Our hidden shame
It’s the dark secret of our healthcare system. Diabetes now causes close to 1000 amputations a year in New Zealand — a toll which has risen by more than 40 per cent in a decade.
As the obesity epidemic grows, even Kiwis in their 30s are losing their limbs. We’ve had more lower limb amputee cases from diabetes in the last four years than we did from returned soldiers after World War I.
A Herald Fair Care investigation has established that services in some
areas are buckling and amputations have spiralled.
Yet there is hope — amputations are highly preventable through early treatment and some DHBs have prevented hundreds after overhauling their services.
In the first of a three-part series,
Nicholas Jones uncovers the scale of the problem and meets a surgeon who performs up to eight amputations a week.
Diabetes causes close to 1000 amputations a year in New Zealand — a toll which has risen by more than 40 per cent in a decade. Services in some areas are stressed and amputations have spiralled. Yet amputations are highly preventable with early treatment and some DHBs have avoided hundreds after overhauling services. Nicholas Jones begins a three-part series
Cliff Barnard saw his doctor about a small cut, and went away with antibiotics. Four days later he was told his toes would be amputated. “They said, ‘You gotta lose a toe’,” the 65-year-old recalls of his hospital visit. “I was shocked, it was so fast.”
Surgeons took the big and index toes on the right foot, and carved down into the joint, where infection had pooled and turned septic.
Barnard has lost feeling in his feet, and about three years ago went on dialysis. That lowers his immunity, and to guard against injury he wears shoes fitted with special insoles, even inside at home.
How he got the fateful cut is a mystery. After seeing the doctor on the Sunday he was told to contact his kidney specialist. A nurse advised upping antibiotics, he says, but he was in hospital by Thursday. The next day, the father of three lay awake on the operating table, with a screen between him and the surgeons.
Almost a month later, Barnard is back at Middlemore for dialysis, and his wound is checked by podiatrist Lawrence Kingi.
At least half of diabetics who have an amputation will suffer another within five years, and Kingi’s work is vital to both heal the wound and make sure putting weight on the leg doesn’t cause future injuries.
Today’s problem: bone left over from surgery that’s worked up to the surface. Kingi teases it free, and the chip squelches as it hits the tray.
Barnard can’t feel a thing, and the two banter as Kingi works. “You want to take that home, Cliff?” Kingi asks of the bone. “Yeah, I’ll put it on my mantelpiece” is the deadpan response.
The former production supervisor for Carter Holt Harvey is determined to get well enough for a life-changing live donor kidney transplant that was months away, but is on hold while the wound heals and tests are done.
On instruction Barnard wriggles the remaining three toes, now isolated.
“I think it takes a while to realise they’re gone,” he says. “Sometimes it feels like they’re still there.”
The number of toes, feet and legs amputated because of diabetes approaches 1000 a year, an increase of more than 40 per cent over a decade. In the past four years, the disease’s silent rise has left over 2300 Kiwis as amputees — more than four times the number of returned soldiers living with lower limb amputations after World War I.
Ma¯ ori are at 65 per cent greater risk of above knee amputations than Pa¯keha¯, even after other factors like deprivation are adjusted for.
It’s a toll more depressing for the fact most amputations are avoidable. Diabetes can be controlled, and foot problems treated early and urgently.
Why amputations happen
Nearly a quarter of a million Kiwis have diabetes, and about 90 per cent have type 2, the sort mostly brought on by lifestyle and linked to obesity.
Diabetes happens when the pancreas stops making enough insulin, or insulin can’t be properly used, and glucose (sugar) from food cannot get from the bloodstream into cells to produce energy.
Over the long term, too much glucose in the blood ravages nerves, organs and tissue, risking heart attack, stroke, kidney failure and blindness.
Collagen also falls and skin turns brittle. Pain is silenced as nerves are damaged, first in the feet. Injuries go unnoticed, and wounds fester because of reduced immunity. Amputation is a last resort to stop infection spreading.
Foot ulcers precede about eight in 10 diabetic amputations. The other cause is when restricted blood flow starves body tissue of oxygen, causing it to blacken and die.
Research shows more than 80 per cent of diabetic amputations are pre
ventable, if problems are detected and treated early.
An annual foot check by a health worker is the best way to pick up any loss of blood flow or injury. Despite the importance, in some regions one in two diabetics don’t get that vital line of defence.
Michele Garrett, podiatrist at Waitemata¯ and Auckland DHBs, says our barefoot culture means people think of their feet as “tough”, but disease means a dab of Dettol is no longer good enough.
“They get a blister or a cut, and have had all those years where it normally gets better. They think, ‘She’s all right, mate’. And it’s not sore because they’ve lost feeling.”
Without pain, smell provides the (too late) warning.
