Wrong treatment, late diagnosis, ignorance others trigger diabetes-induced amputations
“I went through a great ordeal here in Nigeria that my leg got so bad and was bringing out maggots”
These were the words of Ighiwotho Okeoghene, who was diagnosed of type-1 diabetes at a very tender age, as he accused a private hospital located in Festac town, Lagos of destroying his leg till it got amputated.
Narrating his story, Okeoghene said it all started in 2006 when he developed ulcer on his left foot while in the university.
He said he went to a private hospital at Festac town to treat the sore on his foot, which had started bringing out pus with foul odour that made him uncomfortable being around people.
He said a gynecologist attended to him and said if he didn’t cut off the affected toe, he could die, since it was fast decaying. Trouble started when Okeoghene got so scared of losing his life that he agreed, only for the doctor to use razor blade to cut off one of his toes.
“The doctor took me in and told me if I knew this could kill me because there was pus in the leg. He used razor blade to cut my leg, that was where the whole complication started,” he said.
A gynaecologist is a doctor who specialises in women’s health, with a focus on the female reproductive system. He/she has nothing to do with care of diabetes foot ulcer.
According to Okeoghene, the complication on his leg became so severe that he went to a general hospital, where it actually took him almost four to five months before he could see a specialist who examined his foot and said it needed to be amputated.
“I needed surgery, I was admitted in Ikeja general hospital and Gbagada general hospital a couple of months. They took me to the theatre twice and amputated my leg four times,” he noted.
He said after the amputations, though the wound healed, his legs started bending, so he decided to do a corrective surgery.
Okeoghene went to India in 2012 where the doctors performed infrastructive surgery on his left leg, which is why he is able to move around with his prosthesis (artificial limb) with ease.
“At the end of the day I went to India. Since I came back, I have been able to manage my left and right feet, even though I still had little complications, it is much better now,” he concluded.
Olufemi Sadipe, is a Chartered Accountant who was aware of his diabetic condition for over 20 years, but ignored taking care of his health.
Sadipe was living and enjoying his life since he had the resources to do this, until he had a sore in between his toes, which changed his life.
“About late 2016, I observed a sore between my toes and I just applied something. I kept on wearing my shoes because you know as an accountant you will have to suit up with ties and covered shoes. So, I kept wearing my shoes and taking painkillers to douse the pains I felt.
He continued: “Unfortunately, I was not paying attention to what I consider little things. I knew I was diabetic but I was not quite keen that there could be a connection to the ulcer foot.
“I had the prescribed drugs and I was taking them, but the unfortunate thing was that, I was not going for a review or medical check up to confirm. I took the dosage and felt confident. I was eating and drinking whatever that came my way, I was living normally.
“I kept on going until the leg became infected and swollen and couldn’t enter the shoes, so I went to see a doctor who booked me for the initial surgery of removing the mucus in the toe area.”
When matters went worse in 2017, Sadipe visited the hospital where he was asked to see a specialist, particularly an orthopaedic surgeon, who removed three of his toes.
Sadipe said he kept going to dress the wound but the leg kept getting worse. He consulted another orthopaedic surgeon who ran some tests and said the initial amputation was not done properly.
The surgeon told Sadipe that his diabetes had spread beyond the knee upwards, which required immediate surgery that same day, where he had above the knee amputation on May 2017, some months after the first one that was done.
Meanwhile, Sadipe encountered another trouble when he traveled to the University of Maryland Medical Centre in the United States to do a second review and health check, but encountered an accident at the hotel where he lodged.
“ I went to the bathroom and as I was trying to come out of the bathroom, my hand slipped on the door and I fell on the stomp, I hit it hard such that you could see my bone. A review surgery had to be done at Maryland,” he explained.
Tunde Famoye is another victim of amputation caused by his ignorance to his diabetic condition. He had a piece of broken bottle in his left foot, which pained him but never bothered to check.
He said he didn’t notice that he had the broken piece of bottle in his leg, but went to the hospital to receive treatment as he had a consistent feverish conditions.
Famoye was treated for malaria and typhoid, and his condition kept getting worse, while he managed to drag himself to work so he could put food on the table for his family.
According to Famoye, though he discovered the sore early, his experience when he visited the hospital for treatment was quite appalling, as they did not give him proper treatment.
“I went to the hospital and they did not do a good job in terms of treatment. I went to the hospital for three to four weeks, after which the sore got bad. Before they could refer me to a general hospital it had gone worse and when I eventually went to the general hospital, it had gone to the worst stage,” he stressed.
