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.
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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.
It's mostly left to the family doctor to take care of patients with diseased feet and legs, but many specialists say too many wait too long before making office appointments, ignoring blisters or cuts on their feet until infections spread and become emergencies. Some patients also can't feel the sores because of nerve damage from diabetes.
Dr. Oscar Sablan, a Firebaugh family practitioner, said he struggles to get his patients, many of whom are farmworkers, to come for regular visits.
Only recently, a patient with diabetes who he hadn't seen in a year came to his office with an infected toe. It had to be amputated, Sablan said. "His brother told him to come in. He was afraid to leave work because he was afraid to lose work as a farmworker. If he had come in I'm absolutely certain we could have saved that toe."
Poor patients also delay getting care if they don't have transportation to get to the doctor or money to pay for a visit, said Dr. Luis Bautista, an internist with practices in Sanger and Fresno. Some studies have shown poverty is a risk factor for amputations.
Family doctors say they hold some responsibility for reducing amputation rates by checking diabetic patients' feet during routine office visits, as well as measuring the blood pressure in ankles of patients at risk for vascular disease.
"There are not enough people getting tested for the circulation in their feet," Sablan said.
But awareness also needs to increase among patients about the importance of checking feet for sores, scrapes and swelling, Sablan said. "There's not enough public health information for patients to know of the things they can do to take care of themselves and to seek care at an earlier time in their illness."
Ismael Flores, 46, of Kingsburg, is a below-the-knee double amputee. He lost his right leg in 2008 and his left in 2009 when infections developed in his feet and toes.
He didn't know he had diabetes until he stepped on something sharp at his job as a mechanic in 2003. Before that, he hadn't been sick and had not been to a doctor in years. "I'm pretty sure if I had went to a regular doctor and had a physical, I would not be in the same situation I'm in right now," he said.
Phillip Favila, 32, of Fresno, said he ignored his diabetes when he was in his 20s. He was diagnosed with Type 1 diabetes at 18. When he dropped a weight on his left foot in 2009, it didn't heal and last December, his left leg was amputated below the knee.
Doctors tried to save the foot, Favila said, but he was in constant pain and made the choice to have it amputated. "I wanted to be able to walk around Disneyland and play soccer with ," he said. "I wasn't going to be able to do that with the leg I had."
Giving patients options before resorting to amputations has become standard the past 10 years.
Treating peripheral vascular disease, which restricts blood flow to feet and legs, by opening arteries is more common as new tools and techniques have been developed. But it takes trained specialists to do the procedures, and some doctors say that's where Fresno County is lacking.
"We don't have enough endovascular specialists here to open up the lower extremities," said Jay Mukker, a Fresno podiatrist. "It's a huge, huge problem."
Having more of the specialists would save a "tremendous amount of legs and feet," he said. Doctors who open leg arteries and veins are vascular surgeons, interventional radiologists and interventional cardiologists.
A 2005 Rice University study showed the number of vascular surgeons in a community appears to make a difference in amputation rates. The addition of one vascular surgeon for every 33,000 Medicare enrollees resulted in a 1.6% decrease in amputations, according to the research.
Studies show that there is a nationwide shortage of vascular surgeons. Fresno has 11 -- about the national average per capita -- listed in the 2012 Fresno-Madera Medical Society Directory.
The county needs more, according to Dr. Pervaiz Chaudhry. The Fresno cardiac surgeon said the area's leading vascular surgery office has kept the number down. Chaudhry is suing Dr. Randall Stern and Valley Vascular Surgery Associates for unfair competition and contract interference.
Chaudhry, who does not do peripheral vascular procedures, alleges Stern and the group have engaged in a pattern of anti-competitive practices in order to prevent general surgeons, vascular surgeons and interventional cardiologists from receiving hospital privileges.
As a result of their dominant role in the community, they "have caused the quality of vascular surgery services to decline market-wide," the complaint alleges.
Stern's attorney, Russell Ryan of Fresno, said the allegations are "completely false as are 90% of the contents of this complaint. They are just out-and-out fabricated."
Chaudhry's lawsuit also says he has been the subject of personal attacks. In an interview earlier this month, Chaudhry and his attorney, Charles Doerksen of Fresno, confirmed that complaints have been made against him, including that he was intimidating and verbally abusive to medical staff and physicians. The accusations are frivolous and baseless, they said.
Stern said his group is trying to create a limb-preservation center at Clovis Community Medical Center to treat patients at risk of amputation. California has only two such centers -- one in Southern California and one in the Bay Area -- which bring together vascular surgeons, podiatrists and other medical professionals in one location.
Wound care center
But it could be awhile before such a center opens here. Clovis Community CEO Craig Castro said that a "wound care" center is a possibility as the hospital expands. "But there's no decision yet, and that discussion has a long way to go."
Srivatsa, the Fresno endovascular specialist, said he is helping start a Save a Leg, Save a Life chapter here. The Florida-based foundation works to reduce amputations by educating professionals and patients about methods for saving limbs and through community outreach.
"I want more than anything for the public to shout, clamor and pound the table that I want something better than my leg cut off," Srivatsa said. "Amputation should be the last resort."
Others in the community said they're just as concerned about the high amputation rate.
The Veterans Administration Hospital in Fresno plans to add equipment at Valley outpatient clinics to test blood-flow problems in legs. Staff will be trained to identify vascular problems using the new machines.
The goal is to provide immediate referrals to a specialist if a problem is detected, said Dr. Gregory Wille, chief of surgery and a vascular surgeon.
Big medical providers such as the VA and Kaiser Permanente have done a good job of providing preventive care to patients at risk for amputation, said Larry Lavery, a podiatrist in the department of plastic surgery at the University of Texas Southwestern Medical Center in Dallas. Lavery has published about 170 papers on diabetic foot complications.
At Kaiser-Fresno, patients who are diabetic are checked regularly for blood flow in the feet and legs and for foot ulcerations, said Deborah Van Gundy, chief endocrinologist. The patients all are managed by primary-care doctors and chronic-care nurses. "If just left alone to primary care providers, their success rate is low," she said.
Bautista, the Fresno-Sanger internist, said those preventive approaches must be duplicated elsewhere in the county.
"We need to come up with another treatment," he said, "because the way we're doing it now is not the answer."