My name is Tony Kreit. WELCOME to my website.
I intend to use this page for ongoing discussions:-
You can contact me on – [email protected]
Or you can use – [email protected]
Contents
[1] Continuous blood glucose monitors. My Dexcom G6
[2] ‘Diabetic foot ulcers part (i) (2b) Granulation – Over- granulation.
[3] Diabetic foot ulcers part (ii)
[1] HEALTH MATTERS
Post 19 May 2021
MY Dexcom G6 continuous blood glucose monitor.
I have now decided to name my Monitor as a Dexcom G6 because I have recently downloaded the Clarity Dexcom Diabetes Management App. onto my Laptop. This management programme enables me to upload to my computer the stored information contained in my Dexcom G6 monitor. This gives me far more information about my diabetes than I could have ever thought possible for a Diabetes sufferer to have. I now have the full range of 8 different reports from this management App. I have long maintained that the sufferer of any illness has a personal responsibility to help to control it as far as his/her abilities allow and under the management and advice of his/her doctors.
I received a phone call from a G.P about two weeks ago. This was to discuss my latest set of blood tests. My HbA1C came in at 41 mmol/mol – IFCC standardised. That had been the case over the period that I have been using my Dexcom. She described the readings as non-diabetic. This means that I am controlling my diabetes at just within non-diabetic ranges. I must emphasise that I do not use my web-site to promote anything on a commercial basis. I have mentioned the make of my device simply because it more than meets my personal needs and expectations. For that reason I would hope that the NHS as well as Diabetes UK would come to understand just how much money it would save the Health Service by promoting such devices as part of the services that they offer to any diabetic who is using insulin.
CONTINUOUS BLOOD GLUCOSE MONITORS My Dexcom G6. Part2
Diabetes is an illness that Never sleeps. There are no remissions other than the ones that YOU construct through your own behaviour. For years my blood glucose levels have been within the ranges advised for diabetics by the medical authorities. Nonetheless my body has suffered a whole series of side effects which have been costly both to my health as well as to the NHS, very much so to the NHS. I have needed to use some five different hospitals and eleven separate clinical services within those hospitals. This is all because it is impossible for the diabetic to keep the glucose level in his/ her blood to within the very tight range that the ‘normal’ human body manages very nicely.
A continuous Blood Glucose Monitor gives you very much more information than the old ‘prick and stick’ method. Firstly one can set upper and lower warning levels on the device so that it with give out an audible warning together with a vibration whenever your glucose levels move outside the ranges that you have set. I regard the upper one as advisory and have lowered it gradually over the time that I have used the device. That helps me to adjust my behaviour accordingly, eating and exercise for example.
My device also has a central dial with a pointer that tells me of the direction of travel of my blood glucose. Moreover it is equipped with a small screen that draws a trace of the glucose levels in my body over the past two and a half hours.
All these various readings amount to a device that is giving ‘Bio Feedback’ information of the highest value to me, the user. I know very clearly just how each meal behaves in my body. This is all information that enables me to vary my behaviour with confidence.
Prior to August of 2019 my body itself would give me very clear warnings of an approaching low in my blood glucose. Following a series of infections which needed treatment by many antibiotic combinations I totally lost this ability. Going to bed at night became a matter of concern and quite dangerous in fact. I began to use many more Blood Glucose Test Strips than previously; subsequent to which the fingertips of my left hand became unbearably sore.
My Continuous Blood Glucose Monitor removes both the worry as well as the need for sore finger tips. If the glucose level drops while I am asleep my ‘little friend’ on the bedside cabinet wakes me up!
I have not mentioned here the Name of the Device that I use because this is not a sales pitch. What it is, is an attempt to make people aware of how valuable these pieces of equipment would be for Diabetes sufferers of ALL varieties. I am Type two but I have unwillingly cost the NHS huge sums of money over the years. I am convinced that that will not be the case for future diabetes sufferers of this invasive and devastating disease if they are provided with these devices as well as the training to use them properly. Since I have been using my monitor my HBa1C results have been 41mmol/mol which is at the top of the normal range. This gives me a nice straight graph between mid- April 2020 and 31 March 2021. Added to this figure I know that the range of levels to produce this average has narrowed.
