Feet on Solid Ground

I nay be harsh at times, but I always aim to be fair.
I am so direct and open when dissatisfied with a doctor that I feel a need to post when I encounter a really good one. Dr. Thomas Mancini, with offices in East Greenwich, RI and on Mineral Spring Avenue in North Providence, is one of the good ones.
I do not know (or care) if he is related to the other podiatrist Mancini who has an office on Armistice Boulevard in Pawtucket.
Just as I state why I come to dislike or distrust specific doctors, I want to point out the factors of Mancini’s positive appraisal.
He listens. This can’t be overstated. As a diabetic, I have heard a lot of pop-psychology jargon about needing a "medical team" for my care. In such terms, Mancini would be part of the "team" of which the patient should always be captain and manager. We’ve fully discussed aspects of my foot problems, including the infection and the ongoing Charcot condition. It is also obvious to me that Dr. Mancini had put independent thought into things.
He made himself fully available to me and my roommate when and since things went bad with the toe infection. He has been great in booking timely emergency visits as issues arose.
The foot has been fully inspected with each visit and he has done anything and everything necessary, from the Charcot to the infected toe to routine things.
He has answered any questions I posed rather than become defensive or offended by them. There are darker aspects of my long term prognosis that he stayed quiet about, but he sugar coated nothing when I raised such issues. If anything, he seemed genuinely relieved that I was able to bridge the subjects, which included my belief that it is probably inevitable that, sooner or later, I will lose the right foot below the knee due to the Charcot condition.
Dr. Mancini has no God Complex. He is approachable and knows his own limitations. When the hospitalization for the infection ended, the Charcot condition was much worse. Without hesitation, and without trying to pawn me off on someone else, he recommended me to another foot doc, Douglas Grod to look into treatment beyond what Mancini felt he could do. As it turns out, Mancini was not sold on the ultimate wisdom of doing what Grod could do. The point to me is that even with his unvoiced objection to the potential procedure, Dr. Mancini made the recommendation for me to look further into the situation.
I have seen very little humility like that among doctors, and the entire experience–which is ongoing–makes me recommend Dr. Thomas Mancini above any other foot doctor in Rhode Island, for diabetics or people with other foot problems.

Charcot Bait-sics

There’s not a lot on the Internet about Charcot Foot, so here’s some basic facts and warnings.
The chief "precondition" is diabetes.
The second "precondition" is a foot injury, usually a broken bone that neuropathy in the diabetic ma prevent the diabetic from realizing.
The chief symptom is massive foot swelling, usually with no pain or very little.
Other symptoms will usually include elevated temperature in the swollen foot, up to 7 degrees Celsius from the unaffected foot.
The "old" feet smell" may be pervasive even when the foot is clean. I took to spraying my foot with Right Guard.
The swelling may get larger or recede on its own throughout the day. Be aware that your shoes may not fit correctly and could cause cuts or abrasions that could infect easily. The changes in swelling can also infect the skin, including potential for splits or pits as the skin expands and contracts.
If the patient does have broken/fractured bones, se must stay off the foot. If the bones are not given opportunity to heal, they can poke through the foot from the inside.
The patient should see a competent podiatrist regularly. Tell the doctor about any drugs being taken, including anti-inflammatory drugs such as prednisone.
Taking anti-inflammatory drugs is not particularly a good idea if there are broken bones. The swelling protects the broken bones.
Ask your podiatrist or other doctor about bone-solidifying drugs usually prescribed for osteoporosis. This could limit or prevent bone density loss during the healing process.
If you must have some mobility, a Crow boot will buffer the ankle mush more effectively than a flexible cast boot.
Charcot foot is something of an exotic or esoteric condition and is not well known outside the medical circles of diabetes and foot specialists. Go right to pone of those specialists or a sports medicine practice rather than to an urgent care center. Well intentioned doctors who do not recognize the true problem can do you grievous harm.
Do not, under any circumstances, allow any doctor or medical person (or anyone else) to insert anything into the foot, not to drain the swelling or extract to test for infection or any other reason, no matter how reasonable it sounds. The risk of infection is too high, and any infection exponentially increased the chance for immediate amputation. If you see any treating professional coming at your foot with a needle, kick them in the face (with your good foot, of course.) Those professionals will have long forgotten jabbing you when you’re on the operating table having your foot sawed off.

