Originally published October 21, 2014
By Natalie Wilcox
During my surgical subspecialty rotation, I spent one week on the Limb Salvage service. As a branch of plastic surgery, this area of work requires extensive training and academic dedication. Yet a portion of the practice involves a task that, from a distance, appears primitive: amputation of unsalvageable limbs. Although most of my time on this service involved smaller procedures such as debriding old wounds down to viable tissue, the most unforgettable moments of that experience were spent watching surgeons meticulously remove patients’ legs and close up the wounds.
While many of my colleagues reveled in the technique and skillfulness of the procedure, I could not help but question, how did the patient get to this point?
For the vast majority of people receiving amputations in the US, the road is long and gradual. The number one indication for amputation in America is complications from type 2 diabetes. Most of these patients are far from requiring a surgeon to remove one of their body parts at the time of diagnosis. Instead, early stages of the disease are managed by diet, exercise, and many of the most commonly prescribed drugs in the country.
The picture becomes more concerning when diabetes is left uncontrolled. Nerves become unable to conduct as effectively as they should, kidneys are damaged, and blood has a more difficult time traveling through vessels to reach the extremities. Ultimately, a limb becomes so damaged and nutrient-deprived that its presence is harmful to the remainder of the body, and it must be permanently removed.
What strikes me most is that this horribly traumatic experience is preventable. Monitoring of blood sugar and adherence to medications significantly decreases the risk of having a diabetic foot wound let alone needing an amputation. Standing in the operating room felt like watching the last five minutes of a football game where the score was already completely skewed. At this stage we could only hope to win a few more points; there was no chance the patient could be healthy enough to avoid the amputation.
Prevention of course implies primary care, but at my school and many others, more students go into a surgical subspecialty than family medicine. There are understandable reasons for this, of course. The debt coming out of medical school is extreme. At Georgetown, our class’s average debt per person is around $200,000, not considering bills from college. When starting a career with this level of financial insecurity, the higher-paying specialties look extremely appealing.
Nonetheless, our communities are sorely lacking in primary care physicians. Whether or not graduates are selecting this career, these professionals are undoubtedly needed, and most medical students are aware of this fact. Moreover, I would argue that any physician can help to prevent such extreme outcomes as amputations, that it is not only the task of the primary care doctor. Education of patients may be time consuming and challenging, but some of the best surgeons I have worked with have been those who took a few minutes to explain basic wellness and prevention concepts to their patients. In addition, doctors, or any individual in the community, can combat these issues through funding appropriate charities, volunteer work, or contacting political representatives that vote on such issues.
The issue of preventable deaths and morbidity in this country is enormous, and we all have the capacity to help. We can encourage young doctors to explore primary care specialties by promoting their importance and incentivizing this career path, and we can support preventive initiatives in our communities. In doing so we will set up a strong defense and organize effective plays in the first half, so that in the last five minutes, we don’t always need to rely on the surgeon to throw that Hail Mary.