The Psychosocial Aspects of Bilateral Amputations Following Frostbite Injury Complicated by Polysubstance Use Disorder and New Cancer Diagnosis: A Case Report

Case Diagnosis: Frostbite injury resulting in bilateral lower extremity amputations with history of polysubstance abuse and newly diagnosed lung carcinoma.

Case Description or Program Description: A 66-year-old male with history of cervical myelopathy and history of IV drug use/polysubstance use disorder presented with bilateral lower extremity frostbite injury sustained after sleeping outdoors during the Michigan winter. Vascular surgery, Podiatry, and PM&R were consulted to evaluate limb loss and potential for recovery. Following a four-stage right below knee amputation (BKA) and left trans-metatarsal amputation (TMA), the patient’s case was further complicated by post-operative O2 dependence which resulted in discovery of a new 7cm mass, identified as a new lung carcinoma. Pain management was complicated by impaired respiratory status, tolerance to high-dose opioids, high-level cervical myelopathy, phantom limb pain and cancer-related pain. Discharge planning was also complicated by homelessness, further adding to the patient’s psychosocial burden.

Setting: Physical Medicine and Rehabilitation Inpatient Unit

Assessment/Results: Patients substance use history was heavily considered when planning long term pain control and resources were given for continued sobriety. Housing was found with patients mother in the northern part of that state.

Discussion (relevance): The incidence of frostbite in the United States is estimated to be 0.83 of 100,000 people. It's estimated that at least 20% of these individuals suffer from disability from amputation. Risk for cold weather injuries is associated with factors such as African American race, homelessness and substance use disorder (SUD). Premorbid SUD was found to be an independent predictor of amputation. Both SUD and homelessness have been predictors for unstable recovery and unplanned readmission.

Conclusions: Patients with cold injury with amputation in at-risk populations come with multiple psychosocial factors affecting outcome. Outcomes include increased risk of readmission, unstable recovery and mortality. These need to be considered when planning functional recovery and rehabilitation admission while also working towards a safe discharge.