1. Healthcare in Diabetes = a Fight

2. Oranmore Judo Club

3. Healthcare & Martial Arts
We all have a distinct set of skills defined by a ‘profession’
We need to adopt the skills and Knowledge from other professions to try and prevent foot problems in Diabetes
If I could use Karate and Jujitsu in a Judo fight I would win every time.
There are no rules in our fight with Diabetes

4. Diabetic Foot Management
Primary care
Acute Care
podiatry

5. If Connacht can do it? There is hope for everyone!

6. Why am I here today? Breakdown some perceived silo’s
Show you some of the tips and skills from my martial art (Podiatry) that might help in your day to day fight with Diabetes
To Learn from you

7. David Watterson
Manager of Podiatry Services in CHO Area 2 and in Saolta group hospitals within that area.
Based in the Podiatry School clinic in Galway
Honorary Clinical Fellow (Podiatric medicine) NUI Galway
Fellow of the Faculty of Podiatric Medicine, Royal College of Physicians and Surgeons Glasgow
Responsibility for HSE Footwear, Orthoses and Prosthetics budget Galway PCCC

8. Merlin Park Podiatry Clinic

9. Staff and Students working together

10. Are Diabetic foot complications a problem in Ireland?

11. Yes – and this is old data!
In ,634 patients were discharged out of Irish hospitals following lower limb ulceration.
Total bed days of 23,601 used
337 of these clients had a lower limb amputation
Total cost of €11,972,859 Just on the bed days alone.

12. So in 2008 it cost a hospital on Average:
€7,327 Per admission

13. So why admit a client with a Diabetic foot wound into hospital?
1) IV antibiotics
2) Surgical opinion

14. What are the other benefits?
Stabilise the medication regime
Stabilise and regularise meals/nutrition/hydration
Stabilise and regularise personal hygiene
Bed Rest – non or very little weight bearing
Wound dressings monitored more closely

15. When there is more to the Diabetic Foot than first appears?

16. 1st Ray amputation site

17. The infection is spreading

18. Trans metatarsal Amputation

19. Active Diabetic Foot Disease
Defined as patients with an active foot ulcer (defined as a full thickness skin break) or a Charcot foot (HSE Model of Care for the Diabetic Foot 2011)

20. So what is a Charcot Foot?

21. Definition
It is a progressive, destructive condition that is characterised by acute fractures, dislocations and joint destruction in the weight-bearing neuropathic foot. (Frykberg et al 2006)

22. Clinical Symptoms Localised Unilateral swelling Erythema Warmth
+/- Pain 50%
+/- Deformity (Milne et al 2013)

23. Look out for a red, hot swollen foot usually associated with lack of sensation

24. These feet are often diagnosed as a ‘mild cellulitis’ and oral antibiotics prescribed
If a charcot foot is suspected an urgent referral to the specialist diabetes foot team is essential
The patients foot should be immobilised as soon as possible after a diagnosis is made

25. The next time you see your patient

26. What is and active foot Ulcer/Wound?

27. An active foot ulcer is full thickness break in the skin?

28. What about this one?

29. And this?

30. Last one!

31. Appropriate action It is sometimes hard to tell
But usually if you are concerned and the patient is high or medium risk you should probably refer on.

32. Sometimes things look bad

33. And they’re not!

34. And Sometimes?

35. The smallest things can have the biggest consequences

36. The Golden Rules If a diabetic patient has a foot wound
Cover it with a dry dressing
Try and establish if an external force has caused the problem (shoes rubbing)
Refer on if you are in any way concerned

37. Managing the Diabetic Foot
Prevention

38. Screening the diabetic foot is essential

39. Diabetic Foot Screening
4 easy to remember sections
Should only take 5 minutes
Should be done once a year

40. Section 1

41. Section 2

42. Section 3

43. Section 4

44. According to the National Guidelines patients are categorised as:
Low Risk Foot (Green)
Moderate Risk Foot (Amber)
High Risk Foot (Pink)
Active Foot Disease (Red)

45. Low Risk Foot (Green) – No Referral Required annual review by primary care Nursing staff.
Moderate Risk Foot (Amber) – Referral to community or hospital podiatrist for annual review
High Risk Foot (Pink) – Referral to be seen annually by the MDT in the hospital and under regular care of a podiatrist
Active Foot Disease (Red) – Urgent referral to hospital MDT with input from Vascular and Orthopaedics as required.

47. Patient Education Cut nails straight across
Apply moisturiser daily (not between the toes)
Visual check of feet (daily)
Shake shoes out before putting them on
Make sure the shoes are not too tight and are lace up or Velcro fastened
If they find a wound, cover it in a dry dressing and seek assistance (G.P/Podiatrist/PHN)

48. Prevention is the only sustainable way forward

49. If you feel you are in a fight no matter how small

50. Don’t be afraid to ask for help

51. References
Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR,Landsman AS, Lavery LA, Moore C, Schuberth JM, Wukich DK, Anderson C,Vanore JV: Diabetic foot disorders: a clinical practice guideline. J Foot Ankle Surg 2006, 45(5):S1–S66.
Milne TE, Rogers JR, Kinnear EM, Martin HV, Lazzarini PA, Quinton TR, Boyle FM (2013) Developing an evidence based clinical pathway for the assessment, diagnosis and management of acute Charcot neuro-Arthropathy: A systematic review: Journal of Foot and Ankle Research 2013,6:30
National Diabetes Programme Working Group (2011) Model of Care for the Diabetic Foot National Diabetes Programme, Clinical Strategy and Programmes Directorate. Published by the HSE

52. Subungual lesion

53. What was trench foot?

54. A WW1 condition?

55. Not a Galway 2014 Issue?

56. Classic Neuropathic wound

57. Neuro-Ischemic Wound

58. Other Pressure wounds

59. The problems Run Deep