Paid for It With a Leg
In nursing school, diabetes education didn't make an impression on me. My mind-set did a 180 after caring for veterans with lost limbs. The sequelae of this common endemic is etched in my mid as a life-altering, destructive disease. As a new graduate nurse, it is not unusual for me to see elderly military veterans missing a limb. What is a surprise is learning how that person became an amputee.
Working in a geriatric/long-term care setting, it has become common to care for patients who are missing a leg ... or two. Usually, diabetes is to blame. I used to believe inadequate health education about the sequelae of diabetes was the primary reason for the advanced disease progression. I had the idea that military veterans who sought healthcare for diabetes were not receiving enough information to effectively manage the disease.
It has only been a few months since I began my employment at a VA hospital, and already I learned other reasons why military veterans - mostly men - have lost parts or all lower limbs due to diabetes.
Military Culture
On more than one occasion, I cared for a veteran who told me about their life before the limb loss. Veterans from World War II, Korea and Vietnam performed in a culture that rewarded men who could meet the physical demands of the job. The foundation of military culture is the stoic self; physical virility is the spotlight and independence is embraced for survival.
When their service was over, veterans were hired in civilian jobs that were often physically demanding. Physical strength was the oil to drive the engine of employment for the male as a provider. The stress to maintain the expected role sometimes led to poor health choices. Often, these choices manifested themselves as obesity, which laid the groundwork for diabetes. So, early signs of diabetes - polyurea and polydipsia - were overlooked. A foot sore might have been ignored until it progressed to a deep wound that was beyond home care management and instead became a focus of deterioration of quality of life.
Some veterans are admitted to my facility, the VA hospital in Baltimore, with stage III or stage IV foot sores - sores are so deep that muscle and bone are exposed. After the patient is stabilized, he is transferred to my facility. Patients at my facility are referred to as residents because the focus of care is skilled nursing in a home-like environment.
New Nurse Training
As a new graduate nurse, I have been trained by the facility's wound nurse to change dressings (i.e., bandages) of wounds, particularly stage III and stage IV. At first, it was challenging for me to view deep wounds; it wasn't easy to see a resident's face as I unraveled dressings to reveal deep structures such as the Achilles' tendon and plantar fascia. Not to mention odor.
Complete composure has to be maintained; I cannot wince or grimace at the sight or smell of the wound. I know the resident experiencing it would rather not be in that position, to say the least. This is particularly true of the military veteran; he feels defenseless and undignified because he abdicated his ability to maintain the military stoic self.
Unstable blood sugar affects the ability of the body to heal; the progression of time for wounds to heal is decreased. Taking the resident's age into account, deep-staged wounds sometimes do not heal. Necrotic tissue develops around the wound. When caring for one recent resident, I did the best I could to help him maintain his whole leg. But his condition deteriorated, so the next step - amputation - was considered as a viable option.
My resident was transferred back to the VA hospital in Baltimore for re-evaluation for partial limb amputation. After consent, he agreed to amputation. He stayed at the hospital in postsurgical recovery. Within a week, he returned to my facility.
Now, the plan of care has changed; my resident needed to heal from the amputation and eventually relearn to ambulate. He now needed to learn how to maneuver himself in a wheelchair. His physical brawn tested in a whole new way, he is challenged to maintain the military stoic self. Dependence on others is needed for survival.