– For most people, a blister on the heel is a mere annoyance, perhaps a stinging reminder to wear socks with that particular pair of shoes. For a patient with diabetes, peripheral neuropathy or peripheral artery disease, that small blister may very well be the beginning of a life-altering decline in health, mobility and functionality.
About 20 million Americans suffer from peripheral neuropathy (PN), a type of nerve damage that limits sensation, particularly in the feet and lower legs. One in twenty people over the age of 50 develop peripheral artery disease (PAD), which narrows the arteries in the legs and feet, reducing blood flow. For diabetic patients, the odds are much worse. 70% of people with diabetes will develop PN and are also at a much higher risk of developing PAD.
When a person with neuropathy suffers an injury – a blister, bruise, cut, crack or puncture – to the feet or lower legs, that nerve damage means they have trouble feeling the pain of the wound. When a patient has PAD, the compromised blood flow inhibits the healing process. Having both neuropathy and PAD is a double whammy; it means a patient doesn’t feel the pain of the injury and healing is significantly slowed or non-existent.
“It’s a vicious circle,” said Dr. Eugene Tanquilut of Vascular Specialists. “Because the blood flow is damaged, the injury can’t heal. Because the injury or infection isn’t felt, the patient keeps re-injuring the same spot, worsening the wound. This cycle causes deep, infected, chronic wounds, sores and ulcers.” Unfortunately, notes Tanquilut, for about 24% of ulcer patients, the end result is amputation.
Tanquilut is determined to halt that cycle for as many Chicago Southland patients as possible. A fellowship-trained, board certified vascular and endovascular surgeon, Tanquilut created LEA-UP, Lower Extremity Amputation and Ulcer Prevention. LEA-UP is an open group of physicians, specialists, nurse practitioners, and other medical professionals who meet quarterly over dinner to listen to presenters, share case studies and discuss methods and results. The group meetings also offers opportunities to introduce medical products and services to these professionals.
LEA-UP began in 2006 when Dr. Tanquilut joined the Olympia Fields’ St. James Hospital staff. Because of his passion for limb salvage, Dr. Tanquilut’s educational outreach efforts decreased the number of major amputations, above or below the knee, by 54% within just 5 years. “It’s vitally important to work collaboratively to prevent amputations. When physicians of all kinds and specialities can share information, we can offer better and more effective care to our patients,” said Tanquilut.
Susan Marcotte, a family practice physician in Orland Park, agrees. She, along with more than two dozen other medical professionals, attended the August meeting at Zachary’s Grill in Palos Heights. “I’m seeing more incidences of PAD as patients age. I want to stay ahead and learn as best I can, to continue to provide the best care possible to my patients. Gene (Tanquilut) is known for his attention to follow-up and the ability to touch all the bases. His limb salvation numbers are very impressive. When he invited me to join the group, I wanted to hear what they have to say. I want the best, up-to-date recommendations from the best people so I am able to provide the best care to my patients.”
“LEA-UP is a very trustworthy group. There are a number of specialists here who understand how to deal with this multifactorial problem. A family care physician like myself needs to understand how PAD, hypertension, diabetes and other factors can affect ulcers. I can help the patient manage these conditions, but I also need to know when to bring in a specialist,” said Marcotte.
Dale Brink, a podiatrist with Performance Foot and Ankle Center, and his associate Vivek Patel presented at the September meeting. Brink took the group through two patient case studies detailing their medical history, prior treatments, and new treatments while explaining the importance and challenges of keeping weight off the heel when treating heel ulcers. Patel demonstrated the Salvation External Fixation System, a metal frame specifically designed to enable the patient to remain relatively mobile while keeping the foot completely safe from bearing any weight.
A lively question and answer session involved the entire group, with medical professionals discussing synthetic skin grafts, Charcot foot deformities, walkers and immobilizers, patient compliancy and surgical options.
Brink said, “This group is important because we’re forming a real community, a way of sharing that will make all of us better able to care for our patients.”
“One of our practices’ main concerns is wound care, which we see in patients with diabetes, with neuropathy, patients who’ve neglected caring for a callus, or who’ve neglected their overall care, and even those with just a bad walking gait,” Brink continued. “This group combines the expertise of many specialities that work with a wounded foot. We leave no stone unturned when approaching patients, working together to improve care. Taking a more global approach to care, considering everything from orthopedic appliances all the way to vascular care, helps us intervene earlier and save limbs. Our absolute last resort should be amputation.”
Podiatrist Dr. Brian Wittmayer, also with Performance Foot and Ankle Center, has known Tanquilut for over a decade and is enthusiastic about participating in LEA-UP. “We trust each other’s judgement here. Our relationships mean we can expedite care for our patients. The multi-speciality approach that we’re taking means that everyone is on board – vascular surgeons, internal medicine, podiatrists, endocrinologists, infectious disease specialists, nephrology, orthotics, plastic surgeons – a limb salvage team should work together.”
The physicians and medical professionals who have joined LEA-UP all subscribe to this philosophy – that they are not competing, but focusing on excellent patient care. They desire to be proactive, to understand and better treat underlying health issues. The group freely asks questions of each other and exchanges information during LEA-UP meetings. Discussions can ranges from the structure and content of appointments to best practices that can prevent wounds from ever occurring.
“If a patient has diabetes or is experiencing PAD or PN, I recommend daily self inspections of the feet and lower legs, using a hand mirror to ensure every area is scanned,” said Tanquilut. “Daily washing in lukewarm water and thorough, gentle drying is important, and you want to dry carefully between and under toes. Cracking allows bacteria to enter the feet, so use moisturizer each day.”
If a patient notices calluses, blisters, warts or other lesions, Tanquilut recommends seeing a family physician or podiatrist as soon as possible. “Treating these at home can worsen the wound and cause an infection,” he said. Tanquilut notes recommended foot care to avoid wounds: “Always wear shoes or slippers, even at home, to prevent any injuries. Wear comfortable, natural fibered socks and avoid irritating seams or tight elastic. Wear comfortable, properly fitted shoes, and wear those supporting orthotics, lifts or inserts prescribed by your podiatrist. Don’t wear high heels or shoes with narrow toe boxes.” Most important, he explains, is scheduling yearly foot check appointments, even if there is no sign of injury.
Tanquilut notes that nearly 100,000 PN and PAD patients with ulcers lose an extremity each year and about 55% of those will lose a second limb within three years. “My goal is to make amputation very rare in this region. Limb loss and the subsequent decreased physical mobility and activity can be a catalyst for additional, increasingly serious health problems. By forming LEA-UP and including medical professionals from all around the Chicago Southland, I hope to help disseminate evidence-based limb salvage recommendations, best practices and new procedures and therapies throughout the southwest and south suburbs. LEA-UP welcomes medical professionals of all types and specialities, anyone who understands the value of sharing information and wants to provide the best care for patients.”
The LEA-UP group meets quarterly. The presentations and discussions are open to any health care professional. Interested professionals should email jcardenas@vascspecialists.org or call 815-824-4406 and ask for extension 130.
“We aren’t about competition,” stressed Wittmayer. “We are all part of LEA-UP to take care of patients – or to be able to get them the care they need if we can’t provide it. That is what everyone in this room is trying to accomplish. This is a collaborative effort. We are working together to save limbs."
