REPOST: The Swollen Leg

SPEAKER_01 0:11

Hello and welcome to the Home of Medicine Podcast with me, Dr. Amy Beverbridge. I'm a consultant in Acute Medicine.

SPEAKER_00 0:18

I'm Ben Lovell. I'm a consultant in Acute Medicine working in London in the UK as well.

SPEAKER_01 0:23

Right, so Ben, you have a case for me today.

SPEAKER_00 0:25

Yes, I do. It's an STEC case because I know you enjoy them. So it's a same-day emergency care, ambulatory care. And I was the ambulatory care consultant, and we were busy, of course, and we were seeing patients. And a lot of what we see in ambulatory care are people with swollen legs. Do they have a DVT, deep vein thrombosis? And we rule that in or rule that out. And I got a call from UTC, that's the urgent treatment center, which is located really just around the corner from me. We're all sitting together in a little village in one wing of the hospital. And it was a GP working in the UTC. And they said, Oh, can I please send you a patient? Because I have a 55-year-old man here with an acutely swollen, painful leg, and he needs a DBT workup. Can you come around? And I said, Yes, of course you can, send him round. And that's how this story sort of began. And about 10 minutes later, I noticed a patient not walking around from UTC, but being wheeled around in a wheelchair by a healthcare assistant and left in the waiting room in Essec. And I turned and said to my nurse consultant colleague, say, Who is that patient who's just been wheeled around in a wheelchair? She went, That's the DVT you just accepted from UTC. And I sort of went round, peered around into the waiting room and had a look, and my heart sank. Because, well, first of all, why is he in a wheelchair when he was meant to be a fit and well 55-year-old man and he was wearing shorts? And I could see that yes, his right leg was swollen, but end of the uh waiting room assessment, his right leg was massively swollen. It was blue and mottled and did not look so much like a DVT to me as an acutely ischemic limb. And my heart sank, and it sort of sank for three reasons, really, because number one, what I thought was going to be a standard quick DVT workup, which we can do in our sleep in Estec, it's our bread and butter. This has now exploded into what is probably going to be many hours-long interaction with a very sick patient, which we had not managed to plan into our day and didn't really need to have um coming around in our day. Second of all, the patient is in the wrong place. This is in a surgical emergency. I'm not a surgeon. I have a lot of respect for surgeons, and there is not much that I could do with my physicianly wears to sort out an acute ischemic limb with fluids, frusamide, etc. Um, and third of all, I had a little bit of wave of irritation that I've been, how shall I phrase, missold a patient? This a misdirected, mistriage, that's better. I've been mistriarged a patient. This, this is, this really, this should be in majors. This should be having surgeons looking at him. And now he's sitting in my waiting room and he can't wait there because his leg is in so much pain. So I made a very immediate judgment and a very immediate diagnosis from about 20 feet away of an acutely ischemic limb. Um, and I wheeled this gentleman into a clinic room because he simply could not put any weight on that leg. And I said, What's happened to you? He says, Yesterday I noticed my thigh, my right thigh was a bit swollen, and I sort of ignored it. And today the whole leg woke me up in extreme agony. I can't put any weight on it. It's hugely swollen, as you can see, and this has never happened before. And I said a quick sort of history. He was a fit and well guy, did not smoke, didn't drink much alcohol. He had had a hernia operation, routine elective repair, just nearly two months prior to this, was the only thing that happened to him recently. But otherwise, he worked in IT, he was uh an independent guy. And I looked at the the leg and it was cold. And I tried to remember the six P's of acute ischemic limb. Do you remember them?

SPEAKER_01 4:00

Do you know? I've actually just wrote down six P's. I'm like, I must remember these. So it's pale, yeah, pulseless, paresthesia, yeah, perishingly cold.

SPEAKER_00 4:11

Well, that's the only one I could remember: perishing cold, because it's such a weird one. Yeah.

