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Medical Intel


Nov 23, 2018

One of the major goals of our Limb Salvage and Wound Care program is to avoid amputation when we can. Dr. Tammer Elmarsafi discusses how diabetic patients can reduce their risk for amputation, as well as who might actually benefit from the procedure. 

 

TRANSCRIPT

Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Tammer Elmarsafi, a podiatric surgeon at MedStar Washington Hospital Center. Welcome, Dr. Elmarsafi.

Dr. Tammer Elmarsafi: Thank you so much for having me.

Host: Today, we’re talking about identifying patients at high risk for amputations. Dr. Elmarsafi, what diseases or other factors put an individual at high risk for amputation?

Dr. Elmarsafi: There are lots of different things that place patients at high risk for minor amputations of the foot and even major amputations where they lose their entire limb. For the most part, the number one risk factor will be advanced-stage uncontrolled diabetes and peripheral arterial disease, and patients that have a combination of these things are at even more risk. And then, of course, we have patients that have other disease processes on top of diabetes - end-stage renal disease, et cetera, that make for a very challenging process for healing patients with wounds and ulcers, infections, et cetera.  

Host: Could you talk about the sophisticated methods that you use for amputation and how you go about avoiding that, say with a diabetes patient, what therapies would you try before it gets to that point?       

Dr. Elmarsafi: We have a very strong campaign here at MedStar Washington Hospital Center, and we work very closely with all the primary care physicians. I make a very important point to go out into the community, particularly to family medicine and internal medicine groups, to ensure that once they’ve identified a patient with diabetes who have a foot complaint to immediately refer them. That’s before they even have a wound. As soon as they start developing a problem, they need to see us. And, then what we begin to do is to assess whether or not they are starting to develop peripheral neuropathy. And, what neuropathy is, is basically a loss of their normal sensation, and it’s the number one risk factor for developing further downstream problems such as ulcerations and injuries and infections to the foot. If we can prevent those things from happening and we can identify these patients early, then we can address those problems before we even get to the conversation of you need an amputation. And, so that’s the first thing, that we identify these patients very early, we get these referrals immediately, and then we begin to screen these patients for what interval of time is required for each specific patient, custom tailored for them, based on their foot type, how they walk, the problems that they have, the level and depth and severity of their neuropathy, and the control of their diabetes. That tells us how often they need to be seen, and in those interval sessions when we see them and evaluate them in our clinic, we monitor for changes in the foot. We get X-rays, we evaluate them, and over time we get a very good picture for what things are at risk in that foot, and then we can actually do prophylactic surgery, and that’s something that we’ve been entertaining for some time in providing patients with, that has shown to increase the likelihood of a foot that stays with you whole for the rest of your life.                

Host: What do you mean by prophylactic surgery?

Dr. Elmarsafi: If patients have a foot deformity and that foot deformity is causing a different, increased areas of pressure in your foot—let’s say, for example, a hammertoe. Hammertoes are very, very common in almost any patient at any age, but patients with diabetes in particular are at even increased risk for developing these toe deformities. These toe deformities increase pressures at different spots on the toe and on the bottom of the foot. These patients begin to develop calluses. Once they develop calluses, these calluses become hard and essentially begin to pinch the skin and the soft tissue between the hard floor and the bone that’s underneath, and what winds up happening is that with neuropathy and all of the other problems with diabetes, is they develop an ulcer.  But, if we straighten out those toes and make those high-pressure areas disappear, then they never develop those ulcers. If they never get an infection, and they don’t get an infection in their bone, then we don’t run into those problems.

Host: So, what is the patient’s role in the process? What pieces of advice do you give them for self-care to avoid amputation?

Dr. Elmarsafi: For patients that have diabetes and neuropathy, we really emphasize the need for them to check their feet on a daily basis, whether they’ve walked for half an hour or for five hours in the mall, they need to very frequently take their shoes off, look at their feet and make sure that there aren’t any areas that are turning red or are irritated because they won’t know. They don’t have that feeling in their feet. Additionally, we also emphasize the importance of general good health, so we tell them to maintain good sugar control, and, if they’re not well controlled, we’re always talking with their endocrinologist or with their primary care physician to ensure that we can bring them to a good level so that we can prevent further complications. For patients that have wounds, however, the level of scrutiny required by the patient is much heightened, and we make sure that we’re providing the patient with all of the necessary wound care, dressings and medications, and, of course, teach them how to do those dressing changes. Some patients can’t, and that’s when we employ visiting nurses to come to their home and to provide the necessary dressing changes.  

Host: So, how do you have those conversation with a patient when you’ve tried multiple tactics and nothing’s working, when they need more aggressive therapy, such as amputation?  

