4 amputations before he mends his ways

Prevention is always better than cure.
 
SINGAPORE - In about eight years, he went through not one, not two, but four amputations on his right leg.

Mr Heng Liang Hai, 63, a former carpenter, was diagnosed with Type 2 diabetes about 30years ago and he did not manage his condition well at first.

Between 1995 and 2003, Mr Heng had two toe amputations and two lower-limb amputations.

First, it was his ankle, then the knee.

Said Mr Heng in Mandarin: "It was only after that last amputation that I realised I had to take care of my health."

Diabetes remains a major health issue with one in three Singaporeans developing it by the time they are 69, Professor Chia Kee Seng, the dean of the NUS Saw Swee Hock School of Public Health, told The Straits Times in an earlier interview.

Although the number of amputations caused by diabetes has been decreasing, doctors said more can be done.

Figures from the Ministry of Health (MOH) showed that from a high of 717 in 2004 (an average of two amputations a day), it dropped by 36 per cent to 457 cases in 2010.

The New Paper met three diabetic amputees who shared how their lives changed after they lost their lower limbs.

Concerns for the future
One of them, Mr S. Damotharan, 45, who lost his right ankle three months ago, urged diabetics to manage their condition and prevent amputations.

"Try not to lose anything. No point regretting afterwards," said the former canteen operator, who has four children aged between 4 1/2 and 10.

His wife, who works as an assistant engineer, is now the sole breadwinner.

While he maintains a cheerful demeanour, he is concerned about how he is going to provide for his family.

Dr Sathappan, senior consultant in the department of orthopaedic surgery at Tan Tock Seng Hospital, said it is common for diabetics to have microvascular diseases because their blood vessels clog up easily.

This results in deprivation of oxygen and nutrients to tissues in the leg. If left untreated, tissue death or gangrene sets in.

Amputation is necessary because gangrene is potentially life-threatening, said Associate Professor Aziz Nather, senior consultant for foot and ankle surgery at the National University Hospital (NUH).

Dr Bee Yong Mong, director of the Diabetes Centre at the Singapore General Hospital, said toe amputations are the most common, followed by ankle and knee amputations.

Miss Tiffany Chew, a TTSH podiatrist who specialises in the diagnosis, treatment and management of foot, ankle and lower leg conditions, said toe amputations affect how a person walks.

"This results in abnormal pressures on the feet which may lead to ulcerations.

"With the risks of ulcerations being higher, the risk of getting amputation further up on the same limb is definitely higher," said Miss Chew.

Learning not to give up
There is also the psychological effect of limb loss.

To help patients cope with this, SGH set up an amputee support group in 1999.

Miss Grace Lim, the senior nurse clinician in-charge of the group, said: "It was important for them not to give up on themselves, otherwise their health will worsen.

"We got those who had recovered well to come back and visit the patients, inspiring them to live healthily."

Mr Heng, for example, has changed his lifestyle habits. Instead of eating two bowls of rice at mealtimes, he stops after half a bowl.

"I know of another diabetic who is younger than me. He didn't watch what he ate and he's now gone," said Mr Heng.

With his prosthetic leg, he is able to go to the exercise corner near his home every day for 30 minutes and take long walks.

As for Mr Lim Chin Huat, 41, who was diagnosed with Type 2 diabetes in 1988 and lost his left ankle in 2002, he exercises in a different way.

Mr Lim lives in a Sungei Kadut factory owned by a distant relative and his room is so far from the toilet that it takes him at least five minutes to wheel himself there.

"Imagine how bad it is when I get diarrhoea," said Mr Lim, who does not live with his family because he is not close to them.

Type 2 diabetes is caused by the body's ineffective use of insulin to regulate blood sugar levels and the risk of contracting the condition is linked to unhealthy lifestyles.

Mr Lim worked as a driver and security guard for a while but then he suffered kidney failure due to diabetes.

He had to start dialysis and would often fall sick, so he lost his job. His marriage to a woman in the Philippines also suffered as he had limited mobility and finances to travel there.

They eventually got a divorce in 2010.

He will always remember the moment he woke up from his operation: "I felt my life was destroyed. It took me at least two months to come to terms with my loss."

Amputations in numbers:
Number of diabetic patients undergoing lower-limb or toe amputations in Singapore

2004: 717
2006: 597
2008: 466
2010: 457

Breakdown of the 457 diabetic amputations bygender: Two out of three were men (66.3%)

Breakdown of the 457 diabetic amputations by age in 2010:
20-39: 1.8%
40-59: 47.7%
60-79: 42.7%
80 and above: 7.9%

Note: The percentages do not add up to 100% due to rounding error. 


Diabetic amputations are preventable
Up to half of the amputations linked to diabetes are preventable, said Dr Bee Yong Mong, director of the Diabetes Centre at Singapore General Hospital (SGH).

Here are tips from Dr Bee, who is also a consultant at the SGH endocrinology department, and Tan Tock Seng Hospital podiatrist Tiffany Chew:

1. Self-care
Inspect the bottom of your feet and between the toes daily to ensure there is no wound

Wear proper footwear at all times

Thoroughly dry between the toes after bathing or washing your feet

Apply moisturiser daily except between the toes

Cut nails straight across and not too short, then use a nail file (Those who have impaired vision should get help to manage their nails.)

2. Annual foot screening
This is a structured screening process by health-care professionals to identify patients who are at high risk of developing foot complications.

3. Podiatrist care
Specialist care is needed for high-risk patients or those who already show early signs of diabetic foot complications.

Miss Chew said any calluses and corns must betreated by a podiatrist as they are predisposing riskfactors for ulcerations when mismanaged or leftuntreated.

Associate Professor Aziz Nather, senior consultant in the division of foot and ankle surgery at National University Hospital, said Singapore currently does not have many trained podiatrists.

He said there is a need to train assistant nurses and technicians to increase the pool of health-care workers who are equipped to do foot screening and educate on foot care.

NUH runs a foot screening training course for all hospitals in Singapore and also hospitals in the regional countries.

To date, they have run five training classes and trained 116 nurses, said Assoc Prof Aziz.