From Mother To Son
Jackson Moss leaned back on his couch and raised his right leg. His wife, Bernadette, sprayed antiseptic on a gaping wound on the sole of his foot before dabbing it with Vaseline and rewrapping it with gauze.
A stocky man who used to deliver poultry, Moss, 47, said he had to stop working after his left leg was amputated below the knee about 10 years ago. Later, he lost part of his right foot. With Bernadette’s help, he is trying to save the rest of it.
“If I didn’t have my wife, I don’t know where I’d be,” said Moss, who wears a prosthesis on his left leg and uses a wheelchair. “I can’t get around good like I used to.”
Moss, who lives in Compton, California embodies many of the characteristics of people most likely to get diabetic amputations. He is African American with a relatively low family income: about $30,000 a year from his Social Security disability check and his wife’s job with the county mental health department.
Moss has not always received regular medical care. His mother, who also had a leg amputated from diabetes, would take him to the doctor when he was a boy. But he stopped going as an adult. He didn’t have insurance during much of his 20s and 30s. Medical care just wasn’t a priority, he said, until about 25 years ago when his blood sugar shot up so high he passed out at home.
After he was diagnosed with Type 2 diabetes, he started seeing a physician more often. He tried to avoid sugar, as his doctor recommended, but bad habits die hard. “It takes a lot to eat right,” he said, “and it costs more.”
One day, about 10 years ago, he bumped his toe on the bed. He thought little of it until he developed an infected wound. A fever sent him to the hospital, where his lower leg was removed. A few years later, with his diabetes still poorly controlled, he lost the toes on his other foot.
In recent years, Moss and his wife said, health providers have sometimes ignored their concerns. They recalled trips to the emergency room when they had to convince doctors his fever came from a diabetes-related infection. “They wouldn’t take my word,” he said. The couple did not see it as discrimination, more like dismissiveness.
Now, Moss goes to a clinic run by Martin Luther King, Jr. Community Hospital, which serves a large Latino and black population in South Los Angeles. On a recent visit, his doctor asked if he was staying off the foot with the wound. “I just get up when I have to go to the restroom and to get in and out of the bed,” Moss responded.
Moss hopes someday he will be able to do more – get back to taking his grandsons to Chuck E. Cheese or playing dominoes with friends.
“I just sit here all day long,” he said.
‘The Most Shameful Metric’
Amputations typically start with poorly controlled diabetes, a disease characterized by excess sugar in the blood. Untreated, it can lead to serious complications such as kidney failure and blindness.
People with diabetes often have reduced sensation in their feet, as well as poor circulation. As many as one-third of people with the most common form – Type 2 – develop foot ulcers or a break in the skin that can become infected.
Amputations occur after those infections rage out of control and enter the bloodstream or seep deeper into the tissue. People with diabetes often have a condition that makes it harder for blood to circulate and wounds to heal.
The circumstances that give rise to amputations are complex and often intertwined: Patients may avoid doctors because their family and friends do, or clinics are too far away. Some may delay medical visits because they don’t trust doctors or have limited insurance. Even when they seek treatment, some find it difficult to take medication as directed, adhere to dietary restrictions or stay off an infected foot.
Californians with diabetes who have a regular place to go for health care other than the emergency room are less likely to get amputations, according to an analysis conducted for Kaiser Health News by the UCLA Center for Health Policy Research. If they have a plan to control their diabetes, they also have less chance of amputation.
The analysis shows that many amputations could be avoided with better access to care and better disease management, said Ninez Ponce, director of the center. “It’s the most shameful metric we have on quality of care,” Ponce said. “It is a health equity issue. We are a very rich state. We shouldn’t be seeing these diabetic amputations.”
An amputation often leads to a cascade of setbacks: more infections, more amputations, decreased mobility, social isolation. Research shows as many as three-quarters of people with diabetes who have had lower-limb amputations die within five years.
The health system bears surprisingly large costs for what remains a relatively uncommon problem. A single lower-limb amputation can cost more than $100,000. By far, government programs – Medicaid and Medicare – pay for the most amputations.
Experts say the best bet is to intervene well before they become necessary. People with diabetes are “very much in need of the simplest, basic, cost-effective, easy-to-implement treatments,” said Dr. Philip Goodney, director of the Center for the Evaluation of Surgical Care at Dartmouth.
Along with basic measures to control diabetes, regular foot exams are key. The Centers for Disease Control and Prevention estimates somewhere between 11% and 28% of people with diabetes get the recommended podiatric care, a yearly foot exam to check for loss of sensation and blood flow. Under federal rules governing Medicaid, the government program for low-income Americans, such care is optional and not covered by every state.
California includes it as an optional benefit, limiting access to such care. An analysis by UCLA researchers estimated that the use of preventive podiatric services saved the Medi-Cal system – California’s version of Medicaid – up to $97 million in 2014, based on avoided hospital admissions and amputations, and that savings could be much greater if more patients had access.
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