Over the next year, R experienced worsening pain and increased sensitivity in his feet. He started to spend more time in his patrol car instead of on foot patrol because of the pain. He was no longer able to enjoy one of his favorite pastimes, walking barefoot on the beach. During the next several years, R would gradually begin to realize he had no sensation in his feet. He noted this affected his balance and gait. He loved his career in law enforcement, but often the complications of his disease would impact his daily work. He felt he was no longer fulfilling his responsibilities as an officer because of his inability to complete daily assignments due to the neuropathy in his feet. He left his law enforcement career and spent most of his time in an office, which was much less taxing on his body.
Foot Ulcers
In 2011, 15 years after the T1DM diagnosis, R experienced his first foot wound. After a day of hiking and walking in creek beds, he realized he had essentially rubbed off the skin on the ball of his foot. He cleaned it like he normally would; however, the area failed to heal. He developed a hard callus around the wound, but the center remained open. At the time, he did not realize the significance of this type of wound for a diabetic patient.
The foot ulcer was discovered while in the emergency department for an unrelated issue. It was then he was referred to the Greenville VA Outpatient Clinic wound healing center in South Carolina for further treatment. At 36 years old, he was far younger than most of the veterans being treated for diabetic foot ulcers. Per the CDC Report Card, about 90% to 95% of patients with diabetes have type 2 diabetes mellitus (T2DM).1,2 Most persons diagnosed with diabetes are in the fifth and sixth decades of life.1,2 For R, patient education had consisted of learning to manage his diet and insulin therapy. He has no recollection of education about future complications and reported feeling “clueless” about the potential complications of foot ulcerations.
During the patient’s first visit to the wound healing center, R was educated about diabetic foot health, complications, the healing process, and the importance of diabetes management. The center is staffed by a nurse practitioner (NP) certified in wound care with extensive experience in diabetic foot ulcers and by several wound care nurses. Each staff member incorporates patient education and positive reinforcement into every patient visit. According to Jeffrey Frenchman, DPM, director of limb preservation at the Atlanta VAMC in Georgia, “Patient education and positive reinforcement cost nothing to provide and offer great return on patient adherence.” (Jeffrey Frenchman, April 12, 2014, oral interview).
R visited the center once or twice weekly, depending on the appearance of the wound and the type of treatment he was receiving. He noted that having frequent contact with the wound center staff made him feel as though he was making progress. For the staff, ensuring R could adhere to the treatment regimen was paramount. If a patient is unable to follow home care instructions or lacks understanding of the importance of following wound care instructions, then the likelihood of adherence is less.
Continued Complications
R was unprepared for the months of healing. He learned about the importance of offloading (the reduction of pressure), noting that during the weeks he spent more time on his feet, ulcer healing failed to progress or worsened.3 Eventually, the ulcer healed, and he felt better prepared to prevent future problems as a result of having been educated about foot care. Unfortunately, he experienced his next complication a few months later after wearing new boots. When removing his boots at the end of the workday, he noticed blood on his sock. He realized the boots had caused blisters that had ruptured on the third, fourth, and fifth toes. Once again, having T1DM and totally insensate feet caused further problems with delayed healing. Since his first foot ulcer in 2011, R continued to have problems with foot ulcers. Some ulcers were caused by shoe pressure, blisters from hot beach sand, or from a typical neuropathic foot ulcer, which first develops as a preulcerative callus and rapidly progresses to an ulcer. Despite his daily astute monitoring of his feet he noted, “Problems just seem to occur overnight.”
Quality of Life
The greatest impact of diabetes for R was on his quality of life (QOL). He noted that the frustrations of dealing with foot wounds had a profound negative impact on QOL. As an avid outdoor enthusiast, the months he spent on crutches, wearing off-loading shoes, attending numerous wound clinic visits, and being unable to take part in the activities he loved greatly impacted his mental and physical well-being. “Having to change my daily routine such as bathing, driving, and even going out to dinner is hard enough. Having to give up hiking, camping, and swimming changes my entire outlook on life.” R also noted the unintended isolation from friends had a profound impact on his feelings. “They want to include you, but know they can’t. You want to go, but know you can’t keep up. Sometimes being alone is the worst feeling.”