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Costing an arm and a leg

May 21st, 2014



I had a female patient in her 70’s with diabetes. She was on the plump side, weighing around 70 kilograms. She had bypass surgery for narrowed heart’s arteries when she was in her 60’s.

Last year, she came to see me because the felt tired and tight in the chest. That was 4-5 years after her bypass surgery. She was not very careful with food and she did not exercise.  She thought that coronary artery disease or narrowing of the heart’s arteries is probably like appendicitis which she you can only have it once in your life and the bypass surgery would fix it once and for all. The person who took care of her forgot to remind her how important it was to lead a healthy lifestyle after the surgery.

After examination, it was found that some part of her heart muscles had died, which could have occurred during or after the surgery. However, the condition aggravated lately because the bypassed arteries were blocked, as well as some other arteries.

Her condition would not allow another surgery, so I chose angioplasty to widen her artery instead. The treatment was done together with the ECP (External Counter Pulsation) on her legs to stimulate capillaries to send more blood to her heart. She recovered quickly and could walk around without feeling too tired or tightness in her chest.

I reminded her that she should watch her diet and start exercising, but I could not follow up very often because she lived out of town.  The exercise will hopefully improve her blood sugar and blood pressure control.

A year later, she returned to me with chronic wound on her toes and on her left shin that had been there for a few months already. The toes wounds started as a small scrape, while one on the shin was a result of an exhaust pipe of a motorcycle.

They became infected and painful as time went by, so she needed to see a doctor in her home town. Her heart, however, seemed to be fine, but her diabetes worsened because she neglected to monitor her food intake. She had gained 5 kilograms since we last met.

The physical examination showed her pulses was weak on both legs, especially on her left leg. Her left toes were darker than her right toes. The wound on the left shin was about a centimeter long and it was inflamed.

This is common among diabetes patients whose leg arteries are narrowed. The tip of her feet started to lose sensation as nerves in her legs were damaged also from diabetes. As a result, when there was a small wound, she could not feel it and did not take proper care of it. Before she knew it, it had expanded in size and become greatly inflamed and infected.

Diabetes patients, other than increased risks of coronary artery disease, are also prone to having problems with arteries in other areas of the body, and many of them end up losing their leg or foot because of these chronic wounds.

It is very important for diabetes patients to look after their feet and always check if there is any wound or even a tiny scratch. This is because there is decreased sensitivity and sensation of the feet and legs, you might not be able to rely on your sensation alone. If there is a wound, keep it as clean as possible with antibacterial and keep the feet dry. If the wound does not heal in a couple of days, see a doctor immediately.

Soft, close-toe shoes are diabetes patients’ best friend, as they can prevent minor accidents. Stay away from damp surfaces, especially the bathroom, which should be kept clean and dry at all times for diabetes patients’ own benefit.

The eyes are also important. Diabetes patients should have their eyes examined at least every year because diabetes can gravely damage the eyes.

This lady was treated immediately with intravenous antibiotic medication since her wounds did not get enough blood supply and they were severely infected. I examined her leg arteries and found that they were extremely narrowed – the left one was blocked at a great length.

I told her that other than giving her medication, we would also need to clean her wounds daily. By cleaning, it means scraping the dead layers off her wounds, and it would be very painful. The best I could do was giving her painkillers before cleaning, but still, the pain was barely tolerable. I told her to convince herself that they were not her legs and therefore she should not feel the pain. Well, she didn’t exactly take that.

She was also told that she needed balloon angioplasty to treat her narrowed arteries, or perhaps another bypass surgery for her leg arteries. If these two options did not work, and blood could not flow to her legs, she might have to lose her leg, or even legs.

Upon hearing that, instead of feeling frightened or sad, she smiled and said, “Oh, that would not be so bad, doctor. Maybe that would reduce the financial burden for me.”

I did not really get what she was saying, so she clarified, “Well, I was thinking if the hospital had my leg as collateral, my bills would probably come down?”

Luckily, she did not need to lose her legs, not even a bypass surgery. She still had to pay for the balloon angioplasty, and with money, not with her leg!

Prof Nithi Mahanonda is consultant cardiologist and interventionist, Perfect Heart Institute.

Reference :


High Blood Pressure VS Heart Disease
Weight worries
Putting your heart to test

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