Figures released by Diabetes UK show that the number of diabetes related amputations has risen to an all time high of 135 per week. What is particularly worrying is the evidence that 4 out of 5 of these amputations could have been prevented with appropriate care. On current figures, that equates to 108 preventable amputations a week or over 5600 a year.
Diabetes is the number one cause of lower limb amputations in the UK. NHS statistics suggest that those with diabetes are 15 times more likely to require an amputation than those without the condition.
As a medical negligence solicitor, I have seen first-hand the devastating psychological, physical and financial impact that a diabetes-related amputation can have on both the individual and their family. This is even more so where the diabetes and associated complications are not recognised or treated effectively leading to life-changing lower limb amputations that could and should have been prevented.
Why are diabetics at such a high risk of amputation?
Diabetes is a condition characterised by levels of glucose in the blood that are too high. This occurs either because no (or an insufficient amount) of insulin is produced by the pancreas to process the glucose or because the insulin that is produced does not work effectively.
High blood glucose levels can damage both the sensory and motor fibres of nerves. This damage typically begins in the extremities i.e. fingers and toes). Sensory nerve damage can reduce the perception of pain and other sensations (for example, hot or cold). This can increase the likelihood of injury from burns, cuts, sharp objects or simply from ill-fitting shoes. Damage to the motor fibre of nerves can exacerbate the effect by altering the positioning of the foot and stabilisation of the arch leading to distortions in weight distribution that may go unnoticed due to reduced sensation. This may also result in deformities to the foot itself (e.g. conditions such as Charcot foot). As a result diabetics are more prone to foot injuries that can lead to ulcers and or infection.
Infection in the foot of a diabetic patient is itself a common problem. High blood glucose levels can also weaken the immune system defenses, so that diabetics are more vulnerable to spreading or severe infection.
Diabetes is also a recognised risk factor for peripheral arterial disease i.e. poor circulation in the arms and legs. Reduced blood flow impairs the body’s ability to mobilize normal immune defenses and nutrients that help fight infection and promote healing. This contributes to slower healing times and compounds the impact of any acquired infection.
Poorly controlled diabetes can therefore result in a high risk tri-factor of reduced sensation, poor circulation and increased risk of infection such that even minor injuries can then develop without warning into ulcers, infection, tissue death and gangrene.
If caught early then these conditions can often be treated effectively with antibiotics and debridement (medical removal of dead, damaged, or infected tissue). However, if not addressed they can spread to become increasingly painful and potentially life threatening. In such circumstances amputation becomes necessary to salvage any healthy tissue in the residual limb before it is too late.
Prompt action is particularly important in cases of active diabetic foot disease. Examples of active diabetic foot include: active ulceration, spreading infection, critical ischaemia (lack of blood supply to the foot), gangrene, or an unexplained hot, red, swollen foot with or without the presence of pain, painful peripheral neuropathy, or acute Charcot foot.
Delays in the diagnosis and management of diabetic foot problems significantly increase the likelihood of a major amputation.
Education is key to the prevention of diabetic amputations. By providing patients with a solid understanding of diabetic foot care and providing training to professionals significantly reduce avoidable and serious complications.
Foot ulcers affect 1 out of 10 diabetics. If all diabetics review high quality regular foot check-ups as a part of their care routine then problems should be detected at an early stage. Previous amputations, diabetic nerve damage and reduced circulation all increase the risk of amputation and may provide a basis for more frequent clinical review.
As part of their ongoing Putting Feet First campaign, Diabetes UK are calling on the NHS and other health care providers to minimise amputations by making key improvements to the standard of diabetic foot-care.
The integrated footcare pathway advocated by Diabetes UK highlights the importance of rapid referral to, and management by, a member of the Multidisciplinary Footcare Team whenever an individual has active ulceration or infection in their foot. It is also important to ensure that those at high risk of foot problems can be identified through good quality annual foot checks and regular review by a specialist podiatrist or another trained member of the dedicated team.
Specific concerns raised by Diabetes UK regarding the current care provided to diabetic patients include:
- Too few diabetics are receiving good quality annual foot checks. Data produced in April this year showed one in seven people with type 2 diabetes and almost three in 10 sufferers with type 1 were not receiving the recommended annual health review for their feet;
- Of those patients who did receive a annual foot check, too many were not informed about their risk status or provided with advice on how to reduce that risk;
- In cases of active foot disease referrals to specialists are not being made with sufficient urgency even though a significant deterioration can potentially occur in a matter of hours
- NICE (National Institute for Clinical Excellence) guidelines recommending that inpatients with diabetes receive foot checks during their hospitals stays are not being followed
- Specialist foot care teams are either not available or referrals are not made sufficiently promptly.
Whilst not every amputation that is preventable is necessarily the result of substandard or negligent care, the concerns raised suggest that there are a significant number that would fall into that category. Examples of potentially negligent causes of diabetic amputation may include:
- Delays in the diagnosis and treatment of diabetes itself
- Failure to monitor and appropriately manage blood glucose levels
- Misdiagnosis of diabetic foot disease
- Delays in the diagnosis and treatment of diabetic foot disease
- Failure to appropriately refer those with active diabetic foot disease
- Delays in diagnosis and treatment of circulation problems
- Failure to perform inpatient foot checks leading to a failure to diagnose and treat active diabetic foot disease
- Failure to appropriately treat infection
By contrast, with early diagnosis and appropriate intervention individuals can benefit from a better range of treatment options and surgical procedures (for example a vascular surgery to improve circulation) to help reduce the risks of amputation that so often leads to the loss of confidence, independence and quality of life.
Putting your own feet first
It is important to remember that the ability to reduce the risk of diabetes related amputation lies not just with medical professionals. As a diabetic you can also help to protect yourself by:
- Maintaining good blood glucose control: this includes maintaining a healthy diet and lifestyle, following specialist medical advice, attending regular medication reviews and monitoring your blood glucose at appropriate intervals.
- Check your feet every day and be careful to identify:
- Any signs of damage such as cuts, sores, burns, blisters or ulcers,
- Any changes in the colour of the skin on your foot,
- Any areas of reduced sensation that may be more prone to future injury,
- Any changes in the shape of your feet.
- Look after your skin and toenails.
- Do not underestimate the importance of well fitting shoes to protect you from injury. Check the inside of your shoes for objects before putting them on and try to avoid prominent seams or other areas that may rub.
- Attend annual foot reviews and if appropriate seek more regular medical reviews. Take these opportunities to ask about your risk of developing foot problems and to seek advice. If you are unhappy with the advice or responses you receive consider seeking a second opinion – it is better to be cautious.
By following these steps and playing an active role in the management of your condition you can help to identify high risk situations and to ensure that you get the care and treatment you need.