When Patients Say "Just Cut it Off"

As the year is coming to an end, our practice finds an increase in surgery demand with folks wanting to maximize their insurance benefits. That also mean getting peculiar requests such as amputations. 

Why would anyone make such a request? Without having to go into too much science, you already know that your feet is needed for day to day activity and it has to support your entire body all the time. I was a weird kid and wanted to experience what it was like to have only one functional leg. So I'd hop around on one leg for a few hours at a time and it didn't take long before I was exhausted. Granted I didn't have crutches or a wheelchair, only my imagination. And I thought, man this would totally suck if it really happened.

But you know it does happen. Children born with a missing limb or needing an amputation are incredibly resilient. They adapt very well, putting most of us adults to shame. Adults who have non-traumatic amputations have a harder time adapting. Walking with one leg increases our energy expenditure (makes our heart work harder) because we're doubling the remaining leg's workload to support our entire body. 

There are legitimate reasons to get an amputation. Trauma, degloving injury, pain out of proportion that has exhausted conservative measures (CRPS, PVD), infection, etc. Often time there is no question about the necessity of an amputation. 

I had a patient who got a small infection in their foot from stepping on a piece of glass and it went ignored for some time. She is diabetic, her daily fasting blood glucose is frequently over 250, and needless to say she has neuropathy, that is no feeling to her feet from the damage of high sugar levels. After having the infection drained, she has an open wound that will take a long time to heal due to a compromised immune system, also a complication of diabetes. She then told me, "just cut off what you need to so I can move on."

 A heel ulcer from neuropathy

A heel ulcer from neuropathy

In the patient's mind - cut off the problem, I need to go back to work. 

In my mind - whatever I cut it'll take longer to heal and I will be seeing her for a very long time.

I think at times what I want and what the patient wants are not always parallel. I want the patient to take her poorly controlled diabetes seriously. She is at a very high risk of an amputation among other things like blindness, kidney failure, and heart problems. What she wants is to go back to work right away. The reality is, whichever road we take, amputation or continuing wound care, it will be a long one. Her body is not equipped to heal as fast as a non-diabetic so "just cutting it off" is not the solution to her problem. 

Things I tell patient to think about when they undergo an elective (non-urgent) below knee amputation.

- Prothesis? Can you afford it? Will your insurance pay for it? If not, can you manage living in a wheelchair for the rest of your life?

- Problems to the other leg - new sores will develop and within 5 years, you will have wound problems and possibly another amputation and possibly you may not live that long

- Stump pain - the stump may still break down and you may still need more surgeries. That's a common complication for diabetics.

There is no easy fix for a diabetic wound but with close monitoring from multiple specialists including you primary medical doctor, nutritionist, endocrinologist, vascular, cardiovascular doctor, and your podiatrist, this can be managed. You don't have to "just cut it off."