Do you know that an estimated 185,000 amputations happen in the US every year? Yes, having complete limbs is fast becoming an “achievement” as there are currently about 2 million people in the US living with a lost limb.
As if this is not appalling enough, it is projected that by 2050, the number would have swollen to 3.6 million. Of the 1.6 million people living in the US with limb loss in 2015, 42% were non-whites. Does the send the alarm bells ringing?
In truth, Black Americans are at a disproportionately higher risk of being amputated than their white counterparts. Whetting this with more statistics, we see that African Americana are about 4x more likely to be amputated than white Americans.The bigger question is: how many of these amputations are necessary?
This biting curiosity led us to invite Dr. Foluso Fakorede, an interventional cardiologist, Cleveland, Mississippi, to come and educate us on the Black Doctor platform on amputations. In this episode, Dr. Foluso Fakorede advises on when you can avoid amputations and what you can do to preserve those precious black limbs of yours.
Examining disparities in amputations related to heart disease
54% of amputations in the US are caused by vascular disease. This sprawls through peripheral arterial disease (PAD) and diabetes. While diabetes is no short of a “celebrity” in the disease world, PAD is far less popular, even if PAD affects over 8.5 million Americans. PAD occurs when excess cholesterol clogs up the wall of the arteries, impeding blood circulation. This is through the formation of plaque, narrowing the arteries.
As Dr. Foluso Fakorede puts it, PAD is slow, progressive, and deadly. He emphasizes that people with PAD. are six times more likely to have a heart event that could lead to cardiovascular disease. PAD is commonly demonstrated in the legs, although it can also be seen in the arteries transporting blood from the heart to the stomach, arms, kidneys, and arms.
Mobility-related handicaps are commonly associated with people having PAD, irrespective of leg symptoms. Either they lose the capacity to walk the long distances (they would go before PAD) or not reach the walking speeds they previously enjoyed.
Studies show that African Americans are more than twice as likely to have PAD as their white counterparts. There are also notable region-related disparities in amputations due to PAD across the United States. According to a Dartmouth Atlas Project report, black people with PAD living in rural Southeast are 7x more likely to get amputated compared to other regions. More than this, there was as much as an eightfold difference in the likelihood of getting limb-preserving surgeries (to enhance blood circulation) in Black Americans across several regions.
Examining diabetes in relation to amputations
Along with PAD, diabetes has been feeding gluttonously on American limbs. In 2010, about 73,000 people with diabetes in the US who were at least 20 years old had amputations. More specifically, 60% of non-traumatic amputations in the US are carried out on people having diabetes. Studies reveal that African Americans on Medicare are 3x more likely to have a limb amputated due to diabetes and peripheral arterial disease complications.
Indeed, diabetes increases one susceptibility to nerve damage and circulation problems. The fact that lesser blood is being transported to the feet increases the chances of developing sores on the lower part of the body. Now in the situation where this individual has peripheral neuropathy – as typified by numbness in the feet or hands – there is a significant reduction in the patient’s ability to notice foot ulcers before becoming severe.
Thanks to PAD, such ulcers may not heal quickly, raising the possibility of the lower limb being amputated. Some symptoms in people with diabetes are highly suggestive of an impending amputation (if prompt caution is not taken). This includes considerable swelling in the feet, development of ingrown toenails, plantar warts, blisters, and open sores.
You should also seek prompt medical attention if a wound on your feet emits a strong stench or ulcers on your feet grow bigger than three-quarters of an inch.
Why are practitioners apt to amputate a limb instead of saving it?
There appears an alarming eagerness in practitioners to severe limbs. According to Dr. Foluso Fakorede, due to the scarcity of specialist intervention cardiologists (worsened by the dearth of awareness about PAD), the bulk of practitioners have amputation as a first procedure instead of employing effort in preserving the limb.
It isn’t a mistake that amputation infamously ranks among the top five surgical procedures in the United States. Compared to the seeming profusion of cancer screening methodologies, most hospitals in the United States lack enough screening infrastructure for PAD. These practitioners are not incentivized by the governing bodies to screen patients early enough in the disease process, thereby amplifying amputation risk later on.
Dr. Foluso Fakorede points to the fact that most clinical decisions in hospitals today are directly influenced at the top level by surgeons. These surgeons have choice places in medical committees, fill advisory capacities to CEOs and CFOs of hospitals, and are critical stakeholders in policy formulation.
With the bulk of the surgeons favoring surgical procedures, by virtue of their profession, the vascular specialist is relegated from being the first line of defense of people having risks of amputations. This explains the bulk of unnecessary amputations being jumped into by general-purpose practitioners.
Are amputations really that cheap?
