Essential #5 of Your Diabetic Foot Team: Be Prepared to Surgically Drain Infection or Remove Gangrene.

In these discussions, we discuss each of the 7 essential skills that your diabetic foot treatment must possess. As an educated patient you will be able to evaluate the competency of your treatment team. Having a competent team will help you prevent an amputation related to your diabetes.

Today we will discuss essential skill number five:

5. If necessary, be prepared to surgical drain any infection or surgically remove any dead tissue (gangrene) at the bedside (debridement).

This is a topic that is not for the squeamish. So prepare yourself.

All amputations in diabetic patients start out as some type of foot infection. The foot infection becomes worse, the bacteria rages out of control, and gangrene sets in. Gangrene is a scary term but simply means death of tissue. Dead tissue happens to be a fabulous medium for bacteria.

This skill is the one most typically referred to as “limb salvage.” If you look up the word “salvage” in the dictionary, you will find “property saved from destruction in a calamity (as a wreck or fire).”

Only by aggressively removing infected and dead tissue can the destruction of a diabetic foot infection be halted.

Emergency surgery is very common in treating diabetic foot infections. The very best way to treat a bad diabetic foot infection is by physically removing the infection…not by giving antibiotic pills. This means opening any area of infection to remove all of the bacteria. The infected compartment of the foot has to be irrigated. This is in addition to antibiotics, not instead of antibiotics.

Your team must be prepared to perform emergency surgery if the infection is bad enough that it is deemed a “limb threatening infection.” You have to keep in mind that the diabetic patient has an immune system that is weak. Because of this one is often unable to fight off an infection.

You have to also remember that poor circulation in the feet and legs (called peripheral arterial disease) is very common in diabetics. Most people with diabetes who are at high risk of a diabetic foot or leg amputation suffer from problems with the circulation in their legs and feet. Any antibiotics are delivered through the bloodstream. So poor circulation means poor delivery of the infection fighting antibiotic drugs.

In 2005, there was a research paper published in medical journal that discussed the risk of hoping to avoid surgey in diabetic foot infections. The article was entitled “Osteomyelitis of the Foot and Toe in Adults Is a Surgical Disease Conservative Management Worsens Lower Extremity Salvage.”

Osteomyelitis is the medical term for a bone infection. The point of this paper was to stress to physicians that hoping for the best and just giving antibiotics does not work. In fact, as the title suggests, that actually makes things worse. Surgery is necessary in order to save a leg from a diabetic foot infection.

Diabetes is a scary disease. Diabetic foot infections likewise can be simple or complicated. In either case, an evaluation is warranted given the potential for the loss of a limb. This should never be taken lightly. Keep in mind that most diabetic foot ulcerations do not need to end up as an amputation.

Although all of this talk about surgery, infections, gangrene and amputations can certainly be alarming, you should remember that your diabetic treatment team is on your side. As long as they are vigilant, you should be able to avoid any of these complications. Make sure you get an evaluation early whenever you notice an open sore. And if necessary, evaluate your team based on these criteria.

Diabetic foot amputation is preventable. Live long and enjoy your life!


Dr. Christopher Segler is an award winning diabetic foot specialist. Although he has performed diabetic foot amputations, he still believes that diabetic foot amputations result from the dismal performance of a failing health care system that prevents adequate patient education. It is his passion to teach strategies that can stop diabetic amputations. You can learn more by requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://www.ineedmyfeet.com.

Why don’t you accept insurance?

Before I went to medical school and I would go see a doctor, I always thought that the insurance company was on my side. I would receive an explanation of benefits that showed that my insurance company had gone to bat for me and dramatically decreased the fee that the doctor was “allowed” to charge me. It made me feel as though they were protecting me from the doctor who is out to “overcharge” me.

Having been a foot doctor and surgeon in private practice who did at one time accept insurance, I realized that the insurance company is only interested in protecting their profits. In fact, the CEO of United Insurance company once stated that the insurance company would never attempt to keep doctors on the insurance plans at the expense of their profits.