Charcot Foot Phase 1.2

At least one account I encountered estimates that approximately 3% of diabetics will "come down with" Charcot Foot. In bygone eras it used to afflict others, but nowadays it’s all but exclusively a diabetic problem. Brief basics, normally the diabetic breaks or fractures a foot bone, usually does not feel the injury due to diabetic neuropathy and the foot swells up in response. Treatment is typically immobilization to prevent the broken bone from displacing. The displaced bone can rip through the foot from the inside.
My injury and affliction was atypical. I had tendon and/or nerve damage (and still do) but not breaks or fractures. (Breaks and fractures are both breaks, just of different severity and separation of the pieces.) The reports that cleared me came from both X-ray and MRI. Doctors at an urgent care center and a sports medicine practice, my GP and "Dr. Dumbass" all gave diagnoses of "no breaks."
So imagine my surprise when Dr. Dumbass–aka podiatrist David Greenberg–told me on the second visit that I did have breaks and fractures.
I had resumed bowling as exercise with limits on frequency and duration based on the "no breaks" diagnosis. This tail-spun me into stressful second guessing and worries of what further damage I could have inflicted to myself. Bowling was neither particularly successful nor painless, but it remained one of the few things I could still do and just about my only social interaction.
The bowling may seem haphazard. Maybe it was. My reasoning was that Phase Two of Charcot Foot is typically a long duration of rebuilding strength and integrity in the foot, things lost by a combination of inactivity and poor circulation that limit the flow of nutrients to the foot. Basically, immobilized and unused feet tend to atrophy during Phase One. I experienced the most evident ankle collapse in the month that I did stay off the foot almost entirely, and little to no evident progression when I did get the limited exercise. The human body is an odd machine: it works better the more it is responsibly used.
Dr Dumbass gave the new diagnosis without the benefit of any new X-ray or scan. Subsequent images ordered and reviewed by a later doctor showed structural damage that is natural progression of Charcot but seemed to confirm that there had been no initial bone damage.
I rectified Dr. Dumbass’s inconsistencies as statistical generalizations of the overall condition rather than any result of examination.
I started seeing Dr. Thomas Mancini when the foot swelled back up in response to discontinuation of prednisone.
Doctor Mancini had some concerns after a thorough examination of my foot, which is something Dr. Dumbass never really bothered to do. Dr. Mancini wanted me to consider Boniva type drugs and wanted me to pick up the leg brace that Dr. Dumbass had prescribed and I had been fitted for custom manufacture before the leg and foot re-inflated.
The toe infection that sent me to the hospital for four days interfered with those plans. The hospital, deeming a blind gimpy guy as a trip and fall hazard, kept me immobilized for the weekend. That proved a long enough time of absolute inactivity for the ankle to suffer further collapse. This change for the worse could be seen in the shape of the foot, felt when the foot was used or moved on its own, and it could be heard when I tried walking on it.

Limping Along

The last general update friends and acquaintances have asked about is life in general. Pre Charcot foot, the passive answer was "Hanging in." Now it is "Limping along."
This summer is the first season in seven or so years that I have not bowled in a league. The timing of the hospitalization interfered with the season start, and the "Crow boot" I must now wear will take some finagling and readjustment. I do intend to resume in the fall.
Mobility issues have me more limited, and my third- and fourth-floor townhouse-style apartment is less than ideal for someone who can no longer see nor feel stairs. I moved the computer to the dining room to get it on the main floor, but have not yet gotten the desk down stairs. As a result, I feel as though I have lost both the office and the dining room and the house feels like much less than what I bought.
This adds to the emotional depression that I feel funny admitting "aloud." People seem amazed at how well I’ve been dealing with the adversity of the last few years, so admitting that it has been and continues to be a struggle illogically feels as though I am letting some people down. The disabilities that have afflicted me have also catalyzed a new level of emotional depression.
The depression is worsened biochemically. Especially since the early Mat hospitalization, I have been keeping the blood sugar at lower levels. This has been good for circulation to the foot and behind the eye, but not good for temperament and feeling happy. The prednisone intake also contributes to those factors.
I stopped taking the generic Prozac after the hemorrhage, when the side effect of "suicidal thoughts and feeling" would irregularly arise. The quality of life issues have not improved, so I continue to avoid pharmaceutical anti-depressants.
I am adjusting to and struggling to accept my increased limitations. I force myself to adopt gratitude for what I can still do.
Most of the things I can still do cannot be done for as long. Gone are the days of 12+ hour exerting days; my stamina is not what it used to be. Gone are the marathons on the word processor; my eyes burn out after a couple hours.
What is not gone is my drive and the fiery will. This feeds the cycles of frustration as often as not.
I am working to do more with myself. I’ve been getting back to posting more regularly on the blog and am working on keeping up with short story submissions again. The next step with the fiction is to get some partially-done short stories finished
I’ve done a couple spots of yard work recently, minor accomplishments but more than most people in with my limitations would attempt, I think.
So I have had to slow down, but I have not stopped. Don’t cringe at the thought of a blind gimpy guy swinging a powered hedge trimmer over rough terrain. Just don’t get too close.

