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Limb Salvage Feelings Lost and The Diabetes Scorecard. A Feeling Lost

Since diabetics can encounter many health issues, often a multi-disciplined approach is needed to treat them. “Diabetes has many, many factors,” Dr. Driver advised. “We became very aware of the eye problems, the kidney problems, the glucose issues, but we were seeing the amputation level continuing to rise. Last year there were 90,000-plus amputations in our country alone that were diabetics. Limb-at-risk issues affect all diabetics potentially, and it doesn’t matter the age-it could be a child. The biggest problem that we have with diabetics is that some of them cannot feel their feet.”

The clinic conducted a study recently that examined 250 of the diabetics treated there. "About 80 per cent of the ones that we screened had no or very little feeling in their feet," Dr. Driver noted. "Now, if you can’t feel your feet and you step on a tack, you won’t know that you even have a tack in your foot unless somebody happens to see it. A lot of diabetics, particularly if they’re seniors, they also have eye problems. So now, they can’t see the bottom of their foot. Taking it a step further, perhaps their waistline is a little bit larger, they can’t bend over to get to it. The literature shows that if you are to amputate a limb of a diabetic, that it is likely that you will go on to amputation on the other side within two years, and death might ensue within two years after that. So, it’s not just taking a limb, it can be thought of as reducing a life span of the diabetic patient, and if a diabetic is sedentary, their blood-glucose is going to go up and then all of their major organs may take a hit from those episodes."

Dr. Driver said there are many things that can be done in the realm of preventive care. "That’s part of our at-risk clinic, a fair amount of education," she said. "What they can do is to better control their blood-glucose, [and] they may be able to control the development of further loss in feeling. There are some studies that are happening now, clinical trials, looking at other ways to control feeling loss. So the key is prevention, educating the patients, showing them how to evaluate their feet on a regular basis, educating their family members what the situation is, what ‘at-risk’ means, because it’s very, very difficult to understand when you can’t feel something. Even for the patients that can’t feel, they’ll come into the clinic, they’ll have a huge wound in their foot and there might be pus all over the floor, but they’ll say to you, ‘You know what, it feels fine, so I didn’t come in [earlier].’ Now, it’s hard to accept the fact that you can’t feel and we always associate pain with a medical problem. But in this case, those patients’ pain is something they want back."

Diabetic patients don’t lose sensation overnight, according to Dr. Driver, and often go through "hyper" pain stages before gradually losing the feeling in their feet. "Most of the time that’s directly related to their blood-glucose control, but not always," she added. "There is a lot we don’t know about diabetic neuropathy. It’s a very complex issue and there are many types of [it]."

Once a diabetic has lost feeling in his or her foot, the options are limited. "There is really not much that can be done," Dr. Driver said. "It is more about education and protecting them from trauma, protecting them from shoes with ridges, protecting them from ingrown toenails, protecting them from cracks in their feet that can become a portal of entry [for] infection. It’s about protecting them from socks that are too tight that they can’t feel. It’s protecting them from something that seems as benign as say a foot fungus that might cause them an opening in their skin. The amputations that happen or the severe problems usually start from very minor problems, perhaps somebody steps on one of their children’s plastic toys. They didn’t feel it and it cracks open the foot, and they end up with an infection. They can’t feel the infection. They don’t feel sick because [with] a lot of diabetics their immune system is poor, because their body doesn’t mount the reaction. It isn’t until the infection gets quite advanced that they really have a sign or a symptom of infection. Before they would feel it or know anything about it, their blood glucose would go up very, very high. That would be their only indication."

Diabetic ‘Scorecard’

Diabetes rates are remaining fairly stable for a couple of reasons. "We are having more seniors," Dr. Driver said. "Plus, obesity [in America] is on the rise. The fact remains that if you have congenital [or] a family history of diabetes and you’re [overweight] then you’re going to have a higher chance of becoming diabetic. So, America is a little fatter than most countries and we have a lot of seniors."

