The Diabetic Foot Bible
D.J.Hough
Smashwords Edition
Copyright 2011 Dominic Hough.
Smashwords Edition, License Notes
This ebook is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people. If you would like to share this book with another person please purchase an additional copy for each recipient. If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to Smashwords.com and purchase your own copy. Thank you for respecting the hard work of this author.
Additional information and books by Dominic Hough can be found at the author’s offical website:
or through select, online book retailers.
For feedback, questions and updates from this book please visit:
http://www.ldfootcare.com/diabeticfoot.html
If you have a problem/ concern regarding footcare then please see a medical professional.
Dedicated to my wife Lucy Hough and to my Techie brother Simon Hough.
What Do You Do if You See an Ulcer?
Why Was This Book Written? (back to the top)
My wife and I are Chiropodists- qualified foot specialists. And we believe that all patients with a certain type of condition should be given all the information necessary for them to understand and cope with their condition, whether that condition is Diabeties, Arthritis, Psoriasis etc. We strive for total patient care and total patient information and there are some basic principles that must/ should be followed.
Unfortunately because the patient doesn't know what treatment they should be expecting, usually they go without.
For a Diabetic patient going without a treatment option or a review is putting that patient at risk and for many reasons. Ultimately if the patient doesn't know that they have poor circulation or they can not feel anything on their feet they will go through their life as normal- not being vigilant and not spotting potential pitfalls or concerns.
I have promoted for a long time that the patient owns their own body. But many patients do not believe this. It is not up to the clinician anymore to dictate what treatment the patient should have. Every patient should have the same treatment- which is basically the best treatment for that individual...full stop. Every patient should know what is being done to them, should know the diagnosis and should question the clinician.
At the end of the day, the clinician is working for you. They get paid to see you, so use their time well. A patient should never leave a clinic room with a question still lingering in their mind.
I hope this book empowers you to ask questions and to find out more about your treatment options as well as preventative measures.
The good thing is that you have decided to read this book, so you want to empower yourself...so keep on going!
Introduction.(back to the top)
When I write I try and put myself into your situation and so this book has gone through many drafts because I want to give you a wider view of Diabetes, a more “hands on” approach.
There will be some of you that will experience some of the problems associated with Diabetes and there will be some that won’t. But you might in the future. And that’s the issue with Diabetes…it is not certain. I don’t want you not knowing about a certain technique, a certain assessment or a certain dressing method.
Yes, you will even find out how clinicians dress wounds, what type of dressings they use and what they look for.
I like the idea that a patient is armed with the right information before they go in and see a specialist. But why should you have information? Aren’t clinicians supposed to be doing their job? You tend to find clinicians are more responsive to patients because they know that you are taking responsibility for your condition, not just leaving it up to them.
If you are willing to learn, listen and ask questions then you will be in a much better power to:
1- take care of your own health,
2- to manage your own health effectively and efficiently.
You should be in control of your body, your health and the only way that can work is if the specialized information is in the public domain and created with a patient focus.
Too many times has a patient come away from a Doctors appointment and when we asked “what were your blood sugars” the patient has looked at us and said “the Doctor said I was ok”.
Now what is ok? Ok to you and I might be different to what a Doctor classes as being ok. This patient is not in control of their condition and in doing so we have to explain what they need to know and how blood sugars are related to their condition. If they knew their condition they would have known their blood sugars, what high and low sugars were and actually what “ok” really meant. In this way a patient is therefore able to:
1- take their own treatment seriously,
2- do more at home and
3- be prepared for the future by asking the Doctor how to bring blood sugars down, why they were high or even low in the first place.
I sometimes wonder why when a patient monitors their own blood pressure or their own blood sugars with machines that they have bought over the counter without medical supervision or warrant. I always ask “what are you going to do with that information?” Most do not know, or some will do something dangerous like stop eating if they find their sugars high.
I sometimes wonder why a patient does not know what medication they are taking and what for. I get handed lists of medication some days and I quiz the patient on why they are taking a certain tablet. “I do not know” is the common response. Now I am not trying to come over all knowledgeable and righteous, but if anyone said I should eat something I would always ask why…what does it do? My Dad is the worse for this. He was prescribed some medication from the Doctor then telephoned me to ask what they did?! I asked why he didn’t ask the Doctor. He advised me that 1) the Doctor only has a limited amount of time, and 2) he didn’t want to bother them.
