Amputation is the surgical removal of all or part of an extremity. The most common amputation surgery is above or below the knee.  The indications for leg amputation include severe trauma, significant tumor in the bone or muscle, lack of blood circulation due to peripheral arterial disease, worsening or uncontrollable infection, failed management of acute compartment syndrome, failed management of Charcot’s degenerative osteoarthropathy, or debilitating extremity paralysis from infection or pressure-related complications. Failute to timely diagnose and treat infection, tumor, pressure sores, vascular disease, compartment syndrome, and Charcot’s all may result in the unneccessary amputation of a leg and give rise to allegations of medical malpractice against negligent health care practitioners.

The amputation procedure varies depending on the extremity undergoing the operation. To determine the operation site and the amount of tissue to remove, the surgeon relies on the following factors: the patient’s pulse, skin temperature, areas of reddened skin, and sensitivity to touch in the affected extremity. The presence of a palpable pulse proximal to the level of amputation is a positive predictor for successful healing; however, the absence of a pulse does not necessarily reflect future wound healing failure. The level of the amputation is based on the extent of the damaged tissue, the healing potential of the area, and the rehabilitation potential of the patient. In addition to a thorough clinical examination, objective tests such as ankle pressures, toe pressures, transcutaneous oxygen measurements, and skin perfusion pressures are useful.

The preoperative evaluation and preparation involves medical risk assessment, nutrition assessment, prosthetic and rehab consultation, and possibly a psychological consultation. The diseased tissue is removed along with any crushed bone and the maximal amount of healthy tissue is left behind. The blood vessels and nerves in the surrounding area are sealed off. Following the amputation, the site can be left open due the possibility of further amputation or covered with skin flaps and closed. The remaining muscles in the area are shaped so the end of the limb can be fitted for prosthesis, also known as an artificial limb.

Thromboprophylaxis is recommended for all patients undergoing major lower extremity amputation because patients are at high risk for thromboembolism, the blocking of a blood vessel by a particle that has separated from a blood clot at the formation site. Antibiotic prophylaxis is typically recommended within one hour of skin incision for lower extremity amputation due to high risk for surgical site infection.

Generally, the patient undergoes physical rehabilitation soon after surgery and practice with the prosthesis can begin 10-14 days after surgery. The patient’s postoperative outcome is dependent upon preoperative functional status, comorbidities, and the level of amputation. Wound healing must be monitored and dressing changes performed. Patients with advanced diabetes, significant heart disease, or serious infection are at a greater risk of complications from the procedure. Possible complications include infection, joint contracture, necrosis, deep vein thrombosis, pulmonary embolism, hematoma, and wound opening. In addition, patients may experience phantom pain, a sense of pain in the amputated limb described as burning aching, or electric. Other causes of pain such as ischemia, infection, neuroma, or pressure related wounds should be excluded before determining the diagnosis as phantom pain.

Diabetes affects over 23 million people in the United States and is the 7^th leading cause of death.  Uncontrolled high levels of blood sugar can cause vascular damage to the retina of the eye, the filtering system of the kidney, and the peripheral nerves.  In fact, diabetes is the leading cause of adult blindness, kidney failure, and non-traumatic amputations in the United States.  Failure by a health care provider to diagnose, treat, and educate diabetic patients may constitute medical malpractice should a serious injury occur.  Preventative measures such as annual dilated pupil exams,  annual foot exams, and prescription medications to control high blood pressure can greatly reduce the risk of injury to the diabetic patient.  Outpatient laser treatment to seal off abnormal blood vessels in the retina may significantly delay or prevent the onset of symptomatic diabetic retinopathy and blindness.  ACE inhibitors are drugs that can lower blood pressure and prevent damage to the filtering system of the kidney.  Effective patient education (by a diabetic educator) about the importance of a maintaining a healthy diet, daily exercise, and proper hygiene are essential to help prevent diabetic complications.

Diabetes may arise for the first time during pregnancy and cause serious complications.  This type of diabetes is referred to as gestational diabetes and can cause the fetus to become oversized and fat due to the excess glucose in the umbilical blood.  Unfortunately, an oversized fetus may render a vaginal delivery high risk as birth injuries such as shoulder dystocia are more likely to occur.  Failure to diagnose and treat gestational diabetes may result in life threatening complications to the fetus and the mother and may give rise to a medical malpractice claim.

On the flip side, low blood sugar can cause hypoglycemic episodes that may result in brain damage or death.  Over administration of insulin, or a failure to monitor low blood sugar levels in diabetic patients may constitute medical malpractice.  Reduced blood sugar levels (blood glucose below 65mg/dL) may result in neurogylopenic effects such as impaired judgment, dizziness, slurred speech, seizures, and coma.  In a hospital or nursing home setting, glucose fingerstick testing may be necessary every few hours to prevent a serious hypoglycemic episode from arising.