Doctor Dumbass

Dr. David Greenberg is one of the founding partners and president of Rhode Island Foot Care, Inc. I saw him three times in the winter of 2012. He had been referred by the doctor at Foundry sports medicine, where the Charcot foot had been first diagnosed. Liked the Foundry doctor and that practice. The sole negative I can say about the Foundry practice was that they recommended Greenberg. I heard Greenberg referred to as the best podiatrist in Rhode Island. Maybe that gave me unrealistic expectation. My GP had referred another patient to Greenberg at the checkout desk this spring. I shook my cast-boot covered foot at the patients, told them I referred to Greenberg as "Doctor Dumbass" and urged them to see the podiatrist I later experienced successful with, Thomas Mancini.
While I did not come to think of Greenberg as dumbass until the third visit, I really did not like him from the first. This was a basic consumer issue that I did not feel as though he really looked at the foot or listened to me. Supposedly he had looked over disks containing the MRI scan and X-ray before he entered the room. Am I wrong in thinking that was not enough without an on the spot exam? The MRI was a couple weeks old by that time and the X-ray was approaching four weeks past. The swelling had changed for the worse in that time, and the tendon in the foot had gained much more pronounced deformity. I left feeling as though I had paid for him to arrogantly confirm, "Yup, that’s Charcot foot," and nothing more. Between the Foundry doctor’s diagnosis and my research of the diagnosis, there wasn’t any doubt that Charcot was the problem. He gave advice of the best thing for my foot was to take care of my diabetes and sounded no different from every busybody with diabetic cousins who think the cousin makes them qualified to dispense advice about diabetes.
The second appointment got postponed by Greenberg’s office, and they indicated that one of his associates would see me o the follow up. I had no problem with that, and was disappointed when Greenberg saw me. He at least did look at the foot, in part because the swelling had receded on significant levels. He thought that was a good sign and did not correlate the prednisone eye drop prescription with the healing. My attitude: he is a doctor and should have suspected that, particularly because I mentioned it prominently; my tummy was rolling when I was there, and this had been the first time I had seen him after the retina reattachment surgery..
He was worse this time for being nice. He came across as patronizing, complete with a shoulder pat best reserved for little leaguers who hit a home run. I am not sure if his superior attitude or the prednisone is the true cause of my need to vomit before I left the office. I managed to contain the eruption to the medical waste barrel in the examining room.
The third (and guaranteed last ever) visit was in March. He declared the Phase One of the Charcot foot over and Stage Two healthily begun. He gave me a prescription for an in-the-shoe brace, a print out with choices of where to have it custom made, and no future appointment. Any actual examination was at best cursory.
He officially became "Doctor Dumbass" the day I went to get molded for the brace. The address on his printout had the wrong number on the right street. The orthopedic appliance place said they had moved twelve and had frequently asked Greenberg’s practice to update this. The prescription contained minimal information, and said nothing about the ankle collapse or how that problem had shortened my right leg.years before
The real kicker came in April, when (with the eye doctor’s approval) I stopped taking the prednisone. The leg swelled right back up, proving that Charcot’s Phase One had not passed, but had been disguised by the anti-inflammatory steroid.

