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Episode 14 : Diabetic Foot Care

Release Date: April 4, 2007

Dr. David Meyerson:  Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this edition of Vascular Disease Foundation's HealthCast.

We are privileged to bring you wonderful peer- reviewed science for our listeners as a public service so that you may maximize your functional capacity and minimize and live better with diseases that we all have to deal with.

Diabetes is a disease not just of blood sugar, but it's a disease of small blood vessels all over the body.  Diabetics get heart and blood vessel disease sooner than almost everyone else in the population. With regard to peripheral arterial disease, diabetics can lose their limbs, get horrible, horrible ulcers and really become terribly disabled.  Diabetic foot care is absolutely critical to those people with diabetes and to talk a little bit about that, bringing to our HealthCast microphones, I have Carolyn Robinson. She is a vascular nurse practitioner at the Veterans Administration Hospital in Minneapolis, a past president of the Society of Vascular Nursing, a member of the PAD Coalition and a member of the Society of Vascular Medicine and Biology.  She's also a member of the American Academy of Nurse Practitioners.Carolyn, thank you so much for being with us today.

Carolyn Robinson:  Thank you for having me.

Dr. David Meyerson:  The diabetes and the foot.  This is a critical, critical message for all diabetics to listen to. Diabetic foot care, how important is it?

Carolyn Robinson:  Well, diabetic foot care is extremely important because people develop ulcers that oftentimes very hard to heal and can cause eventually lead to amputation.

Dr. David Meyerson:  The diabetic -- again, we talk about disease of small blood vessels, how does it get started?  Diabetics don't have normal sensation, do they?

Carolyn Robinson:  No, they have things like diabetic neuropathy, that's damage to the nerves that occurs oftentimes when the diabetes is uncontrolled. Oftentimes, people who have neuropathy don't feel heat, cold or pain, therefore, if you don't feel the different things that attack your feet, oftentimes, you're walking on sores and the sores get worse.

Dr. David Meyerson:  So you don't have the warnings that other people would have.  Small sores go unattended, they enlarge, they get deeper and you just don't know.

Carolyn Robinson:  Exactly.

Dr. David Meyerson:  And sometimes, I can remember a story -- I've told the story previously, but it's absolutely true.  When I was a resident, I remember a forty -- a man in his middle forties who had a daughter that played with jacks, you know the small little metal things that you would pick up onesies, twosies, I don't know if you ever played that when you were a girl, but I remember he related having stepped on one of those and he felt a little pressure, but he didn't feel the intense pain that most of us would feel and he really didn't do much about it and two weeks later, he had a horrible infection in his foot that was so deep and so active and so rampant, that he actually lost a segment of his foot.

Carolyn Robinson:  Well actually, this is not unusual and we've seen many patients come in that actually have walked all day with something in their shoe and that's why we talk to patients about the importance of shaking their shoe out before they put it on because these things can cause really serious infection.  You're exactly right.

Dr. David Meyerson:  And so what we're talking about would not only hold for diabetics, but for anybody who has an impairment of sensation in their feet perhaps, right?

Carolyn Robinson:  Exactly.

Dr. David Meyerson:  So how do we get started?  What kind of patients come to you?  Do they come to you before they get disease to prevent disease? Do they come to you with active ulcers?  Where in the pipeline do you see most of your patients?

Carolyn Robinson:  Well generally, unfortunately we see them after they've developed an ulcer.  Many, many times the patients have come in have no idea that they even have any type of ulceration and they've gone to their health care provider and have been told that they have an ulcer.  Generally, they come in walking on the ulcer and oftentimes aren't able to clean it well enough so in addition to having walked on it, it isn't always real clean.

Dr. David Meyerson:  So what happens is I guess you evaluate these patients and if there's an infection, you try to isolate whatever bacteria it is and then try to find out why it's not healing.

Carolyn Robinson:  Well, we do that and also we evaluate any patient that comes in with diabetic ulcers for peripheral arterial disease because diabetes affects the flow of blood and it is not unusual for patients to have peripheral arterial disease in addition to their diabetic ulcers.  They may need to have some type of additional blood supply to their foot to heal the ulcer.

