Emily’s career in the field of diabetic care
A career as a podiatrist is one thing, but one in a specialty of its own demonstrates how far podiatry has travelled to provide help to the nation’s foot health. The field of diabetic care has blossomed with podiatry contributing to saving limbs and lives. As a career it is fulfilling. We join Emily who has dedicated her career to this area of podiatry. Emily Haworth lived in Eire as a child and on reaching that age when A levels determine the next stage of her life she travelled to the UK mainland to train. Her passion drove her with a willingness to explore new territory.
Podiatry has grown over the last 50 years and is one of the best-known areas to prevent limb amputation. All podiatrists will manage diabetes and it is essential to realise that as a nation that lower limb amputations have increased by 18.3%. Over 27 thousand operations were carried out in England between 2015 and 2018 (Diabetestimes 2020). According to Diabetes UK, only one in six hospitals still do not have multidisciplinary specialist foot care teams (MDFT). These teams, which often include podiatrists, physicians and nurses, are integral to delivering a high quality of care. However, their absence may result in inconsistent access to treatment and outcomes across the nation. When foot ulcers deteriorate because of lack of sensation to pressure, poor blood supply and deep infection, they not only are slow to heal but there is an increased risk of amputation. Saving NHS money by preventing amputations is the crucial role of MDFTs and podiatrists like Emily Haworth.
Emily’s story blames her father, a university professor at Salford, as he believed that her first choice, midwifery, would not suit her. Finally, she stumbled across podiatric medicine after reading about different courses, including pharmacology, microbiology, medicine and anatomy. Although her father would never have stood in the way of her first choice, she decided to enrol at the same university where her father worked. With some sadness, she spoke about the regret that he did not see her qualify but accepted that her career pathway had been correctly engineered.
The first chink of light
During her training, she was on placement at the North Manchester General, where a podiatrist called Louise Stuart inspired her career. As a result, Emily’s interest in diabetic foot health was initiated, which she would eventually excel in.
“Louise threw me in at the deep end and said take that dressing off. The dressing went up to her knee. She was ischaemic but not neuropathic, but the poor woman was in agony. Then, having removed the dressing, I stared at her foot and leg. It was a decisive moment in my life.”
At the time (1995), it was not easy to find a job for even a primary grade in the NHS. Emily needed a support network such as the NHS before embarking on setting up on her own. She buddied up with a senior podiatrist at the outset. Emily says with some amusement, “we didn’t even speak to senior I’s – the highest level associated with clinical podiatry”.
She lived in a nurses’ accommodation for 12 months until renting a 2 bedroom house. While Emily found her placement a rude awakening, she was now thrown in at the deep end. Although she had Foot Care Assistants to help, she might see 30 patients a day and go out on domiciliary (house calls) with a workload of 25 a day.
Emily’s first year gave her an essential grounding in podiatric medicine. She knew the basics of the profession and thought it a fantastic learning year. She also had to go into some rough areas around Rotherham. She attests to the importance of having a mentor, but she was a woman who wanted to push her boundaries—just getting everything out of life. She was like human blotting paper and needed to taste everything on the table. It is only through experimentation and getting things wrong that we learn. This contradicts the idea we must get everything right in our lives.
Early experience with the boss
Having a good boss as a manager is a lottery. However, Emily’s manager seemed to understand that her new employee was seeking to go to Italy to join a friend. Her manager had confidence in Emily and was approachable for the most minor problems. She started to tell her manager about her friend in Italy and hadn’t even finished the sentence when her manager said “go,” and with that, she was promised her job would be there for her when she got back. With little sense of hubris, Emily relays the conversation. Finally, she said, “I love your work, your energy and ethics and patients adore you. Mail me 5 weeks before you come back and I’ll set you up with a new position.” And so Emily spent 18 months in Italy and returned to her job as promised as a Senior II.
