Diabetic foot complications are a major global public health problem. Amputation rates vary throughout the world but are always increased in people with diabetes compared to those without diabetes. Amputations are increasing in diabetic patients. Throughout the world, health-care systems, both public and private, have been unsuccessful in managing the overwhelming problems of patients suffering with diabetic foot complications. The results of this failure are shown in the following case histories, illustrated in Figs 1-5.
Fig. 2 Foot from Ukraine. This 48-year-old man with type 2 diabetes of 12 years' duration trod on a nail and developed severe infection with wet gangrene of the right 5th toe. He had a longstanding neuropathic ulcer of the left foot.
Fig. 1 Foot from the UK. This 85-year-old man with type 2 diabetes of 8 years' duration received regular dressings of his ulcerated ischaemic foot for 9 months, but was not referred until extensive gangrene had developed.
Fig. 3 Foot from Sudan. This 80-year-old lady with type 2 diabetes of 15 years' duration and neuropathic feet sustained a puncture wound through the thin sole of her sandal. She did not seek advice and developed profound sepsis.
These pictures show authentic diabetic feet from five continents of the world. Foot catastrophes such as these, as Elliott Joslin pointed out, do not strike like lightning out of heaven, but are too often due to ignorance and apathy, which prevent patients from detecting problems early and seeking treatment, and which prevent health-care professionals from organizing rapid and effective care. In nearly every case there are warning signs which, if acted upon, could prevent tragedy. However, because of local barriers to effective care, patients often do not receive help in time to save their feet.
Diabetic patients in the real world are often perceived as the poor relations, the 'lepers of our time'. Indeed, diabetic foot patients have more in common with lepers than just neuropathy: in many quarters they are regarded with disgust and antipathy as dirty, smelly, 'unclean', socially unacceptable feet belonging to patients who take up hospital beds for unacceptably long periods of time.
Equally, diabetic foot patients may be regarded by inexperienced staff as 'feckless' patients, who fail to look after themselves and are directly responsible for their problems. Health-care systems are 'symptom-led' and thus fail to respond to the needs of the diabetic foot patient, who usually has neuropathy, numb feet and no complaints.
In addition, diabetic foot problems are frequently underestimated. Just as there is no such entity as 'mild' diabetes, there is no such thing as a 'trivial' lesion of the diabetic foot.
Sadly, there are many areas of the world where people with diabetes are unable to obtain good foot care, or where the provision of such care is dependent upon the patient being able to pay for it. A recent tragic case involved a diabetic man with indolent neuropathic ulceration, who amputated his own leg (using a railway line and a passing train) because he could not pay for medical care.
However, amputations are not inevitable. The aim of this book is to help readers to achieve good care for patients with diabetic foot problems and so avoid preventable amputations. Progression down the road to amputation is not inevitable and relentless. Patients can be rescued.
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