Page 20 - SAM September 2019

PUBLIC HEALTH

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Intervention
Designing the appropriate clinical inter-
vention strategy for amputation prevention
is truly a patient-by-patient endeavor. The
breadth of the available toolbox is deter-
mined by the combined skill sets of the team
taking care of each patient. Primary infection
control is commonly obtained through sur-
gical intervention by incision and drainage,
debridement, or digital amputation. Diabetic
foot infections may harbor treatment-resis-
tant bacteria, requiring the infectious disease foot specialists, for example, can be sched- see diabetic amputation rates fall, along with
specialist to initiate appropriate infection uled to see patients inside a hyperbaric oxy- improved health outcomes at every turn.
control therapy and guide long-term, culture- gen facility in conjunction with the wound
specific antibiotic therapy. In many cases, ar- specialist. An alternative could be that the pa- Together, We Can Make
terial insufficiency is an underlying factor tient’s transportation for the day be coordi- a Difference
which could require revascularization rang- nated to visit multiple specialists at their The collective challenges we face in San
ing from distal arterial bypass to pedal artery independent facilities on a single day. Antonio which lead to diabetic amputations
angioplasty. Optimal wound healing may also may be unique to our city, but a wide range
require the wound specialist to administer The Dream: Upstream Prevention of possible solutions can be found by ap-
hyperbaric oxygen therapy, requiring 5-day- All of us healthcare professionals under- plying a little creativity to adapt existing
per-week treatment for up to two months. A stand that diabetic amputation prevention models to our community. Collaborative
significant proportion of patients will have cannot begin at the presentation of a diabetic amputation prevention can be the future of
comorbidities involving any mix of heart dis- foot ulcer. Amputation prevention begins in San Antonio by leveraging the well-estab-
ease, kidney disease, hyperlipidemia, and hy- childhood, with the establishment of healthy lished Toe-and-Flow model, and trading a
pertension, adding additional layers of nutritional and exercise habits. Amputation bricks-and-mortar medical tower for a tech-
specialists that need to be consulted and in- prevention continues at every step through nology-enabled, passionate pool of com-
formed along with a major juggling act by life, regardless of whether one is rich or poor, munity-oriented resources who are willing
primary care physicians. white or Hispanic, more educated or less ed- to tackle Social Determinants of Health
The interventional mix described above ucated. We cannot ignore, however, that risk with our patients. Achieving this vision
would be daunting to most people facing factors for diabetic amputations have a ten- would undoubtedly create a new model that
such issues, but even more so to those with dency to creep into our lives with varying de- may benefit cities throughout the United
limited resources of finances, time, trans- grees of disproportionality. This opens a States, but it has to start somewhere. Let’s
portation, and health education. How can a complicated Pandora’s box. What are the Toe-and-Flow, San Antonio!
single, stay-at-home grandmother with an roles of government, educational systems,
Resources
8th grade education raising two grandchil- parenting, community resources, housing,
1. Centers for Disease Control, 500 Cities: Local
dren on a fixed income without a vehicle be transportation infrastructure, and safe envi-
Data for Better Health, 2018; https://chronic-
expected to make all of the appointments ronments? All of these and more undoubt-
data.cdc.gov/500-Cities.
requisite to amputation prevention, let alone edly have an impact on health outcomes, as 2. Economic Innovation Group, Distressed Com-
understand each step of the way? This is described by countless studies of Social De- munities Index Report, 2016; https://eig.org/
where an emphasis on Social Determinants terminants of Health. As a community of wp-content/uploads/2016/02/2016-Distressed-
of Health by all members of the amputation healthcare providers, we must optimize the Communities-Index-Report.pdf.
3. Rogers, et al, Toe-and-Flow: Essential compo-
prevention team can make the most signifi- care we provide to our patients, but we must
nents and structure of the amputation preven-
cant impact. Coordinating resources in also challenge ourselves to help our patients
tion team, Journal of Vascular Surgery,
today’s smartphone-connected world is not in ways that extend beyond the four walls of September 2010; 3www.jvascsurg.org/article/
as challenging as it may seem. Vascular and the exam room. Only then will we begin to S0741-5214(10)01325-X/pdf.

20 San Antonio Medicine • September 2019