One Alternative to Amputation
by Allan Nichols

From the Editor: Alan Nichols is chairman of the Amputation
Prevention and Treatment Committee established by the
Diabetics Division of the National Federation of the Blind.
He provides support and information to anyone interested in
amputation.

     As a diabetic I've had many physical problems over the
past thirty years.  I became blind in 1978, lost kidney
function in 1979 and I've lost both feet to amputation in
1981 and 1987. In this article which focuses on amputation,
I send a clear message to readers: learn from my mistakes!
Take good care of yourselves!  Take good care of yourselves!
If your medical staff says to do something, do it! Too often
I have ignored good advice and have paid a price for having
done so.  I pray that my experiences and the information I
share will benefit readers.  Information learned today may
be useful months or years down the road.  Again, I implore
you to take good care of yourselves!
     Following the amputations of both feet, artificial legs
enabled me to walk again.  New light-weight designs, high
technology feet, and other prosthetic improvements made
during the last 13 years permit amputees, like myself, to
walk and function fairly normally.  Even so, complications
may arise because stumps do not remain static.  Depending on
the amount of walking, limbs may shrink or expand over the
course of a day, or even in a few hours.  Environmental
temperature and internal factors can cause problems with the
way legs fit and feel.  To prevent development of pressure
points and sores, I have a constant battle maintaining a
comfortable fit.  I am usually successful, but on a few
occasions, sores develop causing me a great deal of
suffering as well as inconvenience.
     My first experience with this kind of problem occurred
during the 1989 National Federation of the Blind Convention
in Denver, Colorado.  I remember that particular week
because each day the temperature exceeded over 100 degrees.
The combination of heat and a great amount of walking caused
a sore to develop on my right stump which quickly became
infected.  Abandoning any plans I had to attend the final
day of the convention, I returned home and entered the
hospital where the sore was surgically closed and the
infection was treated with antibiotics.  This sore, which
took three months to totally heal, and another major set
back six weeks later, put a major crimp in my plans and
prevented me from completing my training and the Colorado
Center for the Blind.
     Four years later in the fall of 1993, my five-year-old
artificial legs no longer fit properly and caused another
sore to develop in the same place.  I needed a new
prosthesis, but I had to wait for funding for my new legs to
be approved by Wyoming's Vocational Rehabilitation Service.
Such funding covered a substantial portion of the cost --
$3600 of over $13,000 -- which wasn't picked up by Medicare.
Meanwhile, the sore on my stump increased in size.  Funding
was eventually approved and I got my new prosthesis, but the
skin-deep sore could not heal properly inside the closed
environment of my new prosthetic leg.  In spite of my best
attempts to keep the wound site clean, it slowly worsened.
Realizing I'd have to spend a lot of time in a wheel chair
or use a walker, as I had done five years earlier, I kept
putting off proper treatment; I didn't want to spend any
significant time off my feet.  Had I known what I know now,
I would have gladly taken a month or two off -- off my feet
-- instead of spending twice that amount of time to heal the
wound later.
     About the same time, I began to experience acute pain,
due to neuropathy, in the fingertips of my right hand.  In
fact, my fingers became so uncomfortable that I sought
relief at the Wound Care Center in Fort Collins, Colorado.
Doctors weren't able to do anything for my hand except
prescribe pain medication.  I still suffer occasional
soreness in my fingers as I await the full resolution of
this problem.
     However, it is quite a different story with my leg
because circulation is much better in my leg than in my
hand.  The improvement is due to a fairly new treatment, a
substance called Procurin.  It is manufactured by drawing
blood and processing it in the lab to concentrate growth
factors.  The product is frozen single-application plastic
tubes which are stored in a freezer.  Thawing takes place on
the day of usage.  Once liquefied, it must be used within 24
hours.  After exposure to room temperature, Procurin must be
used within fifteen minutes and the remainder discarded.
Because it is made from one's own blood, it can't be used on
anyone else.  Kept moist with a soaked strip, the wound is
covered and sealed with a Vaseline gauze patch.  The site is
wrapped with loose-fitting gauze and then taped.
