In early March, podiatrist David Armstrong, MD, faced his own decision from Sophie: should he or should admit his diabetic patient to the hospital to prevent another amputation, but put them at risk of contracting Covid-19 Do you allow the patient to stay at home and forego an operation that could save their life?
The patient had recently undergone complicated surgery, partial bypass surgery, and partial foot amputation that left a large wound. But he was no better.
“His wound was really getting worse and it needed … care,” explained Dr. Armstrong, professor of surgery in the University of Southern California Medical School and director of USC’s Southwestern Academic Limb Salvage Alliance. He was convinced that the patient would die if exposed to Covid-19, but the infected foot would also lead to his death. “It just killed him more slowly.”
The story of Dr. Armstrong is one of many doctors shared in 2020. The pandemic has changed the routine and delivery of medical care. A recent study found that people with diabetes were ten times more likely to need an amputation since the pandemic began. The study looked at diabetics who were in hospitals during the pandemic and found that these patients were more likely to have had an emergency or needed an amputation compared to pre-pandemic times. A study from Italy gave similar results; Diabetics were more likely to have gangrene and amputations. The total amputation rate has doubled since last winter. A team in the Netherlands found that there were already more amputations in 2020 than in 2018 and 2019 combined, although not all were for diabetics.
Diabetes can cause serious complications. People with diabetes are at risk of developing what is known as diabetic ulcers, and diabetes is also one of the comorbidities that can make Covid-19 more deadly. For some patients, deferring care appears to be a safer option. This decision to miss medical appointments and routine treatments can cause diabetic ulcers to spiral out of control and, in extreme cases, lead to surgery and even amputation.
Permanent possible harm, a condition known as diabetic neuropathy, is another possible effect of diabetes. People with untreated neuropathy can no longer feel any sensations in extremities such as hands and feet. Once someone is deaf, “You can literally have a hole in your foot like you or I would have a hole in a sock or shoe,” said Dr. Armstrong. “This hole is called a diabetic foot ulcer. And it is often painless. ”
Once this painless hole in the foot is open, it can lead to infection and the infection can spread. The infection can spread to more tissues, such as the rest of the foot and leg, but also the bones. Once the infection becomes too severe and cannot be stopped, amputation may be required. “Imagine if you had a wound that was just there and got infected and it hurt you,” explained Dr. Armstrong. In this situation, prevention can really pay off.
For many, the search for care has fallen by the wayside during the pandemic. People have avoided hospitals and doctor’s offices. Some due to lockdown measures, others due to the Covid-19 risk or delayed care. More telemedicine appointments mean fewer physical exams. Data from the early days of the pandemic showed office visits decreased and emergency room visits for uncomplicated diabetes decreased by 15%.
For hospital stays in Covid, 11% had diabetes at the start of the pandemic – and diabetics made up 32% of intensive care admissions.
“People with diabetes are at increased risk of serious illness because of COVID-19,” according to the American Diabetes Association.
Although Dr. Armstrong saw no more amputations at USC, he has seen changes. First there was a dramatic drop in hospital stays, later patients came in with catastrophic, life-threatening problems. “A couple of patients died of sepsis … who came to our emergency room from other hospitals in the Los Angeles area while they were waiting,” he said.
While the pandemic has transformed medical care, it also offers new options for treatment and healing. Dr. Armstrong works with a number of interdisciplinary teams to pool their knowledge and experience and find new ways to treat patients. Her focus was on finding ways to treat people at home.
At USC, said Dr. Armstrong, diabetes patients are now taking “foot selfies”. He described how patients, when physically able, take pictures of their feet every day. The images are sent to a secure server and then reviewed by a team of doctors in “foot selfie laps”. The team can go through 50 to 100 images in about 15 minutes to identify patients at risk.
Another innovation: Patients check the temperature of their feet with an infrared thermometer. Dr. Armstrong explains that this is helpful because “a wound heats up before it collapses”. This technology is available in high-tech socks and bath mats, but a simple thermometer also works. People have sometimes done this in the pre-pandemic world, but it has become a more important and widely used tool for doctors and patients trying to take medicine at home.
What about Dr. Armstrong’s patient who needed surgery to clear the infection but was too sick to risk Covid-19? Innovations came to the rescue again. Dr. Armstrong and his team wondered how he put it, “How can we operate on him without operating on him?” when they decided to go back in time medically and ordered some maggots. “We had the maggots [actually] The larvae were used in what appears to be the first telehealth-driven defragmentation of maggots, ”explained Dr. Armstrong. These were not just any maggots, but medical maggots that only eat the dead skin, leave the healthy and avoid infection.
Family members can also be represented to help with home care. Dr. Armstrong had two pieces of advice. The first is for patients to keep their appointment to keep their feet.
People who are concerned about a diabetic friend or relative should encourage them to keep their appointments. For long-term results, it is incredibly important to see a doctor. “If you just see your podiatrist and another member of the diabetes team, your risk of amputation drops by about 20% to … nearly two-thirds for the next six years,” said Dr. Armstrong. Many offices offer telemedicine appointments for people who are concerned about the risk of Covid-19.
Regarding the second piece of advice, Dr. Armstrong, the relatives of these patients should “take off their socks.” The best way to notice changes in your feet is to look at them closely and often. Family members should look for swelling, differences between the two feet, calluses, bleeding, heat, or redness.
And while looking at their feet, relatives also need to watch the patient’s mood. Depression makes self-management difficult, which of course can lead to disaster. In 2011, a team of researchers studying diabetic veterans found that depressed patients were 33% more likely to need an amputation. “[Today] Almost all of our patients suffer like this, ”said Dr. Armstrong.
The outlook for people with diabetic ulcers was bleak before the pandemic. A 2008 study of the importance of communicating how deadly a diabetic ulcer can be found that the 5-year mortality rate, the percentage of those with a new ulcer who would be alive after five years, was between 43 % and 55% was.
“This problem is like cancer except that nobody talks about it like that,” said Dr. Armstrong.
In addition to his work in the hospital, Dr. Armstrong Co-Founder of the Southwestern Academic Limb Salvage Alliance (SALSA). SALSA’s mission is to make diabetic amputations a thing of the past.
For many of us, feet are easy to forget: they hang at the end of the legs, are stuffed into uncomfortable shoes and step on them.
Dr. Armstrong sees the feet differently. “I can’t think of anything that is more an expression of humility than taking care of my feet. I mean, it transcends culture, it transcends ethnicity, religion and borders. “