Charcot Attack

Charcot Attack
The last ongoing or recent medical BS to update is the Charcot foot. I could deal with this better if I wasn’t so visually impaired. The original injury that triggered this rare diabetic problem would not have happened last autumn if I was not blind.
Very briefly, Charcot is a massive and typically painless swelling of the foot in response to and injury, one of the body’s usual defense mechanism gone into overdrive. There’s two main stages, both typically prolonged. The first is the healing of the triggering injury. The second is recovery from the healing. During the Stage One process, the swelling typically restricts circulation and thus limits nutrient and blood supply to the foot. These reductions cause the foot to atrophy and weaken. As my triggering incident did not include broken bones, I was able to be more active during Stage One than most people can be. I tried to stay active despite my roommate’s restrictive mothering in order to reduce any atrophy.
Maybe things would have been worse if I had completely reposed last autumn and winter, but a sinister level of atrophy did occur.
The almost cartoonish level of swelling ran from the toes to the knee with the most bloated and most stubborn point at the ankle. It stayed swelled for months, from October to February. It drastically reduced in February through April, but this was in reaction to the prednisone prescribed for the retina reattachment recovery, not true healing. I learned this when I temporarily discontinued the prednisone to reduce the steroid’s side effects.
I seemed to have two periods in which the ankle collapsed. Both of these happened at times when I was fully resting the foot and leg, the first in November when I temporarily ceased bowling, and the second while I was imprisoned in the hospital.
I note here for people reading this via an online search for Charcot foot: in the times in between the full rest periods, I could use the foot only because I had no broken or fractured bones that might shift and stab out of the foot. Most Charcot patients do have broken bones and should stay off the foot entirely.The difference before and after the hospital stay was drastic and unignorable. Before, the foot was uncomfortable to use. After four days totally off the foot, the boned in the ankle creaked and clicked if I tried to use it. The longer period of rest in the autumn made the changes less obvious at the time, but drastic changes had occurred.
The foot had swelled and remained that way for months. This did reduce circulation, which inhibited the flow of nutrients to the foot. The are that developed the worst problem was deepest, not furthest in the foot and maintained the worst swelling: the center of the ankle.
The ankle collapsed enough that my right legs was about a half inch shorter than the left leg.
I had seen a podiatrist three times, and on the third visit he prescribed a brace to be made and wished me luck.
True to my luck, I just keep hitting the jackpot with the quality of doctors I end up with. People referred to that first podiatrist as the best in the state. I quickly came to refer to him as "Doctor Dumbass."

Healing Power

The infection that sent me to Sturdy Hospital has healed up nicely enough.
I’m not positive how it happened. As I learned a full thirty days after discharge, the infection was a staph and strep combination, so it did come from me and not something I stepped in.
Prior to the infection, I had a minor cut on top of the toe, which I had picked at a week or so before. Also in that timeframe, I had pulled away the looser dead skin of a callous, as I’ve done a couple times a year for the past couple decades. So the infection would seem to be my fault, even though those two suspects did not seem to get actively involved in the major problem.
Think of the toe as a throwing die, with six sides, one of which is attached to the foot. The top cut was on a second side, and the callous on a third. Somehow, in events beyond my power to imagine, a small cut appeared on the side of the toe that was protected and sheltered by the adjoining toe. That side also did not seem to be a problem. The last two sides, the toe tip and the bottom, harbored the problem.
The Charcot foot allowed the problem by reducing circulation. I think it also caused the abrasion-type wound that developed on the tip. The foot had been massively swelled again, which made my shoe too small, which allowed a friction burn to rub on the tip. This area had the worst of the infection. The bottom soon afflicted with dry gangrene.
My podiatrist had seen the stagnant cut on the top of the foot and had prescribed an antibiotic cream. As I can’t really see my own feet in any detail, my roommate had been putting that on. Good thing, as that was the only reason that anyone who could see my foot was looking at it regularly. The =abrasion and infection and gangrene developed in two days. Things looked a little red that Wednesday; the bottom of the foot was gangrened Friday.
If it had gone on longer, the infection would most likely have penetrated to the bone and I probably would have lost the toe.
Many different antibiotics went through the IV at the hospital that weekend. I was prescribed Augmentin , a combination of amoxicillin and clavulanate potassium. The amoxicillin is a derivative of penicillin. The clavulanate potassium is one of those things that fights antibiotic resistance. I felt no side effects from the antibiotic, but luckily also never have been prone to such problems.
More than a month after the prescription ran out, things are going well. The podiatrist sees me every couple weeks and cuts away excess dead skin. The toenail is growing back nicely, and the dry form of gangrene never spread. The podiatrist has a visiting nurse coming for eight weeks after discharge, just to make sure trained (and working) eyes were on the healing wound a couple days a week. I went along with this as patiently as I can but look forward to this being the last week. I find the visit intrusive, and the question of when my last bowel movement seem more personal and intrusive than necessary. The nurse is also pretty humorless. He gave no discernable reaction when I answered the regular question "Any problems with your urine?" with "It’s been talking back and skipping school."