By Herbert A. Sample
California Health Report
Ehud Giladi knew he was in trouble in November 2010 when he summoned his son to help remove a sock from his foot.
Giladi, known as “Udi” to friends and family, had been badly overweight for years, and was a diabetic. His left foot had developed neuropathy – the loss of feeling in extremities common to diabetics – so much so that when a toenail partially detached, he “ripped it off” without feeling a thing. “I knew I was getting worse, but I just did not want to deal with it,” the Warner Bros. studio guard said.
But after his son helped remove the sock and took him to the emergency room, doctors told Giladi all five toes should be removed to save the infected foot. During the operation, though, doctors couldn’t stop the bleeding and he was transferred to Valley Presbyterian Hospital’s three-year-old Amputation Prevention Center.
It was there that Giladi says his foot – and his existence – was saved. “I pretty much owe them my life,” he said.
There seems to be dozens of stories like Udi’s at the Amputation Prevention Center, the only one of its type in California. The unit, housed at Valley Presbyterian’s campus in the San Fernando Valley, is run by a wry, veteran vascular surgeon and a baby-faced podiatrist who contend their team approach has saved the limbs of some 94 percent of the patients they see with wounds, infections or related ailments.
The strategy at APC seems simple: All the specialists needed to evaluate and treat a patient in danger of losing a foot or leg are in one place; there’s no need for crucial weeks of delay as patients shuttle between doctors’ offices, their conditions worsening.
“This is a unit where we all practice together,” said Dr. Lee C. Rogers, a podiatrist and co-medical director of the APC, “We’ve often heard … the shock from patients: ‘I just saw six doctors in 30 minutes. I just can’t believe that I saw that many doctors.’”
Collaboration also is vital, said vascular surgeon Dr. George Andros, APC’s medical director and something of a Zen Master at the center.
“You know, a lot of doctors don’t play well in the sandbox with other children. They just don’t do it. So you got to have people who know how to cooperate on all levels,” said Andros, who co-founded the Diabetic Foot Conference, an annual meeting of physicians from around the world known as “DF-Con.”
Jonathan Labovitz, chair of the Department of Podiatric Medicine, Surgery & Biomechanics at Western University of Health Sciences in Pomona, lauded APC’s approach.
“Doctors typically work in silos,” said Labovitz, who also is a podiatric expert with the American Diabetes Association. “We work on the patient from what works in our eyes and what we’ve seen and the experience we have and the literature we’ve read, whereas what they’re doing is exactly opposite of that.”
Indeed, APC’s doctors do seem like good buddies, prone to bantering with each other as easily as discussing the fine points of revascularizing an endangered foot.
Asked how he came to be at APC, Dr. Ronald J. Belczyk, a podiatrist, was about respond when Andros interjected: “Insanity!” Belczyk didn’t miss a beat: “You have to be a little bit insane, I guess.”
That jovial spirit certainly can’t hurt in a unit that ministers to a lot of patients who are dangerously close to having all or part of a leg, a foot or toes removed. Unfortunately, there are plenty of patients in such dire circumstances.
Nearly 26 million U.S. residents, children and adults alike, suffer from diabetes, according to 2010 statistics released early last year by the American Diabetes Association. That’s 8.3 percent of the population. Another 79 million Americans are pre-diabetic, their blood glucose having reached abnormal but not diabetic levels.
The disease impacts ethnic minorities in high proportions: While 7.1 percent of non-Hispanic whites had been diagnosed with diabetes, according to the 2010 statistics, 12.6 percent of non-Hispanic blacks, 11.8 percent of Hispanics and 8.4 percent of Asian Americans suffered from it too. And among Hispanics, 13.2 percent of Mexican Americans were afflicted – a huge number in California, where the predominant sub-group are Mexican Americans.
Diabetes can lead to heart disease and strokes, blindness, kidney disease, neuropathy and amputations. According to the diabetes association statistics, more than 60 percent of non-traumatic amputations of lower limbs occurred in diabetes patients.