Dr. David Meyerson:  And that would be a complaint common in people with peripheral vascular disease as we mentioned, a non-healing ulcer or maybe they started months or years ago with what we have called claudication which is the pain that you get in your foot or leg when you're walking a certain distance and the blood supply is limited and at such a point where the demand for blood is outstrips the supply, the leg starts to hurt.  It's a little bit like angina when somebody has narrowing arteries that go to the heart muscle and they do a certain amount of exercise and the demand of blood supply coming to the heart is greater than the supply, people start to get that warning pain. So do you see people coming in with claudication as well?

Carolyn Robinson:  We do see people come in with claudication although that is not seen as much with people with diabetes.  Oftentimes people with diabetes don't really -- they may not walk any distance to really recognize their claudication and oftentimes they may have what's called small vessel disease, where they'll have normal ABI's, but very poor blood flow to their feet.

Dr. David Meyerson:  Carolyn, I'm looking at a page from the preventive food care in diabetes from the American Diabetes Association and they talk about things like peripheral neuropathy with loss of sensation.  They talk a little bit about altered bio mechanics in the presence of neuropathy.  Do people with  neuropathy walk in an unusual way which causes extra pressure and discomfort and breakdown in parts of the foot as well?

Carolyn Robinson:  Well, they do and oftentimes people with neuropathy will come in and describe they feel like they're walking on crushed glass or on stilts.  And their gate is often distorted. They also often have structural changes in their feet. The bones may be collapsing causing pressure points that other people wouldn't have.  They also oftentimes will have deformities in their toes and so they put on a normal shoe and they're going to get pressure against the area say where the toes are clawed.  So consequently, it's very important that these people have adequate shoes.

Dr. David Meyerson:  Let's go back to our diabetic population that are trying to maintain their best possible health and they don't have specific complaints except to know that they have diabetes which is in need of good control.  What would be the things that you would recommend to patients?  When should they seek care from a foot, a diabetic foot care specialist? How -- I imagine you would tell them for example, they should never trim their own toenails for fear of introducing an infection or cutting too much, with neuropathy they might not even know how much to cut. What -- how -- where do we get started with educating our population?

Carolyn Robinson:  Well, we actually want these patients with diabetes to inspect their feet daily.  This is so important because changes can come almost overnight.  We want them to look between their toes for cracks or blisters and we encourage them to use a hand mirror because oftentimes they don't see quite as well and then to actually seek assistance from a friend or you know a spouse if they have one, to also look between the toes.  We want them to wash their feet daily with warm water and a mild soap, drying them carefully and be sure that they get between the toes. We really -- a lot of patients love to soak their feet and we really discourage that because when you have diabetes, unfortunately the normal hydration that you would have in your feet, kind of disappears and the feet become very dry and cracked.  When they soak them in water over time, they just become more dry.

Dr. David Meyerson:  You think that would be the reverse, that the hydration from the liquid would improve the suppleness of the skin, but it just serves to help it break down, doesn't it?

Carolyn Robinson:  It does.  And we also encourage them to use lotion on their dry and cracked feet, but never to put it between their toes.

Dr. David Meyerson:  And so when you have the cracks, it's important to take care of those because those could be a portal of entry of bacteria, right?

Carolyn Robinson:  Exactly.

Dr. David Meyerson:  Now I just thought about something very interesting.  If someone has diabetic neuropathy and wants to care -- and they want to bathe or something like that, when most of us draw a bath, we usually put our toe in the water first to see what it's like.  You probably wouldn't recommend that.

Carolyn Robinson:  No, we actually encourage them to have a thermometer and if possible, but if they don't have that to put their elbow in the water.

Dr. David Meyerson:  Really?

Carolyn Robinson:  Because the neuropathy also affects the hands and they might stick their hand in water and not even feel the temperature and you bring up a really good point there when you talk about temperatures because one of the things that you'll see also is people who are walking barefooted, maybe around a swimming pool or something, may burn their feet on the hot sidewalk and not even know it.