Some insurance companies contracted rates that they offer as pay to doctors are so low that it is simply impossible to provide good patient care.

I once received a package via FedEx in my office from an insurance company. The delivery person said that I needed to sign for the package in order to receive it. When I opened the package there was a contract modification that dramatically reduced the rate the insurance companies said they would pay me for taking care of their members. Unbelievably, at the end of his contract was a paragraph that stated that by signing for receipt of the package constituted agreement to all of the conditions contained within the contract inside the package. It is absolutely ludicrous to think I would have agreed to rates without ever even opening a package. But these are the games that the insurance companies play.

The insurance company industry representatives have stated that any doctor should be able to see a patient in five to seven minutes. If you’ve ever been to the doctor, this is ridiculous. Now having said that, I have worked in clinics where I saw 60 people a day. I also believe that the patients did not receive quality care.

What I believe is quality care is providing evidence-based medicine as well as thorough explanations and patient education. All of this is necessary in order for a patient to participate in their own care. Providing a prescription for an order for an MRI or just an recommending that someone return in a few months is not really providing care.

Anyone with diabetes or any complicated medical condition deserves to have explanations. They also deserve to have their questions answered. And they certainly deserve more than five to seven minutes.

I have had multiple other doctors contact me and ask me for surgical second opinion on the patient. I have had many cases where these patients clearly needed a procedure that the insurance companies said they would not pay for. Those doctors then asked me what the second-best procedure was. I would supply them with my opinion. In most cases these other doctors would say, will you please come scrub in with me on the procedure that is covered by the insurance company.

In this scenario, my answer was always the same… absolutely not! , I would tell them that if you want to allow an insurance company to tell you to do the wrong procedure just because it cost them less money than you can do it yourself, and I will not participate.

At the end of 2008, I decided that under no circumstances would I allow an insurance company to tell me how long I can spend with the patient. Under no circumstances can insurance company tell me that the cheaper procedure is necessarily better. At least not better for the patient. So I opted out of Medicare and decided to no longer accept any insurance whatsoever.

High quality medical care is expensive. It doesn’t have to be prohibitively expensive, but it does have to provide the best outcome for the patient. Making decisions based only on price is a mistake for the patient. It is also a mistake to the doctor in the long run. A string of bad outcomes (whether because the wrong procedure or wrong medication was chosen) would certainly not be good for any doctors reputation. But when doctors choose to follow the guidelines of the insurance companies rather than their own medical decision-making, this is exactly what happens.

But this is not a problem for me, because I don’t accept insurance. Patient care comes first and cost is second.




Dr. Christopher Segler is an award winning diabetic foot specialist. Although he has performed plenty of diabetic foot amputations, he firmly believes that diabetic foot amputations result from a continually worsening health care system that the force patients to live with the lowest cost treatments and deprive them of patient education. He does not accept insurance assignments of that he has the time necessary in order to provide the education for his patients that can prevent diabetic amputations. You can learn more by requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://www.ineedmyfeet.com.

Evaluating the Competency of Your Diabetic Foot Treatment Team: Essential Skill #1: Assessing the Circulation to the Feet and Legs.

In these discussions, we discuss each of the 7 essential skills that your diabetes treatment team must use in order to help you prevent an amputation related to your diabetes.

Today we will discuss essential skill number one.

1. Assess the circulation (blood flow) to the feet and legs to determine the risk of gangrene.

There is a long-held joke among podiatrists that the only function of the heart is to pump the blood to the feet. The suggestion with this is the over-emphasis on the importance of delivering oxygenated blood to the tissues in the feet in order to keep a diabetic patient from developing a problem that might lead to premature death.

It is a well-researched fact that diabetics develop problems with their blood flow at a much faster rate than other people. This happens everywhere in the body. Through the process known as atherosclerosis (or hardening of the arteries) blood vessels become lined with plaques that are deposited over time. As these deposits increase, the diameter of the inside of the blood vessel becomes smaller and smaller, effectively decreasing blood flow.