“In my research I’ve interviewed people saying things like, ‘I thought I’d spilt milk or there was a packet of meat I hadn’t found in the car. But then I realised it was my foot’,” Garrett says. “You forget about the gift of pain — it tells us something’s wrong.”
Dialysis and foot care
Changes at Middlemore Hospital show amputations aren’t inevitable.
It used to take an average of 42 days to get patients before a podiatrist. By then, the leg, foot or toe was often beyond saving.
Kingi, one of Counties’ hospital podiatrists, was freed up to attend dialysis clinics, and any foot problems go on his rounds list.
Analysis of the “feet for life” programme, which started six years ago, found it prevented surgery in more than 80 per cent of cases where amputation was identified as a possibility.
Shadowing Kingi reveals how. Chris Davis, 62, has a wound the size of a $2 coin on his left heel, formed when callused skin pressed into the foot and damaged healthy tissue. To stop such injury, podiatrists arrange special footwear to relieve pressure. As Kingi shaves away skin he gently badgers (the textbooks would call it educating). “Where’s your offloading boot? What did they say when they gave it to you, ‘Leave it at home?’ You definitely need that boot eh.”
Patients missing appointments aren’t a problem for Kingi — if people don’t get dialysis three times a week, they die.
Things go wrong even if help is on hand, particularly without the “gift” of pain. One woman’s injury was dressed at her rest home but got infected. The dialysis team found the wound riddled with maggots. She lost flesh but avoided amputation.
‘People would rather lose a toe’
At Auckland City Hospital, vascular surgeon Venu Bhamidi performs four to eight diabetes-related amputations a week, and sometimes several a day.
Some years ago he and colleagues looked at the numbers behind their work. One in every three to four patients with foot wounds had an above-ankle amputation, despite hospital care.
The response came in mid-2014 with a new clinic, which is fortnightly and takes referrals from any GP, podiatrist or clinician. Specialists rotate between patients. A vascular surgeon checks if an operation is needed to open blocked arteries, remove dead tissue or amputate. An endocrinologist works on blood sugar levels. A nurse talks diet, exercise and medication. Special footwear might be sorted by a podiatrist or orthotist.
A recent study found fewer major amputations and deaths, and savings of about $10,000 in inpatient costs per person (down to about $21,000).
Bhamidi supports the multidisciplinary model expanding, motivation he says comes from “a very personal space”. His father, who lives in Bhamidi’s native Australia, has type 2 diabetes, and found it difficult to get the care needed for serious complications.
“If that happened to a surgeon’s father, imagine what would happen to someone who doesn’t have the connections.”
Amputation a ‘postcode lottery’
The care at Auckland and Counties helps explain the lowest amputation rates in the country, along with the other Auckland region DHB, Waitemata¯.
Ground-breaking research released last month tracked 215,000 New Zealanders with diabetes to see who had amputations over four years.
Researchers adjusted data for factors that could influence the likelihood of amputation, including sex, age, ethnicity, deprivation, rurality, other health problems and prior amputation.
Auckland DHBs had the lowest rates of major amputations (above or through the ankle), and Waikato and Hutt Valley had the highest. There were other DHBs well above the national rate.
“It shouldn’t be the case that where you live alters your risk of having an amputation,” says Dr Jason Gurney, lead researcher and a Ma¯ori epidemiologist working at the University of Otago. “There are pockets of fantastic foot care services entwined with vascular services. But they are the exception to the rule.”
Targets missed
A landmark strategy to turn the tide on the diabetes epidemic started in 2016. “Living Well with Diabetes” set nine targets, including a reduction in the rate of amputations by 20 per cent by 2019 (30 per cent for Ma¯ori and Pacific).
That and four other targets have been or are likely to be missed, briefings to the Health Minister show, and some services are at or beyond capacity, including foot care.
The ministry briefings note the number of major amputations is steady despite more people having diabetes, and says more minor (below-ankle) amputations, “could be indicative of earlier intervention”. (About a quarter of the 989 amputations in 2017 were legs, the rest mostly toes).
Herald calculations show just over four amputations per 1000 diabetics in 2017, up from 3.6 in 2015.
The ministry says it’s too early to judge progress, with noticeable results expected after five to 10 years.
It couldn’t say how many diabetics were getting foot checks — that crucial preventative measure — but revealed audits done by some DHBs “have indicated foot checks are not done consistently for individuals with diabetes across the country”, and fixes are being considered.
A quiet killer
Cliff Barnard grew up around diabetes. His mother, a Cook Islander, and her 11 siblings all suffered the disease, and it also afflicted members of his English father’s family. His own diagnosis came in his early 20s.
“In the beginning I sort of just didn’t worry about it . . . a lot of people don’t accept those sort of things. I was one of them.”
Advancing sickness punctured that delusion.
He agreed to speak out to raise awareness, and help others take better care of themselves.
“What they say is that diabetes is a silent killer. And that’s dead right.”