When Patients With Diabetes Become ‘Bathroom Surgeons’

David was a new patient who came to my office on an “emergency” basis with a presenting complaint of a wound to the great toe of his left foot. He was 79 years old and had type 2 diabetes controlled by oral medication. He also had arthritis, could barely see his feet and could only reach them with some difficulty. When I greeted him and asked, “How may I help you?,” he told me his story. 

“Doc, I was just trying to trim my nails and it happened, I didn’t even realize it. I was using a razor blade because that was all I had in my bathroom. I saw something laying on the floor in front of me after I trimmed what I thought was my big toenail. At first, I thought it was my toenail but when I saw some blood on my toe and my fingers, I knew it was something else. Then I realized I had cut the end of my toe off. The funny thing is that I didn’t feel it. It didn’t even hurt me.”

The problem is all too common. Over my 40+ years of clinical practice, I have seen patients mutilate themselves while attempting to provide the basic tenets of foot care: cutting of nails and trimming of corns and callouses. I have come to call this activity, “bathroom surgery.” 

If I had my way, I would revoke the “bathroom surgeon” license from every person with diabetes. Unfortunately, this was not the first time I encountered a patient with diabetes who had performed self-mutilation. The danger here is that this mechanical trauma can trigger an infected wound, a foot ulcer and, in the worst-case scenario, an amputation. The irony of the situation is that these self-inflicted wounds are almost 100 percent preventable with proper patient education.

Patient Education: The Cornerstone Of Prevention

There are a number of risk factors that can contribute to the development of a foot health problem in a patient with diabetes. They include poor diet, lack of exercise, questionable self-management of blood glucose, high blood pressure and lipids, smoking and not practicing preventive foot health behaviors. The combination of risk factors is the backdrop that can set the stage for patients to develop foot health problems. 

One of the most often ignored and easily addressed ways to decrease the risk of developing a foot problem is patient education. If David had been educated about the risks to his overall health associated with his diabetes and especially to his feet from diabetic sensory neuropathy, he may have thought twice about trimming his own toenails.  

When it comes to ongoing foot care, many vulnerable patients with risk factors like numbness, poor vison and poor hand-eye coordination (just like David) continue to perform “bathroom surgery.” The risk for developing a problem like an infection or worse is very high due to the fact that, in the presence of inadequate lighting, these folks use non-sterile, sharp cutting instruments such as scissors, clippers or even razor blades on their feet to trim their nails, corns or callouses. 

The number of people in the United States with diabetic sensory neuropathy reveals a potential for many more preventable tragedies. Nearly 50 percent of people with type 2 diabetes, 20 percent of people with type 1 diabetes and 18 percent of the 84 million people with prediabetes (15 million people in the U.S.) suffer from peripheral neuropathy.^1,2 Accordingly, there is a large pool of patients with diabetes and neuropathy, who have the potential to do exactly what David did.

A part of the solution to patient-generated foot problems is patient education. David could have learned about the risks to his foot health due to diabetes and sensory neuropathy from his primary care physician, his podiatrist/foot health specialist or his diabetes educator. Alternatively, there is a massive amount of foot health information for people with diabetes on the Internet that David, his family or caregiver could have accessed. 

One clinical study revealed that, “The remarkable improvement in the Health-Related Quality of Life (HRQoL) in the Interventional Group (IG) at six months follow-up [of a diabetic foot ulcer] suggests that patient education (PE) significantly improves (HRQoL) in DFU patients.”³

What Is Your Patient Education Strategy?

Patient education is not usually a reimbursable podiatric service. Therefore, with time being at a premium, it is often overlooked. With that in mind, what is your strategy as a podiatrist to educate your patients with diabetes about risks and prevention of foot health issues? 

A good starting point would be to inquire if your patient has ever received information or counseling on risks, prevention and diabetic foot health. If they have had previous counseling, perhaps an update and review would be helpful. If they have not had any previous education, here are a few suggestions for you to show your patients that you care about their well-being and knowledge level on these topics.

1. Take a few moments to discuss the issues of diabetes, risks, prevention and foot health with your patient, or have a member of your staff perform this important task.

2. Provide a written handout on preventive foot health activities to dispense to patients with instructions to review it about once a month (see PDF attached at the upper right of this article for an example).

3. Place information on your office website concerning diabetes, prevention and foot health for easy patient access. Another option is recommending a couple of resource links to patients for information on prevention and diabetic foot health.

• https://www.cdc.gov/diabetes/library/features/healthy-feet.html
• https://www.uptodate.com/contents/foot-care-for-people-with-diabetes-beyond-the-basics

4. Offer to refer your patient to a diabetes educator for more in-depth diabetes education. 

Final Notes

Regardless of the method you choose to accomplish this goal, empowering patients via patient education on risks and prevention in diabetic foot health will go a long way toward patients understanding their responsibilities, preventing patient-generated foot problems and communicating to your patient how much you care about his or her foot health.

Dr. Hinkes is President and Chief Medical Officer of ePrevenir, Inc. He is board-certified by the American Board of Foot and Ankle Surgery, and is a Fellow of the American College of Foot and Ankle Surgeons and the American Professional Wound Care Association. He is the author of “Healthy Feet for People With Diabetes” and “Keep the Legs You Stand On,” which are available at www.amazon.com.

References

1. Harrar S. Diabetic neuropathy: causes and symptoms. EndocrineWeb. Available at: https://www.endocrineweb.com/guides/diabetic-neuropathy/diabetic-neuropathy-causes .  Accessed October 20, 2020.
2. Mann RH. Prediabetic neuropathy: diagnosis and treatment. Available at: https://drrichardhmann.com/prediabetic-neuropathy-diagnosis-treatment/ . Published August 21, 2019. Accessed October 20, 2020.
3. Sekhar MS, Unnikrishnan MK, Vijayanarayana K, Rodrigues GS. Impact of patient-education on health related quality of life of diabetic foot ulcer patients. A randomized study. Clin Epidemiol Glob Health. 2019;7(3):382-388.