A practical manual of diabetic foot care

By Edwards, Foster & Sanders. I’m currently finishing this book.

I’m pretty sure nobody who’s reading this blog semi-regularly will want to read this book; unless you’re a diabetic or a health care provider working with diabetics I guess it’s not easy to come up with a lot of good reasons why you should read it. But I decided to blog it anyway. If you do decide to read it, unless you’re used to medical textbooks I’d advise you to schedule your reading so that you only open this book when it’s been a while since you’ve last eaten; unless you’re at least somewhat desensitized to this kind of stuff (like I am at this point..) you’ll probably want to vomit after looking at some of the pictures in this book. This book covers everything from ‘Stage 1: The normal foot’ to ‘Stage 6 – The unsalvageable foot’. Good luck guessing what the latter looks like – if you don’t want to guess you can go here for images of a similar nature.

I know a lot more about the subject than I used to do at this point, but not all of this was new stuff to me – I’ve covered related matters before here on the blog, for instance here. However most of the stuff I’ve read in the past related to ‘epidemiology’, whereas I have not spent much time dealing with the actual disease process – what’s going on when the foot ‘goes bad’, how it may happen, what can be done about it, etc. – and here the book most certainly delivers.

I figure some curious diabetic googlers may stumble upon this article later on, and so it makes sense here to emphasize one thing before going any further – a point the authors of the book emphasize as well: There is no such thing as a trivial lesion of the diabetic foot; all foot problems need early diagnosis and appropriate intervention. If you’re a diabetic even a small wound/ulcer on your foot indicate that you’re (at least…) in stage 3 of their 6 stage categorization system. Next step after that is the infected foot, and the step after that one involves necrosis. You do not want to go there. What I found really surprising was the asymmetry between the time it takes for damage to be caused and the time it takes to heal that damage afterwards; necrosis can develop really fast, but healing may on the other hand take a very long time, especially if rapid and effective intervention is not undertaken at the early stage of the disease process – for example: “The average amount of time spent in a cast by diabetic patients with Charcot’s osteoarthropathy is 6 months but some patients may need a cast for over a year.” And here’s another related fact: “In our experience, fractures in stage 2 and higher stage diabetic feet take two or three times as long to heal as they do in low-risk or normal feet. Many health-care professionals appear to be unaware of this.”

I found the patient case studies particularly interesting, because they somehow make it all much more concrete and tangible. Of course it’s nice to know that: “Throughout their lifetime 15% of patients will develop ulceration; 85% of amputations result from non-healing ulcers” – but the case studies somehow makes all of this a bit more ‘real’. I have posted some of them below. I would like to remind you that I am 27 years old and that I have had diabetes for over 25 years at this point.

“A 17-year-old girl with type 1 diabetes of 4 years’ duration was referred to the diabetic foot clinic for education. A paternal uncle had type 1 diabetes and neuropathic ulceration. Her background was a chaotic one of great poverty and social deprivation with a history of truanting and running away from home. Her HbAlc was 14%. She had frequent admissions to hospital for ketotic episodes and traumatic lesions to her heels and her navel which became infected. She was educated in foot care and footwear but continued to wear unsuitable shoes; she also frequently missed appointments at the diabetic clinic and diabetic foot clinic. However, she agreed to attend the clinic in emergency and to take antibiotics if her foot lesions became infected. She had no more admissions for foot problems, but subsequently developed severe neuropathy, proliferative retinopathy and end-stage renal failure and is currently on dialysis.” [Usually we think of chronic complications to diabetes mellitus as disease processes that only rear their ugly heads after many years, if not decades, with the illness; this case study is a good reminder that even relatively short time periods with poor metabolic control/compliance can have catastrophic consequences for the individual in question.]

“A 62-year-old lady with type 1 diabetes of 40 years’ duration, retinopathy and neuropathy went on holiday to Blackpool, removed her shoes and socks and sat in a deckchair on the beach for 3 h. Her head and torso were shaded by an umbrella but her feet and legs were exposed to the sun. She suffered a full-thickness burn on the dorsum of her right foot (Fig. 3.10). She was admitted to hospital for debridement and skin grafting and the foot healed in 6 weeks.”

Yes, you got that right – going to the beach for 3 hours lead to a burn that took 6 weeks to heal. Here’s a similar example:

“A 25-year-old male patient with type 1 diabetes mellitus of 14 years’ duration, profound neuropathy and endstage renal failure treated with dialysis, slept in a bed next to a central heating radiator. During the night, in his sleep, his leg slipped against the radiator. He sustained full-thickness burns to his leg, but only attended the diabetic foot clinic when these became malodorous. There was a moist leathery eschar with purulent discharge. He was admitted to hospital for intravenous antibiotics. The burns were surgically debrided and split-skin grafts applied from a donor site on his thigh. He healed in 5 months.”

Note how well the last three guys are doing – they’re all in their 40es:

“A 46-year-old man with type 1 diabetes of 33 years’ duration, end-stage renal failure treated by renal transplantation and severe neuropathy, received regular foot checks under a renal foot study protocol. Three days before he went on holiday to the Channel Islands his feet were routinely checked and nothing abnormal was discerned. Two weeks later he came to the clinic on his return from holiday to report that his foot was ‘a little swollen’. He reported no trauma to the foot, but had been walking more than usual on cobbled pavements. The foot was red, 5°C hotter than the contralateral foot and very swollen. X-ray revealed a Lisfranc’s fracture-dislocation and he developed a rockerbottom foot. He was treated in a total-contact plaster cast for 6 months following which he wore bespoke boots to accommodate his deformity.”

“A 40-year-old male with type 1 diabetes of 30 years’ duration, proliferative retinopathy treated with laser photocoagulation, sensory neuropathy and autonomic neuropathy including postural hypotension, developed an acute right mid-foot Charcot’s osteoarthropathy. Because of a previous episode of severe sepsis…”

“A 44-year-old woman with type 1 diabetes of 26 years’ duration, proliferative retinopathy, profound neuropathy and end-stage renal failure treated by renal transplant had her feet checked at monthly intervals at the renal unit as part of a research protocol. Her foot pulses were palpable. She was educated in foot care, foot inspections and early reporting of any problems. However, during a 3-year period she suffered nine separate episodes of foot trauma, none of which she reported early: they were detected at her renal unit appointment. Causes of trauma included blisters from ill-fitting shoes, picking at dry skin, pulling off pieces of nail and being ‘trodden on by a baby’. In the last episode she stubbed her toe while walking barefoot, did not report the injury and presented late to the renal unit with spreading cellulitis, wet necrosis and septicaemia. She was resuscitated and treated with intravenous antibiotics and underwent 1st ray amputation to remove the source of her sepsis. Despite this, her septicaemia progressed and became overwhelming and she suffered a cardiac arrest and could not be resuscitated.”

March 21, 2013 - Posted by | Books, Diabetes, Personal

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