4) If the answer to question 3 is affirmative, was Williams' E.
Coli infection recognized and diagnosed as expeditiously as
possible under the circumstances?
4) Did the Otisville medical staff provide Williams with
medical care and treatment in conformance with acceptable
standards applicable to the diagnosis and treatment of
infections in the diabetic foot?
5) What were the roles or extent of contribution, if any, of
predisposing diabetic microangiopathy and/or neuropathy*fn26
as accessories to the infectious process and eventually in the
development of gangrene?
6) What was the role or extent of contribution, if any, of
Williams' use of cigarettes, drugs and alcohol in predisposing
him to the infectious process and gangrene or in exacerbating
his condition or impairing his treatment?
7) What was the causitive relationship, if any, of the
improperly sized institutional shoes Otisville furnished to
Williams to the E. Coli infection?
Each of the foregoing questions in turn have a multitude of
subissues which have been raised by the parties and considered
by the court.
After careful review of the trial testimony, documentary
evidence, and depositions admitted in evidence, and determining
the weight and credibility to be accorded to the evidence, the
court finds that plaintiff has sustained his burden of proof by
a preponderance of the evidence.
The etiology of the gangrene that developed in Williams'
right foot was essentially the E. Coli infection and its
microvascular sequela causing occlusion of arterioles, necrosis
and gangrene, as discussed below. The short of the matter is:
the effective proximate cause of the gangrene and consequential
below-the-knee amputation of Williams' right leg was the
failure by the Otisville medical staff to provide plaintiff
with medical care, treatment and diagnosis in accordance with
the most basic acceptable standards applicable to an infected
Dr. Lord meticulously traced the genesis of Williams'
deficient medical care from September 6, 1985 and the chain of
inept diagnoses and treatments of Williams' condition by the
medical staff at Otisville that finally culminated in the
amputation of his right leg. Dr. Lord's testimony points up
that medical care for foot pain and possible infection that
would meet acceptable standards for a patient in good health,
may be grossly deficient where the patient is a known diabetic
with possible concomitant vascular and nerve complications of
diabetes affecting his legs and feet, particularly when these
conditions may be exacerbated by smoking.
As above, where Williams' pertinent medical history at
Otisville was outlined chronologically, the deficiencies in his
medical care will be similarly discussed.
September 6, 1985
On September 6, 1985 Williams complained for the first time
to PA Garcia of pain in only his right foot. Garcia found
tenderness in the plantar surface of the right foot at the base
of the third toe, but did not suspect and therefore did not
look for the presence of infection.
Dr. Lord testified, and the court finds, that Garcia failed
to act in accordance with the accepted standards of medical
practice in the community at that time. Specifically, Dr. Lord
characterized Garcia's examination of Williams' foot and his
recommended treatment as "very deficient" (Tr. 210). According
to Dr. Lord, Garcia should have suspected an infection and
examined the plantar surface of Williams' right foot for a
break or laceration of the skin through which bacteria could
enter, especially between the toes and web spaces. Such a
thorough probing examination was indicated since Williams was
a known diabetic and had a history of fungal infection
(see entry for June 6, 1985) (Joint Exh. 1A, G001060), "which
is the commonest cause of infections that [he] had seen over
the 40-odd years of practice, [and] source of
the introduction of pathogenic bacteria" (Tr. 211).*fn27 The
accepted standard of practice in 1985 in the case of a diabetic
with a painful foot required a careful examination of the foot,
including the web spaces, under good light (Tr. 821). Garcia
failed to make such an examination.
Dr. Lord further testified that if Garcia had made a careful
and appropriate examination, he would have found a fissure
between the fourth and fifth toes, where ultimately pus
appeared eleven days later. If a fissure had been found, the
next proper step would have been to make a diagnosis of early
cellulitis (diffuse subcutaneous infection without pus). Since
Williams was diabetic, the proper treatment should then have
been all-encompassing including: (1) strict bed rest from and
after September 6, 1985, and avoidance of walking, which puts
pressure on an infected foot and massages the infection into
the surrounding tissues thus spreading the area of infection
(Tr. 794)*fn28; (2) a culture of the fissure to identify the
infectious organism and the specific antibiotics to which it is
sensitive; (3) warm compresses to draw the infection out to
eliminate the cellulitis or lymphocytis; and (4) administration
of broad spectrum oral antibiotic treatment until the culture
report was received identifying the specific infecting organism
and the antibiotics to which it is sensitive (Tr.
Dr. Lord testified that if the foregoing appropriate
examination and care had been given to Williams on September 6,
1985 (or within a few days thereafter), the amputation of his
leg would almost certainly not have been necessary — the
chances were better than 95 out of 100 that Williams' leg could
have been saved with proper care at that early stage (Tr. 213,
On cross-examination of Dr. Boxhill, counsel for Williams
read into the record portions of Management of Diabetic Foot
Problems, Joslin Clinic and New England Deaconess Hospital
(1984). Dr. Boxhill was familiar with the Joslin Clinic in
Boston, which treats solely diabetics, and of the six
contributing authors, he was familiar with three of them and
"would give great credence to anything they stated" (Tr. 655).
The foregoing circumstances are sufficient to regard the text
as authoritative for the treatment of diabetic foot problems,
including the basic procedures in treating diabetic foot
infection. On the basis of the portion of the text read into
the record by plaintiff's counsel, it is clear that the
accepted standard of medical care for treating a diabetic foot
lesion, as Dr. Lord testified, mirrors precisely the "textbook
approach." The court accepts Dr. Lord's testimony (which was
subjected to rigorous cross-examination) as independently
credible, and buttressed by the textbook.
The record is clear that Otisville failed to observe basic
standards for managing a diabetic foot problem, particularly
the procedures for treating the infected diabetic foot, and as
explained below, ineptly conducted those procedures that it
In Chapter 1, p. 5, covering "Diabetic Foot Disease: A Major
Problem," with obvious reference to foot infections, the text
Bed rest is the key to managing diabetics with
foot disease. No matter how much effort is put
into treating the local lesions by giving
antibiotics and regulating diabetes, the foot with
the lesion must be put to rest if it is to heal.
Crutch walking or walking `on the heel' is in most
cases, no alternative. Bearing weight on an ulcer
or a healing incision breaks down the fibroblast
network or barriers and slows healing by squeezing
bacteria into the surrounding healthy tissues.
Every step is a moment of ischemia to the damage
area. Therefore, bed rest is the first order of
treatment. [Emphasis added.]
At chapter 12, p. 119, discussing, "Local Treatment of the
Diabetic Foot," the authors state: "Bed rest is the first item
in the care of a diabetic foot lesion. It must be absolute and
continuous" (emphasis added). Dr. Boxhill agreed that bed rest
is "important," that Williams should have been advised to stay
off his feet as much as possible and that Williams' walking
should have been "restricted" (Tr. 657-59).