Dr. Elmarsafi: I think most patients really understand, particularly long-standing ulcers and problems with their feet, when you get to a certain point, your quality of life dramatically decreases. Patients are in and out of clinic on a weekly basis, they’re being admitted in and out of the hospital for multiple infections and repeated surgeries, and it’s so disruptive that it affects their work life, their social life, and putting some kind of closure with a definitive surgery, even if it sounds extreme, like an amputation, is sometimes comforting to the patient, and in most cases, most patients are very open to that. Very little do I ever encounter a patient who says “No, I don’t want that.”

Host: When you’re working with a high-risk patient, say an individual with diabetes to avoid amputation, what sort of goals are appropriate for them and how do you help them set realistic goals, you know, walking again versus jogging again or something along those lines?  

Dr. Elmarsafi: That’s a really important aspect of any amputation, whether it’s a partial toe amputation or a below-knee amputation, and from the very beginning our clinical expertise allows us to be able to evaluate the patient, have a really good sense of what this patient will need by the end of their admission or the end of their process. Setting up expectations and appropriate goals for these patients really varies, but it is nonetheless extremely important. Whether you get a partial toe amputation, a midfoot amputation or even a below-knee amputation, each patient needs to really understand what their limitations are and what they can actually perform.

For most young patients, any level of amputation winds up being OK. As long as they were able to walk before their amputation, they’re probably going to walk just fine afterwards. Our prostheses these days, particularly for major lower extremity amputations--that is to say, below-knee amputations and above-knee amputations, have come a long way. Patients do very well with them, we rehab them very quickly, and in an order of a month or two at most, patients are able to get back to their normal routine. That’s in the healthier patient. For our more elderly patient who is bedridden and doesn’t really do much walking and really just needs to transfer out of the bed and maybe go to the kitchen and back, and that’s, that can be a huge hurdle for them, even with both extremities, so for these patients it may be a little bit more challenging, but with good physical rehabilitation we’re able to provide the patient with good support and good follow-up for major amputations. For most lower extremity amputations at the level of the foot, most patients do great. Patients can walk. Patients have the same level of balance as they had before. Patients can wear essentially the same shoes. Losing digits toes in the foot is not a big deal. In terms of aesthetics, patients usually have an aversion to that, but that over time they get used to it just like anything else. And patients over the first two or three office visits almost get used to it and feel that they’re fine with their amputation, and over the course of, you know, the next year, they don’t even refer to their amputation anymore. It’s a normal part of their existence. So, it’s a process and each person goes through a different, you know, rate of acceptance of what they need to deal with, but most patients do very well with foot amputations, toe amputations, and almost all of our patients that require major lower extremity amputations also do quite well.   

Host: If an individual is recommended by their doctor that an amputation would be appropriate for them, what would you recommend to them to ask to their doctor? Do you always recommend a second opinion on those?

Dr. Elmarsafi: I love second opinions. I think patients feel much better and much more confident about what is about to happen to them. For some patients, it feels like it’s a life-changing event. They’re about to lose a body part. It’s not to be taken lightly, and for the mental process and emotional process to happen, I think that’s very comforting to know that you’re allowed that, and I encourage it. We have multiple physicians that we trust that are in the community that we openly say, you know, “Here are some good doctors that we can send you to for a second opinion.” And, many times after they hear that they’re usually, “OK, no, I’m all right. Let’s just move forward.” There’s very few times where they do want that second opinion, and that’s good, that’s healthy, that’s healthy in any specialty.          

Host: Do you have any exemplary patient stories that you would want to share? Do you have any patients, perhaps, that have come in just dejected with their condition, and then left after their amputation feeling better or different?   

Dr. Elmarsafi: There are several patients that I can recall, but one is the most striking, and this is a patient that I had dealt with even when I was a resident here, and she was a very nice woman, but unfortunately wound up having many, many bad infections that had her at some point in the ICU from sepsis and as a result of her foot infection. And she was very much afraid of losing her foot. And, there was a very strong encouragement for her to undergo a midfoot amputation, and she was very reluctant. And I remember seeing her, at some point down the line, but she was seen by the vascular surgery team, and they told her there was absolutely no way that you will survive, you will die if you do not have an amputation today. It was a very, very bad infection of her leg, and at that point she kind of gave in, and, as I was passing her by the hallway, she grabbed a hold of me, and she had changed so much I couldn’t even recognize her. She looked very, very sick. And, I talked with her, and when she told me she was about to go in for an amputation, she asked me to go into the operating room with her. I got permission from the surgeon. I said, you know, she requested that I be in there for her, and the surgeon was fine with it. And, when she came out, she was already feeling better. It was that dramatic. Her white count came down over the course of the next 12 hours and she blossomed. She was discharged, I think, about four days later, and I asked her to let me know when she would be followed up again in clinic. And I ran to see her as an outpatient and she was just a new person. Amputations can be a bad thing for patients emotionally, but for her, it was such a good thing for her. She felt amazing and she, the first thing she said when I saw her was, “I wish I took your advice a long time ago.”  But, this is a very frequent retrospective occurrence. Patients say that all the time.

Host: Thanks for joining us today.

Dr. Elmarsafi: Thank you so much.

Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.