This has been well documented in the coronary arteries of diabetic patients. We know that if you take two patients (one who is diabetic and one who is not) who are otherwise identical, the patient who has diabetes is four times more likely to have a heart attack. In large part this is due to the accelerated rate of atherosclerosis.

This same process occurs in the arteries of the feet and legs. Because of this process, the blood flow to the feet is dramatically reduced over time. Without blood flow, there is no oxygen delivered to the tissues. Without oxygen tissues die. Gangrene is nothing more than death of the tissue. Gangrene is one of the leading causes of amputation among diabetic patients.

With all of this is in mind, it is very easy to understand why your doctor must assess the blood flow to your feet. There are many ways to do so.

The simplest tests (and those most likely to be performed by any doctor evaluating a diabetic patient’s blood flow to the feet) involve a simple physical examination. During this exam, the doctor will likely attempt to feel the pulses behind the inside of your ankles (posterior tibial artery pulses) and on the tops of your feet (dorsalis pedis artery pulses). If the clinician is able to feel these pulses easily, the chances of developing extraordinarily bad blood flow known as critical limb ischemia are very small.

If the clinician is unable to feel these pulses, a hand-held Doppler device will typically be used in order to further evaluate the blood flow. This is a simple easy to perform test that does not cause any discomfort to the patient and can give a great deal of information about the state of blood flow.

More extensive tests are sometimes needed. Other tasks include transcutaneous oxygen pressure measurements (Tcp02), toe Doppler wave form analysis and toe pressures, and arterial duplex ultrasound.

If the results of these studies show severely compromised blood flow, it may be necessary to perform other more expensive exams including computed tomography angiography or magnetic resonance angiography. These are tests that use either CT scans are MRI evaluations to closely evaluate the state of blood flow in the feet and legs. They can provide an extraordinary amount of information but are oftentimes difficult to get approved by insurance companies due to their extraordinary cost.

The combined results of all of these exams are considered closely with the patient’s history, other physical exam findings and symptoms. In many cases all that is needed is continued monitoring of the patient. However, if findings warrant rapid intervention, it may be necessary to have an angioplasty or arterial stent placement in the leg in order to restore blood flow by a vascular surgeon. Other times an open arterial bypass is sometimes needed.

One thing that is clear is that delays in evaluation of the blood flow to the feet and legs can create huge problems. The most obvious of these would be development of gangrene as a result of critical limb ischemia that would make an amputation necessary.

The bottom line is that any doctor evaluating a diabetic patient should check (at the bare minimum) the pulses in both feet. If you see your diabetic doctor and the he/she does not ask you to take off of your shoes to evaluate the pulses in your feet, you should immediately find another doctor.


Dr. Christopher Segler is an author, inventor and award winning diabetic foot doctor. After discovering how amputations resulted from a failing health care system, it became his passion to teach strategies to stop diabetic amputation. If you have diabetes, you can learn more by requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://www.ineedmyfeet.com.

Diabetic Foot Infection

Today I saw a patient who had a diabetic foot partial amputation only 3 weeks ago. He called the office and said he had a new spot he was worried about. Just earlier this week I had taken out his stitches from the amputation site. He had already been admitted to the hospital, taken to the operation for emergency surgery and then had an amputation.

Today the new spot was a blister right next to the amputation site. He said that his neuropathy causes his feet to feel cold. So he sleeps with a heating pad on his feet. Unfortunately the heating pad caused a second degree burn which since became infected.

So, today I used a scalpel and tissue nippers to trim off the dead and infected tissue. I took some wound cultures from the pus draining out of the blister. That way we can tell what bugs are living in there and causing the infection. I also started him on antibiotics. But his still has an open sore and the potential for another preventable diabetic foot disaster.

This episode illustrates the way additional amputations can happen in a those with diabetes and numb feet. Statistically a person with a diabetic foot amputation will experience re-amputaion in less than 5 years.