Just like others, Famoye underwent multiple amputations on his left leg because the condition kept reoccurring after each surgery.
Famoye’s life has never been the same, he lost his job, his children dropped out of school since there was no source of money to pay their school fees, as their mother, who is managing her little business became their bread winner.
“I know what it takes to cater for myself and the family and it has not been easy. My wife has been the one taking care of the family, we had to withdraw some of our children from school, leaving others. I have not been able to work for almost six years. When I go to look for work, the employers look at me with pity and refuse to give me work because of my amputated leg,” he moaned.
Another pathetic story is that of Adeniran, a Nigerian living with diabetes some years ago. His right foot was amputated following a protracted foot ulcer, which is a complication of diabetes now on the increase in Nigeria and the world at large.
Adeniran was diagnosed with diabetes in 1987. But his ignorance worsened the complications of his diabetes foot, as he lived in pains with a decaying leg.
The complications did not only add to the huge burden of managing his diabetes, but also limited his ability to fend for his family.
Though after several surgeries and amputations done on his leg, Adeniran was able to move about for some time before he eventually died.
Foot ulcer, a major complication of diabetes, is a global problem, which according to experts is now on the increase, following the rapid surge in the incidence of diabetes worldwide.
Diabetes becoming endemic
It is estimated that approximately 25 per cent of the more than 150 million people with diabetes worldwide, at some stage have foot ulceration.
The National Desk Officer, Diabetes, Federal Ministry of Health (FMoH), Abuja, Dr. Alayo Sopekan, said diabetes is a common clinical condition in Nigeria, being managed at the primary, secondary, and tertiary health centers in both private and public sectors, adding that it is the commonest endocrine disorder encountered in clinical practice, as its prevalence is increasing worldwide.
He noted that the risk for diabetes, particularly type 2, in the population is rising and is heightened by overweight/obesity and the proliferation of industries producing unhealthy diets, including high sugar drinks.
According the National Desk Officer, the current global burden of diabetes disease is estimated to be about 366 million people, while it is projected to reach 500 million in year 2030, with 80 percent of the increase expected to occur in the developing countries, including Nigeria if nothing urgent is done.
He said the resultant effect would be several complications of diabetes, more especially diabetes foot complications, which may result in one form of amputation or the other.
“It is interesting to know that this disease was previously not very common in Nigeria and erroneously believed to be a disease of the affluent. However, with the globalisation and demographic transition, the disease have become prevalent in all parts of the world and affects all segments of the population, rich and poor alike,” he added.
Unfortunately, awareness on diabetes remains very low in Nigeria, as people living with the disease lack the basic knowledge of foot care.
According to experts, ignorance has remained the major factor leading to the increasing rate of diabetes foot complication, as about four million Nigerians living with the disease have little or no knowledge of the complications until it gets to the worst stage.
Sopekan stressed that in Nigeria, an estimated rate of foot ulcer among people living with diabetes is between 8.3 percent and 19 percent in the different zones of the country.
He further stressed that the rate of amputation is also estimated to be as high as 53.2 percent in people with foot ulcer in some centres, thereby making diabetes foot the most common cause of non-traumatic amputation in the lower extremities in Nigeria.
He said there is hardly any day that goes by without the sad news of a relative, friend or colleague who died suddenly from this disease.
“Sadly most people are unaware and only get to know they have diabetes when irreversible and fatal complications leading to amputations, blindness, stroke and others have set in,” he noted.
Worried about the trend, the Unit Head of Endocrinology Diabetes and Metabolism Division, Lagos University Teaching Hospital, (LUTH), Dr Olufemi Fasanmade, stressed that many patients are not aware they have diabetes, as some only get to know when they have an injury in their oot, which sometimes could be caused by a sharp object piercing through their feet, which get infected.
He noted that if not spotted and treated on time, it could lead to amputation, which according to him is the situation almost everyday at LUTH, such that lots of people have gangrene in their legs, which he noted results in several amputations occurring every week in most teaching hospitals in Nigeria.
“If you go to our wards in LUTH at any given point in time, you see many people who have had a limb amputated because of diabetes,” he said.
All the victims of amputation blamed their predicament on the wrong treatment from the doctors in the hospital.
While Okeoghene’s toe was cut off with a razor blade by a gynaecologist in a private hospital, Famoye was treated for malaria and typhoid instead of focusing on the injury since he was diabetic and Sadipe’s initial surgery wasn’t done properly.