SPEAKER_01 4:16

Pales, pulseless, peresthesia, perishingly cold, hair loss. Is that one of them? But it's not obviously no, remind me of the other two.

SPEAKER_00 4:26

Pallor, pain, pallor, paresthesia, paralysis, pulselessness, and perishingly cold. Now, if you've coloured an equation, you could change perishingly cold to uh poikilothermia if and if you're fluent in ancient Greek, but perishing cold, weirdly, was the only one that stuck in my brain from 2005 when I ever last revised these sorts of things. So his leg was cold, it was as I say, it was blue and it was mottled. I could not feel any peripheral pulses in his feet. Um says it felt numb. He said, My leg, it feels dead, which was never a good sign. And um, and yeah, so that's where that's where I stood with that patient at the moment. Sitting in technically, what is an outpatient area? So this is more a question of logistics, but what would you do? How did how would your your department be set up to manage a patient like that?

SPEAKER_01 5:17

I think the first thing is to make sure that, and I'm sure that you did this, is that the patient is safe, they're hemodynamically stable. I always say A to we. I think I probably say that about 200 times a day, just because I always go back to basics. So A to We assessment, make sure he's not in any pain, make sure he's comfortable, check his blood pressure, you know, his observations. You know, is he in fast IF? You know, trying to think about what has caused this ischemic limb. Has he got anything in the abdomen? Check the thigh out. You said that there was an issue with the thigh. So have a look at that. It was very swollen. Was it swollen because of poor blood flow, or was it swollen because there'd been an injury? Had he been lifting weights? I'm thinking compartment syndrome. I'm just I'm basically thinking very lunchally. But aside from that, I would try and find somewhere comfortable for him to be, because certainly sitting in a waiting room with an acutely ischemic limb is not the best place to leave him. So pop him in a waiting room, I would do his observations, I would get an ECG, I would do some blood tests on him, check his clotting, hemoglobin, kidney function, liver function, probably do a group and save because thinking ahead, is he going to be going to theatre or not? And then start to think about, okay, who is the best person to manage this patient? And it's certainly not going to mean me as an acute physician. So I would probably reach out to, depending on hospitals, but in my hospital, we do have a vascular surgeon on call. So I'd speak to the vascular team, probably the registrar, consultant, depending who I can get hold of, ask for some advice, ask for an opinion, ask them to come and see the patient. And then it's probably going to need an urgent angiogram of the limb. Um, and potentially that may involve interventional radiology as well, depending on what treatment options are at your hospital. So that is probably where I'd be going at this moment in time. I probably wouldn't move him. Um, so an option would be actually to transfer him to the surgical assessment units. But before I move him, I probably want to, because he's been moved already from one area to another area. And I think Thomas, we do move patients a lot. Um, and actually, while I've got him with me and I'm doing the bloods and ECG, I'm going to make a few phone calls before I move him onwards.

