VOL: 98, ISSUE: 44, PAGE NO: 55
Janet Webb, BSc, RGN, DipN, Cert Health Prom, is a practice nurse in LincolnMr Smith is a 48 year-old man with insulin-dependent diabetes. His diabetes was diagnosed 25 years ago and initially he was treated with oral hypoglycaemics. His mother has type 2 diabetes, and he is married with three daughters. He has never smoked, has a body mass index of 29, and 'likes a drink'. His glysated haemoglobin (HbA1c) is usually between 7.5 and 8. He has clinical signs of diabetic neuropathy.
Mr Smith is a 48 year-old man with insulin-dependent diabetes. His diabetes was diagnosed 25 years ago and initially he was treated with oral hypoglycaemics. His mother has type 2 diabetes, and he is married with three daughters. He has never smoked, has a body mass index of 29, and 'likes a drink'. His glysated haemoglobin (HbA1c) is usually between 7.5 and 8. He has clinical signs of diabetic neuropathy.
Mr Smith used to work as a builder and wore steel-toe-capped boots everyday. He has a passion for working on his model railway and used to love driving his classic sports car.
Nine years ago Mr Smith had bilateral proximal interphalangeal joint spike arthrodesis of the second toes, then two months later presented at the surgery with an infected ulcer under a callus on his right fifth metatarsal (MT) head, and a callus over the third MT head. His ulcer was dressed with a povidine-iodine fabric dressing, and he was prescribed antibiotics and referred to the podiatrist.
Two months later a sinus had developed, and two weeks after that there was inflammation on the dorsum of the foot. His antibiotic dose was doubled and his oral hypoglycaemic medication increased; he was being seen in podiatry and hospital diabetic clinics and was referred to the orthopaedic surgeon for plaster-casting to relieve pressure. The ulcer was now being dressed with a hydrogel dressing.
When the cast was removed a new ulcer had developed over the first MT head, followed two months later by marked inflammation of the fifth ray. This culminated in the excision of the fifth toe and MT, and Mr Smith was started on insulin therapy. He was fitted with an insole and went back to work.
Eight months later, Mr Smith was back at the surgery with an ulcerated forth toe. Further antibiotics, dressings and orthopaedic referral followed, but six weeks later X-rays showed signs of osteomyelitis, and his forth toe was amputated. He was fitted with an MT dome support.
The following August Mr Smith returned with an infected second toe - he was still wearing steel-toe-capped boots for much of his working day. Following treatment the toe healed completely, but in December he was back with a thick callus on his right sole. This was debrided to reveal an ulcer, 2cm in diameter with a sloughy base. A further orthopaedic referral and plaster casting were followed by admission to hospital for bedrest just after Christmas. He was discharged with the ulcer much improved and a re-fitted insole with arch support.
Mr Smith had developed a pattern of attending clinics only when he had a problem; he is very independent and prefers to make his own decisions about health care advice.
Due to sick leave Mr Smith missed his chance of promotion at work, and in March 1996 he agreed to take voluntary redundancy. His ulcer was completely healed shortly afterwards.
Those involved in his foot care felt relieved, but Mr Smith's independence had been underestimated. He found work with a local landscape gardener, stopped wearing his insole and trapped his right foot between the slabs of a path he was laying, sustaining three large haematomas. At this stage he was still seeing the hospital orthopaedic and diabetes consultants, the podiatrist and practice nurse.
By September Mr Smith needed a Scotchcast for pressure relief. The following month he left work on ill-health grounds - this time to take up tree-pruning and felling. This was a short-lived career, however, as by February 1998 his driving licence was withdrawn due to retinopathy and he was finally forced to give up work - and his sports car.
By August another ulcer, with a sinus, led to further hospital admission and a forth MT osteotomy. Following surgery the plastercast needed replacing repeatedly, as the ulcer was producing exudate. Mr Smith became angry and frustrated, but also for the first time defeated.
The question of amputation had been discussed as a possibility on many previous occasions, and he had apparently coped well with the loss of toes. Now he had lost the independence of being the 'breadwinner' and had to rely on his wife - who was working to support the family - to drive him. He would spend days sitting in front of the television; his blood sugar increased and his foot was more painful than ever. The inevitable hospital admission this time resulted in a right mid-foot amputation.
Following discharge, Mr Smith's surgical wound healed well after two months. He was fitted with a surgical boot and given crutches. In April he arrived back at the surgery, very much the man we knew. He was regaining some independence along with mobility, albeit on crutches. He had taken up cooking, his model railway was a welcome diversion and his eldest daughter was getting married.
However, a new ulcer had developed from a split in the skin underlying a callus on the new weight-bearing sole area of his shortened right foot. By now he was seeing the tissue viability nurse as well as two consultants and the podiatrist. During the following months, Mr Smith decided he no longer needed the tissue viability nurse or podiatrist and planned to attend the GP surgery for dressings.
I gained experience in sharp debridement and established liaison for advice with the podiatrist. I used a hydrogel dressing and a foam dressing, alternating with an alginate dressing and a foam dressing, according to the amount of exudate, and gradually the ulcer granulated. It is now dressed with a very absorbent hydrocolloid covered with a foam dressing. Mr Smith finds this combination comfortable and it contains the exudate after twice-weekly debridement of the thick callus rim.
Monthly wound swabs are usually negative. Mr Smith will usually agree to blood-tests eventually and does home blood-glucose testing, which ranges from 4-20 mmol/l. He very seldom provides urine samples and, most worryingly, declines annual podiatry checks and examination of his left foot.
Mr Smith's care should focus on pressure relief, metabolic control and long-term preventive measures. However, his model railway is in the attic, reached by a ladder, and the accumulated dust on his dressing indicates that Mr Smith does not make use of his special footwear. His HbA1c results have room for improvement, and his left foot should be regularly checked. All this must be attempted while considering his quality of life and respecting his tendency to disregard advice.
I have discussed my concerns with the podiatrist. She offers access to Mr Smith if he will arrange a suitable time. This has been relayed to him with some measure of persuasion. Discussion about the need for regular meals and coordinated insulin injection has resulted in good-natured banter with Mr and Mrs Smith and he has promised to try harder.
Mr Smith is now beginning to accept the need for pressure relief. We have discussed replacing the loft-ladder with steps, and he has started to elevate his foot while he is working on the model railway, although he still needs to be persuaded to wear his boot and use crutches indoors.
The National Service Framework Guidelines for Diabetes (2002) state that people with diabetes 'will receive ... regular surveillance, timely, appropriate and effective investigation and integrated health and social care'. I interpret this as providing information so that Mr Smith can make an informed decision about what he is willing to accept. He is an individual, with his own priorities, and his health needs need to be juggled with respect for his lifestyle and autonomy.