Case Study

Burn on the beach

A 62-year-old lady with type 1 diabetes of 40 years' duration, retinopathy and neuropathy went on holiday to Blackpool, removed her shoes and socks and sat in a deckchair on the beach for 3 h. Her head and torso were shaded by an umbrella but her feet and legs were exposed to the sun. She suffered a full-thickness burn on the dorsum of her right foot (Fig. 3.10). She was admitted to hospital for debridement and skin grafting and the foot healed in 6 weeks.

Key points

• Diabetic patients who go on holiday are vulnerable to injury. Thermal injuries are common and patients need to protect themselves from the sun

• Every diabetic foot service should have a special holiday foot care programme.

Dangers of airports include:

• Carrying heavy luggage which puts extra pressure on feet

• Airport trolleys which may run into or over the feet or lower leg

• Other passengers in a hurry who may step on toes

• Patients losing control of the situation in airports: they

Fig. 3.10 Third-degree burn on the dorsum of the foot.

cannot limit their walking, or predict whether it will be a long walk to the gates. Patients who fly should:

• Walk up and down the gangway to reduce the likelihood of severe oedema or a deep vein thrombosis

• Wear adjustable footwear

• Avoid dehydration: drink plenty of water, avoid tea, coffee, alcohol and fizzy drinks.

We advise patients with a previous history of severe foot problems to organize a wheelchair at each end of the flight, and to allow plenty of time for embarkation and disembarkation.

General safety rules for patients on holiday include:

• If skin becomes dry use emollient

• Seek help from a local health-care professional if problems arise

• Telephone home foot care service for advice if necessary

• Always take out health insurance

• Avoid sunburn

• Wear plastic sandals on the beach and in the sea. Occupational factors

Neuropathic patients may develop foot problems associated with jobs entailing much walking, and will some times need to seek desk jobs. Neuropathic patients whose job entails standing for hours in a factory in front of a machine will need to shift their stance from time to time and can be advised to set their watch beeper to go off at every quarter hour, whereupon they should 'stamp their feet about'. (They should probably explain to colleagues why they are doing this!)

Making patients feel safe

It is very frightening for high-risk patients if they sustain a trauma and cannot get immediate help without working their way through bureaucratic barriers and delays.

Many patients say that they only feel safe when they know that if they find a foot problem they can come to the diabetic foot service immediately for treatment and advice. The foot clinic should be a safe haven for people with diabetes.

Addressing psychological factors

Educators dealing with diabetic foot patients should be aware of the importance of psychological factors.

Diabetes arouses strong emotions of anger, fear and denial which can be barriers to successful management. Newly diagnosed patients are inundated with advice from health-care professionals and from well-meaning friends. Some advice may be inaccurate or unnecessarily negative. Patients may deny that diabetes or diabetic feet are a problem. On the internet a vast amount of unrefereed information is available which may give patients unrealistic expectations of the future.

In devising education programmes, the clinician should be aware of the psychological importance of the loss of protective pain sensation.

Protective pain sensation keeps behaviour within certain constraints: as we grow up we learn to avoid obvious noxious stimuli because of the unpleasant sensations associated with them. This reinforces safe behaviour, and less obvious stimuli will soon be detected because they give rise to discomfort, but it seems that this pathway needs constant reinforcement. When sensation is lost, behaviour can become reckless and hazardous.

Lack of touch and lack of pain perception have profound effects on the patient's body image and awareness of the physical boundaries of self in the following ways:

• Patients may feel that their neuropathic feet are no longer a part of them, and may ignore them and fail to look after them

• If ulcers or other problems develop, the patient is also likely to neglect them because they are not painful (and we have all been brought up to believe that if there is no pain the problem is not serious)

• Patients may therefore not perceive themselves to be at risk.

Psychological factors can worsen outcomes because they:

• Prevent a patient from understanding his foot problems

• Make him underestimate the risks he faces

• Make him refuse treatment or neglect to follow advice. Work with paraplegic patients has indicated that patients who do not perceive themselves to be at risk are more likely to neglect themselves and more likely to develop foot problems. It is essential that patients are made aware that they are at risk.

Management of patients with psychological problems The health-care professional should always:

• Tell the truth to patients

• Avoid deliberately frightening patients (unless there is an urgent need to change their behaviour, for example when a very sick patient wishes to self-discharge from hospital or refuses a life-saving operation)

• Issue realistic advice. It is well worth taking time to explain to patients that they lack protective pain sensation, so that they understand the practical implications of their inability to feel a 10-g monofilament. In theory lack of protective pain sensation can be compensated for if patients are made aware that they will not feel pain, and taught trauma prevention and the need for regular foot inspections.

There are some patients who, despite regular and frequent education, appear to be unable to care for themselves or to take responsibility for their feet. They are labelled 'difficult patients'. They often have associated problems including:

• Concurrent medical conditions

• Intellectual deficit.

Once such patients are identified it may be necessary to provide:

• Frequent treatment

■ Home contact (telephone calls and postcard reminders) between appointments to ensure that all is well

• 'Conspiracy' with the community nurses or other carers to organize regular foot checks at home.

Some patients learn a sharp lesson the first time they develop a serious problem and never let it happen again, but others seem to be incapable of learning from previous experiences.

Diabetes coupled with renal disease may make patients even more reckless. There is a singularly high incidence of trauma in renal transplant patients.

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