Contains disturbing content.
“A knife for the skin.”
I had never heard his expression before. I’ve also never heard of a piercing crack from the fibula bone being cut in two. But we all heard it. Knife for skin. Bone-cutter for bones. And now a new sound: the urgent, frenetic buzzing of the power oscillating saw.
Dave Lewis – a vascular surgeon who used to work in Christchurch, New Zealand, until the 2011 earthquake destroyed his home – moved the saw towards the newly formed opening in Kay’s sole leg. They are positioned just below the knee.
It resembles an ordinary hand-held power drill – bar a rectangular blade of steel, serrated at the end, instead of a drill-bit. Within seconds, it cut through Kay’s remaining tibia bone. More cutting, more cauterising follows. The leg has been severed. “Thank you,” Lewis said quietly to his team.
Kay lay motionless, her face and body hidden under a light blue surgical drape. Covered, keep the hair at the top, under the anaesthetic.
The disembodied leg, with a slightly blackened, ulcerated leg, was wrapped in a dull green sterile bag, tied at the top, and thrown into the “trash bin” of Cardiff’s Operating Theater 15. It contained the instruction: “Destroy by incineration.”
In 2021/22, diabetes was linked to more than 650 amputations in Wales (in England the annual average is more than 9,000). This is Kay’s number two. As the number of diabetic patients continues to increase, there is a growing demand for healthcare services. “This is a huge public health crisis,” said the charity Diabetes UK, “and it’s growing rapidly.”
We first met Kay on the vascular ward of Cardiff University Hospital of Wales. Of the 38 patients there, surprisingly, almost half had diabetes – a condition characterized by high blood glucose levels when the body cannot produce enough insulin (or the insulin itself does not work properly). Kay has had type 1 diabetes since childhood. Nearly all other patients have Type 2, which is often preventable and is generally associated with obesity, low physical activity, and old age.
“All the hairy arteries inside,” Kay said, kicking on the hospital bed, glancing down at her opened leg.
The soles of his feet are rough, red and scabrous. Two of his toes were almost black, the tissue seemed to be missing, sacrificed to gangrene. The risk of infection further poisoning the body left no choice but amputation.
About one in three people with diabetes, like Kay, will develop a foot ulcer, often due to peripheral nerve damage. Loss of feeling in the ‘diabetic foot’ can lead to horrific wounds. “We have patients with sticks and needles,” said ward manager Rhiannon Joseph. “Or a set of keys on a shoe that he doesn’t know he’s been walking on for a week.”
Rhiannon Joseph’s ward is growing in number of amputees. “There has been a big increase especially in the last few years,” he said. “Last week we did six amputations, this week we have scheduled up to three. Amputations of toes and front legs we do every day. They estimate that 80% of patients have diabetes.
At least 8% of the adult population in Wales now has diabetes, the highest prevalence rate in the four English countries (ie 7.3%, for example, in the UK), with the consequence of increasing hospitalizations. Wales is relatively old and frailer as a nation, with high rates of obesity. But the rate of new diabetes registrations, mostly Type 2, continues to be staggering.
Over the 12-year period (to 2021/22), Public Health Wales reported an increase of almost 60,000 people with diabetes in Wales. That’s a total of almost 40%. “If current trends continue,” the Welsh government’s health agency warned recently, “we estimate that around 1 in 11 adults will have diabetes in Wales … an increase of almost 48,000 people by 2035/36.”
Amputation only occurs in extreme cases, and with support (including from charities like Diabetes UK), many people with diabetes can manage their condition effectively. But clearly, this huge burden of diabetes, fueled by rising obesity rates, is stretching across the long-standing NHS, from kidney to stroke and beyond.
Forty miles away, in a hospital room in Swansea, Richard sat alone, peering out of the window. In truth, this is an exercise in futility. The 57-year-old school cafeteria worker can barely see through the window frame, let alone beyond. He has diabetic retinopathy, where excess sugar in the blood has caused abnormal blood vessel growth in the retina of his left eye. His vision was blurry now as he was bleeding from a ruptured vessel.
“You’re just a figure, a blur … that’s all,” he replied when asked what he could see. So much blood was leaking into his left eye that he needed an hour-long ‘vitrectomy’ operation to extract it.
One of the consultant ophthalmologists at Swansea’s Singleton Hospital, Gwyn Williams, points out “the tsunami of diabetes … we are filling clinics faster than we can handle them.” In response to a Channel 4 News request, the Welsh government estimates that 69,000 people in Wales currently have some degree of diabetic retinopathy.
The cruelty of vision – among other debilitating (in some cases fatal) complications experienced by some people with diabetes – is compounded by the inherent injustice. People from Black African, African Caribbean and South Asian backgrounds, for example, are at risk of developing Type 2 diabetes from an earlier age than the white population. Type 2 diabetes is also more common in low-income areas. Inequality is a critical background to this crisis.
In a deteriorating picture in the UK, the number of young people being diagnosed with Type 2 diabetes is increasing rapidly. Clearly, the financial cost to the NHS is enormous.
Last month, the University of York’s Health Economics Consortium (commissioned by Diabetes UK) published new research which estimated that the direct cost of diabetes in 2021/22 to the NHS, across England, would be £10.7 billion.
Across the UK, various national Diabetes Prevention Programs have been established. In Wales, the government has moved forward with a diabetes eye screening programme. It makes interventions through GP surgeries for patients deemed ‘pre-diabetic’. In Cardiff, the health board has created a new care model with an emergency diabetic foot clinic.
But it is difficult to detect significant dents in the issue. Meanwhile the obesity epidemic shows no signs of abating.
In the operating theater in Cardiff, Dave Lewis and his team have been threading stitches around Kay’s newly formed stump. As we left, I asked about the forecast that, on current trends, there could be almost 50,000 more patients in Wales with diabetes within ten years. “The NHS is certainly very good at dealing with it,” he replied, “but it’s going to be a big ask, isn’t it?”
And with that, other operating teams started arriving, waiting for the next slot. Knife for skin. It is not bold.