Dr. David Meyerson:  So you would basically tell all of your diabetic patients to walk barefoot is just absolutely prohibited.

Carolyn Robinson:  Exactly.  We encourage them to keep slippers right by their bedside and slip them on before they go anyplace.

Dr. David Meyerson:  And like a slipper sock probably wouldn't be good enough protection for this particular population.

Carolyn Robinson:  Well, I prefer them to use regular hard-soled slippers because slipper socks have

Dr. David Meyerson:  Like from the 1930's movies?

Carolyn Robinson:  Yeah, exactly.

Dr. David Meyerson:  And then they have to get their smoking jacket, God forbid, but we don't mean smoking, you know, that's just the name of the garment.

Carolyn Robinson:  Well, we want them not to wear those kind of thong type shoes too because they put pressure in between the toes, so that's an important thing to remember.  That's why those old- fashioned slippers are really quite good.

Dr. David Meyerson:  Something as simple as athlete's foot in a diabetic can lead to terrible consequences if untreated because again, it's that portal of entry of bacteria, right?

Carolyn Robinson:  Right.  I mean, everybody gets things like athletes' foot, fungus infection, calluses, etcetera, but in people with diabetes oftentimes they can lead to infection and serious complications and ultimately can lead to amputation if not taken care of.

Dr. David Meyerson:  So what would be the warning signs?  So, we recognize already in the beginning of our discussion that diabetics get a blood vessel disease sooner than everybody else in the population, that they have diminished sensation of the feet which is one of the reasons, so they don't have the warning system to know when they have a problem, so they have to inspect frequently and again get diabetic foot care.  I guess, a podiatrist would be the best place to get that kind of care?

Carolyn Robinson:  Well actually, it doesn't need to be a podiatrist.  It can be in any primary clinic.  Primary clinic should be geared to recognize, I believe the recommendation is that they be tested with a monofilament as well at their regular primary appointment.

Dr. David Meyerson:  What would you mean by that?

Carolyn Robinson:  There's a -- it's a monofilament test is a test to check the sensation in the foot and it's gently used on the bottom of the foot and there's certain areas in the foot where we can tell whether the sensation is decreased.

Dr. David Meyerson:  So it's just taking a little piece of plastic, if you will, that's very tiny, maybe a little thicker than a hair or something like that and just tickling the bottom of the foot and seeing where they sense the sensation?

Carolyn Robinson:  Yes.

Dr. David Meyerson:  And just out of interest, so you said put your elbow in the water, that's an area that's usually protected from neuropathy and you have very thin and very sensitive skin there that is pretty much reliable in terms of sensation.  Is that right?

Carolyn Robinson:  That is good, but again a thermometer is even better.

Dr. David Meyerson:  I was -- Dr. Kerry Stewart is sometimes in the studio with me and he is our engineer today and he's been kind enough to give me some suggestions about questions to ask and he would like to know should patients take their shoes off before the doctor asks them to?

Carolyn Robinson:  Well, yes they should because the doctor may not ask them to take them off.

Dr. David Meyerson:  Uh-huh [affirmative]. And you know, sometimes we've seen situations where the amount of time that patients have with doctors appears to be getting shorter and shorter these days and I guess if you don't engineer your best healthcare, you might not get it.

Carolyn Robinson:  That's true, but I think that all offices, the nurses should be encouraged to -- encourage the patient to take their shoes off as soon as they get there.  I know in our clinic, no matter what they're there for, they have to take off their shoes.

Dr. David Meyerson:  Now can I ask you an unrelated question?  We're going to take a little bit of a diversion for a moment. I understand that your clinic handles a fair number of people who have been part of the military in the Iraqi War and you are involved with helping some of them heal as well.

Carolyn Robinson:  Right.  We don't see as many people with diabetes from Iraq, but unfortunately we do see many lower extremity injuries because of the type of injuries that they receive in Iraq, so luckily we haven't seen a lot of diabetes with these people. Diabetes is a disease that manifests itself more with increasing age and you -- one of the risk factors for diabetic foot ulcers is increasing age.