SPEAKER_00 7:41

That's I'm thinking that's a really uh you made two points that really jumped out at me there. One is about looking at the patient as a whole, because to confess, I was in that room talking to and staring at this patient's leg. And you're right, A to E assessment's really crucial, and it's very easy to fixate on the glaring problem in front of you. Um, so I'm standing there taking history whilst pretty much fixated on the leg, touching the leg, assessing the leg, you know, and the patient might be like, hello, my eyes are up. What's uh would you like to ask me any questions? What's my blood pressure? You know, what is my chest clear? Are there any arrhythmias? But you're absolutely right. And I think it's really important to try and maintain that focus. And we always talk about A to E, but the the thing is it's a really important anchor as well as a cognitive aid. It's useful to do an assessment, you shouldn't miss anything, but it's good to anchor yourself back to your um to a place where you can see the patient as a whole rather than jumping to the C or the E or the B or whatever, in this case the E, I guess, exposure, whatever um the abnormality is. It's a good way to make sure you don't miss anything out. So that definitely uh resonates with me. Going back and doing the A to E assessment rather than fixating on the one the one place. And the other thing is um, yes, who is the right person to copy and what do we do now? The patient has unfortunately just moved down into an area where where you know it's it's outside a standard operating practice. And I think the key thing here, and this is what I always say to other people as well, is try not to waste too much cognitive bandwidth in the moment focusing on how did this happen? Who who who let this happen? Where what's what's going on? This should never have happened, this should never, you know, getting yourself agitated, but also you have to sort of deal with the situation in front of you, accept that it should it shouldn't have happened because you know systems are complex and one little thing can result in an outcome that you didn't appreciate. But in the moment, when especially when there's a sick patient in front of you, that's not the time to be trying to pick up the threads of what went wrong uh and and sort of make that investigation. We have to sort of swallow that down a bit and say, well, this isn't ideal, but this is what the situation is. What are we going to do with the patient right at the center and the focus of this situation to keep him safe now? Um and uh, you know, in acute medicine for me and you, I think we find ourselves in situations that maybe quite frequently where we're thinking, ah, this shouldn't have happened. Uh, this this wasn't appropriate for this to have turned out this way. But I always say to myself and to others, focus on the patient now. We'll do the post mortem a bit later on when we've got the bandwidth to do it. Because we've got to make sure this patient with an emergency is safe. So I as you say, we did our assessment and I rang the vascular registrar, and I can't remember how, but I got through to the vascular consultant who was anyway very, very helpful. And she uh said, I'll come down and see the patient. And she did. And we saw the patient side by side, and I presented the patient to her saying, Look, I've got a patient here in my S deckus, in the assessment clinic with an acutely ischemic limb L. Um, I'm happy to arrange a scan that you might like, but but we can't look after the patient and we need your expertise moving forward. And she came and saw the patient very quickly. She came with an ultrasound scanner and she put it on his dorsalis pedus, and it was so swollen his foot, I couldn't feel his DP, and neither could she, but we could see on the Doppler flow there was a pulse, it was pulsing. And she went, Oh, this isn't acute ischemia. Look, he's got good peripheral arterial flow. This is something else, and it was a condition that I've heard of before, but this was my first time seeing it. Phlegmasia cerulea dolen. Have you heard of it?

SPEAKER_01 11:21

No.

SPEAKER_00 11:22

Brilliant. So I get to teach.

SPEAKER_01 11:24

I haven't no phlegmia. Did you spell it phlegmasia?

SPEAKER_00 11:28

Yeah, phlegmasia is P-H L-E-G-M-A-S-I-A. Phlegmasia. He put the leg in phlegmasia, this guy. And phlegmasia, for those who don't speak uh what Greek, I suppose, swelling. It's phlegmasia, cerulean, dolens. Cerulean fans of uh Devil Wears Prada will be screaming. That means blue.

SPEAKER_01 11:50

Oh, yeah, yeah, yeah.