In all likelihood, this incident will be less eventful than the last, but it was also avoidable. As with just about every other diabetic foot problem, an ounce of prevention is worth a ton of cure.

Some basic rules:

1. Always check your feet for open sores, red areas or new problems. Check twice-a-day.
2. Never sleep with a heating pad, hot water bottle, or other heat source near your feet.
3. Seek treatment immediately as soon as you see a new sore or detect a problem.

If the antibiotics work, he will stay out of the hospital. If the infection gets worse he will be admitted to the hospital with more of the hideously expensive intravenous antibiotics beating up his already weak diabetic kidneys. If it goes badly he will get diabetic foot amputation #2.

Lets hope for the best.



Dr. Christopher Segler believes diabetic amputations are preventable. He teaches strategies that help his clients avoid amputation. He is also and award-winning diabetic foot surgeon, inventor and author. If you have diabetes, you can learn how to avoid amputation by more by requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://www.ineedmyfeet.com.

American Limb Preservation Society Site is Up!

The new website for the ALPS is now up. It will be full of diabetes facts and information about diabetic foot sores (diabetic foot ulcers), foot infections, and diabetic amputation prevention. Go to www.ineedmyfeet.com to learn more about staying healthy and active, in spite of your diabetes.


Dr. Christopher Segler is an author, inventor and award winning diabetic foot doctor. After discovering how amputations resulted from a failing health care system, it became his passion to teach strategies to stop diabetic amputation. If you have diabetes, you can learn more by requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://www.ineedmyfeet.com.

Diabetic Foot Infection... Emergency Surgery as it Happened Today

Today was one of the days I dread. I was coming out of a treatment room and Sherrie stopped me to ask if we could ad an emergency diabetic patient. A diabetic man man was on the phone. He had called and said his big toe was "black and blue and squirting blood." Never a good sign. I told Sherrie to tell him to either come in immediately or go straight to the Emergency Room.

Twenty minutes later he was in my podiatry office sitting in a treatment room. He was right, it was black and red. But squirting more pus than blood. I started to trim a way some of the thick hard callus to drain the infection. And drain it did, odor and all. Paula, who was assisting me, asked to leave the room.

I explained that he was going to need surgery. I had him sign a consent form and explained what we would need to do. I took some cultures, wrapped up the foot and sent him straight to the hospital to be admitted for powerful antibiotics and to get ready for surgery. I sent over some orders and then saw the rest of the patients.

After I finished seeing all of the post-op bunion patients, heel pain cases, and a guy that almost lost his toe a year ago, I went home to eat with my wife and son Alex. He's going to be a year old next week. We ate dinner and I waited for the hospital to call, to tell me when we could start. After Alex went to sleep, I headed back to the hospital.

In the operating room, I took a scalpel and opened the end of the big toe. The bone in the end of the toe was mushy and soft. I took some pieces to send for culture (to see what kind of bacteria is growing in there). I removed the bone and flushed it out to wash away the pus and bacteria. I packed the end of the toe and wrapped it up.

In a few days we will go back to the O.R. and remove whatever looks dead or infected. Or if all is well, I will close it so he can go home for Christmas.

The reality is that this episode was preventable. With proper monitoring and careful attention to the feet, this man would not be in the hospital. I would have been at home with Alex. He would have been home with his family instead of in the hospital.



Dr. Christopher Segler is an author, inventor and award winning diabetic foot doctor. After discovering how amputations resulted from a failing health care system, it became his passion to teach strategies to stop diabetic amputation. If you have diabetes, you can learn more by requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://www.ineedmyfeet.com.

Statistics on Life Expectancy After Diabetes Leg Amputation from Gangrene

One question I was asked recently is was... What are the statistics on life expectancy after diabetes leg amputation from gangrene?

Well, I wish I had good news. Whenever a loved one gets gangrene, it can be traumatic. Not just for the diabetic who winds up with an amputation, but the spouse as well. The kids, the whole family take a beating emotionally. They see the foot turn black, they smell the foul odor. They watch their loved one go from a lively person to someone who will be luckey to ever walk with a prosthetic leg.