According to Dr. Foluso Fakorede, such keenness to amputate can be attributed to the misrepresentation of amputations as being cheaper than preserving and healing the limb. The costs of amputations are high, both on the patient and the hospital. Dr. Foluso Fakorede breaks this cost into the clinical and economic variants. On the clinical side of things, patients who undergo amputation are more at risk of chronic pain. 80% of people who have amputations will experience phantom limb pain.
More interestingly, a hefty 37% of amputees suffer anxiety across their lives, with another 20% suffering from depression. It would have been a less bitter pill to swallow if the ills of amputation ended there. Still, amputation comes with the risk of increased mortality in patients, especially those with vascular diseases.
Do you know that almost half of the people with vascular diseases who get amputated die within 5 years? To better put this in context, this 5-year mortality rate beats that from prostate cancer, colon cancer, and even breast cancer. Studies further show that 55% of diabetics who undergo lower extremity amputation will need the second leg amputated within 2-3 years after the first procedure.
On the economic side, Dr. Foluso Fakorede asserts that these revisions could cost a single patient across his/her lifetime up to the tune of $500k. The economic costs also spill to the hospital. In 2009 alone, hospital expenditures on amputation cost over $8.3 billion. So do you now agree with us that the aptness to carry out amputations screams of shortsightedness on the part of hospitals?
What increases your risk of amputation?
Aside from diabetes, trauma, and PAD, certain conditions increase your disposition to being amputated in the United States. These risk factors include age, race, socioeconomic determinants, and access to health care. Let us tell you a bit about this.
Age
It is no revelation that elderly people (particularly the octogenarian class) are more prone to having amputations. Most practitioners inaccurately attribute pains in the lower extremities of older people to arthritis instead of poor circulation. This would lead such practitioners to adopt a surgical procedure instead of fundamentally ascertaining if a circulation blockade could be responsible.
Racial disparities
Not the most comforting truths, but black Americans, especially in the South have a higher risk of amputation.
Take Mississippi, for example. Reports show that there are 16.1 amputations per 1000 Black American patients in Tupelo and 14.2 in Meridian compared to 4.8 in Tupelo and 3.8 in Meridian for nonblack patients.
I will leave you to make your deductions, but I am not expecting you to deny that racial disparities influence one’s chances of amputation.
According to Dr. Foluso Fakorede, Blacks in the South are least likely to get angiograms and revascularization. These procedures are crucial in determining how preventable amputations are, with angiograms reducing the odds of amputation by 90%.
Socioeconomic factors
Where we ever going to talk about disparities in healthcare without mentioning income levels? You don’t need a sermon to understand that low-income earners, uninsured patients, and Medicaid beneficiaries are far more likely to get amputated.
Access to healthcare
Being in regions with poor access to qualitative healthcare puts you at higher risk of amputation. Given that PAD doesn’t get much of “press” compared to other diseases like cancer, a larger fraction of general-purpose doctors and nurses understand little to nothing about PAD.
Medical incompetency and insufficient volume of vascular specialists in certain regions in the United States make people inhabiting such areas more prone to limb loss. For instance, Dr. Foluso Fakorede is the only cardiologist in Bolivar County, Mississippi.
With such ridiculous density of cardiologists, it is no longer rocket science why Mississippi has one of the lowest numbers of limb-preserving and heart-saving procedures in the United States.
What can Black Americans do to avoid unnecessary amputation?
As Dr. Foluso Fakorede puts it, “there are a lot of things to do to be preventive on the frontend and a lot to do in the backend to know our rights.” Dr. Fakorede stipulates that the most important way African Americans can avoid unnecessary amputations is by seeking advocacy.
When a practitioner recommends amputations, always ask for a second thought (or request for assessment for blood flow and chances of blockage) and seek to consult other specialists – preferably cardiologists – for more options.
In most cases, such ulcers that don’t heal and appear to write off that limb are simply because of a circulation blockage. Clearing such arteries can save that limb. More than this, Dr. Foluso Fakorede recommends getting your feet screened when you go for examinations. Such feet screen is particularly important for people:
- Over 50 with a history of diabetes or nicotine exposure as not every Black American smokes (some chew tobacco, vape)
- With a history of heart events like heart attack, stroke, high blood pressure, and kidney disease on dialysis
- With a family history of poor circulation or amputation
In this feet screening, the patient takes his socks off, and the doctor touches the feet, feeling the pulse.
Aside from that, lifestyle changes can help you reduce your risks of amputation. First on the list is diet. In the words of Dr. Foluso Fakorede, “the number one preventable cause of death is diet and what we do with our time in terms of exercise.”
Ensure to cut your sugar intake, diligently watch your cholesterol, stay committed to your medications, and get quality exercise. Prioritize your limb, there are a lot of beautiful places it can still take you to.