These, coupled with the rigorous stress of getting access to public teaching hospital to get the opinion and care of a qualified specialist, were virtually what all the patients experienced.
The Managing Director, Rainbow Specialist Medical Centre, Dr Afokoghene Isiavwe said diabetes is the cause of multiple amputations in Nigeria, noting that many trearments go wrong because the doctors fail to address the issue from the point where it needed to be addressed.
She said the reason for multiple surgeries and repeated amputations on a particular leg with ulcer is that “the first one was taken at a level that it shouldn’t have been done. If the surgeons had actually looked at the blood supply, they would have actually known where to cut and hopefully with more awareness the people will know the basic things to do.
She explained that “usually you find out the sore is at the toe, but the problem may be at the knee and by the time they do an examination they find out that the blockage is coming from up the knee. The best thing to do is cut at that level, but what we see people trying to do is to manage and cut, even when they go deeper it will not heal, until they get to the main place where blood supply is coming from.”
Professor of Endocrinology and Diabetology, Department of Medicine, College of Health Sciences, University of Abuja Teaching Hospital, Felicia Anumah, said some of the causes of wrong treatment could be seen when the healthcare providers are not empowered in diabetes foot care, complications and management, hence, it could be mismanaged.
She explained that multiple recurrent amputations of a particular limb is because of mismanagement and inability to locate the level of blood supply in the leg, which makes the wound not to heal.
“If any part of the body does not have blood supply that part dies. When a diabetic foot problem shows up as a wound, there has been a problem with the nerve supply for a long time.
“If they are to be properly treated, it means the doctors are to check the blood supply of that individual with diabetes foot who requires amputation, if you don’t cut it to the level where there is good blood supply, the wound will remain,” she added.
Anumah also noted that some of the doctors try to sympathise with the patients, in which rather than cutting from the ankle at the early stage, they cut one toe where the wound is to see what happens next.
She noted that after removing that one toe they find out that it can’t work and then they have to go up again to cut again.
“If there is a problem with one leg, for the remaining human being to live, if you have to cut that leg you have to, so that the rest part of the human being can live because the infection would be so severe that it would get to every other part of the body and that person will die.
“But there are ways of accessing the blood supply adequately, particularly if the patients come to the tertiary health facility, you know where the blood supply is adequate and where to cut the limb once, instead of doing the foot cutting multiple times,” she said.
Anumah stressed that diabetes has become a huge problem in Nigeria presently, with increasing complications, which are most times dangerous and could result in the death of the affected individual, if not addressed on time.
According to Anumah who is also the Dean, Faculty of Clinical Science University of Abuja, the problem most time with the diabetes foot patient is that, by the time he/she gets to the health centre where the right and proper care can be given, it is usually late, as 50 per cent of the only option to save that person’s life is amputation.
“The plight of the common Nigerian is death due to lack of early detection, no funds, ignorance or refusal for immediate treatment of worst stage diabetes, which leads to amputation.
“As diabetes is increasing, the complications are also increasing because the most dangerous thing about it is that it can be quiet until the complications show up, so the individual may not know that he or she has diabetes and suddenly has a heart attack, stroke or kidney damage,” she maintained.
Untrained health personnel
The President, World Walk Foundation, Jamaica Chapter, Owen Bernard, said for every five seconds, a lower limb is lost to amputation as a result of complication from diabetes, which he noted is due to lack of education about the disease and the inability to identify its symptoms.
Bernard lamented that there are no enough health personnel on diabetes treatment and care in many countries across the world, noting that it is important to train as many personnel as possible in the health centres present in Nigeria, so as to eliminate some of the disease problems at the primary care level.
He said the major aim is to help reduce the rate of diabetes and prevent amputation because there is so much burden it places on an individual, noting that Nigeria needs to spend more time and more resources in training and retraining manpower to prevent loss of the limbs/legs.
Sopekan maintained that diabetes foot disease is a leading cause of hospital admissions in Nigeria with the economic burden becoming quite significant, as most of the health expenditure in the country is from out of pocket expenses.
Anumah stressed that the cost of assessing diabetes treatment is very expensive, with complications like kidney failure, heart attack, stroke and even amputation, which costs not less than N100, 000 a week for dialysis, and about N360, 000 to N540, 000 for diabetes treatment and much more for amputation, noting that not many Nigerians can sustain that.
