a small cut or blister, combined with compromised vascular systems, can allow such injuries to develop into full-blown ulcers, with devastating consequences. Almost 100,000 limbs are amputated each year in the United States due to complications from diabetes, according to Christopher E. Attinger, co-director of the Center for Wound Healing at Medstar Georgetown University Hospital in Washington, D.C. A recent study in the United Kingdom found that people with diabetes are 210 percent more likely to have a leg amputated above or below the knee and 331 percent more likely to need part of a foot removed than is the general population. Taking a collaborative approach to diabetic foot care isn’t new. New England Deaconess Hospital in Boston established the nation’s first foot hospital in the 1920s, and by the 1950s had established itself as a world leader in foot care and treating ischemic foot ulcerations. What is new, however, is the sophistication and pace of the team-based approach to saving limbs from diabetic-related amputations. “A team approach to diabetic limb salvage such as that developed at Georgetown University Hospital over the past 20 years can result in a much greater number of limbs being saved,” says Attinger. At the Madigan Army Medical Center in Tacoma, Washington, the number of diabetes patients increased 48 percent from 1999 to 2003. At the same time, however, the number of lower-extremity amputations dropped 82 percent, from 33 in 1999 to 9 in 2003, according to a recent study published by the journal Diabetes Care. The chief reason? “The value of a focused multidisciplinary foot care program for patients with diabetes,” the study concluded. After Broadlawns Medical Center in Des Moines established an amputation prevention program with the team approach, the number of limb losses decreased by 72 percent.
“The greatest advancement is availability—that we can actually talk with all the different disciplines in the hospital and blend all the professionals together and determine the best course of action.”
While at Broadlawns, Lee C. Rogers, DPM, now co-medical director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles, developed a six-step protocol for diabetic limb salvage that incorporates a wide range of medical specialties. The program, which Rogers teaches at medical facilities nationwide, begins with an acronym, VIP—vascular, infection, and pressure—although not in that order. The first step is to address the infection, which is the most common reason for losing a leg. After that comes vascular management, and then off-loading of plantar pressure. Wound management follows, with debridement, promotion of granulation tissue, and wound closure.
Becoming a Team Player The big difference in treating the diabetic foot, as opposed to, say, a heart attack, is the need to combine multiple disciplines, says Rogers. “If you go to the emergency room with a heart attack, you see a cardiologist who can do everything you need. When you are at risk of losing your leg, there is no single doctor who can intervene and do everything.” Diabetic ulcers are a complex problem and therefore require an array of specialties, including infectious disease specialists; podiatrists and foot surgeons, who debride wounds; and vascular surgeons, who address blood flow issues that can contribute to ulcers and slow their healing. Endocrinologists and nutritionists attend to patients’ glycemic levels,
—Charles Crone, CP
and teams also can include internists, orthopedic surgeons, nephrologists, and plastic surgeons. O&P practitioners fit ankle foot orthoses and full and partial prostheses when needed, and pedorthists supply therapeutic footwear. All of those specialties need to be organized, and at the Georgetown Center for Wound Healing, chief residents and nurse managers are the quarterbacks of communicating, says co-director John Steinberg, DPM, ensuring the flow of information and coordination of services. In addition to the availability of so many relevant specialties at the Georgetown center, what sets the team apart is its egalitarian approach. “Everyone is empowered,” says Steinberg. “The hierarchy and egos are removed. The patient is the center of the puzzle, not the medical team.” That spirit of collaboration is one of the challenges to establishing a team approach, according to Rogers. “Doctors, especially surgeons, don’t have the best reputation for working well together,” he says. “When implementing programs, we have to do a lot of team building and philosophy sharing.” The Georgetown center provides both inpatient and outpatient limb salvage and wound care. If a patient needs to be admitted, there is a seamless transition and continuity of care. Caregivers meet weekly to review cases and participate in a group learning activity. “Team members attend different conferences and come back with new knowledge,” says Steinberg. JANUARY 2013 O&P Almanac