By Fred H. Olin, MD
During my orthopaedic residency, one of my professors commented that he considered every amputation to be a failure of the “system.” When asked to elaborate on that statement, he pointed out that, in the case of wartime amputations, the failure is political: the powers that are in charge of things were unable to control matters and deal politically with whatever the conflict happened to be. As a result, the horrors of combat supervened, leaving thousands with missing limbs and a need for care and rehabilitation.
In the civilian world, amputations occur after accidents involving motor vehicles, construction mishaps, violent crime, misadventure, substance abuse, post-surgical infections, etc. Could all of them have been prevented? Probably not, but it is easy to see that changes in our society, our technology and our performance as physicians undoubtedly could make a difference in many of these situations. However, none of those are the declared subject of this month’s San Antonio Medicine…diabetes is.
As noted in other articles in this issue, and as we all should know, diabetes is one of the supremely multi-factorial conditions to which the human condition is subjected. When one considers the diabetic changes such as peripheral vascular disease and diabetic neuropathy which contribute to the appalling number of lower extremity amputations (and the occasional upper extremity problem as well) it is easy to become nihilistic, figuratively throw up our hands and say, “That’s just the way things are.”
However, considering that we know the results of our failure, the effect that amputation has on the patient’s life and family and the expense to society that loss of limbs causes, it becomes evident that those of us entrusted with the care of diabetic people must try harder to prevent this appalling situation from increasing even more.
Note, please, that the word “patients” was not used in that last sentence. We must keep these people from becoming patients who need amputations. How to do it? In one word, education.
Who needs this education? You, me and the public, that’s who. Does every physician who sees a patient who is known to have diabetes take a look at that person’s feet? Unlikely, indeed. Over the years, I was involved with several amputations that might have been prevented had this been done. One which comes to mind involved a younger woman with severe diabetic neuropathy who happened to tell me that she had seen her gynecologist a short time before presenting at the ER with a penetrating ulcer and sepsis which ultimately resulted in the amputation of part of her foot. The ulcer was present but hadn’t progressed to bone before the GYN visit, but neither the doctor nor her nurse asked her remove her shoes for the examination.
Proper instruction in self-care, instructions to the family about evaluating their loved one’s skin, and physicians who are willing to take a few more moments with their patients can aid in decreasing the incidence of this sort of systematic failure and its devastating result.
Fred H. Olin, MD is a semi-retired orthopaedic surgeon who has discovered the pleasures of breakfast at 9 a.m., not getting midnight phone calls and never having to write orders or make rounds.
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