A 28-year-old man with type 1 diabetes mellitus for 18 years attended the casualty department complaining of a painful foot. He was well known to the hospital and was addicted to crack cocaine. He had severe infection of
the left hallux, and deep, infected ulcers over both 1st metatarsal heads (Fig. 5.27). He was admitted to the ward for intravenous antibiotics and possible surgical debridement but walked off the ward 2 h later before treatment was started and was lost to follow-up. Three weeks later he presented again at casualty and accepted admission. He explained that he was a crack cocaine addict and had self-discharged because he was fleeing from his dealer to whom he owed money. In the meantime he had accepted treatment from another hospital two hundred miles away where he received a short course of intravenous antibiotics. Again he self-discharged when his supply of drugs ran out. Back at home he did not seek further treatment until he developed wet necrosis of the hallux and the pain in his foot became extremely severe.
He underwent extensive surgical debridement of the 1st ray and amputation of the hallux. The foot was slow to heal, and he frequently left the ward for periods of several hours without saying where he was going and a cast with a window over the ulcer was applied to protect his foot. Nursing staff on the ward found him a very difficult patient who would not follow advice. He discharged himself after 8 weeks, and kept two follow-up appointments in the casting clinic but was then lost to follow-up.
• Drug addiction is an enormous barrier to care. Patients are frequently non-compliant with erratic attendances.
The door should always be left open to these patients
• Addicts are frequently unable to attend clinic regularly, to follow the treatment regimes suggested, to control their diabetes adequately or to attend early when problems arise
• Refusal to enter hospital and self-discharge from hospital against medical advice are also common in these very challenging patients.
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