     The application of Procurin resulted in positive
indications that my leg wound had begun to heal.  After
spending a lot of time off my feet, it became evident that
my leg was healing faster.  I used my prosthetic leg
sparingly and my wound continued to heal steadily.  During
each trip to the Wound Care Center, the staff and Dr. John
Martinez photographed and measured the wound to record
healing progress.
     At a particularly critical juncture, I made a major
mistake which dramatically set back my progress.  During the
July 1994 convention of the National Federation of the Blind
in Detroit, I walked excessively just as I'd done in Denver
five years earlier.  At home, I usually walked two or three
blocks per day, but at the convention, I walked two to three
miles per day negotiating my way around the massive hotel
complex in Detroit.  After four days of constantly walking,
my legs let me know in no uncertain terms that I couldn't
walk any further.  The convention nurse treated my leg with
Procurin and noticed that my right leg stump was infected
and my left stump had a silver dollar sized blister.  I
developed a low-grade fever.  For the next four days, I
traveled around the convention using a wheel chair.  Had I
been thinking rationally, I would have gone home and had my
legs treated immediately.  But, being hard-headed, I chose
to stay at the convention until the very end.
     Back home in Cheyenne, I spent a full week in the
hospital while the infection was treated before returning to
Fort Collins for additional treatment.  Prior to my Detroit
trip, the wound had been nearly healed.  Now, with the
increased depth of the would, healing would take an
additional two to three months.  While exploring alternative
treatments, a plastic surgeon suggested creating a skin flap
to cover the injury, but later he said that procedure
wouldn't work due to the lack of healthy tissue which keeps
the flap viable.  With no other treatments available, Dr.
Martinez encouraged me to use Procurin again.  Along with
other predictive tests, the doctor conducted an oxygenation
test.  A base rate of 30 indicates that a wound has a fair
chance of healing.  Although the reading was nearly zero
around my sore fingers, the area around the wound site on my
leg had an initial reading of 43 in May.  By July, the
reading was an encouraging 53.  The text showed that the
wound would eventually heal.
     In many cases, using Procurin will prevent the need for
amputation.  Had the treatment been available in 1981, or
1987, I might not have lost my feet.  Today, this procedure
gives many patients an alternative to amputation.  In fact,
it can make amputation unnecessary.
     In many wound care centers across the United States,
treatment includes procedures and techniques which are much
less radical.  Procurin certainly isn't inexpensive.  It is
usually tried after all other alternatives are exhausted.
The retail cost of the medication is around $80 per dose.
Fortunately, for the vast majority of patients including
myself, wound care centers often subsidize the costs.  About
98 percent of patients pay from $0 to $20 per dose.  Cost to
the patient depends on income and insurance coverage.  In my
case, Poudre Valley Hospital in Fort Collins, Colorado
covered the expenses and I only paid for the doctor and
nurses who followed my progress at the Wound Care Center.
     At home, my wound is treated twice each day by home
health care nurses.  Because Procurin is only effective for
about twelve hours, the soaked gauze must be alternated with
a saline dressing which, in effect, gives the growth factors
a rest.  Because I am on Medicare, the costs of the
treatment in my home are covered 100 percent.  Home health
care is different than many other medical costs which
involve a Medicare patient, who must cover up to 20 percent
of the average medical bill.
     Ultimately, it boils down to what a limb is worth to a
person.  Often the costs of an amputation exceed the costs
of treatment of a wound, even over a protracted period of
time.  The loss of one's limbs also has a traumatic
psychological and functional effect.  Having already been
through this process twice, I can say that it certainly was
no fun losing my feet.  Procurin is now another alternative
in the arsenal which modern medicine has to treat the
ravages of diabetes and other medical conditions which
threaten the loss of limbs.  For more information about
Procurin and wound care treatment, I encourage everyone to
contact his/her local wound care center.  I would be glad to
answer any questins readers may have about my experiences
with the treatment, wound care, or amputations.  For
information contact: Allan Nichols, 1885 Cherry Curt, Apt.
C, Cheyenne, Wyoming  82001; or call (307) 638-8037.