Dancing on your 50th wedding anniversary..nope. Going for 18 holes of golf..nope. Running down the street to teach your grandson to fly a kite...nope. So the patient sees all these things that were taken for granted, drifting away. And the family sees it too. Then they start to wonder about the bigger picture. How long can you live after an amputation?

The statistics regarding diabetic life expectancy after an amputation related to diabetes complications (such as gangrene, diabetic foot infections, and bone infections (osteomyelitis)) are quite bad. Every 30 seconds a limb somewhere is amputated as a consequence of diabetes.

In fact, we know that diabetes makes you 46 times more likely you will have an amputation. Within one year after a diabetic foot amputation, 26.7% will have another amputation. Three years after the first diabetic amputation, 48.3% will have another amputation. Within 5 years of a diabetes related amputation, 60.7% will have another amputation.

If that isn't bad enough, diabetics with amputations don’t live very long. We know that about 50% of all diabetics with an amputation are dead 3 years after the amputation.

65% of all of those with a diabetic amputation are dead 5 years.

In spite of this, there is hope... most are preventable. Watch your blood sugar. Check your feet every day and see a podiatrist, podiatric surgeon, or foot surgeon specializing in diabetic limb salvage if you start to get any open sore or wounds on your feet. Do not wait until it is infected.

With these simple interventions you can keep your feet. And maybe you will dancing on your 50th after all.


Dr. Christopher Segler is an award winning diabetic foot surgeon, author and inventor. He is the founder of a groundbreaking private consulting firm that specializes in diabetic amputation prevention. If you or someone you care about has diabetes, you can learn more by simply requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://www.ineedmyfeet.com.

Diabetic Former Pro Baseball Player. No Legs and No Hall of Fame.

Ron Santo is true icon in baseball. And he has seen some tough times. If nothing else, he knows how to persevere.

If you don’t know him, he has too many records to list. Here are a few. Santo played third base for the Chicago Cubs from 1960 to 1973. During his career, he was a 9-time All Star, won 5 consecutive Golden Glove Awards, and is the only third baseman in history to go 8 straight seasons with 90 runs batted in. In addition he is true team player as evidenced by the fact that from 1966 to 1974 he held the NL record for assists in a single season.

By any measure he should be a Hall-of-Famer. But again this year its not in the cards. "Everybody felt this was my year," Santo told the Chicago Tribune paper on Monday, in his typical gracious manner, even though the years are slipping away.

He is already 68 years old. No spring chicken for a double amputee with diabetes. "To me, two years, because of what I have with the diabetes and [getting] older, it's like eternity," he recently said. He is not alone, because every 30 seconds, another leg is cut off due to diabetes related complications. Statistically, most people who have diabetes are dead within 5 years of having amputations of both legs.

Santos has fought with diabetes for decades, but kept it a secret for most of his career with Cubs. In the late 1960’s he started having trouble. The pro baseball player ended up with the common diabetic sores that led to more than 24 surgeries and partial amputation of both legs. But he still roots for the Cubs from the bench.

"I don't know how he does it; his spirits are always up," said his friend Savelli. "I'm sure he's taking it like a man. Ronnie's a hard-core guy. He has to be to take all he's taken. I'd have been dead a long time ago."

Santos is one of those lemons-from-lemonade types. Whenever he is not working as a member of the Cubs broadcasting team, he is fighting diabetes through community involvement and fundraising. He started the Ron Santo Walk to Cure Diabetes about 30 years ago. Through that effort he has raised $60 million for juvenile diabetes research. He keep high hopes both about a cure for diabetes, as well as his chances for induction into the Hall of Fame.

Personally, I hope he gets both.


Dr. Christopher Segler is an award winning diabetic foot surgeon, author and inventor located in Chattanooga. He is the founder of a groundbreaking private consulting firm that specializes in diabetic amputation prevention. If you or someone you care about has diabetes, you can learn more by simply requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://www.ineedmyfeet.com.

