Case 1 — Robocop
Case History: Alex Murphy, 52, is a distinguished beat cop in Lower Manhattan, USA. A friendly figure in the area, Alex, has had Type 2 diabetes for the past 15 years. His A1C has always been a bit too high for comfort at 8 percent, and he prefers a US diet of high fat and high carbohydrate, despite his diabetes education. As on the day of doctor’s presentation, Alex had fried chicken and sweet Southern tea for lunch, completed his regular beat by sunset and had returned home. Upon removing his work boots, his wife immediately noticed an angry looking sore on the bottom of his left foot. She asked him what had happened, and he said he didn’t know. His wife went to investigate, and looked in his shoes. In the bottom of the left shoe, just under where the new sore was on Alex’s foot, was a metal ring. Alex had unknowingly walked on the piece of metal all day, and he didn’t even know it.
Case Observations: Roger had walked on the metal ring and had not felt it due to his diabetic neuropathy, a direct complication of his Type 2 diabetes. He now had a diabetic foot ulcer, uncontrolled diabetes, and was at risk of gangrene and subsequent amputation of his left limb.
Case Result: Below the Knee Amputation on Alex’s left limb; shortlisted for prosthetic limb
Case Duration Post Presentation and Prior Result: 1day
Case 2 — The Case Of Four Weddings and a Funeral
Case History: Charles, 45, is an exclusive rental car service driver in North London, UK. He chauffeurs groups across the city and sometimes to sub-urban districts for various social gatherings. Charles is an invaluable asset to the rental service company; his ability to absorb bust schedules was commended by all. Charles would take extreme measures to deliver in his job constantly, often ignoring personal health; he has done multiple double shifts just for the perks of meeting new people and had avoided feeding adequately. On a particularly busy Saturday, Charles was contracted to chauffeur for four different weddings to drop the groom at the respective wedding chapels and travel outskirts to chauffeur back a grieving family from a funeral. Charles is a healthy male, with no history of diabetes or hypertension. However, during his last trip outskirts, Charles started to feel some numbness on his right leg. He couldn’t feel his heels in a while and lost control of the accelerator pad and swerved into a tree. Barely conscious, Charles was admitted into emergency and had suffered a broken neck and a hip injury.
Case Observations: Charles was tested normal for diabetes but was found to have non-diabetic peripheral neuropathy, which could have been caused due to Charles’ poor nutrition. His hip injury has proliferated into his nerves, which increases the probability of him losing the entire leg
Case Result: Hemipelvic Amputation; with a road to recovery in 9 months
Case Duration Post Presentation and Prior Result: 3 days
Case 3 — The Ratatouille Chef
Case History: 35-year-old Remy is a head chef, specializing in sous-vide styled French cuisine in Lille, France. Remy lives a typical high-class Frenchman; he drives to work in his Mercedes, he co-owns a Michelin star restaurant and eats high-quality food. He lives in his bachelor pad in downtown Lille, which has state-of-the-art décor. It was the time of yearly reviews and Remy’s restaurant has been awarded two Michelin stars. After all customary celebrations, Remy returned to his residence, watches a movie and ends up cooking a snack before bedtime. Unfortunately, while cooking pasta, Remy’s hands slipped and few drops of hot olive oil fell on the toes of his right leg. Remy attended to the wound immediately by dipping the toe in cold water and nursed it with a bandage. Two days after the incident, Remy had to be rushed to emergency care after he reported severe pain on his right foot.
Case Observations: The scald injury was immediately attended to by removing the bandage. Initial debridement of scald tissue revealed that the burn had proliferated into the tissue and had affected the nerves. The eschar from the toes was indicative of possible necrosis and the amputation of the affected parts was suggested.
Case Result: Partial Foot Amputation with Therapy; recovery in 4 months
Case Duration Post Presentation and Prior Result: 2 days
Case 4 — The Gods Must Be Crazy
Case History: Okoye, a 59-year-old animal conservationist from Kenya, had a life on her heels. Right from the tender age of 23, Okoye has been the centre of attraction when it comes to conservation of Africa’s indigenous creatures like zebras, rhinoceros and most importantly cheetahs. At the age of 27, Okoye garnered world-wide fame when she opened a private conservation reserve for several endangered animal species in Nairobi. Okoye was forced to have a sedentary lifestyle after 40, much to her resentment, when her Type 2 diabetes took a toll on the toes of her left foot following a minor road accident. Post amputation, Okoye had indulged in various on-field activities, which included opening multiple conservation reserved in Zimbabwe, Mozambique and Congo. Okoye insists on visiting all facilities at least twice a year. During doctor’s presentation, Okoye has developed gradual numbness of her legs, which she had failed to notify her family. Also, her right toe has started to develop necrosis, which she had failed to notice owing to her melanin-rich skin tone. Okoye decided to visit the doctor after her foot started to develop an odour.
Case Observations: Okoye’s numbness is attributed to Peripheral Neuropathy, which has developed aggressively due to Type 2 Diabetes. Also, the development of necrotic tissue on the right leg shows that the ulcer has progressed and could be a cause of infection, owing to the smell and gangrene. Debridement of the right toe showed significant tissue death and samples were sent for culture to test for pathogens.
