Dr. Conway McLean, Journal columnist

I would like to tell you a story, although this one does not have a happy-ending. This is the story of a kindly gentleman who, like so many in our culture, had developed adult onset diabetes. This might be due to the fact he was ill-informed about nutrition and its vital role in health. This relationship eludes many healthcare providers who have, by the way, received little education or training on this topic. What is the relationship between our general well-being and the foods we consume? Questions remain about the specific effects of what we feed our bodies. More than ever, we are learning more about the importance of the nutrients we provide our cells. It seems obvious our diet can be an important factor in the development of diabetes.

This particular gentleman, who we’ll call Dave, happened to be mentally handicapped. An affable fellow, his language skills may not have been the best, but he was kind, a gentle soul, and easy to talk to. Suffering from diabetes as he did, there are certain problems he was innately inclined to develop. These are referred to by specialists in limb salvage (the specialty of preventing limb amputations), as the “Terrible Triad.”. The three factors leading to limb loss consist of arterial disease, neuropathy (the nerve changes of diabetes), and an impaired immune system. These three factors combine synergistically to create tremendous problems for those with diabetes.

The manner in which these three organ systems work in concert, under the influence of diabetes, is complex and multi-factorial. Working together in a negative fashion, ulcers are much more likely to develop. These openings in the skin allow bacteria in, and infections in this population often worsen quickly. But that’s not the topic for today’s discussion. Suffice it to say, these are well-recognized aspects of diabetes leading too often to amputation.

Indeed, many experts in the care and prevention of diabetic amputations state that too often these tragic events could have been prevented. This ambition, of reducing the number of diabetic amputations, can be achieved simply by providing better education. We need to teach everyone with diabetes about better foot care.

Every routine medical visit for a diabetic should include a foot exam. Unfortunately, this is not always the case. Dave, our subject today, saw his primary care physician on a regular basis. During one such visit, Dave mentioned some pain in his heel. Due to a very busy schedule, the physician did not take the time to examine Dave’s feet. He complained once more at the next visit but was told the pain was due to the nerve changes of diabetes. (Neuropathy is first experienced in the toes, so that was not a good explanation). Dave was developing an open wound on the bottom of the heel.

Typically, diabetic foot problems are easy to resolve when the individual comes in early in its development. It is so critical that those with diabetes evaluate their feet on a regular basis. They do this just by looking, ie visually examining the bottom of their feet, as well as between the toes. No medical training is necessary: simply recognize some area looks different, something has changed. This could be a reddened area or drainage from somewhere. Waiting for your next visit with a healthcare provider entails too great a delay. A month is plenty of time to develop an infected foot ulcer, since the opening allows bacteria access into the foot. With their impaired immune system, these infections can worsen quickly.

Amputation is an extraordinarily debilitating, life-changing event. Unfortunately, it is also a life shortening event. Although modern medicine is still not certain of the mechanism, a major amputation too often results in a reduction in lifespan. Many do not survive another five years.

Dave did not experience pain from the open sore developing on his heel because of the reduced sensation of diabetic neuropathy. Although difficult to thoroughly incorporate into their thinking, anyone with diabetes needs to understand they cannot rely on pain to tell them they have a problem. Neuropathy is called “the first step on the stairway to amputation.” This cliche refers to the trickle-down effect of losing the ability to experience pain properly (which does not imply they have no feeling whatsoever). If we can intercede in this chain of events, it is believed 85% of the diabetic amputations could be prevented.

Because Dave’s foot ulcer went unrecognized for so long, it penetrated to bone before effective treatment was utilized. Prescribed was a novel form of electric stimulation which promotes better blood flow into tissues, in addition to the application of a wound VAC. This latter device stimulates the growth of healthy living tissue, and the two together worked to significantly reduce the size of the ulcer.

Many marvelous new techniques have been developed over the last two decades. During this time, great attention has been paid to the art and science of wound care. This is by necessity since with the aging of America and the epidemic of diabetes, more and more are suffering from chronic, non-healing wounds. Statistically, these most often occur in the lower extremity, primarily below the knee where circulation is reduced and where the nerve problems first develop. Let us not forget the physical stress to the feet of bearing weight and ambulation.

The battle to reduce the amputation rate needs to occur “in the trenches”, in the day-to-day life of someone with diabetes. It needs to take place in the offices of the primary care providers. No diabetic should be seen by a provider without a foot inspection. Every newly diagnosed diabetic, along with a referral to a diabetic educator, should be referred to a foot specialist. In addition to the medical and vascular evaluation performed, education will be provided about how to take care of their feet.

Dave was seen by an orthopedic surgeon, who told Dave he needed an amputation. This is certainly a definitive plan of action, eliminating the need for the pain-staking and slow process leading to healing. Wound care takes patience and time, along with knowledge of approved techniques. For some, this kind of decisive treatment, amputation, seems attractive. Yet many underestimate the effect an amputation will have on their quality of life. Some cannot successfully use a prosthesis, confining them to a wheelchair. More consequential, as mentioned, the lifespan of those who suffer an amputation tends to be greatly curtailed.

Diabetic foot problems are generally easily resolved when evaluated and treated early in the process of ulceration-infection-amputation by the appropriate specialist. Several excellent studies demonstrate podiatric care lowers amputation rates. Once you get up to the second or third step on that “stairway” I mentioned, the success rate goes down precipitously. Still, with some of the new techniques available, many limbs previously thought unsalvageable can now be saved with use of modern wound care techniques.

If you know someone with diabetes, make sure they have had an evaluation by an appropriate specialist. This should provide them with an education on the “do’s and dont’s” of diabetic foot care. It can save their leg, and save their life.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.