The Caribbean experience with the diabetic foot management of the diabetic foot

ABSTRACT

The foot complications of diabetic patients are one of the commonest and most devastating of medical problems that occurs in the Caribbean. The scale of the problem is reflected in the fact that, on average, 75of the beds in the general surgical wards of the Queen Elizabeth Hospital in Barbados are occupied by patients with this problem. Of the patients admitted, a third lose a limb by amputation and another third of the patients lose toes or part of their feet and remain in hospital an average of two months as doctors struggle to prevent them losing their limbs. Half of the patients are in their 70s when they are admitted to hospital but 4 per cent are as young as thirty to forty years. It is clear to the surgeons who struggle to save the limbs of these patients that preventive care and early and aggressive intervention, when problems occur, are the best way to avoid prolonged hospitalization and loss of limb. The events that precipitate the problems often appear trivial to most people. a little nick cutting a nail or a callus, a crack under the toe, an ingrowing nail, stepping on a rock in the yard or, even more devastating, on a dirty or rusty nail. The diabetic's foot is more susceptible to injury, sepsis and gangrene because of an altered inflammatory response and an increased incidence of occlusive vascular disease and neuropathy. Injuries normally considered minor can threaten the limb in diabetics by rapid progression of necrosis along tissue planes. Prevention is of primary importance and patients need to be educated and to remind themselves over and over again to clean their feet daily, paying particular attention to the interdigital areas: looking at them to make sure that there is no swelling or cuts or change in colour. Looking is important since diabetics, especially those with neuropathy, cannot rely-on pain as a symptom of injury. Patients have to be trained to recognise and respond to the signs of injury and infection without relying on the signal of pain that they and the health care workers usually rely upon to assess the seriousness of most conditions. Diabetics should wear something on their feet at all times, in and out of the house. What is worn should have a good firm sole to prevent penetration. If a sandal is worn, it should be strapped on so that it does not slip off easily. If something goes wrong, or is noticed to be wrong with the feet, professional help should be sought the same day. Treatment and observation are neede.