Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor
Dept. of Podiatric Medicine
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences
St. Pomona, CA

Treating the Diabetic Foot –
When We Lose Technology

Lately, my luck seems to have taken a downturn – at least as it relates to technology. Just about a month ago, the engine in my car died and needed to be replaced. Two weeks ago, my computer motherboard died (I lamented the loss of this device in a recent Practice Perfect). With this week comes a new technology loss story…

One week ago my 8-year-old son went to Phoenix to spend a week with his grandparents (my parents). We had previously agreed that I would drive out this past weekend to pick him up (about a 5 hour drive from the LA area to Phoenix). It’s not a bad drive, except for the 105 degree heat of the Sonoran desert. It's a good thing I have air conditioning. Due to my son missing his parents (it was his first actual trip away from us) I came out to pick him up a little early, taking Friday off from the office instead of leaving after work.

I was driving along, just outside Phoenix, when my check engine light turned on. I turned off everything that was running — radio, air-conditioning, cruise-control — but there was no change.

I listened carefully for any unusual sounds, clicks, grinds, squeals, etc. Nothing unusual.

I accelerated the car, awaiting some change to its performance. Nothing.

Before my trip, I had checked all of the fluids, tires, etc. I hadn’t noticed any new leaks, either. And the car continued to run without any appreciable change. I decided, considering the outside temperature, to risk driving the car to my destination. So, with fingers crossed, and a heavy uneasiness, I continued to make my way into Phoenix.

As I was driving – and mostly because I am a nut job dedicated to my career – I was reminded about the loss technology in podiatric practice. I recently saw a patient in whom I had to rely on “old fashioned” methods.

Low Tech Treatment Options

My patient was a very nice 45 year-old diabetic male with a history of neuropathy and pedal complications, including a Lisfranc Charcot neuroarthropathy and prior reconstruction that ended in nonunion. I first met him in consultation to reconstruct the nonunion, and we successfully took care of that. I had been seeing him in follow-up when, 6 months later, he ulcerated his medial malleolus and ended up with a large abscess, requiring incision and drainage (figures 1 and 2).

Figure 1. Initial presentation of left medial ankle abscess.

Figure 2. Intraoperative view of wound after initial incision and drainage.

The procedure went fine and the patient resolved his prior leukocytosis from 18,000 to about 10,000, all clinical signs improved, and the patient was ready for discharge – except for one problem: the use of technology. A couple of days after his procedure, I applied a Negative Pressure Wound Therapy (NPWT) device. Due to the depth of the wound, I wanted to the patient to continue this therapy as an outpatient. Unfortunately, after multiple attempts, we were unable to convince the insurance company to approve coverage of this technology. The details are unimportant, but suffice it to say he could not leave the hospital with this therapy. In fact, they would not cover any treatment. I decided to go old school: wet-to-moist dressing changes.

Low Tech: Wet-to-moist dressing changes

I have to say that in this day and age when NPWT is not only the gold standard but the single most appropriate treatment in patients with this type of wound, it’s a travesty that we could not use it.

The patient happily left the hospital with multiple follow-up visits in my office. At one week postop, all of the acute symptoms had resolved, and the patient was reasonably comfortable (figure 3). I should also mention that it’s nice to have good partners in practice, because while some of the patient’s postop care was occurring, I was on vacation. Without a strong level of trust in my partners, I would have been forced to stay home and postpone my vacation – not a healthy prospect (my wife would most likely have murdered me).

Low and behold, at about 3 weeks postop, the patient had almost completely granulated his wound (figure 4) with nothing more than surgical debridement and wet-to-moist dressing changes. It’s been a long while since I used this type of dressing for chronic wounds. With the number of options now available, this method is soon to go the way of the dodo. But, as in all things, there’s an appropriate time and place for anything. Being forced to use this older dressing reminded me not to forget the past and the foundations of medical care – even if they seem out of date at the time. When our advanced technology fails, let’s not forget our more “primitive” yet effective options.

Figure 3. Wound right medial ankle 1 week postoperative.

Figure 4. Right medial ankle wound 3 weeks post incision and drainage with use of wet-to-moist dressing changes.

Back to Me and My Car Crossing the Sonoran Desert

Now, with my car situation, technology was failing big time. Here I was in the middle of the Arizona desert, engine light on, awaiting any second the signs and symptoms of my car dying.

“Why didn’t I bring extra water?” I chastised myself. “Get ready to call a tow truck,” I kept thinking.

It was a small miracle that I actually made it to Phoenix. I called two dealerships, and the second one was able to get me in immediately. At this time, it’s about noon, and I’m hoping to turn around and return home within 24 hours. You see, I have a wife at home desperately waiting to see her little boy again, and if I didn’t get him home soon, there would be hell to pay.

They hooked my car to the computer and diagnosed the problem: my transmission was failing and needed to be completely replaced. Disaster!

Boy, was I lucky.

Lucky, you ask? What’s lucky about this?

It’s lucky because not only were the repairs covered by my warranty, but they also had my transmission in stock. But not only this. With hard work, and the mechanic coming back on his day off, they completed the repairs the following day, and I was able to bring my son home only a few hours late. Disaster averted! My life was saved!

When technology fails sometimes reliance on older methods, hard work, and a little luck help us make it through our trials and tribulations.

I could use a little more luck, though, because my story ends on a sad note. When my son and I returned, my wife notified me that while I was gone, our microwave died and would need to be replaced. Technology! AAARGH!!!!

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]