Dr. David Meyerson:  Lets talk a little bit about how you would go about treating a diabetic foot ulcer because again, you don't want this to get deep, you don't want it to become an infection that invades the deeper tissues and then ultimately could invade the bone and cause something called osteomilitus, so what is the proper approach?  How does a patient know that they are getting good care of their diabetic foot ulcer?

Carolyn Robinson:  Well, I think it's really important that whoever is looking at it is evaluating it closely, looking at the location, kind of finding out what it looks like and to probe that ulcer to see if there's any depth to it, because unfortunately sometimes these ulcers can go completely through the foot.  Very important to evaluate them for peripheral arterial disease and we always do a foot film to rule out any type of osteomilitus or maybe a foreign body in the foot that could have been stepped on or worse case scenario that there would be gas in the area.

Dr. David Meyerson:  How often do you see people presenting with a problem with the foot and then you take an X-ray or probe and actually find a foreign object?

Carolyn Robinson:  Very seldom do we find a foreign object, but often we find osteomilitus.

Dr. David Meyerson:  And how -- that's a more involved treatment, would that --

Carolyn Robinson:  Right.  That involves extensive possibly debridement and extensive antibiotics.  Many of the patients aren't willing to have the toe amputated or they really want to try to save it with antibiotics first.

Dr. David Meyerson:  And it's that old combination where if the blood supply is not adequate then you can't get the intravenous antibiotics don't get adequately into the tissues to actually cure the infection so it's a double whammy for the diabetic foot, isn't it?

Carolyn Robinson:  It is and you know, we're fairly aggressive in going to intervention, whether it be radiological or surgical fairly quickly with people with diabetic ulcers.

Dr. David Meyerson:  How often should a normal diabetic, you know that's a kind of an incorrect terminology, but the average diabetic, how often should they be getting professional foot care?

Carolyn Robinson:  Well --

Dr. David Meyerson:  I know you said look at your foot every single day and I guess you would say if you see -- can we go through the list of what would make them seek further attention and then answer the question how often they should be seeking attention even if everything looks okay?

Carolyn Robinson:  Well, the recommendation is four times a year.  The --

Dr. David Meyerson:  And that's for the diabetic foot that is otherwise without ulcers, without discolorations, without any kind of unusual finding, four times a year, they should have a professional look at the foot to make sure they're not doing something that will then create an ulcer or a problem later on?

Carolyn Robinson:  Yes, that's the recommendation.  I don't know that that's going to happen with everybody, but it certainly is, you know, should be at least twice a year.

Dr. David Meyerson:  Well, you only have to, but know someone who has even a young person, relatively, who has lost part of their lower extremity and if you imagine what they've been through, Abraham Lincoln as we've said previously, once said, "When my feet hurt, I can't think."  And that is a quote by Abraham Lincoln, by the way.  But if you seen what happens to someone who has gone through an amputation that should be enough to tell you that this is something that I don't want to see happen to my diabetic patients or a family member or any diabetic for that matter.

Carolyn Robinson:  Well, I think yeah. That's very important because if you think about the major cause of hospitalization, diabetic foot lesions are right up there in top with approximately twenty percent of all diabetics in the hospital because of foot problems.

Dr. David Meyerson:  That's incredible.

Carolyn Robinson:  And nearly fifty-five thousand lower extremity amputations are performed each year on diabetics.

Dr. David Meyerson:  Wow.

Carolyn Robinson:  Accounting for fifty- percent of all non-traumatic amputations and I just think this is a huge number and it doesn't have to happen.

Dr. David Meyerson:  This is preventable disease.

Carolyn Robinson:  Exactly.  It does not have to happen.

Dr. David Meyerson:  This is absolutely preventable disease and that is the message.  That's what the Vascular Disease Foundation would like our listeners to know, that even though they have diabetes, even though they have compromised circulation, treated, watched, observed the right way, we can prevent the disability.  That's what the Vascular Disease Foundation would really, that's the message that we want people to know.  Is diabetic foot care covered by insurance most times?

Carolyn Robinson:  Well, you know unfortunately, I can't speak to insurance that much because I'm in a government situation.

Dr. David Meyerson:  I see.

