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Diabetic Foot

Nov 14, 6:00 AM

Because of its high prevalence, India is considered as the diabetic capital of the world. Diabetic foot is the most expensive and devastating complication of Diabetes Mellitus (DM), affecting 15% of diabetic people throughout the course of their lives. The severity of diabetic foot problems, such as avoidable amputations and possible mortality, can be reduced with early and good diabetic foot management, as well as the overall quality of life. Join the discussion with Dr. Sunil Vaze as he sheds some light on the diagnosis & management of diabetic foot.

uh very good morning to everyone i'm dr naveed and on behalf of team netflix i welcome you all to today's session uh on occasion of world diabetes day uh netflix brings to you a discussion on diabetic foot and its management uh according to a study that i was reading recently out of the 62 million diabetics in india around 25 percent develop a diabetic foot um of which 50 percent become infected and require hospitalization and of them uh 20 may end up uh with an amputation so let's let's understand about uh this topic and salvaging a diabetic foot more uh with dr sunil he's a senior consultant uh general surgery at sl rahejra mumbai with over 40 years of experience let's learn from his experience good morning i am dr sunil today is a world diabetes day i have greet everybody and i agreed all the diabetics on behalf of the medical and the surgical fraternity and i hope they had have a safe life they keep their sugars under control and they observe basic things so today i'm going to talk on the philosophy of limb salvage and the surgical management of the diabetic food i was also given a topic uh on that can people with ethical practice become rich i will touch upon that a bit later if time and these young ladies permit me so here i go philosophy of limb sandwich and surgical management management of the diabetic food now why does the patient get admitted to her through a hospital in usually these diabetes get admitted because they have some infection in some part of the body it can be infection it can be just ulceration or it can be a ganglion of a limb i am going to talk of lymph because again diabetes affects the limbs especially the lower limb more than anything else of course there are some target organs for diabetes like the eye the kidney or the heart but also the foot so i'm going to talk on the foot because i have been doing a lot of surgeries on the diameter there are there are some images which may be grotesque and if you may not uh you know find them very alluring but so big i mean it will actually just awaken all all of you and also teach you to teach your relatives friends and uh their parents to be careful about diabetic yeah here now i want to tell you one thing every slide has got a story there is a story hidden with every slide here's a man who came with a huge kabukala kamuku is a swelling on the back with an abscess there it was a massive thing and it took us three hours to uh to eradicate the whole thing the patient went home but ultimately we lost him to follow up here's the patient who obscures scrotal gangrene just called as a fool me as gangrene with the scrotum before that yeah here is a gallbladder which is called gangrene is perforated and you can see how dark it like itself it's like a coal you know she was a 82 year old man this without him this is a a calculus cognitive status with gangrene this gallbladder so you can see that huge government tends angry looking and this is the four nearest gangrene of the scrotum you say look at the amount of fuss which is being trained i think most of them i'm talking to many doctors so i they will be understanding they will be able to understand what i'm saying this have a gentleman had a huge totally dangerous infection was pouring from everywhere we're going to do a partial protectively his rejection fraction was 15 but we still we managed to do it we i did the whole thing under local anesthesia now what i think uh you know my presentation may have a lot of i i but here i'm not i do want to tell you not i'm not bragging but i'm telling you my experiences in management of diabetic food here's a lady who came with you know vascularities of her abdomen as well as her lower part we could not have it do not have any solutions for this so my friend of mine who had referred this patient to me he says what do we do i said let us give it a try of five sessions of uh hyperbolic oxygen feeding so five i said i told him if it becomes or if we give it a trial if we if we are successful in five settings and if we chose any so shows any sign of improvement we'll have it three more sessions so we gave him eight sessions of hyperbaric and this is the first the final result very very satisfying the statistics of diabetic food like she was saying there are six from 64.5 million diabetes india in india 30 to 40 percent of admissions in specialized centers for diabetes and for food ailments excuse me the incidence of re-amputation is 15 times more in diabetes as compared to the non-diabetics 85 percent of lung of all diabetic amputations are preceded by non-healing ulcers the non-healing action may be because of poor issues or you know issue bites and small treatment injuries and which lead to oxidation then those ulcers get infected and because the the immunity in these diabetes is low they get fundamental infections up to 50 percent of