated amputation, though in her condition unlikely to survive operation in Afib RVR (a clue as to the etiology of the likely embolus) with profound metabolic acidosis with respiratory compensation. As of now there is no vascular surgeon in this country, however there are surgeons able to amputate in the regional theater for the southern half of the country. Though we have theater at this rural district hospital, we are equipped for Csections, hernia repairs, hydroceles, large I and Ds, but not large scale amputations. Transport arranged (2.5 hrs on bumpy, at times impassible road) to regional center, however patient was deceased before leaving. The reality of the patient’s condition at time of diagnosis was, in the absence of critical care (securing airway, hyperventilating, bicarb drip, etc), palliative.

A last teaching point from a family medicine perspective is on the importance of building relationships and trust with your fellow providers. The skepticism encountered ("Other providers have a different opinion of this patient..." was a providers response to the ultrasound) is a natural reaction to people who come and go (an often occurrence at these projects). These clinical officers and MDs here in Malawi have been dealt a limited education and limited resources with overwhelming patient numbers and a seemingly insurmountable mountain of work on a daily basis. To enter this experience is humbling as I recognize the amount of support/back-up/resources and communal expectation of positive outcomes where we train and practice. Gratitude. The model of PIH is based on 'accompaniment' from patients to providers. In the words of co-founder Paul Farmer:


 * //"To accompany someone, is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end…There’s an element of mystery and openness….I’ll share your fate for awhile, and by ‘awhile’ I don’t mean ‘a little while.’ Accompaniment is much more often about sticking with a task until it’s deemed completed by the person or person being accompanied, rather than by the accompagnateur.”//**

So case by case we will see patients together, share ideas. I can teach ultrasound and they can teach the intracacies of chest xray interpretation in TB. And we'll give case presentations when we find something we think all could benefit from. And though I may leave in 3 months time (cough... loans... drag), the power of institution to institution accompaniment has its own power as I know others will continue the work behind me.