Dr. Christopher E. Attinger's Acceptance Speech for the Edward James Olmos Award for Advocacy in Amputation Prevention at DFCon 07

I want to thank Mr. Edward Olmos, Dr. George Andros, and Dr. David Armstrong for awarding me the Edward James Olmos Award. I gladly accept this award on the behalf of all the people who have made it possible: the georgetown wound healing team that puts so much effort day in and day out into saving threatened diabetic feet, the surgical and podiatric residents who approach these difficult problems with contagious enthusiasm and energy, and most importantly, the patients who continue to teach us more than we know. Their courage in the face of overwhelming disease is not only inspirational but helps all of us keep everything else in perspective.

As you heard yesterday, the data for diabetic patients who develop foot ulcers is frightening: one quarter undergo immediate leg amputation upon presenting with an ulcer, recurrence rate after healing is 15 – 40% at 7 months and 40 - 80% at 27 months. After amputation, over 50 % loose the contra-lateral leg within the next 3 years while over 60 % die within the next 5 years. Most frightening is the rapid worldwide increase in the incidence of diabetes.

Obviously, as we learned yesterday, the most effective use of health dollars should go into patient and physician education for ulcer prevention: identifying those at risk of limb loss, tight control of blood sugars and protective shoe wear. Unfortunately, our health care system is not that sophisticated and we continue to put our emphasis on treating the effects of the disease rather than preventing them from occurring. Meetings such as this are designed to reverse that trend.

For diabetic patients with an ulcer, the thrust should be toward educating health care givers about what can be done. The negative attitude many physicians have toward diabetic ulcers helps explain the immediate amputation rate of close to 25%. If a diabetic has renal failure, then the immediate amputation rate can be as high as 60%. Even the media get it wrong: in yeserday’s Grey’s Anatomy, a foot was amputated for a small heel ulcer with grade one osteo. Such a pessimistic attitude is unwarranted as up to 96% of diabetic foot ulcers can be treated successfully.

A team approach has the highest chance for limb salvage because the components of a diabetic foot ulcer are beyond the talents of any given individual. The team should have a vascular surgeon, podiatrist, orthopedist, endocrinologist, internist, nephrologist, and wound care team involving a physician, nurse, nurse practitioner and physical therapist, pedorthetist, prosthetist, nutrionist, and physical therapy. The team will only be as good as its weakest link as each play an integral role in the salvage effort.

This conference is designed to educate the health care giver about prevention of and about the treatment for a diabetic foot ulcer. Our role as physicians treating diabetics to develop the capacity to assemble a team who can manage these complex problems. It often requires persuading hospital administration to support the effort because salvage is expensive and requires manpower including hospitalists, nurse practioners, nurses, nurse assistants, physical therapists etc.. It also requires real estate including the wound center, a dedicated hospital floor for wound patients, and dedicated operating rooms. It then falls on us to set the example which is the most effective tool in teaching residents, the future physicians, that successfully treating diabetic foot ulcers is not only possible but also very rewarding.

I thank you again for this award because it recognizes the tireless efforts of the team that i am fortunate enough to work with to save the diabetic foot. Our goal in the future is to better define whom we can successfully save so that we can efficiently get patients back to normal life while avoiding complications, failure and prolonged immobility.