SPEAKER_00 11:51

Cerulean blue, dolens, dolens, doloris, is painful. Yeah. So acute, but basically blue, painful swelling of the leg. PCD. I'll call it PCD now if you don't mind, just to say my um, but phlegmates cerulean dolens, it is the end of the spectrum for deep vein thrombosis. It is total venous occlusion to the point where the leg has no outflow and it becomes engorged, engorged, engorged as arterial blood continues to pump into the leg with no way out. The leg then becomes, first of all, white. That's called phlegmatia, phlegmasia alba dolent, alba meaning white. And that's when the all the venous outflow from the leg is coming by the collateral systems. But when they are capacitated and they there's no more outflow, then it becomes PCD, cerulea, the blue phase. And actually, effectively, it is ischemia because um once you've got no outflow from the leg, you simply cannot flow into the leg, and the arterial system becomes slow, slugation eventually stops. And these patients can be gangrene within hours. Um, so it's very similar to arterial ischemia, but the crucial difference is the problem lies in the venous system. And she moved her ultrasound scan woman and she just put it on his um femoral vein and she went, aha, look there, you see. Completely full of clot. There was no blood flow at all. We could see the femoral artery next to it pulsing weakly, but the femoral vein, no colour on it, there was absolutely no flow. She says, I think this guy's clotted off all the way up his femoral vein, all the way up to the eyelacks and maybe the IVC. So now he has PCD, he has no exit from the vascular system in his leg, and he has affective arterial ischemia secondary to that. It is just like arterial ischemia, an emergency, and he needs removal of the clot very urgently. And she said, Yes, get the CT and well, actually, I think I'd got the CT angiogram at that point, and we're waiting for the report. But um, it was a really interesting moment for me, and I was sort of looking at us as a threesome, me, the vascular surgeon and the patient in the room. And I thought to myself at a time, this is actually really nice. We've got two consultants here side by side, one of them's showing, teaching, telling another something new, and and we were working together for the patient. And um, I just thought it was a really it was a really nice moment for me. And I kind of feel empowered now. If I ever were to see this disease again to pick up an ultrasound probe, I know what buttons to press now, it's just dead easy. I know what I'm looking for. And it was a real learning moment for me. I obviously I went home and to look up PCD, and it said that 40% of these cases are associated with malignancy, and you kind of should do a malignancy screen on these patients. And I guess that would be obviously a good history and possibly cross-sectional imaging, like a CT abdo um chest x-ray, looking for any common primaries. And the mortality is actually pretty high. So this guy sitting in my waiting room had a 20 to 30% mortality from this condition, which was a bit higher than the usual clientele we have in our STEC. And the patient was moved very quickly round to um A ⁇ E majors. Again, that's unusual. That's not a normal direction of travel in our hospital, STEC to majors. It's normally exactly the other way around. Um, and he was started on a heparin infusion, and then he went to uh theaters with interventional radiology and they did catheter directed thrombolysis. They busted that clot. He went to PACU, their poster um assessor, part of ICU for post-doc patients, for an ongoing heparin infusion. And he walked out of hospital about four days later with excellent blood flow in and out of his legs. So he had a really excellent outcome. And in his particular case, the uh clot was put down to his recent surgery to uh six or seven weeks ago, he'd had this hernia operation, so it was considered um provoked rather than a spontaneous uh clot, which obviously has an impact on how long you are anticoagulated for after this is all removed. So, yes, it was a good two hours of my time from what I thought was going to be a 50-minute have-a quick look and see if there's a DVT or not. And the DVTs that we see in STEC are usually below knee, they're usually uh short, and they cause a bit of local inflammation and swelling, but not much more than that. And our interactions are usually do they need a D-dimer, do they need a well score, do they need a scan? And if it's all shown up positive for a clot, we cancel them for a doac, we give them a doac, and we send them home with follow-up at the anticoagulation clinic. And we've got that down to a fine art now. The doctors who work there, the ACPs who work there, we can do that process very, very quickly. So this was a bit longer than usual. But thinking back, the referral was kind of correct. It was a DVT that was sent around, but it was a DVT which is technically a vascular surgical emergency and probably didn't want to be in ambulatory care in the estate department. But the system worked, we rallied, we coordinated, we brought down the relevant experts to the bedside who came, made the diagnosis, and the patient had a really good outcome.

SPEAKER_01 17:02

Wow. Yeah, I mean, really interesting case from lots of different angles. Um, one of the things I did write down was POCUS. And obviously in acute medicine, we're doing a lot more point-of-care ultrasound. Um, and I'm slowly getting there. Um, I was I didn't really do it in training because I was a bit of a late trainee in acute medicine. Um, I went to it after rheumatology training. So I didn't really do POCUS as a reg, so I'm doing it now as a consultant, which is also interesting, trying to learn a new skill. Um, so you know, what is the role of POCUS in the STEC setting and in this case? And it sounds like the vascular surgeon, she actually used it, didn't she? And said, Look, you can see the clot, you can't feel a pulse. From a management perspective, long term, are they on a doak after the initial treatment? Yeah.