Anumah noted that the reason for the situation is that the National Health Insurance Scheme (NHIS) is still at the nursery stage, with a coverage of less than five percent of the Nigerian population, which has encouraged an out-of-pocket system as far as health is concerned in Nigeria.
Anumah said: “Education is very powerful and makes a difference between life and death. Diabetes education is most important for individuals diagnosed with the disease and not necessarily the drugs you prescribe.
“We believe there is treatment of diabetes, and the management of diabetes is an act that is possible. It means when you empower the diabetes patient and he/she becomes very knowledgeable about the disease and how to care for it, the patient is now in charge of the disease, rather than the disease being in charge of the patient.
“There is a lot we can prevent in the area of diabetes complications generally, if we educate and empower these patients to be in charge.
“We also need to empower the primary health care centre, in fact the truth is that if we empower the primary healthcare workers, the right thing will be done, so these patients don’t have to come down to the teaching hospitals the way they come. If the right things are done they don’t have to come down to the stage of amputation..
“In the University of Abuja Teaching Hospital, efforts are also being made to reduce the rate of amputation which was about 40 per cent before for patients coming down with diabetes, but we have been able to reduce amputation to about 10 per cent.
“This is because we had to put imperatives in place in locating patients and properly prepare them even when they present with foot ulcers.We just concluded the National Guideline for diabetes treatment and that can boost so many drugs that people can use even at the primary health centre.
She, however, called on the country’s leaders at all levels of government to fund the care and treatment of diabetes in order to prevent the rising amputation and most times death of individuals living with the disease.
“Low cost interventions are the cheapest, easiest and most effective ways of preventing diabetes in our patients as well as preventing amputation.”
Isiavwe said with diabetes, being a global emergency problem with associated complications, it requires training first responders and community health extension workers to improve management and prevention of the disease complications, as well as raise awareness on proper foot care in persons living with diabetes melliatus.
She explained that the diabetes foot first responders are persons with specialised training, who are among the first to arrive and provide assistance at the scene of an emergency, which when present in Nigeria would stand in the gap to reduce diabetes amputation, until a formal university training begins.
“What we have now is that the firsts responders – the community health extension workers, and pharmacists, who are the people the diabetes patients meet on a day-to-day basis don’t know much about diabetes, which causes trial and error and by the time these patients get to centres that know how to treat diabetes properly, it is usually too late and all that can be done is to cut the limb to save their lives,” she stressed.
She, however, added that it is important to ensure primary healthcare workers are trained to be able to recognise the high risk diabetes foot and know how to promptly decide the order of treatment to reduce delays in getting appropriate foot care services.
“Training needs to be done and somebody needs to bear the cost of the training, but unfortunately what is happening in our health sector is that many hospitals are struggling in terms of resources and health workers are poorly paid.
Even if they want to attend such programme, they don’t have the resources to, which is why we are experiencing massive brain drain, a lot of our doctors and nurses are leaving the country in their numbers.
“The problem is deep, government needs to the do something and encourage private organisations that are giving out training to the health workers, maybe give us tax free, amnesty, because right now we are fully funding it from our pocket and you know how much it costs to bring trainers in.
“ We need funding and structures, because having money is one thing, but putting it to use is another. We also need structures and policies, such that when the money comes, the people will get the trainings, there would be guidelines, referral packages, so there will be no more trial and error. Right now there is a lot of trial and errors.”
Sopekan said the FMOH recently finalised the National Guideline for the Prevention, Control and Management of Diabetes in Nigeria, which is expected to ensure standardised protocol for medical care and patient self-management education to prevent the onset of complications among Nigerians living with the disease.
On the part of funding, he said: “Given the global priority to scale up a package of essential cost-effective and person-centered interventions for diabetes prevention and treatment at all levels of health particularly at the PHC level, the Federal Ministry of Health is doubling her effort to strengthen the primary healthcare system to become equitable, efficient and resilient enough to cater for the growing health needs of persons living with Diabetes in Nigeria and the Integration of Diabetes complication, that is, Foot care (assessment and referral) into the existing health care service at the Primary care level.
He, however, added that, currently the FMOH is carrying out a Diabetes Awareness and Care project in two states of the federation (FCT and Imo state) through the support of the World Diabetes Foundation, WDF.
These supports, he said, also include capacity building at the Primary Care level within the selected sites and medical outreaches, which is envisaged that the project would be scale up to other states of the federation.