Carolyn Robinson:  But I believe that there's a certain number per year and I can't give the answer to that.

Dr. David Meyerson:  I guess I would be optimistic that it would be since it is that compelling a disease process.  I think we've talked about a lot of interesting things.  What would you tell somebody who is a diabetic who is also smoking?

Carolyn Robinson:  Well, I would really encourage them to stop smoking.  You know, it is just another risk factor that's going to increase their risk of amputation.

Dr. David Meyerson:  Do you feel that people with ulcerations that you've seen, that the spectrum of what you've seen is worse in diabetics who are smokers?

Carolyn Robinson:  Absolutely.  Absolutely. And with diabetes, it's so important that the glycemic control is excellent because the higher the A1C gets, the worse the risk of diabetic ulcers.

Dr. David Meyerson:  So Carolyn, we're coming close to the end our podcast here.  Are there any other things that you would like to tell our diabetic listeners or family members of people with diabetes just to recap?

Carolyn Robinson:  Well, one of the most important things I want to say is avoid bathroom surgery.  Many people want to use, they want to get rid of their calluses with a razor blade at home, or with different type of corn medications that they receive over the counter and these things are very dangerous for people with diabetes and I would really encourage them to always seek medical care when they develop any type of callus or any type of malformation on their foot.

Dr. David Meyerson:  And the reason for that again is having to do with the idea that the neuropathy doesn't allow them to really know what to cut.  They're really not trained what and where to cut and anything that they would cut with would just introduce the potential for serious bacterial infection?

Carolyn Robinson:  Yes, that and they don't oftentimes know they may have peripheral arterial disease and unfortunately once you make an ulcer in a foot that has peripheral arterial disease, you may not heal that ulcer.

Dr. David Meyerson:  So again, can you -let's repeat that.  Once you develop an ulcer in a leg, in a foot with peripheral arterial disease, you may not be able to heal that ulcer.

Carolyn Robinson:  Right and you --

Dr. David Meyerson:  But -- I'm sorry, go ahead.

Carolyn Robinson:  No, that's okay.

Dr. David Meyerson:  So, so I guess again, it just reiterates the critical nature of prevention.

Carolyn Robinson:  Exactly.

Dr. David Meyerson:  We've been listening to Carolyn Robinson.  She's a vascular nurse practitioner at the Veterans Administration Hospital in Minneapolis. She is past president of the Society of Vascular Nursing, a member of the P.A.D. Coalition and a member of the Society of Vascular Medicine and Biology.  This has been very, very important information for all of our diabetics.  If you have a diabetic in your family, if you are one, prevention is the critical name of the game.  Seek care for your feet, seek care for your heart.  Sometimes if you have an ulcer, it may be a clue that -- the feet may be a clue that we have to look more carefully upstairs as well to the coronary arteries and other areas of the vascular system.  But in any event, the Vascular Disease Foundation would like you to know, please these are largely preventable and treatable diseases.  Seek the care.  The advice that we got from Carolyn Robinson is truly critical. She said, "Don't do self surgery on your own feet." You should probably not even trim your own toenails. Leave that to a professional because once diabetics develop foot ulcers, they may be nearly impossible to heal without surgeries and antibiotics and a great, great deal of difficulty or they may never heal at all. And there was an interesting movie once called War Games and War Games was a very fascinating movie with Dabney Coleman and Matthew Broderick and it was about a Department of Defense computer that was trying to decide who would win a nuclear strike, a nuclear war. And it had these calculations if whoever fired first, whether it would be sea-based from a submarine or from land-based, whether it was a large volley or just a few things and a few missiles sent and at the end of the movie, the computer in its computer voice said to the programmer, said, "Dr. Falken, I've come to the conclusion that the best way to win this game is not to play it.  The best way to win this game is not to play it."  And with diabetic foot ulcers, the best way to win this game is not to play it.  For the Vascular Disease Foundation, for Dr. Kerry Stewart, for Carolyn Robinson our wonderful guest this week, I'm Dr. David Meyerson, have a good night.

Carolyn Robinson:  Good night.

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