That’s the direction Robert Winkler was headed. A part-time jewelry salesman from Sherman Oaks, Winkler had developed neuropathy and a condition known as Charcot foot, the degeneration of bones, joints and soft tissues that often afflicts diabetics. After metal plates were surgically implanted in Winkler’s left foot, and wearing special shoes for a few years, an ulcer the size of a silver dollar developed on his foot. That led his then-doctor to recommend an amputation below the knee.
Winkler refused, and was referred in the spring of 2011 to the Amputation Prevention Center. Once there, Rogers set about healing the ulcers in part by using small skin grafts derived from the foreskins of baby circumcisions, Winkler said. Andros increased the foot’s blood supply by performing an angioplasty on a blood vessel. Though he may have to wear a special boot for the remainder of his life, Winkler still has his leg and foot.
“In my prayers every night, I do bless those doctors,” said Winkler, now 66. “If I were a millionaire, I’d give them a million bucks.”
Giladi is just as grateful. When he first arrived at APC, he said, Andros told him his condition was so advanced that in another month, without treatment, he could be dead. But before he’d operate, Andros demanded a promise from his 54-year-old patient that he’d lose weight, Giladi recalled.
The pledge was made, and in late 2010, Andros revascularized Giladi’s left foot, leaving 100 stitches along his leg, Giladi recalled. Then Belczyk and Rogers covered portions of his leg with the $1,500-a-piece skin grafts. Giladi said he’s had three or four operations and spent months in rehabilitation, but is now back at work, thinner and with both legs.
“The nice thing about Dr. Andros that I like is he’s old school,” Giladi said. “He just made me realize that if I don’t do this, I’m not going to come out alive.”
Patricia Magallon was a mess when she arrived at APC. The 38-year-old Carson resident previously had shattered her ankle, but it was misdiagnosed, she said. She later suffered through months of infections and metal contraptions that screwed into her leg. A diabetic for 21 years, Magallon also had renal problems that required regular dialysis.
Doctors eventually told her a persistent infection prevented them from effectively treating the broken ankle, and that amputation was the only alternative, Magallon recalled. With only days to go before the operation, her mom saw an APC ad in a Spanish-language newspaper. After some bureaucratic maneuvering, Magallon was quickly admitted and avoided an amputation.
“Before, I had already accepted amputation because I didn’t know any better,” she said from her Valley Pres hospital room in late May. “I was ready for it. But now I can’t even put that thought in my head.” Belczyk, though, noted that Magallon was not out of the woods yet, particularly if her ankle bones failed to improve.
Rogers said APC is so focused on saving limbs because 68 percent of leg amputees die within five years, in part because of the sedentary lifestyle patients often are left with.
APC personnel have incorporated high-tech devices in their regimen. A “silhouette” camera, modeled on equipment used to film “The Lord of the Rings,” can provide 3D views of ulcers. Another tool, originally developed for the military, senses iron in blood and determines the degree of circulation in a patient’s feet and legs.
There are a few other facilities in the U.S. that more or less follow the same model as APC, such as Georgetown University Medical Center’s Center for Wound Healing, Andros said. Labovitz said he’s hoping to open a similar unit at Western University later this year.
The dearth of such facilities doesn’t surprise Andros. “This is hard work,” he said. “Nobody wants to take care of these sick old folks with stinky diabetic feet. So it’s not sexy. It ain’t got sizzle. But it’s important.”
Besides, Belczyk noted, the mortality rate associated with diabetics in dire conditions is unappealing to many doctors. “Many people shy away from this (discipline) because it’s very difficult,” he said.
But the doctors insist their strategy of saving rather than excising limbs through professional collaboration, quick access to specialists and high-tech tools is successful, cost-effective and in the end, best for the patient.
“We have a policy here if we can do it,” Andros said. “Even if you didn’t walk in, you’re going to walk out.”
Herbert A. Sample is a freelance writer based in Los Angeles, CA. He can be reached at firstname.lastname@example.org