Limb Salvage; Education And Patient Realization

Vickie R. Driver, MS, DpM, Clinic Director
Madigan Army Medical Center- Foot at Risk/Limb Salvage Clinic

Dr. Driver said the clinic provided conferees with hands-on training with various labs and modalities, as well as a CD on all the lectures. "I [also] do a fair amount of lecturing all over the country," she said.
Lt. Cdr. D. Andrew Wolfe, DpM, USPHS, a podiatrist for the Crow/Northern Cheyenne Indian Health Hospital in Crow Agency, Mont., and owner of the Yellowstone Foot and Ankle Center in Billings, attended the clinic's conference last fall and said it was "cutting edge" in the limb salvage arena. "It was an exciting conference," he said. "I'm looking forward to going back again. There was a lot of free exchange between different specialties, which is often needed in medicine."

Dr. Wolfe said diabetes is the number one reason other than trauma for amputations. He said about 40-50 per cent of the reservation population he treats has type 2 diabetes. "We used to have a high number of amputations and we've been aggressively working on limb salvage, ourselves," he said. "With diabetes, there are often cardiovascular problems, but when you lose a limb, you can't get around as easily, so it decreases your life expectancy."
Type 2 diabetes affects Native Americans about twice as much as the general population, Dr. Wolfe added. "Some of the highest rates of amputations in the world are on reservations," he said. "When people become diabetic, peripheral neuropathy [can develop], which kills the nerves in the feet. You can get an infection, but can't feel it, often until gangrene has set in. We see a lot of pathologies secondary to type 2 diabetes. It's very commonplace to see gangrene, terrible non-healing ulcers and people coming in with wounds where their tendons are showing."

Dr. Wolfe said some of the reservation patients he encounters have no running water in their homes, dirt floors and no cars available to them.

But Dr. Wolfe added that the incidence of pre-diabetes and diabetes appears to be rising in the general U.S. population, as well. According to the Department of Health and Human Services, in 2000 there were an estimated 17 million people with diabetes in the country, including 5.9 million undiagnosed cases.

Dr. Wolfe said the conference worked well because it encompassed many different perspectives from a wide range of specialists. "Everything was pulled into one," he said, adding that workshops were held on full contact casting, therapeutic shoe gear, and wound care products. "There was a lot of free exchange of information. All of the people who attended are considered experts in their fields. [But] if you're just off in your own world, you're not doing a service to medicine. Medicine is about the free exchange of information."
Dr. Wolfe said his clinic employs several different techniques in diabetic foot care. Sterile maggots can be used to debride tissue, bioengineered human tissue can be used for skin grafting wounds, and new drugs are available for opening the microvasculature to heal ulcers. Since maggots eat only dead tissue, Dr. Wolfe said it's actually pretty good therapy in terms of cleaning out wounds. "It's not uncommon," he said. "The number one thing is to clean everything out. It's less traumatic to the tissue."

Other areas that are important include nutritional support and new wound care products that are less cytotoxic than in the past, Dr. Wolfe added.

David C. Larsen, DpM, who also attended a Madigan diabetes conference several months ago, said it was one of the best exchanges of information among many different specialties that he's witnessed. He said those that attended were really open to ideas and looking for new answers to preventing amputations. Dr. Larsen, who attended the conference with his wife Shannon Meyer, DpM, operates a practice with her in Hayward, Wisc., called Comprehensive Foot and Ankle. They do a lot of consulting on diabetes with Native American tribes in northern Wisconsin. "We've been developing diabetic programs since '97 with a mix of [IHS] grant money and private funding," he said. "We've seen a definite change in mentality among patients, a lot fewer problems just by developing programs for tribal clinics. We used to see one to two limb-threatening infections a week. Now it's down to one a month, so the tide is changing. The conference was really influential in recharging our battery."

Dr. Larsen said the conference brought together a lot of different specialists that can help form a limb preservation team. "It really becomes a question of developing good lines of communication between [providers and specialists]," he said.

