Diabetes

OK, this is another post I started a couple days ago, and am trying to get finished. So let's give it a shot.

Today, along with a host of other tasks, I put a Hickman Catheter (a special central IV good for a couple of months) in a Diabetic with poorly controlled diabetes. It is to give IV antibiotics long term to treat osteomyelitis (infection of the bone) of his foot. I also debrided the complex, foul smelling wound on the outside of his foot. He'll be non weight bearing on this foot for the next 2-3 months while we try to heal this. If this doesn't work, he'll lose the foot. His kidney function is about 1/2 of normal, and odds are good that within a year or two, I'll be putting in some form of dialysis access. This is the real world of Diabetes.
Lee Iaccoca, in his autobiography, talks of his wife dying of diabetes, and his desire to try to promote education about this terrible disease. To the general public, diabetes means insulin shots, but not much else. To those of us in medicine, it is a whole category of patients. Type "cost of diabetes" in your google search box, and your mind will reel with the numbers. A recent study calculates the US cost of diabetes at $174 Billion. That's a pretty mind numbing number for me, sort of like the bailout figures. So I'll just talk about diabetes from a personal viewpoint.
There is an old, rather morbid joke we tell about diabetics. "What do you call a diabetic with 2 legs?" "Pre-Op." "What do you call a diabetic with 1 leg?" "Pre-Op." For surgeons, a diabetic means chronic, nasty, foot wounds. These wounds are a result of several factors. First, the chronically elevated blood sugars slowly destroy the sensory nerves. This happens from longest to shortest, so the first to go are the feet. So when a diabetic steps on a tack, or starts rubbing up a blister because their shoes aren't fitting properly, they don't feel the pain, and so, don't treat the early injury. Second, the diabetes is a disease of microvessels, the tiniest little vessels that supply blood to the tissues. Once again, the farthest vessels are affected first, ie, the feet. So when the diabetic has an injury, there is inadequate blood to the area to allow proper wound healing, and inadequate delivery of white blood cells to fight infection. Third, the high sugars essentially poison the white blood cells, impairing their ability to fight infection even more. Finally, diabetics have a very high incidence of what is, for lack of a better term, a complete collapse of the structure of the mid-foot, meaning the arch collapses, the bones of the ankle collapse to the middle, and the patient is left with a near crippling deformity of the foot, all the more prone to ulcers and pressure injuries. For the surgeon, it means months of treating these wounds, with pretty poor results, and more often than not, amputation. Sometimes this is in stages -- a couple of toes, then mid foot, then rear foot, then below knee. Other times, there's already a raging gangrene set up when we first see them in the ER, and the first cut is an above knee amp. It's frustrating, because we all know where the outcome lies, in a below knee amp, but the patient generally will not accept this early on in the process. What we, as surgeons, know, is that with the conservative approach, the patient will be non weight bearing for months, with multiple courses of antibiotics, hospitalizations, surgeries, and chronic pain. If we go almost directly to a below knee amputation (almost always successful), the patient can be up walking with a prosthetic in a matter of a couple of months. Today's modern BKA prosthetics allow fairly normal ambulation and activity, and most estimates suggest about a 25% increase in the effort of walking. Diabetes is the number one cause of amputations in my personal practice.

OK, I've got more to say, but I was up early doing an appendectomy, so I'm gonna get this posted, and in our next installment, we'll discuss diabetes and the kidneys.

Sleep tight.