Case Result: Samples were positive for bacterial infection, which is progressing upwards after necrotizing the right foot. Toe amputation done; with a risk of possible Below Knee amputation in the near future due to progressing infection. Projected recovery is 18 months.
Case Duration Post Presentation and Prior Result: 3 days
Case 5 — Bhaag Milkha Bhaag
Case History: Milkha, 42, is an upper-middle class male from Delhi, India. Milkha, during his youth, had represented his district as a 100-meter dash athlete. An avid sports enthusiast and a fitness freak, Milkha maintained an excellent physique and represented the state and the nation across various competitions. Unfortunately, an Anterior Cruciate Ligament (ACL) injury had resulted in Milkha terminating his athletic career at an early age of 29. Milkha’s physiology took a toss when he was bed-ridden from the injury for a year, which resulted him in developing Type 2 Diabetes and minor indications of Peripheral Artery Disease. The stress of not being an athlete anymore induced hypertension too. After years of constant rehabilitation, the then 32-year-old Milkha started to walk again. True to his determined sportive nature, Milkha wanted to engage in active sport through marathons and started to train hard. However, prevailing diabetes and hypertension ruled him against all odds of possible competition. Bordering depression, Milkha started a new lifestyle that involved minimal athletic activity and utter disregard to physical health. At the age of 41, Milkha’s peripheral artery disease took a toll on his right leg.
Case Observations: Progression of peripheral artery disease has been aggressive due to Milkha’s new lifestyle. Toes of the right leg are primed for amputation, with a focus on preserving limb tissue, so that Milkha can support his family.
Case Result: Right ankle disarticulation combined with therapy. Possibility of Below Knee or Above Knee amputation due to consistent high Type 2 Diabetes levels and hypertension. Projected recovery unseen.
Case Duration Post Presentation and Prior Result: 4 days
The five cases mentioned are mere representations of an alarmingly growing global population of amputees. There are more than 1 million annual limb amputations globally — one every 30 seconds. Nearly half of the individuals who have an amputation due to vascular disease will die within 5 years. This is higher than the five-year mortality rates for breast cancer, colon cancer, and prostate cancer.
What is an Amputation?
Amputation is described as the separation of a bone in healthy tissue or the removal of a limb at a joint (exarticulation). Amputation surgery may be necessary if an injured or diseased limb is not expected to heal and if the patient’s life is endangered as a result. Primarily, amputation is the consequence of a traumatic or non-traumatic event.
The amputations performed below the pelvis of the human body are collectively referred to as Lower Extremity Amputations (LEA) or Lower Limb Amputations (LLA).
To understand different LEA ‘amputation levels’, click here.
The Significance of A Silent Epidemic
Limb loss is much more common than many people realize, and the numbers are growing. By learning the facts about limb loss, we can start to be better advocates for our friends and family, feel less alone during our journey with limb loss, and raise awareness through meaningful, fact-based discussion.
- 85% of lower limb amputations are proceeded by a foot ulcer
- Around 30% of people with limb loss experience depression and/or anxiety
- People requiring amputation due to poor circulation from conditions like peripheral artery disease (PAD) or diabetes account for 60% of non-traumatic amputations
- Those with diabetes have a 10 times higher risk of amputation compared to those without diabetes. 10% of people with diabetes have a foot ulcer. The lifetime risk of developing a foot ulcer for someone with diabetes is 25%
- Between 10–15% of diabetic foot ulcers do not heal. Of diabetic foot ulcers that do not heal, 25% will require amputation. Following an amputation, up to 50% of people with diabetes will die within 2 years
- Waiting to be seen by a doctor for a diabetic foot ulcer for longer than 6 weeks can increase the likelihood that the ulcer will result in an amputation. After a lower limb amputation someone with diabetes remains in the hospital an average of 9–12 days
- An ulcer present for more than 30 days is more likely to become infected. Osteomyelitis, which is an infection in the bone, is seen in 15% of people with diabetic foot ulcers
- The International Diabetes Federation (IDF) predicts that current global prevalence of diabetes will burgeon from 285 million to reach 435 million by 2030 and 642 million by 2040.
The summary of the clinical presentation and outcomes of the cases mentioned would look like:
- Though the symptoms take an average of about a day or two for traumatic injuries and about a month or two for non-traumatic injuries to develop, the time taken to arrive at an amputation decision is quite rapid and consistent (approx. 3 days)
- With an exception of traumatic injuries, the reasons for the lacunae between symptom(s) and clinical presentation can be attributed majorly to personal neglect to physical health and lack of awareness to foot care
The risk for amputation may be decreased by up to 75% if a team specializing in the care of diabetic foot ulcers is involved. This team may consist of specialists in wound care, diabetes podiatry, infectious disease, and a vascular specialist. Up to 50% of diabetic foot ulcer cases can be prevented with appropriate education focused on teaching people with diabetes how to care for their feet.
In the next blog post, we shall introspect into each case study and understand how this epidemic shamefully exposes a nation’s healthcare inadequacies.