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A Wound as Small as a Dime: Improper Care Can Lead to Death in Diabetics

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For an alarmingly high number of Native Americans, a diagnosis of Type II Diabetes is the first in a series of preventable conditions that result in premature morbidity. The second is Diabetic Neuropathy, a nerve disorder caused by the uncontrolled blood sugar levels associated with diabetes.

Neuropathy damages nerves throughout the body. Burning, numbness, pain or tingling in the feet or legs are common symptoms of neuropathy—all of which signal that more serious problems may develop, like a foot sore the size of a dime. As any untreated foot sores grow, they can lead to the next serious complication, amputation. The final destination in this series of conditions is loss of life.

According to Carlyle Begay, board president at the Phoenix-based American Indian Health & Management Policy and member of President Barack Obama’s National Tribal Advisory Committee, diabetics who lose a limb have a “substantial mortality risk.”

But, of course, none of this has to happen. Not only is Type II Diabetes completely preventable, if caught early enough, it is also be completely reversible, he says. “Most of us are taught that diabetes is not reversible and that we are destined to be diagnosed with diabetes,” Begay, a Navajo from Arizona, laments. “Although diabetes is prevalent in our American Indian communities, diabetes can be prevented, treated and reversed if you are pre-diabetic.”

Even at the stage when the foot ulcers associated with neuropathy develop, loss of life is not inevitable. With proper wound care, the path to wellness can be walked—with both legs, both feet and all ten toes intact.

The key, according to Begay, is access to quality care. “If you are diagnosed with diabetes, you are at an increased risk of developing a wound if:

  • your blood sugar levels are high,
  • you have nerve damage that causes a loss of feeling in your feet, or
  • you experience changes in the shape of your feet.

It is important to see your doctor and monitor and manage your disease. Healing wounds is a complicated matter and a simple bandage is not likely to result in wound healing. Therefore, it is important to seek treatment by a wound care program that helps to avoid the risk of foot infection, actually heals your wound and reduces any risk or possibility of an amputation. Time is of the essence; the longer a wound remains unhealed the greater the risk of infection and amputation.”

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Unfortunately, too few Natives seek quality care in time to save their limbs—and their lives—because they have limited access to primary care and comprehensive wound care.

The wounds associated with diabetes won’t disappear when wrapped in homemade bandages and hope. If an open wound is not properly healed in the first five weeks, the risk of infection is substantially increased. At that point, Begay says, the chance of amputation increases 155 percent. “A wound," he adds, “is a threat to a life or a limb.”

Most Native patients with the wounds associated with diabetes are referred to non-Indian health care providers using Contract Health Care, a program that compromises care coordination and continuity of care. A new Indian Health Service initiative, a best practice model for wound healing, hopes to eliminate the need for Contract Health Care and generate better outcomes for diabetics throughout Indian Country.

This wound care program gives Indian Health Servicers providers the training they need to adequately treat the wounds associated with diabetes, saving millions of dollars. The shift within the Indian Health Service, according to Begay, is from a “cost to treat model” to a “cost to heal model,” and aims, ultimately, to achieve “cost avoidance” through early intervention. “You’re more cost efficient to treat simple wounds and reduce the waste in spending,” Begay adds. Saving lives—and limbs—has the added benefit of saving the Indian Health Service money.

“The fact that our people suffer at a higher rate than others from diabetes and other related co-morbidities, coupled with the fact that Indian Health Service facilities are continually challenged to provide quality patient care despite decreasing resources, makes chronic wounds an almost fatal condition for our people,” Begay concedes. He thinks that, with 16.3 percent of Native adults suffering from diabetes, a frustrating mindset has developed.

“In our American Indian communities,” he says, “diabetes is almost becoming a culture and a belief that no matter what we do we will be diagnosed with diabetes at some point in our lifetime.”

This sense of inevitability and lack of adequate health care has had grave consequences. Begay says that American Indians with diabetes have a greater risk (greater than two-fold) for developing neuropathy when compared to the adult U.S. diabetic population and adds that lower extremity amputation increases the risk for death by 4-fold in diabetic American Indians. Toe amputation corresponded with a 2-fold death risk.

The Best Practice Model aims to change all this and offer diabetics their limbs—and their lives. “The cornerstone of this approach is consistency; consistent application of clinical guidelines and practice, supplies/medications, and increased access,” Begay says. This model also provides patient education not only on wounds, but also on co-morbid conditions such as smoking and obesity, and provides opportunities for prevention with community outreach.

“The program demonstrates that wound care is cost effective and is economically feasible as a direct care program within Indian Health Service,” Begay says, then adds this: “Most importantly, the average patient would receive wound care that can actually heal their wounds.”