People in Fresno County are more likely to have toes, feet and legs amputated than almost anywhere in California, a ranking that has doctors and podiatrists debating what can be done to prevent the loss of limbs.

The amputation rate -- .46 per 1,000 in Fresno County in 2010 -- was almost 50% higher than the statewide rate of .31 per 1,000, according to the latest figures from the Office of Statewide Health Planning and Development. Fresno County's rate was higher than all but three small California counties.

"You have to go to Alabama or someplace like this to find an amputation rate higher than ours," said Fresno Dr. Sanjay Srivatsa.

Doctors say many who get lower-limb amputations are poor, obese and smoke. And many have diabetes. Most of the blackened, gangrenous toes, feet and legs are consequences of diabetes, which left unchecked can cause circulation and nerve problems.

Some doctors, however, say that can't fully explain Fresno County's amputation rate since neighboring counties with similar socioeconomic demographics and numbers of diabetic patients have lower amputation rates. They say too often patients aren't given limb-salvaging procedures to open clogged arteries before an amputation.

Not seeking help

It would take a study of every amputation done in Fresno County to get a clear picture of why the county's lower-limb amputation rates are high, said Dr. Matthew Campbell, a Visalia vascular surgeon.

"I don't think you'd find that you don't have good doctors or that you don't have good surgeons," he said. "You're dealing with a population with restricted access, with restricted education."

Dr. Randall Stern, a Fresno vascular surgeon, said about half of the amputation cases involve vascular issues. Half are diabetic foot ulcers that have festered too long to be saved, he said.

Dr. Rohit Sundrani said the problem in Fresno is access. Sundrani is an interventional cardiologist and a peripheral endovascular specialist in Fresno.

There are specialists available, but patients have to be referred, he said. "When I get called, I see the patient. But I have to get called."

New technology can allow even severely blocked arteries to be opened, Sundrani said, but the outcome of a vascular procedure often depends on whether the circulation problem has progressed too far, he said.

Sundrani said that too often, low-income patients without insurance or on Medi-Cal, the state-federal health insurance program, can wait weeks for appointments with primary-care doctors, and the wait can be even longer for referrals to specialists -- if someone can be found who accepts the government reimbursement, which is among the lowest in the country.

Sundrani said he sees some Medi-Cal patients when family doctors make referrals, but he has to limit the number. "We've still got to pay our bills," he said.

Low-income and uninsured patients often have little choice but to go to the emergency room, and by the time doctors see them there, toes, feet and legs can be gangrenous and too late to save, Sundrani said.

Patients with diabetes who see podiatrists on a regular basis reduce their risk of infection by more than 50%, according to a Swedish study, said Kathryne Rupley, a Fresno podiatrist.

But again, access can be a problem.

Podiatrists no longer see Medi-Cal patients in their offices since the state cut the care in 2009, Rupley said.

Fresno also doesn't have enough foot specialists for its population. The recommended number is one podiatrist for every 30,000 people, Rupley said. Fresno has 19 working podiatrists and would need almost twice that number to be at the recommended level, she said.