This tale is unusual but provides a sense of Emily’s dedication at being promised a job on her return. But for the reader, who might think this is common, it isn’t. Primary grades were unusual because of the dire shortage of podiatrists and so they were inexpensive. Emily met a period when seeking a job was more difficult and had to start on a basic grade. Today this would be Band 5. By 2019 the reverse had occurred and podiatrists were again in short supply meaning that negotiation could be considered in favour of the new applicant gaining a higher grade.
At the end of the 20th century, senior managers were usually podiatrists. Today NHS managers are more often from other professions and budgets are configured differently. Podiatry managers were often more sympathetic and could take care of staff more intimately than managers from different professions. A good employee may well be rewarded with a sabbatical. However, the promise of a return job would probably only arise if it was in the NHS Trust’s interest and travelling may not be seen as adequate criteria.
In Italy, Emily had to learn the language from scratch. She said that she had to knock on doors to teach English. Sometimes she didn’t have work, which meant eating was meagre in leaner times. By six months, she was working for companies teaching English full-time and then ended up teaching doctors and nurses medical terms in English. This allowed her to learn the terminology; there was no podiatry in Italy. She pointed out that she came back a different person.
The role of a podiatrist in diabetic care
There is no absolute model through which podiatrists pass to specialise in the field of diabetic care. And, not everyone seeks to specialise. Specialisation is determined by the fact that the clinical work is either mostly, or wholly in the same field. Working within a team led by a consultant physician is usual although ‘lead’ means someone who holds the overall budget and takes some managerial responsibility as a clinician. Most podiatrists are experienced at this stage having worked with other senior podiatrists and medics. Nurses are often very well qualified and nurse practitioners with extended scope capabilities may work with the team. While Emily’s professor father originally told her that she wasn’t a team player she was determined to contradict this perception.
“When a team works together, it’s an amazing thing.,” she reflects. As her knowledge of wounds grew, she found she knew which pathogen was caused by the smell. As far as managing diabetic patients, she felt the motivation came down to understanding the impact on someone’s life and helping them through an amputation. The change brought about by people’s behaviour and the whole psychology appealed to her in ‘huge buckets‘.
Vascular surgeons are part of the team as well as nurses. Today many podiatrists will hold a consultant position on a higher agenda for change grading at 7 or above. They may prescribe a range of medications and pay special attention to patient blood sugars. This means they have to know the right tests to order to make sure that circulating sugar is not too high. The correct value is 4.0 to 5.4 mmol/L (72 to 99 mg/dL) when fasting but 40 mg/dl or below normally. This means there is a difference between eating and not eating of course. The sugar levels should come down quickly for normal metabolism after a couple of hours.
Wounds not only need to be kept clean but purged of infection. This means that skills with using a scalpel are essential so any dead tissue is removed and knowledge of the organisms inhabiting wounds. Cutting back until healthy bleeding occurs seems quite the opposite of what one might think. Intimate knowledge of blood flow is maintained using Doppler ultrasound. The bones and joints can be damaged with a condition called Charcot’s joint which is a mixture of blood supply and nerve damage.
All podiatrists will assess the blood flow known as vascular status and check the flow from the groin to the foot. The many tributaries can become furred up, blocked and reduce the efficiency of supply, more so under exercise. This has the effect of removing waste products and supplying oxygenated nutrients to the skin, muscles and nerves.
The nerve status is important and so working on the sensory nervous system uses specialist filament devices to work out how lacking in sensation the skin is. Once a diabetic is seen to be unstable, advice is paramount. Hypoglycaemic events indicate the importance of the blood sugar being regulated by diet and medications used to help improve the pancreas organ where insulin is manufactured. These ‘hypos’ as they are called demonstrate how the body responds with confusion, irritability and at worst sleepiness leading to coma. Severe diabetics will have indwelling pumps attached to the skin or have to inject themselves with insulin that they cannot manufacture themselves. Podiatrists have to have an intimate knowledge of pressure measurement under the foot and use this knowledge to offload pressure which causes damage to the foot’s skin tissue. To do this they will use a wide range of products including pre-made specialist footwear, which is cheaper than bespoke footwear, but more effective, and less likely to end up at the bottom of a wardrobe (Tarr, I. 2020).