For My Diabetes Journey Please read Under the ABOUT section:-
MY Feelings about the terminology ‘Diabetic Foot Ulcer’.
‘Diabetic Foot Ulcer’ is a term that is frequently heard and, which in my experience has led to harm to me. I claim that there is a tendency for medics of all levels to see the diabetes first and the ulcer second because of this usage.
I suffer from both Diabetic Retinopathy and Diabetic Neuropathy. I can accept these terms because these conditions occur as a direct consequence of the Illness Diabetes. Foot Ulcers do NOT! They are caused often by carelessness but are made more difficult to treat because of the Illness. There is a huge difference between the two. I have had disagreements with several medics over this terminology because they refuted my argument that its use often informs the treatment and and can actually mislead it.
I have had five ulcers on my feet over the past eight years and they have always been through someone’s carelessness usually, but not always, mine. For me the danger is through the language of the term which places the disease before the injury in question. I maintain that my feet have never had diabetes. I have the diabetes and through my own negligence on three of the occasions my poor old feet have suffered through ulcers which have been affected badly by, but not caused by, my diabetes. In that way I place the guilt for the Ulcer itself firmly where it lies; with yours truly. The subsequent misguided treatment however lies firmly at the door of others.
The first occasion was some eight years ago when I needed an operation on my left ankle. The calcaneus which is one of seven tarsal bones that make up the foot and had split vertically. The calcaneus is a short bone which forms the structure of the heel, it is a type of bone which it is about as long as it is wide. At first the medics thought that the Achilles tendon had snapped but an X.ray showed clearly that the tendon was still attached to the bone but was pulling the two pieces of bone apart. After the delicate operation to pin the calcaneus together had been performed there was a period of some weeks when the foot and leg were in plaster. The operation was a difficult one which had required three entry points around the ankle. (I still have the scars.) These entry points were all quite close together. When the plaster was removed it was very strange that all but one of the entry wounds were clearly healing very well. The moment that the surgeon saw that one wound was not healing he claimed emphatically “It’s the diabetes!” I pointed out quickly and politely that it was barely an inch from the two which were healing perfectly. “How can that be?” To give him credit he looked at me and grinned hugely and began immediately to examine that wound more carefully. His tweezer action needed some review forcing me to wince a bit as he worked but, after not many seconds he pulled out a small object. “What we have here is a stitch infection.” And there we have it. Don’t blame the Disease First! The wound did take a while to heal after that but that was due to a process called ‘over granulation’ which I will explain below with information gained from a reading of the American Journal of Medicine.
Medicine of course has its own language of medical terms and that is a it should be. Medics though use them very frequently without explanation. One of these that confused me during the observations regarding the ‘newly’ defined status of the wound on me heal was that of ‘over-granulation’. The terms ‘granulation’ and ‘over-granulation’ are not expressions that are common to everyday usage. When they were first used in my presence I asked their meaning. Granulation, it was explained is the four stage process that the body undertakes during the normal healing of a wound. It is moreover far more complicated than the term ‘four stage’ explanation would imply. ‘Over-granulation’ is a term that was never satisfactorily explained to me until I consulted Dr. Google and the American Journal of Medicine. Simply put, I have taken it to be that for one or more of a range of reasons the natural healing process is disrupted. For a short further explanation see (c) below:
The second occasion where a diagnosis of DIABETIC ulcer caused me a great deal of suffering, discomfort and inconvenience sprang directly from the first. The ulcer did heal once we began to get the hang of why it seemed to be taking longer than it should. The answer to that was provided from my reading about ‘over granulation’. I will come back to that when I have finished with Ulcers.