Or you can go the other way. One patient of ours states that they regularly read up about Diabetes and know everything there is to know. But, they do not stop smoking, they miss apointments and they fail to implement some basic things like moisturizing their feet.
Why?
Because it interferes with their life pattern. They don’t want to adjust. They cherry pick the things that can fit into their life and disregard the rest.
Now it seems like I am being harsh, but I am not. This is the way this book will go. Clinicians can only do so much and they really need you to do some helpful work at home. Clinicians can guide you, they can advise you and they can get you back on track if things go a bit awry. But ultimately it is you, the patient that has full control of your own health and of your own conditions. It is like a Band Aid. The plaster itself does little in the way of healing the wound- all it does is lets the wound stay in an “environment of healing”. It is actually your own body that heals itself.
With the right information, with the right guidance you will be able to make the right decisions, take the right action and know that Diabetes is something that can be lived with. It doesn’t have to be such a burden, it doesn’t have to be something to be feared. It just has to be respected.
Diabetes Overview. (back to the top)
There have been many talks, and many books dedicated to the condition of Diabetes. There are some very good reasons for this:
1- Diabetes is a very big subject and it usually needs more than one book to cover everything that is Diabetes.
2- Research is constantly ongoing with new theories, medicines and treatment options being developed weekly. Therefore lectures and books/ papers are the only way to convey this research.
Within this section of the book I am going to (very briefly) talk about general Diabetes. It will not be deep and it won’t cover everything that is Diabetes related, but it should give a good overview. If you desire background information to Diabetes as a condition, to further your understanding and to understand the continuing research into the condition, then you can always check out the following:
American Diabetes Association. http://www.diabetes.org/
Canadian Diabetes Association. http://www.diabetes.ca/
Diabetes UK. http://www.diabetes.org.uk/
I am not going to give you stats about how many people have Diabetes or that certain races and populations are more predisposed than others. There is no point. Honestly, how is it going to help our treatment if we know that so many millions people are diagnosed or so many millions non-diagnosed? To know that we are not alone in the fight? To know that other people are in the same boat?
One of the main ideas that you must realize is that: Everyone with Diabetes is different. No-one is truly the same. It is hard to compare because you will find someone going against the grain of thought. For instance, If someone is taking Insulin and someone is taking a “diet” plan- it means nothing. Not one is more worse than the other. Some Diabetics seem fine at high blood sugar levels and that is where their body seems comfortable, but when my wife, who had Gestational Diabetes, went a squeak over 7, she was very ill.
The main point of this section is to explain the problems upon the feet that Diabetes can induce. But first we need some background, as in, why these things occur to our feet. If we know why they are occurring we can then have a good understanding about prevention and ways to treat.
Diabetes Mellitus (DM), or sugary water, is all about the use of the hormone Insulin. Normally, Insulin is released continually from the Pancreas- this is called a basal amount. At meal times a larger amount, or bolus, is released. And medication is used to try and emulate this natural process.
What is the point of Insulin? It regulates our uptake of the sugar Glucose. One of its jobs is to tell your body's cells to open up and accept Glucose, which they use as fuel to live.
Therefore the body always produces glucose for us to live, so the body has to always produce Insulin. If we increase our activity we use up more “fuel” and the body responds by creating more Insulin to counter the increase in Glucose.
Glucose attaches to your blood and your blood stays active for 3 months until it is broken down and replaced. With this simple knowledge, Diabetes can be monitored and a more accurate prediction of blood sugars over a 3 month period can be found.
The HbA1c is basically the amount of sugary blood cells that are floating around. The units are a percentage. So a reading of between 4-7% is good and shows a “normal” level of Diabetes control. An HbA1c reading of over 7% or under 4% can show over (hyper) or under (hypo) glycaemic readings respectively over a 3 month period. It is a good system because of the range over a long period of time that can be detected. Therefore it is beneficial because it demonstrates if the patient has been “good” with their Diabetes control. However, lower than expected levels of HbA1c can be seen in people with shortened red blood cell life span, such as with sickle-cell disease or any other condition causing premature red blood cell death. On the other hand, higher than expected levels can be seen in people with a longer red blood cell life span, such as with Vit B12 or Folate deficiency.
Other methods of monitoring blood glucose levels is through normal “prick finger tests”. Usually done on the fingers because glucose concentrations are more in those areas and the area is usually painless. This test shows the clinician and the patient how their Diabetes is doing at that point in time. A lot of drug companies give away blood testing machines for free. However they usually charge for the testing strips.