Lumbar puncture is a procedure performed in the lower back area, where a needle is inserted between two vertebrae to remove a sample of cerebrospinal fluid (CSF). The patient flexes his/her back to widen the spaces between the vertebrae so it is easier for the physician to access the region. The back is washed with antiseptic soap or iodine and covered with a sterile sheet. A local anesthetic is used to numb the area and then a thin hollow needle is inserted through the spinal membrane and into the spinal canal. During this portion of the procedure, the patient generally feels pressure. The CSF pressure is measured, a small amount of fluid is removed, and the pressure is measured again. The needle is removed and the site is bandaged. The total procedure takes about 45 minutes.

Lumbar puncture is used to collect CSF for analysis to help in diagnosing conditions such as subarachnoid hemorrhage (typically caused by ruptured aneurysm or traumatic brain injury), meningitis (inflammation of the membranes around the brain), and cancers of the brain or spinal cord. Lumbar Puncture may also be utilized to inject anesthetic medications, chemotherapeutic drugs, contrast material, or radioactive substances into CSF.

Lumbar Puncture may be used to identify increased or decreased CSF pressure.  Increased CSF pressure can be caused by increased intracranial pressure as is seen with traumatic brain injury, ruptured aneurysm, and sometimes hydrocephalus. On the other hand, decreased CSF pressure can be caused by spinal cord tumor, shock, fainting, or diabetic coma.  Normal CSF appears clear and colorless. When an infection is present, the CSF may look cloudy and be yellow or pink in color. Infection may be suspected if there is an increased level of white blood cells and/or protein. Increased CSF glucose indicates hyperglycemia whereas decreased CSF glucose may reflect hypoglycemia, bacterial or fungal infection, tuberculosis, or meningitis. If tumor cells are detected, the patient may have cancer in the brain, spinal cord, or CSF.  If there are increased gamma globulin levels, the patient may be suffering from multiple sclerosis, neurosyphilis, or Guillan-Barre syndrome. The analysis of the CSF by the lab and the measuring of CSF pressure recorded from the lumbar puncture help in determining a diagnosis in many serious clinical situations.

Primary Hemochromatosis occurs when too much iron builds up in the body. It is usually caused by a specific genetic problem that causes too much iron to be absorbed. If there is too much iron in the diet, the extra iron is absorbed in the gastrointestinal tract and builds up in the body tissues, particularly the liver, heart and pancreas. The result is damage to these organs. Primary hemochromatosis is the most common genetic disorder in the United States, affecting an estimated 1 of every 200 to 300 Americans.

Hemochromatosis affects more men than women. It is particularly common in Caucasians of western European descent. Symptoms are often seen in men between the ages of 30 and 50 and in women over 50, although some people may develop problems by age 20. There is increased risk if a relative has or had the condition.

Symptoms include severe fatigue (74%), impotence (45%), and arthralgia (44%), abdominal pain, decreased sex drive, lack of menstruation in women, hypothyroidism, and bronzing of the skin. Clinical manifestations include liver disease, skin pigmentation, diabetes mellitus joint damage, (arthropathy), impotence in males, and cardiac enlargement, with or without heart failure or conduction defects. The most common presentation is a patient with an enlarged liver (hepatomegaly), skin pigmentation, and arthritis.

Along with an elevated serum iron level, other abnormal lab values include an elevated transferin saturation, which measures the amount of iron bound to transferrin, a protein that transports iron, an elevated ferritin, a test used to evaluate the body’s iron stores, and an abnormal liver profile (a group of blood tests used to evaluate liver function). Commonly alanine amino transferase (ALT) or alkaline phosphatase are elevated.  When iron stores increase in the pancreas, pancreatitis leading to potentially fatal diabetes can occur. Iron overload damages the liver causing jaundice, which leads to fatal hepatic cirrhosis. The heart is another organ that excess iron can damage, causing it to fail.

Fortunately, primary hemochromatosis has a relatively simple treatment, and these complications, if caught early enough, can usually be reversed by treatment of the iron overload causing them. This treatment in an otherwise-healthy person consists of regularly scheduled phlebotomies (bloodletting). When first diagnosed, the phlebotomies may need to be performed fairly frequently, perhaps as often as once a week, until iron levels can be brought to within the normal range. Once iron and other markers are within the normal range, phlebotomies may be scheduled every other month or every three months depending upon the patient’s rate of iron absorbtion.

For those patients unable to tolerate routine bloodletting, or whose blood count is not high enough to allow for it, there is a chelating agent, known as desferoxamine (deferoxamine) that can be used. Chelating agents such as desferoxamine bind with iron in the bloodstream and enhances its elimination from the organs involved via the urine and feces. Typical treatment for chronic iron overload requires subcutaneous injection over a period of 8–12 hours daily.

Primary hemochromatosis must be considered in any patient presenting with an enlarged liver. It also must be suspected if any one liver blood test, seen on any routine metabolic profile, is elevated without an explanation. The same is true for elevated fasting blood sugar levels. This is a disorder that can be successfully treated. And if caught early, a patient can expect to live a normal lifespan. Once the heart, pancreas or liver are damaged, life expectancy is considerably diminished.  Failure by a doctor to timely diagnose hemochromatosis before permanent damage to any bodily organ occurs, may constitute medical malpractice.