The initial break in the heel of my foot had been pinned by the surgeon with two pins the heads of which were contained just under the surface of the skin at the back of my left heel. My foot was so swollen after the operation that I did not notice them or feel any effect from them at first. After a while the swelling began to diminish which was much to my relief because it meant that I could begin to use my normal footwear; this included my walking boots. At the first opportunity I went on a country walk with some friends. On the return home I discovered to my alarm that my left sock was very bloody at the heel. On examination I was realised quickly that the cause lay with the heads of the pins which I could now feel clearly through the skin. When I managed to make an appointment with a GP the diagnosis was made that the ulcer, that had developed from the initial broken blister after the walk was as a result of my diabetes. My request to be referred back to the surgeon was not acted upon at that stage. For nearly two years my heel ulcer was treated as a ‘Diabetic foot Ulcer’ by one of the practice nurses. Eventually one of the GPs sent me for an X-ray to check for osteomyelitis. At that X-ray session I was able to have look at the image which confirmed my own long held conviction. The heads of the pins were clearly visible bang against the interior wall of the skin of the heel. Any pressure from any movement of the foot caused the pins to aggravate the heel from the inside. I did ask my GP to take a look at the X-ray for herself, the X-ray department being only 50 yards away along the corridor. That, apparently, was not possible.
The X-ray also confirmed that no osteomyelitis was evident Again I requested a referral back to the surgeon. However, yet again, this request for a referral back to the surgeon was not taken up; that is until I managed to have a conversation with the senior practice nurse. This did have some effect because I later heard that she had persuaded the senior G.P. that my request for a referral should be agreed. I saw the surgeon who had his own X-rays taken there and then. He agreed that the pins needed to be removed. That done my ‘Diabetic foot Ulcer’ responded quickly to dressings and that part of my body is now working well. “Touch Wood!”
I have to say at this point that the whole event came about as a series of misunderstandings and that I have the greatest respect for all concerned. I have not named any person involved in this saga for that reason. I am writing this here solely to draw serious attention to my claim that feet do not contract diabetes but that people do! It was my responsibility to protect my feet from the initial injury. These were however just two reasons for my strong dislike of the term “Diabetic foot Ulcer”. I will outline a further three events in (d) below after short discussion re Over Granulation. Tony Kreit 29-03-21
(2b) Over Granulation.
re – Over-granulation of wounds; I have decided to write this brief explanation here because it is directly connected to the initial treatment of the “Stitch Infection” incident which certainly slowed the normal healing process; whereas the diabetes did not!
What then is over-granulation? My understanding from my reading from the American Journal of Medicine is that it is an excess of granulation tissue that rises above the surface in the wound bed and therefore hinders healing. This is an aberrant response with overgrowth of fibroblasts and endothelial cells with a structure similar to normal granulation tissue. It has a spongy, friable, deep red colour appearance.
Over-granulation can be caused by a number of factors. You can, if you wish conduct a search on Doctor Google for the complete list. One of the main factors, however, that hit me full in the face is that it can be caused by an unwarranted delay in the normal healing process. In my case I identified the “Stitch Infection” incident as the probable cause of the Hyper-granulation or over-granulation.
One basic treatment is to use a dressing that bears down on the excess of tissue rising above the surface of the wound bed so that it begins to heal where it should, i.e. at the surface of the surrounding tissue. This may sound crude to the trained medic but all I can add is that; IT WORKED FOR ME!
(3) ‘Diabetic Foot Ulcers part (iii)
The third occasion for the diagnosis “Diabetic Foot Ulcer” came directly from an otherwise wonderful holiday we took in Jersey. The fact was that on this occasion the responsibility for casing the initial blister was entirely my own. Any subsequent treatment shortcomings were not.
The holiday trip to Jersey took place in the summer about five years ago. ON the very first full day of the holiday I wore a seemingly innocuous blister on the fifth toe [the little one] of my left foot. The blister was on the under part of the toe. We purchased some ordinary sticking plaster from a chemist shop and felt that that was all that would be needed. WRONG!