Providers should not keep their patients to themselves, but rather utilize all the services that are available to help their patients, Dr. Larsen said. "We have to break down that old mindset of 'this is my patient,' " he said. "Let's work for the patient."

Dr. Larsen said Madigan is fortunate in that the limb preservation clinic there has a whole group of providers in one area, whereas in northern Wisconsin things are spread out over a rural area. He said there are several IHS clinics that he consults for to help integrate podiatry and regular foot examinations into a stage diabetes management program. "We work with them and we look at risks," he said.

Dr. Larsen said the conference feeds into the mindset of stopping problems before they get really bad and correcting serious troubles more rapidly. The diabetic limb preservation concept is one that has not been given enough attention in the past, he acknowledged. He said there is a mindset among some providers that diabetic patients won't listen to how they can prevent problems, so oftentimes there is a lack of education given to patients. "So they don't have enough information to prevent problems," he said. "There is an old school mindset that they are not compliant and are just going to do what they want anyway."

Dr. Larsen said that's not really the case with most patients. "To get the information they need to prevent problems is imperative," he said. "It's about lifestyle-'How many things do I need to change to make my life better?' We, as a whole, I don't think have done enough with patients to spend more time educating."

Another aspect of education promoted at Madigan is that treating things like hypertension can also produce improvements in diabetes, making a multi-disciplined approach ever more crucial. "The [use of] aspirin [to help ward off heart attacks and strokes] and all those other things is from the overall training because it's really a medical and surgical approach to limb preservation," Dr. Driver said.

Although the Madigan Foot at Risk/Limb Salvage clinic already has three surgical residents, a research fellow, a wound care nurse, a project manager and two clinical research coordinators, there are plans in the works to expand. "We are developing a limb preservation center that is a step above where we are that will be a service in itself that will have three legs: education, research, and patient care," Dr. Driver said. "Our focus will be to develop some standards of care that would hopefully be utilized for other military medical facilities. We're looking to develop a center of excellence. We've already created some interim facility guidelines for training and we hope to do a fair amount more of that to help other institutions develop satellites of what we have, perhaps a similar type of system. We are very, very focused on developing outcomes management, research-related projects, looking to develop not just institutional guidelines, but we want to sort of add to the equation for limb preservation not just as an Army hospital, but as one of the members of the DoD medical facilities. We're developing a new structure for the center. We are expanding the service and expertise and we'll be doing more research and getting new equipment, as well as a research fellow and an outcomes research nurse. It's just jumping off the platform."

When asked if she perceives a culture in mainstream medicine that doesn't place a lot of emphasis on limb preservation, Dr. Driver said, "Yeah, I think they don't put enough emphasis on it, but primarily because it's really a specialty that's been blossoming over time, over the past really five to ten years, the last couple of years full steam ahead. You don't go to medical school and say, 'I want to save limbs,' necessarily, but it requires a certain amount of extra education and organization of a clinic to prevent the limb loss. So, I think with primary care departments being so busy and them not having, for example, scalpels in their clinic to debride or even the skills to debride a wound-some of them do it and some of them I'm sure do it well, but for the most part they don't have time to do that kind of thing because they are focused on all the other aspects of the patient. There is oftentimes nobody in these facilities that knows how to do it or has time. It's become a specialty within the system."

The clinic has hosted two interdisciplinary conferences on diabetes care in the past year and is sponsoring the NW Limb Preservation Conference, March 15-17 at Meydenbauer Center in Bellevue, Wash., on prevention of diabetic amputations with a focus on medicine, surgery, research and wound care. These conferences are attended by a very wide spectrum of physicians, from infectious disease docs to orthopedic, vascular, cardiac surgeons, wound care nurses, internists and endocrinologists," Dr. Driver said. "The last two that we have had have been 'train the trainers.

To learn more about the conference click here
( http://www.thegenevafoundation.org/events/NWLimb.html)