In the seventies and eighties, amputation of the legs of those with diabetes mellitus was very common. Unlike these days amputation was an emergency life saving procedure. Once the diabetic state goes out of control due to an infection, everything seems to go haywire in a kind of vicious cycle. The diabetes fuels the infection and on the other hand the infection aggravates the diabetes. The picture really gets frightening when adjacent skin becomes inflamed and swollen, a condition known as CELLULITIS and the body temperature refuses to go down. At this stage, the Orthopaedic surgeon is called in to let go the leg. The endocrinologist and the orthopaedic surgeon were then bedfellows.
The situation is fast changing these days. I will recall two cases to put us in the picture how far we’ve come with diabetic foot challenge. First was in 1988. The patient was a retired engineer from a state civil service. His right leg had been amputated two years earlier and he was walking with the support of an artificial wooden leg! Not even a plastic prosthesis. Then he developed dry gangrene of the small toe of the left foot which progressed to affect the other toes. They were in turn amputated and an intractable ulcer developed. It was time for the plastic surgeon to be called into the management team.
He raised a skin flap on the abdomen. And when blood flow between the ends of the flap was established, he detached the end close to the belly button and anchored it to the left forearm to establish blood flow between the flap and the hand. This flap was intended, ultimately to be transferred to the leg to cover up the poorly healing ulcer as a skin graft. We didn’t get there. The diabetic state went out of control due to severe CELLULITIS of the leg with a fever that refused to subside. It was painful, but the decision had to be made; a below knee amputation (BKA) as an emergency procedure to save his life had to be performed.
When the news was broken to the chief, he was psychologically devastated. It is only those who have gone through it know how it feels when you are told that your leg is going to be cut off. And on that faithful day, the orthopaedic surgeon, the plastic surgeon, the anaesthetist and yours truly, a rookie then were fully mobilized. Everyone was in high spirit in readiness to chop off somebody’s leg! When the chief was wheeled into the theatre his countenance was very distant. He took a brief look at me and said “thank you for everything my son.” After that, the anaesthetist put him to sleep while the surgeons scrubbed.
At a point I asked whether it was still necessary to go on with the amputation. Of cause the orthopaedic man yelled out. “Please sir, can we have a look at him again?” By this time everyone in the theatre was in frenzy and dazed. Amputation has been forgotten; all were now involved in CARDIOPULMONARY RESCUSITATION (CPR). The chief was dead. We were all sweating unmindful of the air conditioning. The first to speak up was the plastic man: “Honestly I am not used to this type of situation.” The orthopaedic man simply walked away and I was left to write the death certificate and figure out the cause of death! Juniors always do that in a big set up. This was in the 80s.
Sorry, I have to tell another story. This happens to be a close friend of mine and a big chief. He has diabetic ulcer at three pressure points (we will talk about that later) in his right leg. Then came this night when he had serious fever with rigors and by dawn the leg was swollen or rather oedematous. He was rushed to the hospital. When his friends saw him; without his consent they bought him a flight ticket to America. My role was to pick him up at the domestic airport, kill sometime with him in a hotel and the take him to the International Airport for onward journey to USA.
When I saw my friend, who I affectionately call The Godfather, I wondered what they had done to him. He was walking supported like a man headed for the hangman’s guillotine. He was jerking like the Fulani cattle captured by the legendary poet, J. P. Clerk:
“Contrition twines me like a snake
Each time I come upon the wake
Of your clan undulating along in agony.”
My friend was finished. When we got to the hotel room, out of curiosity I requested to see the leg. After examining the ulcers and the oedematous leg, without knowing that I did it I said: “I see NO surgeon’s knife here.” Immediately the room went dead silent. They were all stunned by my comment. They didn’t expect that from me apparently after they had prepared the chief’s mind for the worst case scenario. It was the chief himself that spoke first. He asked: “You mean that they are NOT going to CUT the leg?” I told him that no surgeon would get near this leg, that all he needed was an experienced physician. A friend of his that was around even asked whether I was a surgeon. The effect of my comment was magical. His spirit was lifted; the chief suddenly came alive, took his insulin and ate voraciously.
That was the day Hull City wanted to cause an upset in the Premiership FA cup finals against Arsenal. The chief even placed his bet on Arsenal who was two goals down confidently in a boisterous manner and at the end of the game, he won. I don’t know whether his friends have paid up their losses because he boarded the plane at the end of the match in very high spirit. He believed what I told him because I sounded very confident and even asked for drink.
When I called three weeks later to find out how the chief was fairing, it was the sister that picked the phone. She told me that he was doing fine and that the good news was that they are not going to cut the leg! Can you imagine? What I told them before departure. We should learn to believe and trust in our ability, because that is the right way to go. Well that is the difference between 1988 and 2014.
Diagnosis has used these cases to illustrate how far the management of diabetic foot ulcer and cellulitis has come with robust antibiotic arsenal and anti-inflammatory drugs. I often laugh when our people are quick to go abroad for some ailments and when they are terminal are sent back for palliative management.
We will pick it up from here next week, but first;
THANK GOD AND THANK YOU ALL
By the time you read this; DIAGNOSIS would be exactly one year since it debuted. We want to use this opportunity to thank you all for your phone calls, E-mails and text messages. They keep us going and we appreciate it. Special thanks to the production and editorial crew at The Sun for accommodating our style knowing the challenges in writing CLINICAL PATHOLOGY on the pages of newspaper and making a DIAGNOSIS.
Above all, we thank God almighty for making it possible for us to learn together. God bless you and see you next week.