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Have a challenging patient.59 year old insulin dependent diabetic with what started out as a Wagner grade 2 ulcer sub 2-3 metatarsals left foot.Soon,this developed into a grade 4 Wagner ulcer that necessitated hospitalization.The doctor that he had seen as an inpatient refused to amputate his toes as his circulation was poor and the hope is that the toes will fall off by themselves-an autoamputation.
I thought of maybe starting him on maggot therapy.Is this a good idea?What is the cost to him or me?(he is a dual eligible-Medicare/Medicaid).Where would I get maggots?And what of autoamputation?Is that really desired?Any input would be appreciated!

Dr. Spina:

I read with interest your question regarding 1) mummification and 2) larva therapy. Let's go with them in the above-mentioned order:

1. I am not certain whether there is a right answer to the mummification question. If indeed the patient has very poor blood supply and is not excessively active, allowing the digits to mummify (autoamputate) is probably acceptable.

2. Larval therapy might be a good choice in this case as an effort to reduce the risk for infection and to keep the wound clean. Larvae are available in the US from Monarch Laboratories (http://www.monarchlabs.com/). I am not certain about the payment/billing issue, but perhaps the laboratory is. The cost is typically around 80USD for a jar. The jar is good for around 5 days if kept refrigerated at around 6 degrees Celsius. Remember also to order the chiffon mesh dressing (another few dollars).

I do hope this helps.

Cheers, -DGA

DG Armstrong
Chicago, IL, USA
armstrong@usa.net

Related threads:
A Creepy story for the gippy stomach amongst us!
Negligence lawsuit for maggots on wound

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Thank you for the dual answer.I gained some knowledge of the situation.