Diabetic Surgeon Protocol

Diabetic Surgeon Protocol

• Protocol diabetic foot surgery an example part 1

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1. What is the purpose of this protocol?

• What is the need of having a protocol for diabetic foot surgery?

Treatment of diabetic foot nowadays is a complex series of events like any other medical condition. It involves dressings, consultations, antibiotics, operations, investigations, plastering techniques, certain special therapies, special shoes, etc. Also, by default, a diabetic foot patient has many other illnesses and complications. The reason being, diabetic foot problems happen after many years of poorly controlled diabetes. So the patient has, apart from Diabetes and foot problem, other complications like heart, kidney, eyes or other complications. Hence, one has to follow certain rules and take precautions in order to maximize good results and minimize any adverse events or complications of surgery.

This protocol is only an example and general guidance. In individual cases, the patient must take advice of a properly trained diabetic foot doctor and the doctor should adopt the protocol as per his situation and the facilities available.

• First contact (likely a telephone call).

You may be asked details about your medical illnesses and the nature of your problem. If asked, you can send photos and reports. Subject to the services and specialist availability, an appointment might be fixed. The doctor cannot give any advice about investigations or treatment without seeing the patient in person. By default this happens in a hospital with appropriate facilities. So please don’t ask for any advice about investigations or treatment before the patient is seen in person by the specialist. Telephone consultation or online consultation is not a good idea in diabetic foot treatment.

• Consultation (face to face).

• Please bring all your previous records, previous reports, all the medications and actual boxes and strips of tablets with you, and all the files related to the same patient even if they may be from different doctors and from bygone years.
• There will be discussion about your problem.
• Examination and dressing will be done if required.
• Investigations – Usually an MRI and Doppler studies are suggested. Please note a few things about MRI.
• MRI is usually considered the gold standard for investigations when it comes to diabetic foot. When you go for MRI studies usually you see a technician only. He will run through standard procedure; this way sometimes important area may be missed. So it is important that you show the photos of the foot to the concerned doctor that is radiologist, so that the films of the important area are taken with special care. The diabetic foot specialist can or may forward the necessary photos to the radiologist if he knows him or you may give the photos to him.
• Usually there is no need to do a contrast (injection) study. Also, the contrast can cause side effects including damage to the already delicate kidney.
• Occasionally, they may even take a few sections of plain CT scan of the area of interest if required.
• Foot MRI is not an investigation done routinely in India. Hence, not many radiologists are skilled in reporting it. Sometimes, specific radiologist with a special interest in diabetic foot is suggested for the tests. All this precautions are useful if one wants a good report or wants to avoid repeating the scan. Patient may do MRI anywhere, but if the report is not satisfactory, then the specialist may request reporting (something like a second opinion) from an experienced radiologist. In such situation, there is no need to repeat the MRI. The same MRI’s films and CD will do.
• You need to inform the radiologist about any implants in the body, because MRI creates a strong magnetic field.
• More or less, same things can be said about Doppler but since Doppler investigation is done quite often.  Usually, it is done reasonably well in most places in MRI. In Doppler there are arterial and venous studies. Since in diabetes usually it is the circulation going to the foot that is important (arteries), usually arterial Doppler is enough but, if there are certain issues suspected from the examination then, a venous Doppler may also be advised.
• There may be other tests advised if patient doesn’t have any recent reports about his current medical problems. Please note that chronic diseases like heart, kidney, lungs, asthma, blood pressure, allergies, liver diseases are forever. Even though you may not be actually getting any problem from them, they need to be checked before any surgery.

• Second consultation with test reports.

• Reports are reviewed and explained.
• Treatment decided. Treatment may include dressings, antibiotics, special plastering or surgical operation. The urgency of the situation also may be discussed. You may visit pages on this website about these individual sections of treatment for further information.

• Second opinion.

The specialist himself usually suggests a second opinion or the patient may ask for one. There is nothing wrong in asking for a second opinion. It’s a routine culture now. There is no need for the surgeon to feel insulted or the patient to feel embarrassed.

It’s quite possible that another diabetic foot specialist may have a different approach. He may decide the treatment depending upon his level of knowledge, experience, skills and the facilities available. In such situation, the onus is upon the patient to decide which approach to take. Usually most specialists avoid to criticize or to comment upon other specialists work unless it is absolutely necessary for the wellness of the patient.

• Hospital location partly depends upon the operating surgeon that’s being chosen by the patient. Every surgeon will have his select operating places. Since the treatment involves contribution from a big team, and needs necessary infrastructure, it is not possible for any surgeon to suddenly change the place of these operations. A hospital may be one of the best in the world, but still may not have the necessary arrangements for a particular surgeon and for a particular surgery.

• Expenses.

