Case History: A 54 year old man with type 2 diabetes mellitus was referred in 2014 to our multi-disciplinary foot care service for the management of ulcers. One year previously he had undergone a left hallux amputation due to underlying osteomyelitis. Over the period 2015 through 2021, he required multiple admissions for management of limb threatening foot sepsis with exposed necrotic mid and hind foot bone. In 2016 he suffered a cerebrovascular infarct and in 2019 an episode of AKI.
Investigations: Arterial duplex scans in 2014 and then angiography in 2015 showed severe peripheral arterial disease. Bacteriology across this time period yielded a range of positive cultures with variable antimicrobial sensitivities. In 2018, cultures were positive for carbapenem resistant organisms.
Treatment: Clinical decision making was undertaken by a multi-disciplinary team comprised of diabetic physicians, vascular surgeons, microbiologists, specialist diabetic nurses, podiatrists as well as those involved in the patients wider social care needs. Issues addressed by the MDT included whether the patient might have an undiagnosed learning difficulty. There was disagreement amongst health professionals as to whether he had mental capacity. Bone and soft infection worsened significantly in 2019. The patient refused to consider the possibility of below knee amputation the only surgical option if revascularization and medical management failed. Successful angioplasty, six months of intravenous antibiotics and intensive nursing and podiatry care has enabled him to avoid below knee amputation and maintain independent mobility. Non-clinical staff played a critical role by getting him to appointments and coordinating his care.
Conclusions and points for discussion: The 2014 Lancet Commission on Culture and Health has emphasised how inseparable health is from cultural perceptions of well-being. A range of initiatives, for example the City Changing Diabetes Project, are intended to address the social and cultural factors which can increase type 2 diabetes vulnerability amongst certain people living in urban environments. Our case report highlights the efforts required by a team of health professionals to support a patient at risk of losing limb, mobility, independence and dignity arising from complications of the diabetic foot. Also, how multi-disciplinary team decisions taken across a period of 7 years have helped our patient live with his diabetes. The culture of clinical decision making, care giving and how to best take into account patient wishes within diabetic service delivery is worthy of its own study.