I decided that it would be safe to swim in the sea because, as the common understanding goes, the sea is salt and therefore safe for swimming with a minor injury such as a small blister. I know now that my blasé understanding of the situation was severely misplaced. I swam in the sea most days during that two week holiday. The fact is that the blister did not improve. I must also have picked up a secondary infection that was eventually diagnosed as osteomyelitis.
The immediate and predictable diagnosis was, of course, “Diabetic Foot Ulcer”. Almost every medic I saw over the next couple of months referred to the difficulty in treating my toe because of my diabetes. My argument that real difficulty was due to its position on the underside of my little toe. My GP referred my treatment to one of the surgery nurses and this continued for a while. At the same time I had been referred to a podiatry service for general oversight of the condition of my feet. After a very short time one of the podiatrists expressed a concern that the toe might be developing osteomyelitis and sent an immediate Email to my GP. An Xray was arranged and the diagnosis came back with a confirmation of osteomyelitis in the fifth toe of my left foot. The toe continued to be treated by the practice nurse whilst I was treated with anti-biotics for a couple of weeks but a second Xray revealed that the osteomyelitis was still present.
Over time I have come to the conclusion that there are some people who just cannot ‘feel’ pulses. The podiatrist was perhaps the best. She was able to detect a good pulse in the foot both manually and with the doppler machine. That device is so reassuring when you hear the strong swish – swish it makes when it detects a strong pulse against all other opinion.
One of the GPs had already advised me that he was going to refer me to a specialist team at a local hospital but each time I phoned the surgery I was told that there had been no response. This went on for weeks and I became quite concerned that the toe might have to be amputated or even worse if the infection were to spread.
I did eventually receive a letter advising me that arrangements has been made for me to see a doctor at a local private hospital. I was somewhat dismayed at this because from the style of the letter it was clear to me that the gentleman was surgeon. I did go to see that doctor but it was clear from his attitude that he felt that the only way forward would be to amputate the toe. I thanked him and returned home and immediately phoned the surgery to see another GP for a second opinion.
I was becoming really desperate and quite angry when following that GP session I received a further letter from a gentleman at a different local hospital who was yet again clearly a surgeon. I telephoned his team to confirm that and politely refused the appointment. I felt both very angry and even more desperate by this time but that very morning I received a ‘phone call from the endocrinology department that I had wanted to be referred to at the very beginning of this trail. They asked if I could get to se one of their Doctors that very afternoon! With great relief I accepted that appointment. I had fortunately been taking all the while and by prescription a supply of antibiotics. At the beginning this was Clindamycin after a while the GP switched me to flucloxacillin. This was what I was taking when I saw the endocrinologist consultant that afternoon.
I saw a senior nurse at first and she suggested that I had been taking the correct antibiotics but that I should perhaps be taking both at the same time thus giving the infection a real push. The Consultant then appeared. He was a jovial man which helped to break the general atmosphere of doom and gloom that had developed around the idea of amputation.
“No!” he said smiling at me after he had taken a good look at my gleaming toe digit. “I think that we need to give it a bigger whack than that in order to bring the odds back in our favour.” He continued wit his quiet, smiling, delivery; “I am going to ask your GP to prescribe a serious regime of flucloxacillin. Your going to have to take one gram capsules four times a day for the next eight weeks.” He paused for a moment to let that sink in. I knew the beast well and it can churn your stomach much more than any big-dipper. “Yes I know.” this when he noticed the look on my face. “It has to be done! You want to keep the toe?” “of course.” “I’m also going to ask your GP to arrange for blood tests and Xrays at the beginning, the middle and at the end of the eight weeks. You should see some progress at each stage.”
And that was the story of my third experience of the tendency to treat the disease rather than the injury.