• The patient may discuss the estimate of expenses with the billing department of the hospital of their choice. Billing and expenses are usually decided by the hospital administration. Usually, the surgeon has a limited say in the billing unless the hospital is owned by the same surgeon.
• Expenses for the same surgery may vary from hospital to hospital. The reason being that certain hospitals will have advanced medical facilities. To give an example, certain operation theatres will have an advance technology of horizontal laminar flow of air; this keeps the number of infecting bacteria low. There are many such advanced technologies. Each adds to the better result of treatment, but also adds to the cost of the treatment.
• Having the best insurance is not a guarantee of totally cashless treatment. It may not be accepted by the hospital or the treating doctor for different technical reasons. Many a times, the expenses are not completely accepted by the insurance company. This may create unnecessary anguish, blame and problems later on. So it helps to understand and accept the complexity of the matter and try to discuss it as much as possible with the relevant people beforehand.
• Expenses may come under different headings like-
• Expenses during the hospital stay, for example room rent, surgery, etc.
• Medicines and other consumables.
• Investigations.
• Expenses vary from case to case, hospital to hospital and doctor to doctor.
• There can be significant expenses after discharge, for example specialized dressings, medicines, intravenous antibiotics, repeat surgeries, special shoes, treatment of medical problems, and treatment of other medical problems. It is important to consider these issues because; in problem like diabetic foot there can be significant expenses even after discharge. If the patient is not aware of them and not prepared for it, the treatment may remain incomplete, affecting the results. So try to explore these issues as much as possible.
• Like any other medical condition, one can only give a general idea about expenses because medical science is not a mathematical science; there are many possibilities. One expects and hopes that everything goes as per plan but complications and unexpected result may happen. Hence, expenses can vary accordingly.
• The value and importance of an intervention (treatment) may not be necessarily proportional to the amount of money you have to spend for it. For example, interventions like plaster, special shoes or a walker are not expensive things but they are probably some of the most important parts of treatment in diabetic foot. The most useful guidance is about prevention of these problems. It is invaluable but it comes free. Please check the section on prevention for tips on how to prevent diabetic foot problems.

• Purpose of treatment (aim of treatment).

The singular purpose of this whole treatment is to keep the patient walking on his own feet without any appliances or help as much as possible. It is the autonomy and the self-reliance that should be focused upon.

When deciding strategies, usually one wants to first save life, then save limb (and walking autonomy) and then save as much part of the foot and toes as possible.

It is very natural for patient to be emotionally attached to the body parts. People are more emotional about the body parts that are seeing outside, and even losing a fingernail becomes an emotional issue sometimes. But, there are times when one has to sacrifice some parts of foot / toes to save a walking foot. Sometimes one has to sacrifice the whole limb to save life. In such situations, it is very important to follow the hierarchy mentioned above that is-

-First save life

-Then save walking limb

-And then save remaining parts as much as possible.

• Admission – non medical

Sometimes, an admission may be required for non-surgical reason like-

• Intravenous antibiotics, for example, cellulitis (infection that may resolve with good antibiotics in the early stage).
• Plastering and giving complete rest. Example, non-complicated pressure ulcers or acute Charcot’s foot.
• Treatment of other medical problems like uncontrolled diabetes, heart, kidney or other problems.
• Social problems such as not having enough help to look after the patient at home.

1. Admission surgery/ operations.

• Consent
• The decision about doing surgery, about the nature of the surgery, it’s likely and unlikely sequelae and complications that need to be discussed well beforehand.
• It’s important that all the important relatives and/or friends of the patient have been taken into confidence by the patient (who he finds appropriate). It is useful to have a unanimous decision to avoid any feeling of guilt, blame for repentance later on.

• Hospital stay
• An attempt is made to keep the hospital stay as less as possible. Usually most patients need at least 1 to 2 days of preparation before the surgery. This time is used for necessary investigations, intravenous antibiotics, IV fluids, blood transfusions and an attempt is made to stabilize the different medical conditions like diabetes, heart and kidney as much as possible. In some situations one may need more time to prepare the patient for surgery.
• Please bring all your old files and medicines along with you. It is necessary that you bring all the files of that patient even if they are from different doctors.
• On the day of the surgery, it is essential that the patient is fasting (nil by mouth) for 6 hours at least. For example, if the surgery is planned at 2 pm, then the person should not eat or drink or take sips of water after 8 am of the same day. The reason being that whatever be the surgery, it is better to prepare the person for general anesthesia, just in case.

•  Anesthesia

Most surgeries are done under local or regional blocks. Some of the popular ones are ring block, ankle block, or blocks at knee level. The advantage is, that only a small part of the body is anesthetized, so minimal amounts of chemicals go into the body, the person is conscious (maybe sedated ), feeding after surgery can be reinstated faster and pain control lasts much longer. The most useful aspect of this type of anesthesia is that the risk of surgery to the heart and lungs and other organs like kidneys is minimized. This is an extremely important issue for diabetic foot surgery because by default, all these patients are poorly controlled diabetics for many years and unless proven otherwise they have complications of heart or kidney (diagnosed or not). Very few anesthetists are skilled in these kinds of blocks. It is important to discuss this with the surgeon beforehand whether such facility is available or not.

• Typically, plaster may be applied to the operated leg. The purpose of plaster is manifold. It protects the dressings and the foot in general. Secondly, it can be moulded to the operated foot depending upon the nature of the surgery so that the operated part gets more rest.
• After the surgery, immediate complications are minimal because of the nature of the anaesthesia and surgery. But, one should be vigilant for any extensive bleeding at the operated site. The second immediate problem is pain. Usually, after the blocks are given by the anaesthetist, chances of pain on the same night of surgery are less. Many times pain killer is prescribed as ‘as required’ (PRN) medicine. It means it’s given only when the patient asks for. So if the pain is significant (as perceived by the patient), please ask for pain relief.