What causes diabetic foot ulcers and result in infections or amputations, starts with diabetes in general. Diabetes leads to a whole cascade of problems that lead to damage in the feet. One of them is nerve supply and sensation. One can develop loss of protective sensation and quite literally wear a hole in the foot just like we'd wear a hole in a soccer issue. That's called peripheral neuropathy or loss of protective sensation. Another thing that goes out to the periphery is blood flow, so we can have a problem with peripheral artery disease. What happens there (just like in the heart, except longer) we can develop complications that limit blood flow which can not only cause wounds, but more importantly cause wounds not to heal once they show up. Both of those things - both the sensation and the peripheral artery disease - are things that we have to focus on both as patients and as doctors and nurses.
Right now, there are about 30 million folks in the United States with diabetes and about half of those folks with diabetes will develop neuropathy or what one of my mentors used to call loss of the gift of pain. And that neuropathy can lead someone to wear a hole in their foot just like you or I were a hole in a sock or a shoe. Now that hole is called an ulcer, a diabetic foot ulcer. And that happens a few million times a year in the United States. Once it occurs, about half of those folks will require an antibiotic, will get infected at some time during the life cycle of the wound. Once that happens, about 20% of them will end up with some degree of an amputation and some level of an amputation. That's why right now, unfortunately there's an amputation performed every 20 seconds around the world. But I'm here to tell you that nearly all of those amputations are preventable. And our goal together, is to try to work to do that. More important than that is to try to work together to try to keep us, both you and me and all of our friends moving through the world. And that's really the goal of our group at SALSA. And it's the group of many of us that work really hard to both heal people with diabetes and wounds, and to keep them healed. And that's what we're going to be talking about.
If your doctor sees a callus (if your podiatrist sees a callus) he or she may very well want to trim that callus. Why? Because very often under the callus (especially if there's bleeding into the callus) there may be an ulcer that his limb threatening under that callus. That doctor may want to trim that so that they can identify the extent of the ulcer. That is really important that you talk to your doctor about that as that is happening, because that could be something (if it is not done) that could be dangerous, but please understand that the doctor did not create the ulcer. The doctor merely uncovered the ulcer underneath that really dangerous callus. If he or she doesn't trim that, what happens is that ulcer underneath (just like the tip of an iceberg) gets bigger and bigger and bigger and get infected, can create an abscess and that can not only costing you your limb - it could cost you your life.
This is one of these places in medicine and surgery and life where what you can't feel can actually hurt you and even kill you. Now, that sounds kind of scary and I don't want you to be scared. I just want you to respect this because what happens is, ultimately, in folks with diabetes, most people will lose some degree of sensation and that problem is called neuropathy. It puts people at a great deal of risk for getting a diabetic foot ulcer and then ultimately for getting all the other complications like infections, so called gang green, and an amputation. But upstream, what we we have to understand is that these symptoms may not exist. The key thing for you is to understand that what you can do to fight this is really pretty simple: you can knock your socks off every time you go in to see your doctor. That could be your general doctor or your specialist. When you see him or her, you compel him or her to have a look at your feet and he or she might actually see something or they might not. But what it does is it compels them to get down there to look. So that's a little tip that I'd give you, but it's also a part of the key symptom that isn't even a symptom when we're talking about diabetes and the foot: what you can't feel can hurt you.
I don't even begin to know what to tell you about handling different kinds of insurance. I guess it really depends on where you live in the United States or around the world. There are different policies that cover different things. But here's what I'm going to tell you: the most important thing you can do (in addition to checking yourself) is getting in to see your foot doctor. If you do that, along with seeing another member of the diabetes team, your relative risk for getting a high level amputation or other complications like that goes way down - anywhere from 20% to sometimes over 80% depending on the problem that you have. These are really phenomenal numbers. Some things are covered by an insurance company and some things aren't. Sometimes that includes different kinds of shoes and insoles that might be really important. Sometimes it includes certain kinds of checkups that are really, really important. But what I can tell you is: try to make the best effort you can to get in for that prevention. I promise you - your doctor and your nurse, if they're worth their salt (and I bet they are) they're going to work with you to try to make a difference there as well. If you find that happy medium, often that happy medium is a place where you can have a much lower risk for amputation and a higher risk for a high quality life.