SPEAKER_00 17:54

A doak.

SPEAKER_01 17:55

Okay, and because it was yeah, I was probably answering my question. I was gonna say, because it was a provoked clot, is it for three months?

SPEAKER_00 18:02

That's our usual practice. So if someone has a clear trigger for a clot, it's three months. If someone has an unexplained or unprovoked clot, it's six months and further assessment, and that's when you'd start screening has this patient got a secret cancer? Um yeah, yeah.

SPEAKER_01 18:17

Now I'm gonna ask a question now, and I think you may actually stop the recording. Did you do a D-dimer?

SPEAKER_00 18:27

This patient came to me. Do you know what? This patient came to me pre-bloods, which is unusual. Um, because they don't do blood with UTC, it's it's a it's AD miners, it's it's stuff by GPs. So he came to me pre-bloods, and in fact, this is one case where I kind of didn't I didn't care about any bloods. It was almost an afterthought saying, Oh, he's probably gonna go to theatre at some point. We better do some bloods on this guy. Yeah, it was actually maybe a D-dimer was done because it's because the plot was written everywhere and and D-dimers get sent. And I in retrospect, I I don't know actually if you had a D-dimer, I wonder how high it was. I've seen it's about 15,000, our cut off being 550.

SPEAKER_01 19:08

Wow, okay. Yeah, I'm just out of curiosity, really, because I know pretty much you can't get through S deck without a D-dimer, and I'm just intrigued as to actually well, I'd never do one anyway, but I wonder, I bet he's gonna be sky high, wouldn't it? It wouldn't change anything though, would it? It's just all academic, I suppose.

SPEAKER_00 19:24

And this is uh an example of when you know, we we said it on many, many podcasts before. You do a D-dimer when the Wells score is low. Um, you do when you're not technically sure. This man's well score was very, very high. So a D-dimer becomes completely irrelevant. And imagine a scenario where he'd come back with a D-dimer that was weirdly negative. We've got a clock there on the angiogram. We've got an ischemic leg here, really, a functionally ischemic leg. So it makes the D-dimer's academic.

SPEAKER_01 19:52

Can I also ask a question as well? You mentioned about the mortality rate. Is the mortality rate high because of the associated malignancy, or is it high because of the impending arterial ischemia? So, you know, what is the cause of death in these in these patients?

SPEAKER_00 20:09

It's related to tissue ischemia and then organ dysfunction. Patients will have gangrene within six hours if they do not have normal blood stow blood flow restored. And if you can imagine the average journey through um an ED system or an STEC system, you know, you getting uh that thrombolysis in the six-hour time frame. I mean, you might not even get assessed until hour six, you know, if you're waiting a while. Um also, if this gentleman had not come in, this was in the summer, if he had not come in wearing shorts with his leg like a showing like a beacon to all who saw it, I wonder what his journey would have been like if it'd been hidden away under a pair of trousers. And it wasn't until the trousers were removed and he was examined that everyone had this reaction. Um, he may well have sat in the ED waiting room for much longer, um, politely waiting his turn to be seen with this very, very painful leg, with leg pain written written all over his drug, uh, his medication, so I want to say uh his admin sheet, you know. So the fact that it was visible meant that he moved a bit quicker through the system than if it was invisible, which is interesting as well.