Diabetic Foot Ulcers part [iv & v]
I have included two ulcers as a group of one because they occurred one after the other and in similar circumstances and close together in terms of time. They do, taken together, demonstrate for me moreover the innate deficiency in the term “Diabetic Foot Ulcer”.
Before I continue with this claim I must admit, readily, that I was at fault for the creation of each of these two ulcers. In each case though and almost perpetually I felt that medical attitudes placed the illness before the injury.
The basis of the first ulcer was created in a single day whilst my wife and I were on Holiday with our two sons in Sri Lanka in October 2018. The weather was very hot and we did quite a bit of walking during the day. When I removed my footwear in the evening before dinner I discovered to my dismay that I had worn a blister in the arch of my right foot. Due to the diabetic neuropathy in my feet I had felt no discomfort during the day. My wife and I treated the small blister as best as we could with the limited resources on hand. I made contact with my GP and a podiatry team as soon as we got home. It was not a large wound but was in a very unhelpful position. Nonetheless I was hopeful that it would improve quickly because Joyce and I were due to go on holiday in the coming February 2019. All I can say is that it got no worse. We decided that it would be safe to go on holiday. It would be our third trip to Argentina. We have friends in Buenos Aires and I also wanted to make a trip across the River Plate to Montevideo.
On the first day in Buenos Aires we decided to make a trip into the city. This was a bad decision because the local news program had warned viewers that the city “Would be Like an Oven!” that day. In fact it was a very hot 36 degrees. On inspection later that morning back at the hotel I discovered another small blister; this time on the little toe of my right foot. It was therefore just a few inches away from the first injury, by now defined as an ulcer, on the same foot. We were in a big city this time however and, fearing after a few days that the small wound had become infected we went to a local private hospital and purchased some anti-biotics.
Once home, of course we got back to the usual definition of DFUs but I was referred by my GP to a local specialist diabetes centre where I was seen by an endocrinologist consultant. By this time the most recent of the two ulcers had all-but healed and was hardly needing the very small plain dressing we were using, more to protect it from further abrasion inside my footwear than for any further medical reason. The doctor though, as soon as he saw the remaining ulcer; no larger at that stage than the second ulcer had been when we returned from Argentina, pursed his lips and made the immediate Diagnosis “DIABETIC FOOT ULCER!”. I felt really aggrieved at this because in simple ulcer terms the second of the two had almost healed. The one that he was looking at had had about four months extra in which to respond. “Surely,” I tried to point out; “It’s the position of the ulcer that’s important. The second of the two has almost gone and they’re only a few inches apart. I feel that I may just need something that will take the pressure from the wound when I move, when I walk. “.
I felt that the doctor simply ignored my attempt at comparing the healing rates of the two ‘ulcers’ because he looked at me as If he had not heard a word that I had said. He ended the consultation by advising me that he was going to refer me to the centre’s foot care team and that I would get an appointment within the next two weeks.
I never did receive and appointment from that clinic. I wrote two letters and made several phone calls asking what was happening. Finally it was made clear to me that they would not be offering me an appointment because I lived in an area where my local Care Commissioning Group had no contract with them. This was after several months during which the ulcer had been deteriorating very seriously. I made a complaint about the Clinic to my CCG who took the matter up with the Clinic and proper arrangements were established.
My GP was as exasperated as I was. She referred me to a Consultant Vascular Surgeon who saw me within a few days. He did not mention my Diabetes once during the consultation. He examined my pulses both manually and via doppler. “Your pulses are fine. Just keep off your feet for two weeks and the ulcer will heal itself.”
That man was the first doctor that I could remember who had examined me without referring to my diabetes first. He examined my wound, my ulcer, advised me that my pulses were good and that the ulcer would heal quickly if I did as I was told. I followed his advice and with my wife’s help and support I did do as I was told; the ulcer did heal quite quickly, not in two weeks but the progress was tangible within that time. With that doctor’s words ringing in my ears my foot was without its ulcer in about four weeks. No medical treatment other than total rest. Makes you Think!!! T.K (20-06-21)