Patients who have a family history of diabetes and who take certain medications for other reasons can run into problems with that, as well, Dr. Driver added. At Madigan, primary care and internal medicine physicians administer a diabetes ‘scorecard’ to patients to help determine their diabetes risk level. "If a patient is diabetic, most of them would get sent to the foot-at-risk for an evaluation," Dr. Driver said. "If they are low-risk, they’ll be brought here once a year to be evaluated, and we will check their nerves, we’ll check their blood flow, we’ll check the pressure as it relates to their foot. We’ll talk to them about their medicine history and educate them as to all the problems they could have with their extremities. If they are found to have a vascular issue or a poor blood flow, we send them over to our vascular department. And they are seen on a regular basis at the foot-at-risk [clinic]. If they are found to not have feeling in their feet, or partial feeling, then we also see them in the clinic. We give them orthotics or pads to put in their shoes that will help prevent them from getting sores, and we monitor their level of neuropathy. Some people can’t feel their toes, but they can feel the rest of their foot. Some people can’t feel all the way up to their knee. They can’t feel socks; they can’t feel their shoes. And sometimes it’s so bad they can’t tell if their feet are in front of their body or behind it. And diabetics can have what is called ‘night blindness,’ so they get up during the night and if they don’t turn the light on they can’t know where they’re going because their feet won’t give them that connection. So, there are lots of different levels. Once a diabetic has an ulceration on [his or her] foot, they are forever high-risk because there is a reason they got that sore, which means they are at very high risk of developing another one."

Dr. Driver said the clinic staff tell diabetics that anytime their blood-glucose goes from normal to a very high level, they should think about the possibility of an infection somewhere. It’s not necessarily on their foot, but that is the most common place, she added. "The most common admission to a hospital is for a foot-related problem," she said.

In order to avoid such admissions, Dr. Driver said the clinic conducts education, tests, and frequent outpatient visits where patients stay in a waiting room with others who have already lost part of their feet or who are in wheelchairs, so they see what can happen. "Additionally, I have a couple of lectures that I give to the patients on my own computer in my office that shows them some of the problems they can have, and [it] gives them a little bit of awareness of what could happen if we don’t help protect them or if they don’t help protect themselves," she said. "We also give them literature and really try to get all this across to their family members."

Dr. Driver said there are a lot of protective measures that can be taken. "[For] some of these patients, we order special shoes, inserts for their shoes that keep, sort of, their tires balanced," she said. "We set them up with consults to nutrition services they need, we do lots of interfacing with physical therapy-maybe it’s somebody who has a stiff joint and can’t use the joint. We send them to physical therapy or maybe we build them a brace. Some of these patients need certain prosthetics. Maybe they’ve had a partial amputation somewhere, but they didn’t have all that was needed to kind of complete the job, so [we fix it so] they now walk without a limp. Because a patient with a limp can’t feel their feet, you can imagine wherever that limp is, there is too much pressure. Pressure is their enemy. Their skin will die if there is too much pressure placed [somewhere] without relief."

Sores, such as those that form on the heel with little skin on the back of the foot can easily become a bone infection if left untreated, Dr. Driver added.
Partial Amputations

There are a lot of amputation techniques, but a primary goal at the clinic is to leave enough of a limb in place to ensure a good chance for functionality afterwards, according to Dr. Driver. "There are certain ways in which you can take off, if you need to, a toe or two and balance the foot, either by [fitting] the right type of prosthetic or not taking too much of that toe, so that the balance remains there. Sometimes, if you need to, if one tendon needs to go because it’s infected you can re-route another tendon to provide that same function of the foot," she said. "Oftentimes, for example, patients will end up with two or three or four of their toes badly infected, and maybe the toes have to go, but we keep the rest of the foot and they can [function]. We’ve learned to take all the toes and rebalance the tendons so that you can actually use the foot. We put a filler in the shoe and they wear the same size shoe on that side of the foot. Sometimes we do plastics procedures to cover holes in the foot once we’ve cleared [an] infection, everything from utilizing certain surgical techniques to advanced wound care products, like skin equivalents [and] growth factors."

When asked if the clinic ever receives patients who have had bad or premature amputations elsewhere and are in need of prosthetics or surgical modifications, Dr. Driver said the clinic does see some. "We get more than we’d like," she said. "We just learned a lot about ways in which to do amputations that afford the patients more functionality and we have a really wonderful prosthetic department here. It’s a full complement prosthetics [department] and so we can do any type of prosthetic or cast. We also have cast technologists here who do special ‘total contact casts.’ A patient can have a rather large wound on the bottom of their foot. We place the cast on them after we’ve done the debride part. We order a total contact cast, and they build it around their foot, so that they can continue to walk and not put pressure on it. [The cast is] in contact with their leg and their foot, everywhere except for where their wound is, so when they walk they [keep] their wound [free], evenly distributing the weight all around their foot, but not on the wound, so they can continue to go on healing, and not be bed-bound or in a wheelchair."

Next Week, Education and Realization

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)