I've (jokingly, maybe) subtly requested that my husband pursue a specialty in vascular surgery because podiatrists rely heavily on vascular surgeons for patient care the way a married couple would rely on each other for help on dealing with a child or children. He politely and assertively said 'no thanks' and admittedly my heart broke a little. Of course, not anyone could just jump into vascular surgery, it's advanced training dealing with a lot of blood. Of course it's the body's plumbing to provide oxygen, nutrients, and life throughout the body, from heart to brain, limbs and everywhere else. The surgeries could be long, dissection is even more meticulous when dealing with all the vessels and their branches, requiring an intense amount of patience, also not always having a roadmap to follow, knowing when to save a leg or when it's appropriate to let it go.
I have a tremendous amount of respect for vascular surgeons having worked with them throughout my training from residency to fellowship and thereafter. I enjoy sitting together at conference discussing difficult cases, weighing the pros and cons of each particular treatment plan, and then following up on both successful and failed cases. We often share commonalities only understood between surgeons and at times have our differences as well as to how to proceed in limb salvage when a patient's condition is so advanced that no vascular intervention will help the patient. Without a vascular surgeon, there is often few choices I have to help a patient.
What does a vascular patient look like to a podiatrist? The most obvious is seeing black toe(s), see picture. Dry gangrene refers to no blood being present, so the toes are dry and leathery to the touch. This is progressive and the tissues are starving, wilting away like an unwatered plant. Wet gangrene, on the other hand, can be missed often times starting as a small infection between the toes by a crack or skin fissure. This provides a portal of entry for bacteria which can easily run wild creating a wet, soggy appearance with foul smell to follow. This then becomes a surgical emergency to control the spread up the limb and into the blood.
Less obvious is when there is a nonhealing wound, often seen in a diabetic patient. I order arterial dopplers on all patients diagnosed with diabetes with a foot ulcer even if I feel pulses in the foot. Doing this provides a baseline and provides a more objective view of their circulation.
In the picture above, the patient presented with diabetes, peripheral neuropathy, and a wound that is not healing. On closer inspection, there was pus expressed from the site and the bone was affected. The plan was to reduce the infection so that it does not spread and stage the procedure for a vascular workup. Unfortunately, the patient's blood flow was compromised long before he came to us and he then mentioned that in the past no other vascular surgeon would work on him due to the patient being noncompliant with medical recommendations to smoking cessation and regular follow-up care. He's now facing a situation, possible below or above knee amputation, that could have been prevented. At this time, the patient underwent by-pass surgery to improve blood flow to the affected area but too much time had elapsed and tissue continued to die. The patient eventually needed a transmetatarsal amputation to close the wound while giving him a functional foot to walk on once healed. To be honest, I don't know if the patient ever healed. He didn't come back for follow up.
There are many things that we cannot control, like inherited diseases, so we manage them the best we can with our current resources. With things that we can control, like diet, smoking, and exercise, we can certainly strive to live a fuller life. Doctors want to help people get better but people also need to want to get better by meeting us halfway. Prevention is key, having diabetes is a difficult journey but there's a team waiting to help you. You just have to make the call.