Psychological problems

Concurrent psychological problems are also formidable barriers to care.

Figure 5.28a,b shows the feet of a middle-aged depressed man who lived alone and neglected his feet. His right foot developed ulceration over the dorsum of the 2nd toe which was complicated by cellulitis. He had peripheral neuropathy with marked clawing of the toes. He wore no socks, the ulcer was not dressed and his shoes were too tight.

It is important for all patients and their families to understand the dangers of untreated foot infections, that signs and symptoms are often diminished and that it is essential to check the foot regularly to detect deterioration. We use a question and answer sheet to educate patients as follows.

Why is foot infection a dangerous complication of diabetes?

In a diabetic foot, the usual warning signs of infection may be absent or greatly reduced, particularly if you have poorly controlled diabetes, neuropathy or poor blood supply to your feet. If you do not know you have an infection and you continue to walk then infection will be pumped through the foot with every step you take. You can become seriously ill very quickly.

Wouldn't I know there was a serious problem because my foot would hurt?

Infection in diabetic feet is not always painful, but it can quietly destroy the foot. If you wait for pain or other symptoms to develop, the foot infection may need many weeks of treatment and it may even be too late to save the foot.

How can I recognize an infection early?

Your feet should be carefully checked every day for signs of infection.

What are the signs of infection?

You should watch out for:

• Swelling of a foot or part of a foot. Compare your two feet: are they the same size?

Fig. 5.28 (a) Dorsal view of both feet shows severe clawing of toes, ulceration and cellulitis, (b) Plantar view of the same pair of feet shows neglected callus and accumulated crusted exudates.

Colour change. Look for red patches or streaks spreading up the foot and leg, or patches of blue, purple or black near the ulcer

Collection of fluid under the skin which may look like a clear blister, a blood blister or a blister filled with pus. These may also develop under areas of hard skin Pain or throbbing in the foot Foot develops a hot spot

Pus or watery discharge or blood leaking from any part of the foot

The foot smells strongly

Your body temperature rises above 37.5°C

Your diabetes goes out of control for no obvious reason

You shiver and shake

You feel very cold, or burning hot

You feel tired, sleepy, weak or unwell with loss of appetite and 'flu-like symptoms'.

What shall I do if I can't check my own feet for these danger signs?

If it is difficult for you to see your feet clearly or to get down to your feet, then please tell the foot clinic.

Remember that symptoms that feel like flu maybe due to a foot infection. Always check both your feet if you are unwell. If you call the doctor in, ask him to check your feet.

What should I do if I find a danger sign?

• Seek help the same day from your diabetic foot service or emergency department

• Do not walk on the infected foot: every step you take will pump infection through the foot and leg

• Until you get to hospital, lie with your foot up on a bed or sofa

• Do not wait until tomorrow: the worst infections are the ones which are not caught early.

Must I go at once?

Even if you have an appointment with your GP or foot clinic very soon you should never wait until then: always act the same day.

Remember that the earlier in the day that you come to clinic as an emergency, the easier it is to sort out your problem. It is difficult to get any necessary tests and investigations performed late in the day. If you need to be admitted into hospital, and beds are in short supply, then the earlier the hunt for a bed is started the sooner your treatment can begin.

Is my foot really so important? Even if it doesn't hurt?

Please always give your foot a high priority. It may not be painful, but it is very important to start treatment as soon as possible.

What if I don't like hospital?

You may be afraid of being taken into hospital, but one thing is sure: if you delay then any hospital stay will be for much longer.

Isn't it unfair for me to get extra appointments when other people need help too and the foot service is busy?

Never delay coming to the foot clinic as an emergency because you feel it is unfair for you to receive extra appointments over and above your routine ones, or because you know the staff are very busy. Good diabetic foot services always run an emergency service in order to catch problems early. Their workload allows for emergency visits. If you do not play your part in this system and your foot is badly damaged by the delay, then the result will be extra work and trouble for everybody, especially you.

Isn 'tit unwise to take antibiotics for long periods?

Some patients worry about taking antibiotics for long periods. But if diabetic foot ulcers become badly infected the leg is at risk, which is why antibiotics are often prescribed earlier, and for longer periods, than in a patient who is not diabetic.

Didn't I read in the paper that antibiotics cause superbugs which are resistant?

Some patients worry because they read in the papers that taking too many antibiotics can cause germs to develop drug resistance, so that antibiotics will not work for them in the future. The most common cause of this problem is when patients do not complete a course of antibiotics. You can help prevent superbugs from emerging by never stopping your tablets without consulting your doctor. Always take your antibiotics with you wherever you go so that you do not miss a dose.

Do antibiotics cause side-effects?

Some antibiotics can cause side-effects. If you ever develop new symptoms when taking antibiotics you should rapidly contact the diabetic foot clinic and ask for advice. However, you can reduce the likelihood of problems by following precise instructions on the medication, washing down tablets with plenty of water and eating live yoghurt.

How does yoghurt help?

The reason for this is that your bowel (intestines, gut) is full of harmless microorganisms which help you to digest your food. The antibiotics kill the harmful germs in your foot, but also kill the good microorganisms in your bowel. If you eat live yoghurt you will replace the good microorganisms. Below is more information about side-effects.

Possible side-effects from antibiotics

Side-effects: what to do

• Nausea and indigestion: take tablets with lots of water and live yoghurt

If any of the following problems arise, stop the antibiotics and contact the diabetic foot service:

• Severe itching

• Hallucinations

• Hypoglycaemia.

Except in the circumstances explained above you should never stop taking your antibiotics without checking first with the foot clinic. If you stop a course part-way through it may make the germs resistant to the antibiotic so that the antibiotic no longer works for you—or for other patients.

Remember that any other symptoms you develop may have nothing to do with the antibiotics you are taking. Always check it out with your foot clinic.

What else do I need to do if I am taking antibiotics?

Keep a precise record of all the medication you are taking and bring it with you to the foot clinic every time you come. It is very difficult for the clinic to plan your treatment when they do not know what other medication you are taking.

If you see another doctor who stops your foot clinic medication, or prescribes new medication ask him to speak to the clinic. You should also let the clinic know if any new health problems are diagnosed.

How should I look after an infected ulcer?

• Do keep your foot out of the bath or shower unless it is covered with a plastic cast protector. This protects the wound from damage, and protects other people from your infection. If infected wounds are left uncovered they are very attractive to flies, dogs and cats

• Do ensure the dressing is changed at least once a day, and the wound is washed with saline and dried carefully. Ask for help if you cannot look after the wound yourself

• If fluid strikes through the dressing so that you can see it, then it is time for the dressing to be changed

• Do not use a dressing which is designed to be left on the foot for several days. This is very dangerous for diabetic feet which lack protective pain sensation and have an infection because the infection can spread under the area covered by the dressing and you will not know that this is happening

• Do not change the foot clinic treatment regime without consulting them first. If you have a nurse coming to your home to do the dressings and she wants to change the type of dressing used, then ask her to discuss this with the foot clinic. If your doctor changes the treatment, let the diabetic foot clinic know.

Can I use alternative medicines or folk remedies?

It is unwise to use alternative medicine, folk remedies or over-the-counter treatments for an infected diabetic foot. Always check with your foot clinic before doing this.

Is it all right to soak my foot in salty water?

If you want to do this then always check the temperature of the water first. It should be under 43°C. Use a bath thermometer to measure the temperature.

Can I put a hot poultice on my foot to draw out the infection?

No. You risk severe burns.

Anything else I should be doing?

Don't walk. Use crutches or a wheelchair if you have to move. Every step you take will spread infection along your foot. Resting your foot is essential. Every step you take will make the infection worse.

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