Diabetic foot real challenge of rural India

  Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh)

About a man with gangrenous diabetic foot and his fight against amputation

 It was a lazy Saturday evening of my OPD. Suddenly one of my hospital attendant came & told me, “Madam,one OPD patient is waiting for you. Would you like to examine him? He has a bad pus filled, fowl smelling, dirty wound over his one of the foot.” She made a face. But I decided to help him. As I am a primary care physician and helping him is my duty.

I asked my attendant to send him to my OPD. This was my first encounter with Shintre family. I saw one 18 years old young boy was accompanying his 78 years old grandfather who was suffering from left diabetic foot.

It seems he was known diabetic and hypertensive since last many years and was taking treatment from CHC near by because he cannot afford a private physician. He was a poor, illiterate fellow, surviving with his wife in different house. His pension income was 500/- only. The treatment he received from CHC was theTb.metformin 500mg OD and Tb. atenolol 50 mg OD. (Not so preferred combination in old age diabetic person unless indicated).He also had some heart problem (? IHD) in past but no details were available.

The patient was having deteriorating wound day by day even after dressings by CHC staff. The family came to me as they overheard I am a diabetic educator and were hopeful that I will help them in this worsening situation.

This was a tricky call for me. As I have to decide to treat him in my OPD or refer him to surgeon. But family members were not ready for surgical intervention and requested me to do the most needful I can to my best capacity.

I made my mind to take the challenge & win this battle of diabetic foot. I was determined to save this foot as amputation is not the solution .A thorough patient education, family members counselling, appropriate BSL control and wound care is must as treatment.

 I carefully assessed the foot.It was full of pus, slough, dorsum of foot skin was destroyed. Tendons, even some part of metatarsals was visible. The third toe of foot had dry gangrene at distal phalanx and proximal phalanx has developed wet gangrene changes. He has no pain sensation; temperature sensation over the foot. Mild crude touch was intact.

I was worried for changes of gas gangrene and maggots .But to our luck wound has no maggots or crepitus changes.I cleaned the wound and  then washed it properly with betadine, normal saline, spirit and gauze pad. While using gauze pad for dressing I follow one rule taught by my surgery teacher.”Not to use cotton straight on the wound. The small threads of cotton got stuck or attached to slough and margins which delays the wound healing.” Hence I used simple gauze made up of dressing bandage roll. I also immunized him with a tetanus toxoid injection.

I know sending pus culture was a must thing but due to limitations of both my reliability of resources and patient’s economic status I have to cancel that investigation. But I did other relevant investigations like CBC, Sr.creatinine, Sr.urea, lipid profile,BSL fasting & post prandial, ECG, X ray foot.

To my relief X ray has no changes of Charcot joint,osteomyelitis or gas gangrene. But his Hb was low, creatinine, urea, BSL were high.

After evaluation of investigations I switch him to pre-mix insulin, aspirin atorvastatin, oral haematemics and low dose ecitalopam as he was very depressed and anxious about the entire process. I used tramadol and paracetamol as analgesics as since the beginning I was worried for his renal function, hence don’t want to use NSAIDs group drugs (many doctors give diclofenac injection intramuscular quite often as routine without considering renal status.)I also stopped his CHC started metformin and atenolol which has no much role in his treatment now. His blood pressure was 130/80 mm Hg; hence we did not give any antihypertensive with relevant antibiotics.

Slowly he started showing improvement .His pus reduced, wound looks healthy and granulation development was visible. But the third toe was still a concern. It’s the gangrene changes were not resolving. One day during the dressing, the tendon holding the third toe rupture and by next visit the toe was unstable. This happened after 4 months of meticulous dressing.

In this situation I have to take a call of amputation– painful but important. I discussed the possibilities with family and the patient .they gave me the consent for same as by now it’s only a toe they were sacrificing and not the whole limb.:-)

With their permission I did the amputation with a pair of scissors .It bleed profusely post amputation as patient was on aspirin but later after giving a good pressure bandage, stump started healing fast and appropriately.

Initially for almost 2 months we did twice a week dressing.Once wound started healing well we reduced it to once a week. During this treatment anemia correction and use of aspirin works like magic wand. The patient has zero pain, temperature sensation minimal touch sensation over the limb on day one. But as we started regular supervised dressing series he resumed his pain, touch sensation to almost normal level. At times he used to scream, beg and yell for euthanasia .But this pain was worth bearing because birth of new foot has started in his life.Now Mr.Janaba Shintre is doing well. The diabetic foot is almost healed now. He has resumed his day today activities well.


Conclusion
This journey with this patient as primary care physician and diabetic educator taught me a lot. This experience underline few important aspects of patient centered care like good compliance to treatment ,faith in treating physician, role of good patient and family’s education etc.Every diabetic foot does not require amputation. With systematic and periodic care we can save limb from horror of amputation and followed disability.

At the end I thank Almighty for giving me transient healing hands of a physician. Thank you. :-).

_________
Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh)
 M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology  & Geriatric Med.
Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA
Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders  & Geriatric Medicine
C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka
Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum
Blog: drsmrutihaval@blogspot.com
          drsmrutimhaval.blogspot.com
Area of practice- Sankeshwar, Dist – Belgaum ,Karnataka

Epidemiology of your area in brief:  It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes,hypertension,asthma ,hypothyroidism etc.