Communication is Key: An Experience with Diabetic Neuropathy
As I sat in the partitioned room at the local hospital, I sighed again with frustration and reminded myself to be patient. My diabetic father was not taking care of his feet, and this small act of negligence could have been disastrous. The doctor had diagnosed him with a severe infection caused by Staphylococcus bacteria. Days later, a team of health professionals discovered that there was a wound on the sole of his foot and deduced that the ruptured skin made him vulnerable to invading bacteria that resulted in the infection. The doctor in charge of his case stated that he thought it was possible that he had diabetic peripheral neuropathy. I tried not to feel worried, but I felt that this whole ordeal could have be avoided. I have repeatedly explained to my father the dangers of impaired wound healing because of his diabetes and stressed the importance of checking his feet for any signs of injuries. Still, he carried on cutting away the dead skin that builds up around the edges of his feet. For someone with type 2 diabetes mellitus, it was imperative for him to understand the repercussions of foot care negligence and more importantly, to take glycemic control seriously.
Diabetic peripheral neuropathy, or diabetic nerve damage, occurs when excessive glucose concentrations damage peripheral nerves. Hyperglycemia, which is characterized by prolonged high levels of blood sugar, disrupts the complex interaction between delicate nerves fibers and blood vessels. According to the American Diabetes Association (ADA) almost half of all type 2 diabetic patients ages 60 and older have some form of neuropathy. Additionally, the U.S. Department of Health and Human Services reported that between 60-70% of people with diabetes have some form of neuropathy, and more recent reports indicate that it may be even higher. Despite afflicting a substantial portion of diabetics, the exact physiology and mechanism of diabetic neuropathy is not yet well understood, with studies suggesting that it involves many factors and the interaction of multiple pathways. My father was diagnosed with diabetes over 15 years ago, putting him at high risk for complications associated with neuropathy. The longer a patient has been afflicted with diabetes, the more likely symptoms of neuropathy start to manifest. Typically, a patient with 20 years of high blood glucose levels will show symptoms of nerve damage, but many times this is not the case. Factors such as age, smoking, hypertension are also risk factors of neuropathy.
Specific symptoms patients and family members should look out for include feeling weakness, pain and numbness in the extremities, most commonly in the legs and feet. My father explained to the doctor that he would sometimes feel pain and weakness in his legs at night. Feeling tingling sensations like “pins and needles,” increased pain, shooting pain in the legs, and feeling weakness in the legs may be symptoms of nerve damage and should be addressed at your next doctor’s appointment. Some patients feel constant pain and weakness, preventing them from performing normal daily activities or participating in social events, disrupting their quality of life. Since he is shy about admitting pain, my father’s primary care physician and cardiologist was not alerted about his condition until his hospitalization. On the other hand, some patients with severe neuropathy may not experience any pain, or experience a combination of these symptoms. Touch sensitivity and pain sensation are protective factors because it enables the patient to react to and prevent ulceration or breaks in the skins. Patients stop feeling pain sensations in their feet, putting them at risk for further injuries and complications. For instance, patients with neuropathy may step on a nail and not feel it; this makes them susceptible to infections similar to my father’s case, among others like Klebsiella, causing Osteomyelitis in diabetics, or getting Tetanus from dirty rusted nails puncturing the skin. You also may have noticed that diabetics heal more slowly than others who are not diabetic. That is because many diabetics, especially those with neuropathy, have impaired wound healing from their reoccurring high blood glucose levels.
The difficult part of diabetic neuropathy is diagnosing neuropathy and detecting accurate deficits when there are no visible ulcers. Every nurse and physician that came to see my father neglected to thoroughly check his feet because they relied on his self-report of no past ulcerations. Upon finding the wound on his foot, the doctors asked my father a series of questions about experiencing pain or numbness in his feet and legs, then promptly brought out what appeared to be a short wand with a thin stick affixed to the top. He proceeded to brush against my father’s foot in specific areas of his feet, pausing every now and then when my father said “Yes” to confirm that he can feel its touch. This was a Semmes-Weinstein monofilament (SWM) test in which physicians use a 10g nylon instrument to gauge a patient’s touch sensitivity, prompting further intervention if they detect deficits beyond the threshold of normal sensation. Critical areas are the underside of the big toes and the balls of the feet.
Communication is key for both the patient and the physician, yet there are knowledge gaps and disparities in health knowledge. More emphasis can be placed on patient education about diabetic neuropathy by having informative discussions with a physician. Keeping blood sugar levels at optimal levels can help prevent the onset of neuropathy, and to mitigate or delay further nerve damage. After 3 days in the hospital and receiving a hefty dose of antibiotics and informative diabetes care sessions, my father was discharged. In short, the doctors educated him about the recommended steps from the ADA to maintain blood glucose levels in his targeted range, encouraging him to discover the relationship between his diet and exercise and its effects on blood glucose levels. I like to think that this experience helped my father learn effective lifestyle strategies for reducing his blood glucose and taking on a more active role in his foot care management.