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Fight the rot: With both her feet now amputated, Paulina Masondwane must use a wheelchair to move around. (Madelene Cronjé)

When hospitals don't make the cut

Paul McNally
Diabetic patients who aren't treated properly risk having the smallest cut lead to an amputated limb.

Paulina Masondwane was lying in bed at Kopanong Hospital in Vereeniging, south of Johannesburg, when she heard a commotion outside her room in ward 10 where she and other patients were awaiting surgery. 

As she sat up she saw more than 30 men and women – mostly strangers – streaming into  her room. It was early June and they had heard her desperate pleas for help on the community radio station a few days earlier and had come to show their support.  

Masondwane had been admitted to the hospital almost two weeks before but says she had received little assistance from the doctors and nurses on duty. 

"I was left on my own in that room for hours. In the morning we had to bath with cold water and I slept under the same dirty linen for days," says the 59-year-old woman.  

But cold water and dirty linen were the least of Masondwane's worries. She had been in this situation before. 

In 2012, one of her legs had to be amputated just below the knee after the gangrene she had developed in her foot spread.  She knew that, to save her remaining foot, she needed help immediately. 

Adult-onset diabetes
"When I arrived at the hospital I only had a small scratch on my foot, but doctors said my blood sugar levels were too high and admitted me," recalls Masondwane, who was first diagnosed with type II diabetes in 1998 and has a history of high blood sugar levels.  

Type II diabetes is a chronic condition that occurs "when the insulin, which the pancreas produces, is either not enough or does not work properly", according to Diabetes South Africa (DSA). 

The organisation estimates that up to 90% of people with diabetes have type II, also known as "adult-onset" diabetes.  

DSA warns that uncontrolled blood glucose or sugar levels "over a long period of time can cause serious damage to parts of the body and lead to blindness, heart attack or stroke, and amputation". 

According to the International Diabetes Federation, high glucose levels and high blood pressure can lead to nerve damage in diabetic patients, with feet being the most commonly affected areas.  

Gangrene
A 2009 Unites States National Institutes of Health article found that severe infections can "present as a bluish-purple discolouration when there is inadequate supply of oxygen to the soft tissues, leading to gangrene".  

"Gangrene cannot be healed. The dead tissue must be removed surgically," says Gabaza Ngobeni, who runs a Soweto clinic that specialises in diabetes treatment.  

After two weeks of hospitalisation, Masondwane lost her other foot.   

One of Masondwane's unexpected visitors, Stephen Pooe, has had diabetes for 20 years and is still struggling to control his sugar levels. 

Like Masondwane, he, too, has had a leg amputated and knows that, unless he manages his sugar levels better, he will also face a second amputation.  

The South African Diabetic Foot Working Group, a voluntary association of professionals, says that diabetes is one of the leading causes of lower limb amputations globally. 

But there is a lack of data from South Africa, according to the association.  

A study in the online journal Global Health Action estimates that diabetes leads to 2 000 new amputations every year in South Africa. 

Disease management 
Ngobeni says that Masondwane's foot could have been saved if her sugar levels and injury had been managed as soon as she arrived at the hospital. 

"With a diabetic you need to keep a wound covered and clean with antibiotic ointment," says Ngobeni. 

Any other problems, such as an ingrown toenail, should also be treated quickly to avoid infection, according to Anette Thompson, a private podiatrist [a doctor who specialises in foot disorders]. 

Masondwane says she did not receive anything close to this type of treatment.  

Ngobeni says that a patient like Masondwane, with a history of high blood sugar and reduced blood flow to the legs, probably already had nerve damage when she was admitted to Kopanong. It's called peripheral neuropathy and develops over the course of several years. 

This nerve impairment means that damage to the feet can go by unnoticed if they aren't checked on a daily basis. 

High sugar levels
A diabetic patient like Masondwane needs to be treated thoroughly because high sugar levels in the blood mean her immune system, or capacity to fight infection, has been compromised. 

Masondwane's blood sugar level was almost three times higher than what is considered healthy when she entered Kopanong.   

"For a diabetic with rampant sugar levels you need to take quick, decisive action to avoid infection. Once infection starts it can spread very fast. When a patient is hospitalised for high glucose levels, they may need to administer an IV [an intravenous drip] with antibiotics," says Ngobeni.  

Masondwane says doctors at the hospital did put her on a drip and gave her the same pills she had been taking for years at home, but it wasn't enough.  

"The gangrene had come up," she says. "The best they could do was cut my leg quickly and try to save as much of me as possible."  

Masondwane's second leg was amputated a week later at the nearby Sebokeng Hospital where she was transferred to because Kopanong was unable to perform the procedure, as its autoclave, which is used to sterilise surgical instruments, was broken at the time.  

The Gauteng health department says Kopanong was experiencing problems with hospital procedures, including the sterilisation of equipment, at the time of Masondwane's hospital stay, but that these have since been sorted out. 

Masondwane says she was relieved the operation finally took place; she had feared the "rot" would spread to the rest of her body. – Additional reporting by Ina Skosana


Chronic diseases account for 40% of deaths in SA

Many more South Africans are living with, and dying from, noncommunicable or chronic diseases as a result of the rise in "urbanisation, industrialisation and economic transition, and health services that are not always adequately equipped to deal with the issues", according to the national health department.

Statistics South Africa found that, although the number of deaths reported had decreased from 547 724 in 2010 to 505 803 in 2011, there had been an increase in the number of deaths from noncommunicable diseases. The government estimates that chronic diseases account for 40% of all deaths in South Africa. 

Between one and 1.5-million people have diabetes, according to a 2007 South African Medical Journal article.  

"Diabetes is not only the most common cause of nontraumatic amputations and a leading cause of blindness, it also accounts for a significant proportion of end-stage renal disease requiring dialysis and transplantation," the journal states.  

According to the government, chronic diseases such as heart diseases, diabetes and respiratory conditions can be prevented by addressing risk factors: smoking, unhealthy eating, lack of physical activity and harmful alcohol use.  

A 2013 Human Sciences Resource Council study found that 27.9% of men and 45.2% of women are physically unfit, and the number of overweight and obese South Africans has increased over the past decade. 

Obesity among women has increased from 27% in 2003 to 39% in 2012. The study found that 25% of women and 19.6% of men are overweight; 40% of women are obese and 11.6% of men.  

According to the national health department, there are 17-million visits to government healthcare facilities because of hypertension and diabetes every year, but many people with these conditions are unaware of it and so not receiving treatment. — Ina Skosana

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