Miami Herald - Podiatrist Dr. Howard Umansky of Miami demonstrates how diabetic foot wounds can be monitored by telemedicine on smartphones, tablets and computers.
Miami Herald - In January, Jose Mella, 55, of Miami noticed a blister on the bottom of his right foot.
Diagnosed with Type 2 diabetes in the mid ’90s, Mella knew that simple foot wounds could develop into something serious. But he bandaged the blister and hoped home care would heal it.
Six surgeries, several months in a wheelchair and two amputated toes later, Mella says he is grateful to be alive. Diabetes is the leading cause of non-traumatic lower limb amputation in the United States, and foot ulcers — open sores or wounds — precede 85 percent of diabetes-related amputations, according to the American Podiatric Medical Association. About 15 percent of diabetes patients develop a diabetic foot ulcer. Of those, 6percent are hospitalized due to infection or other complications.
“I didn’t go in fast enough,” Mella said. “I tried to cure it at home, and it got infected.”
Mella saw a doctor a couple of times to have the wound cleaned. When he started to feel ill, he was sent to South Miami Hospital’s emergency room, where he was diagnosed with a bacterial infection. Over several months, he endured six surgeries to clean out the infection, amputate two toes, and cut out infected bone.
“They said I was fortunate I survived,” Mella said.
Early intervention is key to saving diabetics from amputation, said Dr. Howard Umansky, a Miami-based podiatrist. Umansky is founder of Mobile Health Inc., which provides home visits to podiatry patients who have trouble getting to a doctor, and the Diabetes Rural Outreach Project, or DROP, a telemedicine program to monitor diabetes patients in rural areas. About 60 to 70 percent of diabetics will develop neuropathy, which is a loss of sensation, Umansky said.
“When that happens, it is very easy for them to develop a wound on their foot. They step on something, or they cut themselves, and they won’t know it, because they’ve lost feeling,” he said. “Once they develop a wound, the infection can turn into an ulceration, which is an open wound. Many times they still won’t know it, and that ulceration will proceed to gangrene, then you’re looking at amputation. If we can catch any of those things — at the earliest stage possible — we can prevent it from happening.” With DROP, patients use smartphones to take and email pictures of foot wounds to medical personnel to be monitored daily, if needed, Umansky said. Smartphone apps also can be used to measure the depth and skin temperature around a wound. “The earlier we can detect it, the earlier we can treat it. If we treat it, we can prevent gangrene, and we can prevent amputation,” Umansky said.
Mella said his medical care, which included cleaning out the wound, intravenous antibiotics and hyperbaric treatments to deliver pressurized oxygen to the wound site, was critical to his survival.
“A bacterial infection, commonly known as a ‘flesh-eating bacteria,’ had kicked in,” Mella said. “The hyperbaric oxygen helped a lot, because it’s a known combatant of this type of bacteria. Oxygen kills it.”
Dr. Rodney Benjamin, medical director of hyperbaric medicine at South Miami Hospital, where Mella was treated, said hyperbaric treatments are “reserved for the worst cases, those that are non-healing for a long period of time — typically six weeks — and for deep ulcers, Stage 3 or 4 ulcers that have gone right through the soft tissue and are approaching bone.” Hyperbaric treatments work by forcing oxygen into the tissue and creating an environment where new blood vessels can form, promoting circulation.
“It is used as a treatment in addition to traditional wound care, plus treating infection, improving nutrition, and off-loading — taking the patient off his or her feet to take pressure off of the surfaces,” Benjamin said. “All of the factors that can be reversed, are reversed.”
Mella was started on hyperbaric treatments a few days after he entered the South Miami Hospital emergency room. He continued for 30 days, and noticed that the tissue on his feet looked “really clean, meaty red — healthier,” he said.
Benjamin said hyperbaric treatment “is a complex way to do something very simple, which is to deliver oxygen to cells. Oxygen is a fuel, and the cells don’t function very well without their fuel.”
Hyperbaric treatment is safe, with few side effects, Benjamin said. “The biggest problem people have is clearing their ears, the same as when you fly, because of the pressure changes.” He said it is an underused therapy, likely because patients don’t know it exists.
Hyperbaric is covered by Medicare and most insurance plans, but not by Medicaid, Benjamin said. A typical treatment plan would be daily, Monday through Friday, for 90 minutes. Most patients need 30 treatments, he said. It is difficult to quantify, but “there is a significant improvement in healing, and improvement in limb salvage,” Benjamin said. “What we are really interested in is ‘Can we provide coverage of the ulcer so the wound is protected?’ and ‘Can we save the limb?’”
The treatment is not necessary in every case, he said. Most patients get outpatient wound care and are fine. “This is for the severe foot wounds, the ones that get bad and don’t heal and expose bone and need operations to drain pus, stuff like that,” Benjamin said. “This is not for the average, ‘I stood on a push pin and got a hole and what should I do?’ It’s for the serious foot wound.”
Regardless of the size or severity of a foot wound, diabetes patients who spot one need to get prompt medical attention, Umansky said. And they need to check their feet every day, including between the toes and the bottom of each foot. “Early detection is so important,” he said. “It’s really the key.”
Mella said he’s lucky the infection stopped where it did. Though it cost him his livelihood — he had to leave his manufacturing job because he couldn’t walk — he recently started a job at a call center. And he is grateful his situation isn’t worse. “I just lost a couple of toes, versus losing a limb, or losing my life,” Mella said. “I thank God and my doctors for a much better outcome.”