Conway McLean, DPM, Journal columnist

This is the story of Jack and his experiences with modern medical care. Jack received a bird’s eye view of the inadequacies of the U.S. healthcare system, which has a well-deserved reputation for a failure to emphasize preventive care.

He eventually suffered a fate too often endured by many Americans. Jack lost a leg and, ultimately, his life. (As we say in lower extremity medicine, “Save a Leg, Save a Life.”) A well-recognized fact is this was likely preventable.

Where to start in this long, sordid tale? Perhaps the family history positive for heart disease and diabetes. Maybe, the life lived loving fun, the life of the party.

Yet, in his high school days, he was quite the athlete, even playing varsity football. Those days are long gone, although he considers himself “athletic” even though the most sporting thing he does these days is the 12 ounce curl (a trite saying for drinking a beer).

His medical condition he considered ‘fair,’ despite the recent addition of a heart medicine to his routine. The latest concern was the proclamation by his nurse practitioner that his blood sugar was getting high and could result in developing diabetes. He knew about the family history but the NP didn’t seem to make very much of it so he didn’t either.

Jack worked in a prison and knew the routine. But he didn’t like the work nor the clientele. It was physically demanding and everything was concrete and iron. But his feet were fine, or so he thought until “all hell broke loose.” He didn’t know he had a problem for weeks. And at the time of the discovery of drainage in his socks, he had no pain. How was he to know something was brewing?

Because of his high blood sugar levels, Jack was experiencing some of the same complications as someone with diabetes, which are nerve changes. The most common is reduced sensation, manifesting as numbness. These people often will feel no pain when some minor skin injury occurs. If they can’t feel and they aren’t looking……they won’t know.

Jack underwent a process that is too common, where a sore develops between two toes, over some weeks, because of pressure. Numerous factors are involved in the development of skin breakdown, of course. This takes time to occur but Jack had no pain. The nerves in his feet had been poisoned by the high blood sugar. They didn’t alert him a problem was percolating in the depths of his foot.

The space between the toes tends to harbor some nasty bacteria, and when an opening develops, they have access to the deeper compartments of the foot. All that Jack noticed was his foot was swollen, but loosening his laces took care of that. He thought no more about it until the next day when there was drainage on his sock, yet still no pain. How bad could it be?

When Jack began to feel feverish, he went to the emergency room of his small, local hospital. The physician’s assistant working at the time prescribed an antibiotic, but wasn’t sure what to make of the situation. The pills made him feel a little better, but not much. By the time the chills were really in effect, he knew something was very wrong. A trip to the nearest tertiary care center elicited the worst possible news, a surgeon was recommending an amputation.

Jack had developed neuropathy, preventing him from experiencing the pain he should have had from the simple corn between his toes. With time, and sweat, pressure from poorly fitting shoes, and reduced skin health from diabetic small blood vessel disease, an opening in the skin resulted, allowing all those bad bugs into a deep compartment of his foot. This would normally be a painful process but the nerve changes prevented that. Neuropathy is a sneaky, gradually developing condition. Most of the people with neuropathy don’t even know they have it.

The experts had difficulty controlling the infection. The antibiotics chosen initially didn’t do the job and the doctors said the infection had been present too long; the foot had to go. He healed okay from the amputation but was never able to successfully use the prosthetic, the fake leg. His activity levels plummeted and soon he rarely got out of the wheelchair. His heart disease finally led to his demise. This isn’t a rarity, a minority of the diabetics who lose a leg are able to use a prosthetic and maintain more normal activity.

This fate befalls too many people with diabetes. Frequently, these people are never educated about the troublesome complications associated with this common malady. These problems result from the combination of diseased skin nerves, blood vessel disease, and an impaired immune system. Those of us in the field of diabetic foot medicine call this the “Terrible Triad” of diabetes. As it was for our protagonist Jack, it can be a recipe for disaster.

As a culture, as a society, we need to better understand the chain of events leading to these debilitating developments. One answer to so many of these lost limbs is education. We need to better teach those who have been diagnosed with high blood sugar about these changes and how to protect themselves (whether or not they have officially crossed into the territory that is a diagnosis of diabetes). Better testing, for both neuropathy and arterial disease, would also help. Understandably, podiatric medicine is in a unique position to make these goals a reality. If you or someone you know has diabetes, get educated about diabetic foot care. It can literally save your life.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean’s practice, Superior Foot and Ankle Centers, has offices in Marquette and Escanaba, and now the Keweenaw following the recent addition of an office in L’Anse. McLean has lectured internationally, and written dozens of articles on wound care, surgery, and diabetic foot medicine. He is board certified in surgery, wound care, and lower extremity biomechanics.