A lot of work going on in this area (in amputation prevention) is really, really exciting. We are now developing better and better tests to assess risk, to predict a potential bad outcome. We can now boil down an entire clinical examination into between 1-3 minutes - we have developed something called the 3 minute foot exam. We've also developed other testing - like there are certain types of genetic tests that may prove promising in identifying people at risk for getting things like neuropathy, for getting things like other types of arthritis that can put them at risk for getting a dangerous deformity that commonly shows up in diabetes and diabetic foot called Charcot Arthropathy or other complications like this. These are just the latest sorts of things. Still even more exciting are: if you have a wound, there are now brand new ways to test the wound that may be able to assess all kinds of bacteria that are growing in their - in the wound. We're kind of moving away from Louie Pasteur and moving more toward CSI, if you will. Some of those tests are becoming more and more standard. How valuable are those? We'll see. They may amount to nothing or they may amount to something pretty special and I tend to think it's probably gonna be somewhere in between. I (for one) am pretty excited about some of those tests.
So living with diabetes in general is just, it's hard. I can't even begin to think about how hard it is. You're told to memorize and think about all these different kinds of problems, probably dozens of times a day. And that doesn't even count when you're checking your blood sugar. And sometimes when you think about the foot, this becomes 11th on your 10 most important things to do in your life. And believe me, I understand that and I'd be the same way. And I'd especially be the same way. If what I had to check wasn't hurting me, trust me when I tell you that what you can't feel can hurt you and what you can't feel can even kill you in the diabetic foot. And so if you just put a few little things into play every day, even just one thing, into play every day, you'll really make a difference. And that one thing is check your feet every day. Like you comb your hair or you brush your teeth. And you would say to me, well, what do I look for? And the answer is you would know if you're looking at your foot every day or if someone else, maybe a loved one, and if they see something that's maybe a little different, like a little ingrown nail or some redness or a callous that's there that wasn't there or maybe a little bit of swelling, any kind of breakdown in the skin, then you can get in immediately to your foot specialist and call him or her and let me tell you, they will get you in. If you have diabetes, you are part of that family and those little things every day can make the difference between the life and limb. Just getting in to see your foot doctor reduces your risk of getting an amputation, especially a high level amputation by anywhere on the low end, just under 20% to on the high end, over 80% depending on what risk factors you have. Since when do you hear about numbers like that? If we just had a 5% risk reduction, that would be a blockbuster drug. What we're talking about is blockbuster prevention, and this is something that we can do in the most low tech manner possible.
Another thing that they might look for on a routine diabetic foot exam is any signs of a deformity. If you have a deformity in your foot, then that can increase pressure points, which can put you at greater risk, especially if you have neuropathy, that's the loss of feeling. Or the vascular disease and all three of those things can come together kind of in, if you will, a sinister synergy to create problems. So they might be moving your toes around, moving your ankle around just to see what the range of motion is like if there are any limitations or or contractures there. That's another thing that can be done.
We have talked about a lot in a rather short period of time and let me just tell you - you are so welcome to come back anytime. You're welcome here anytime. Heck, you're welcome in our clinic anytime. I think I speak probably for most doctors and nurses that really focus on this area to take care of you to say that this is this problem is such a hard problem. But yet every time I walk into my clinic, I tell you what: I find a new reason to have hope because what I see are folks that are dealing with complications that I can only begin to imagine, but yet they're dealing with those things with grace and class and compassion and kindness. But I think if we work together - nurses, doctors, physician surgeons, and most importantly patients - and we marry a little bit of common sense with technology and marry a little tenacity with the technology, we can affect change together and we can end up in a place where there are far fewer needless lower extremity amputations and far more folks leading a high quality life. Because you know what? That's what we all deserve - whether we have diabetes or not - no matter what our health and no matter what our age.
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