LIFE and LIMB
Though amputation is often viewed as a common risk of diabetes, a group of Temple doctors saves limbs instead.
Story By Ilene Raymond Rush
Last year, 64–year–old Hugh Green noticed that a bruise on his left foot was starting to swell. A former tractor–trailer driver saddled with diabetes, heart disease, kidney problems and cancer, Green had lost part of his right leg already. Now he had to worry about losing his left.
"There was a problem with blood getting to the foot," Green says. "The blood wasn´t making it to the toes."
Unfortunately, by the time he sought care at Temple University Hospital (TUH), his toes were a lost cause. But a bigger question loomed: Was there hope for the rest of his foot?
Green´s problem is one that Director of Vascular Surgery Eric Choi often encounters at TUH. When he arrived at Temple about two years ago, he noticed a high number of young people with diabetes who were scheduled for leg amputations. Saddened by the thought of "promising futures marred by missed opportunities," Choi devoted himself to treating the problem.
Diabetes is often to blame for amputations—it can wreck blood vessels and cause circulation problems. Approximately 26 million people in the U.S. have diabetes, and about 65,000 had lower limb amputations in 2006, according to the most recent data available from the American Diabetes Association. A 2012 study from the Centers for Disease Control and Prevention found that among people with diabetes, African Americans had higher amputation rates than Caucasians (approximately five per 1,000, versus three). Adults aged 75 years and older had the highest rate—about six per 1,000—compared to other age groups.
Choi wondered how many amputations might be avoided with earlier intervention.
"Patients don´t always know where to get treatment for these conditions," he says. "They often go from specialist to specialist, losing valuable time in the process. There isn´t always a lot of coordinated care [among different specialists], which is important, since patients sometimes balance a number of conditions including diabetes, heart disease, kidney disease and complications from smoking."
Choi knew Temple had the resources on staff to intervene and possibly prevent some amputations, but he also knew those resources were scattered across departments, from Endocrinology to Podiatry. What if they worked together to offer patients quick and comprehensive care? Could they possibly begin to reduce the number of amputations Choi was witnessing in TUH?
His questions spurred the creation of the Temple Limb Salvage Center in March 2011. It is the first program in the region to offer a limb–saving model of focused comprehensive care.
Philadelphia is an apt place for the center. Not only is the city plagued with high rates of diabetes, smoking and obesity, but amputation rates for men are four times higher in the city than they are in nearby Montgomery County, Pa., according to Ronald Renzi, a podiatrist at Abington Memorial Hospital who recently studied regional amputation rates. This comes as no surprise to Choi, who points out that rates of diabetes are two to three times higher in Philadelphia than in other parts of the country.
"The diabetes problem in Philadelphia is multifactorial," Choi says. "Factors include high obesity, heredity, poor eating habits and lifestyle choices, lack of access to healthcare and lack of resources in general."
To combat this epidemic, Choi has formed a high–powered, multidisciplinary team of doctors who specialize in vascular surgery, podiatry, diabetology (a subgroup of endocrinology focused on diabetics), cardiology, plastic surgery, orthopaedic surgery, radiology, physical therapy and orthotics (devices that support or correct limb function).
Patient care depends on the severity of the problem. For simple injuries, such as a foot ulcer that has not healed, a podiatrist will examine the foot. If a patient has significant circulation problems, the podiatrist can call in a vascular surgeon. If anything else needs to be taken care of—such as removing debris from a wound—it also is handled within one or two visits.
More complicated problems—such as wounds that have not healed in a year or longer—require more information from prior records, gathered during the first visit. Once the patient´s problem and medical history have been established, relevant specialists are brought in, such as diabetologists, cardiologists or plastic surgeons. When all the nuances of the case are covered, the group discusses treatment with the patient. All this activity takes place at the same location.
"Obviously, we can treat patients with multiple specialists during multiple visits," Choi says, "but we expedite the process so that all the tests and meetings with doctors occur within the first or second visit. That makes all the difference, since we don´t have to ask patients if they saw a certain specialist, or if they have had a specific test. Everything is done right here."
Illustration credit: Jon Krause, TYL ´99
If surgery is needed, the center tries to schedule two or three procedures at a time to avoid multiple hospital stays. In addition to using methods to open blocked arteries and improve blood flow to damaged tissues, Choi is researching a new process called therapeutic angiogenesis. That therapy stimulates bone marrow to create stem cells. The enhanced bone marrow is then injected into a patient´s leg to grow new blood vessels and improve blood flow.
"That is important," Choi says. "Many of the problems with these patients involve diabetes or peripheral artery disease [common in smokers], both of which damage blood vessels."
Hugh Green was diagnosed quickly when he visited the Limb Salvage Center to discuss his rapidly deteriorating foot. Once a treatment assessment was made, he entered TUH for an operation that involved a vein bypass graft to restore circulation to his damaged limb. Without Choi´s help, Green might have arrived at TUH for an amputation instead. In fact, his case had already been deemed a "lost cause" by another major medical center on the East Coast.
"The care I had for my left foot was very different than I had for my right," Green says. While he was recovering from surgery in TUH, several doctors from the center, including physical therapists, diabetologists and cardiologists, visited him daily. The doctors not only focused on his foot, but also attended to the many conditions that had contributed to his injury.
"They were proactive from the start," he says. "The morning after the surgery, a therapist said, ´You have to get up and sit in a chair.´" He laughs. "And here I thought I was in the hospital to get some rest."
Nine months later, Green is still learning to balance on his salvaged leg, but is able to walk around his home without a walker. To prevent future problems, his doctors have taught him how to monitor his diabetes more closely. He now regularly checks his blood sugar before each meal and makes an effort to go outdoors in his wheelchair for exercise, which can help to lower glucose rates.
"I´ve finally gotten my diabetes under control," he says.
In May 2011, Beverly Rathemore arrived at the center in a wheelchair. Her foot was encased in a walking boot, but in an effort to keep pressure off a bedsore, she had stopped walking. Though she had previously received wound–care treatment in her former home in New Jersey, the foot had never healed. Rathemore´s immune system also was compromised, from pancreatitis and other serious ailments. When she relocated to live with her daughter in Philadelphia, her primary doctor referred her to Choi.
"When the Limb Salvage Center heard about my case, they said they would see me the next day," Rathemore says. "At the hospital, Dr. Choi and two other doctors looked at my heel and discussed it with the team. It was a very deep wound."
The doctors decided to put in an iliac stent—a small, self–expanding tube placed in an artery to treat peripheral artery disease—and performed a procedure to clear out plaque in the vein to prevent further blockage. By opening up the circulation pathways, doctors at the Limb Salvage Center were able to save her foot.
During the summer, she paid regular visits to the center, and a visiting nurse came to her house to tend to the wound.
By August, it had healed enough for her to decide to abandon both the boot and the wheelchair. "Now, I´m not only walking," she laughs, "I´m on the verge of trotting."
Ilene Raymond Rush is a freelance writer who lives in Elkins Park, Pa. Her work has appeared in numerous regional and national publications.