SPEAKER_01 21:12

That is really interesting, and I think that goes back to something again that we spoke about in other episodes is the importance of truly examining the patient and you know, taking their clothes off, you know, if they've got don't ever listen to the lungs over a shirt and a jumper, because number one, stethoscopes weren't made for that, but also you lift that jumper up and you lift the shirt up and you're like, oh, there's another diagnosis under there that will help identify. One of the things I often see is eritheme abigne, which is the red, bluish discoloration secondary to water bottle usage. And I think if somebody's got that on their skin and they're presenting with pain on that area, that pain's been there a long time because they've had a lot of water bottle usage over there. So actually, there's so many clues on the skin. Know to look at and like you say, this gentleman, if he hadn't actually seen his leg, his course through the hospital may have been a bit different. One of my particular bugbears. The skill, isn't it? I've seen um septic arthritis being missed being not diagnosed over the phone, which is another skill as well. But um, I've lost my train of thought now.

SPEAKER_00 22:27

I think another one, just while I'm thinking about it, is zoster. So um zoster. So when people come and pain and chest pain, it's happened to me on a few occasions that you you you don't see until you look, and then you've got a little herpetic outbreak somewhere, and you go, oh, they're getting zoster, and that is gonna, that's what's causing the severe pain they've got. So no.

SPEAKER_01 22:47

That's a really good one for chest pain as well, isn't it? Particularly anterior chest pain that we're not sure. Is it cardiac? Is it non-cardiac? And then you look and you're like, oh, there it is. There's that little vesicle, and it may be one or two, but then the next few days later, they start to develop and you've got your diagnosis there. Absolutely. Okay, thank you so much for that, Ben. That was a nice, short, succinct podcast with some massive learning points in there. So, what are your three takeaway points for the listeners today?

SPEAKER_00 23:16

I'll go backwards chronologically. So I'll say number one is the is the examination and the visually inspecting the area, right down to the skin, seeing that body part that you're looking at, because you make assumption that the disease which is presenting with these symptoms are coming from within the body, and there's often something on the biggest organ that is visible to the naked eye, the skin, that we need to see as well. So that would be really important. My second one would be um, as I said at the beginning, if you find yourself in a situation and you feel irritated because this is not your job or this shouldn't have happened, or this something wrong, something's gone wrong, and you're doing this work for someone else, I get it. I am I respect it, have that feeling, but you've got to let it go and refocus on the patient in front of you. By all means, we can look at this afterwards and we can see what the weak links were in the chain that led to this happening. And I think if there are any medical registrars who do on call to listen to this, hopefully this is something that's familiar with them because you hear a lot of them saying, Oh, you know, a lot of things come to the med where it was not appropriate. And I I completely remember how irritating that is. But obviously, it's not the patient's fault. The patient is doing as they're told, they're moving through the system as they've been ushered by people that they trust and they've landed in front of you, and that you have you have to deal with the patient first of all, then you have to deal with the system issues and your irritation um when you have the bandwidth to do it when it's safe to do so. Patient safety, it's got to be right in the center of everything. And I guess my third thing would be let's do a nice clinical one. DVT, we often consider a semi-benign situation, which we can sort of see quite quickly. But DVT has an ugly sister and it's called Phlegmasia Cerulea Doland. And if you Google it, the image that comes up on the first Google image that you see was exactly what my chat's leg looked like. It could have been him. So take a mental photograph of that when you see it, and then when you get these DVT referrals and you see something like this, then you'll know. And if you feel capable enough, get out that ultrasound. Um, find the femoral artery. It's dead easy to see there, isn't it? In the inguinal area, pulsing away, and just look at the vein next to it. It should have flow as well. If there's no flow in the vein, maybe you've clinched your diagnosis of PCD and you need that CT angiram on an urgent surgical console.

SPEAKER_01 25:26

Brilliant. Thank you so much, Ben. I feel like I've had a 30-minute brain workout. I think I probably needed today, actually. So thank you so much. Thank you to everybody for listening. Please rate, review, and share the podcast with anybody who you think would be interested in listening. Thanks for listening. Goodbye.

SPEAKER_00 25:46

Bye-bye.

SPEAKER_01 25:47

You've been listening to the Home of Medicine Podcast, a podcast brought to you by the eFIM Academy in association with the European Federation of Internal Medicine, a leading organization for internal medicine. Thanks for listening.