Selfless attitudes combine with a stoic persona
To become a specialist, Emily believes podiatrists have to give up some freedom and be prepared to work outside regular hours. “If you want to get home on the dot without thinking of your patient, then it’s not for you,” she explains. This reveals Emily’s deep-seated ethics. Leaving a patient without appropriate care would haunt her, especially if someone needed a bed or hospitalisation. Empathy and learning to deal with responsibility and going the extra mile seems her essential drive.
“I still worry,” she says, “after all the years I’ve been doing this and go in on Saturday to change dressings. I think you have to be that involved.” Sometimes her consultant physician would tell her to withdraw, but this can clash with her sense of duty. She says openly, “this balances me, which is great.” She adds that she takes it personally if a patient (after all her effort) is exposed to a below-knee amputation.
She recalls how she would go after the vascular surgeon and badger him to let her have another go to save the limb. The consultant would then challenge her and ask on what basis? She would tell him her criteria and he might say, “I’ll give your 4 weeks; if it hasn’t improved by 2-3cm, for example, in 4 weeks, then we’ll prep for theatre and you’ve just wasted my time.” She says she didn’t do it that often, but she would stand up to the surgeon if there were a chance to save a limb. “Most of the time, I was right and he was big enough to shake my hand and say well done and you were right. It’s my job to save limbs.”
She accepted there were no guarantees in saving limbs. A below or above knee amputation brings a massive change to patients’ lives. There’s no psychology, and they are just expected to get on with their life and adjust to fit. The mortality following an amputation is 70% within 3 years. It’s massive, so they are not looking at a long life after surgery. She then went on to tell me about a 58-year-old active farmer she was treating. She said that she would do anything to help a patient and I believed her.
The patient had a bone infection (osteomyelitis) in his right foot with Charcot’s arthropathy. “He once cried on my shoulder because of his financial situation. I tried to keep him as mobile as I could but offload the pressure from his foot. The dual conditions add to the challenge. He hopes to self-discharge, but I know within 2-3 weeks, we’ll be back to square one again.”
The farmer was at risk of a double or bilateral amputation which makes the podiatrist’s responsibility tough. Emily points out that they are seeing patients younger and younger these days. One female died at 32. She saw her before she died. Her mother was deeply affected not just because of the loss of the daughter but also because her daughter had only recently had a baby. Emily’s experience emphasises the horror following patients up to their last days.
“Sometimes, as in the case of the young woman, I would just go up and sit with them and hold their hand. Mum and daughter knew we had done all that we could. Events just take their course and medicine can no longer help them, no one can. Perhaps,” she reflects, “it’s not what people consider that podiatrist normally does.”
On the brighter side, she relates the story of an Aer Lingus pilot who had already lost his left leg when he first came to see her.
“We were struggling to hold onto the right leg. For 2 years, we battled to save this limb. He lost a couple of toes and we couldn’t get him into a prosthesis until we got his right limb fixed. We persevered. I went over to Switzerland to learn about Appligraf. I brought the information back. These are dressings and are only available in the USA. I used the graft on my patient and it worked. So it was worth going to Switzerland as the wound healed. The former pilot’s dream was to ride horses, a passion that I shared. Fifteen months on, he sat proudly on a horse with his new leg.”
Emily has an inexhaustible retinue of stories that fitted her enthusiasm and passion for podiatry at the high-risk end. It came as no surprise as she told me she is volunteering to help the homeless in clinics and heroin addicts.
- How to look after your feet with diabetes
- Diabetes UK
- Podiatry as a career choice?
- Tarr, Ian in Tollafield, DR The Burden of Foot Health. Selling Foot Health as Podiatry. A Reflective Podiatric Practice Series. 2020; Ch.6. P88
Thanks for reading ‘A Career as a Diabetic Foot Specialist’ by David R Tollafield following an interview with Emily
Published by Busypencilcase Communications. Est. 2015 for ConsultingFootPain