"Is it worth it?", Accepting
A.J. lost his foot today. The public health nurses have been to his house regularly to change his dressings in a desperate, but eventually futile attempt to heal his foot ulcer. Heís had a chronic infection thatís finally gone in and destroyed the bones in his foot, and has now spread to his bloodstream and antibiotics are not enough to clear it. Heís had diabetes for years and his blood vessels are so damaged they couldnít provide enough blood flow to heal his ulcer. He has had amputations of his toes twice in the past. Heís strong, he never complains. He has shrapnel in his leg and shoulder from a war injury in Korea. He survived that, but his blood sugars turned out to be a bigger threat to his health than artillery shells and land mines.
David will likely lose his foot tomorrow. He also has a diabetic foot ulcer that is quickly becoming worse. Heís just down the hallway from A.J. The surgeons are going to try to bypass the artery in his leg in order to get blood flow to his foot. This is on his right foot. Last year he had the same problem on the left side. He did get a bypass of the artery to improve blood flow, but it only stayed open for a short time and he lost his leg below the knee. His blood vessels are so damaged from uncontrolled diabetes that it takes him forever to heal. It took him 9 months to heal a scar on his leg when he had his coronary artery bypass (the saphenous vein in the leg is often used in place of the blocked arteries to the heart). It should have healed in 2 to 3 weeks. Heís a father and a grandfather. Heís a good man and he loves his family.
My mom lost her leg when I was in my first year of residency. I was in Seattle and didnít know how bad her leg was getting. She fell in the kitchen and laid on the floor for over 24 hours before one of her co-workers came to the house when she didnít show up for work. My mom was diagnosed with diabetes when she was 38, she died from complications due to diabetes at age 59. She lost her leg when she was 56. She waited her whole life for my son to be born. She died 13 months before that and never got to see him.
Diabetes is more than just high blood sugars. It affects all parts of the body and constantly causes damage if sugars arenít controlled. In medical school we were taught ďIf you know diabetes, you know medicine.Ē All processes in the human body are meant to function properly only if everything is working the way itís supposed to. As blood vessels get farther away from the heart, they branch off and get smaller and smaller. Nerves have blood vessels that supply them. These blood vessels get damaged and the nerves donít get a good blood supply. They either send out burning pain (diabetic neuropathy), or the sensation is lost altogether. I had a patient in Seattle who stepped on a nail and walked with it in his foot all day long. He didnít even know it until he got home and took his boot off. He ended up with an infection and it took months of work by the public health nurses to save his foot.
You donít have to go very deep into most Native patient family histories to find someone who has had an amputation. I see many patients newly diagnosed with (or avoiding diagnosis of) diabetes who assume amputations are inevitable. This is not true. We CAN prevent diabetic amputations, but health care providers canít do this alone. Controlling diabetes can be a difficult problem, but it is controllable. This means regular visits to the Clinic, watching what you eat and exercising. This is a huge responsibility on the part of the patient.
Is it worth it? I donít know. How much is a foot worth? How much is a grandmother worth? Itís been said that an ounce of prevention is worth a pound of cure. To my way of thinking and with the advent of the metric system, I think an ounce of prevention is worth 10 kilograms of cure. Thatís 4.55 pounds of cure. No matter how you look at it, thatís a pretty good deal.