Another way is the urine test. This is where the patient urinates on the strip and then you match up the changed colour with the chart on the testing tube. These are ok if you want to know a very quick way of determining if you are Diabetic or not. However some urine tests will only tell you if you are Diabetic if your readings are over 10. Which is not good, because how about if you were 8 or even 9 it will never get picked up, so you wouldn’t worry about it!?
DM is usually split up into 2 separate “forms”.
Type 1 DM or Insulin Dependant Diabetes Mellitus. This is where there is no or not enough Insulin produced.
The cells do not get their fuel and the person will die in time from various processes, one namely Ketoacidosis if they don't have Insulin. Ketoacidosis is very serious and involves the body trying to find fuel for itself and the only place it can get it from is itself. So it breaks down fats and proteins to give itself energy. In some instances Insulin users will stop using Insulin all together if they feel unwell. Insulin users need to take Insulin constantly because there has to be a continual amount of Insulin running through the body at all times.
Type 2 DM or Non Insulin Dependant Diabetes Mellitus. For some reason the Insulin that some people are producing is not working that well, or the body's cells are not recognizing the Insulin that is being produced. Or the Pancreas is not producing a sufficient amount of Insulin.
There is also secondary DM. This is where something has caused direct damage to the pancreatic cells which in turn has caused DM. The direct damage factors are: severe malnutrition, pancreatic destruction and removal, Cushings Disease, Steroid therapy and Thiazide therapy (various medications).
Diabetics (predominantly Insulin dependent Diabetics) can also become hyper and hypo glycaemic. These are 2 serious problems which the patient needs to be aware of. Also the patients family members need to be aware of hypo’s and hyper’s so that they can react quickly in a critical situation.
Hypo glycaemia represents a fall in blood glucose levels. It’s a mismatch of insulin levels to that of glucose uptake. It is all dependent on the patient of when hypo’s kick in. Some people have warning signs, other do not. Some have hypo’s at lower blood sugar levels compared to someone else, others do not.
Early warning signs involve trembling, sweating, shaking and pins and needles of the lips and tongue. Mild symptoms are double vision, slurring of words and difficulty in concentrating. Unfortunately many members of the public fail to realize a Diabetics problem and assume that they are drunk. So Diabetes bracelets are a good idea.
It is a good idea to know your warning signs. Again they are different for everybody. Get to know them and tell the people who you are around the most what they are. We knew one of our Lecturers signs- it was them slurring their speech. And every now and then they would slur their speech. So we had to sit them down and then get their sugars back up to a normal level, by which time they would realize what happened and get on-top of the problem.
Treatment is simple, quick fast acting glucose in the form of a drink- it acts quicker than a chocolate bar. Some Diabetics carry around special Glucose tablets which are effective. You should also check your blood glucose monitor after administration. Once the patient is back to normal then eating something that slowly releases glucose is the key- a sandwich or biscuits.
If you keep on having hypo's, then see your Doctor.
Hyper glycaemia. A “hyper” starts because blood sugars rise too high. This can occur for many reasons.
1- infection causes blood sugars to rise,
2- over treating a hypo
3- too little Insulin/ missing a dose of Insulin
4- stress
Symptoms can include:
1- thirst and excess urination (the body’s attempt to get rid of the sugar)
2- headaches
3- lack of energy
4- stomach pain
Check your blood glucose monitor. To treat this you may need extra insulin or drink sugar free drinks. However, to be safe, contact your Doctor. Also you may need to test for ketoacidosis.
Causes Of Diabetes. (back to the top)
Most people recognize that in the 21st Century there are more Diabetics and it is due to the food that we eat and how heavy we are getting. This is sometimes misinterpreted with Gestational Diabetes. Pregnant ladies do have a larger tummy however that is not the underlying reason for them obtaining Diabetes- it is also due to their pregnancy hormones that interfere with Insulin and they can become Diabetic through pregnancy, obviously affecting the child if the Diabetes is not controlled and monitored (having a heavy bouncing baby that is full of sugar is not good). After the birth, the Diabetes goes, but there is a much higher risk to the mother becoming Diabetic in the future.
The excess weight theory does gather evidence when it was found that in some patients who underwent a stomach reducing surgical technique and who had been on an “Insulin pump” had to be removed from the apparatus because of the disappearance of their Diabetes.
However, weight gain- the idea of a fat band around the stomach affecting Insulin and causing an increase in Diabetes is a very simplistic idea. Unfortunately it is not that straight forward as pockets of cultures who do not practice “westernized eating” also have Diabetes.