Is Diabetes a Handicap?

Although diabetes is a serious disease, it should only be considered a handicap when it limits the activities that allow you to enjoy life. One obvious way this can happen is through an amputation or blindness. But it doesn’t have to be this way.

Although we know that diabetes can lead to heart disease, stroke, blindness and open sores on the feet that lead to amputation or death, this is largely preventable.

Research shows that regular exercise and a healthy diet are two ways that can help people prevent diabetes, or even to alter the course of a person’s disease if they do already do have diabetes.

One of the very best ways to make sure the diabetes does not become a handicap is with exercise. We know that when a patient has diabetes, diet and exercise can significantly change the way your body uses insulin and help fight the disease. In fact, we know that after 45 minutes of aerobic exercise, such as running, a diabetic patient’s, insulin sensitivity may increase for up to 48 hours. This is extremely beneficial for type 2 diabetics.

Exercise not only changes the way that your body uses insulin, but it can reduce problems associated with cholesterol, blood pressure, risk of a heart attack or stroke and obesity. We know that when a diabetic patient will lose 15 to 20 pounds, it improves insulin levels from anywhere to 30 to 50%. This results in much better blood sugar control that can prevent many of the complications from diabetes that we worry about.

In United States diabetes is the fifth deadliest disease. We actually think it might be much worse than this because people who do have diabetes might die from other complications including heart attack, stroke or complications of an amputation with gangrene related to a diabetic foot sore.

Whether you are a type 1 or type 2 diabetic patient, exercise can provide a tremendous benefit. You just have to be careful and make sure that you manage your blood sugar correctly.

Oral hypoglycemic medicines ( pills to keep your blood sugar down) may also have a significant impact on your blood sugar when you exercise. For example, sulfonylureas (glipizide, glyburide, etc.) and meglitinides (prandin, starlix, etc.) may require dosing adjustments in order to prevent hypoglycemia (low blood sugar) during exercise. Metformin (glucophage) and thiazolinediones (actos and avandia) are less likely to cause hypoglycemia when you exercise. However if you are taking any of these medicines it is important to talk to your endocrinologist or primary care physician to make sure that you don’t get into trouble.

You should also make sure that you get checked by a podiatrist to make sure that you do not have any problems with your feet, such as diabetic peripheral neuropathy ( loss of feeling) that can put your risk of developing the kind of open sore that can lead to an amputation. An annual diabetic foot exam with a podiatrist is a good way to make sure that you are not at risk of an amputation.

And amputation is one sure way they diabetes can become a handicap. Once a leg is amputated, it’s very difficult to move around the home. Even something as simple as turning on a ceiling fan can become a major challenge. We also know that there are a number of risks associated with having an amputation. About half of all patients who have an amputation on one foot will have any vacation on the other leg within five years.

We also know that diabetic patients who have indications on both feet will most often die within five years.

In spite of all this gloom and doom, there is hope for diabetes. There are a number of available technologies which can significantly reduce the risk of amputation of diabetes. This requires intensive intervention from a specialist in diabetic limb preservation. Unfortunately, not covered by insurance, but is essential to making sure that in amputation is prevented.

Although it can be frustrating when you find out you have diabetes, it does not have to be a negative life altering situation. They can be a very positive thing because many of these people will start a new exercise routine, lose weight, and develop a healthy lifestyle that includes athletic activities that they might find intensely enjoyable.

For many of these people, what started out as a bad thing turns into a way to begin to enjoy life. So if you have been diagnosed with diabetes, don’t worry, it doesn’t have to become a handicap.

Dr. Christopher Segler believes diabetic amputations are preventable. He teaches strategies that help his clients avoid amputation. He is also and award-winning diabetic foot surgeon, inventor and author. If you have diabetes, you can learn how to avoid amputation by more by requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://ineedmyfeet.com.