diabetics you have undergone an amputation we have a contralateral amputation within three to five years and 33 your mortality rate of the furthest major of amputation is as high as 50 percent now what is the physician's room physician's right is asking patients for symptoms symptoms of diet is sweating excessive salivation weight loss then i have this the feeling of thirst all the time and then visual inspection examining the patient thoroughly and then hands-on examination for the foot now what are the symptoms in terms of ischemia do you get does he get pain while walking is there does he have claudication does he have to stop before uh if there is a lot of pain in his limbs are the symptoms of neuropathy like loss of sensation or tingling numbness or is there a history of injury or ulceration now as a physician what do you have to do you have to observe feet note the color see for dryness of skin or deformities feel the temperature of the leg check sensations if the legs are pulled it means that the blood supply of the foot or the leg is compromised then check pulsations in the feet to determine the vascular status here it is checking in between the toes now or many many times you've seen fungal infections very common amongst diabetes so you have to check between the toes then check the pulses now this is she is uh the examiner is feeding for the sunny species artery which is the main artery surgery flowing to the to the toes and the lower part of the foot distal part of the foot i'm just saying so i feel further downstairs speed is artery now this is common have you seen this is called as a ingrown toenail this is the commonest thing you have seen in diabetics what happens you know there is some nail made infection which then proliferates and then it becomes more and the patient is not does not bother about it and then ultimately patient uh gets the ganglion of the toe and he might lose the chances that he might lose the great tone so if you find ulceration has taken place the wood is swollen and smelly do not wait and think take things in your hands the patient then needs hospitalization for incision and drainage or excision the food care guidelines so what are the food care guidelines i think you must have in every in every clinic there must be these food care guidelines to be put in there in their offices and i also always also suggest that general practitioners they should also have a uh glucometer in their like blood pressure apertures and things like that they must also have a glucometer because if the patient is diabetic you should know what the sugar is so what does that do is and do not first is do's examine fade feed daily for blisters cuts and wounds protect the feet from all hot or cold objects i will show you later what has happened with the patient is not protected wear a pair of common uh cotton socks at night because at night some you know they have uh this insect bite or rad bite and things like that and so i always we always suggest that they should wear something at night i want sitting cross legged sit cross legged your every likelihood that the blood supply or no supply may get hampered in this in especially in diabetics inform your doctor of any change in skin color or pain or abnormal sensation clean between the digits and keep the space between the digit dry and have a strict control on diabetes you have to client us or usually you know uh this dhoti cloth is a very thin soft loin cloth so i asked them to clean it with uh with a soft dhooty cloth it's better than the mouse speed because these goggles sometimes tend to rub on the skin no food care lines again food guide care guidelines don't i want to be walking barefoot no diabetes should not work barefoot at home and even and outside we have you know gained there in front of a house go walking to that house to the terrace we have seen often the patients uh go to you know temples and they go out for that parikrama uh and then they without feet and their temperatures in the on this uh times is so hot that they don't know what is the temperature because there is no sensation and ultimately patients get problems with the food do not perform bathroom surgeries we have seen patients right there see they see a small corn and they excise it with a blade or something and then they don't know how deep they are going and they cut it without asking anybody and then they pierce the word length and then it and then problem starts clean the nails straight across and then find them gently and refrain from smoking and alcohol okay there we have sometimes patient 85 86 here see very senior citizens who come with issue mechanic angry in his leg and the patients and the relatives tell us that they he's been smoking for a long long time and the patients tell us that doctor please ask these people would ask my father not to smoke because he smokes 10 videos per day i then i asked him how many years has this been he been smoking he says they tell me he's been smoking for the last uh it last 60 years and i tell them later he is now 83 damage has already been done so if you want to smoke letting smoke but of course ask him to curtail it and i'll call you refrain from alcohol because alcohol is a it's like a slow poison you know we sometimes we have patients getting admitted to hospital then i asked them we have class history of alcohol he says the patient tells me yes earl has to smoke what i have i've earlier has to drink but now i have stopped drinking so i said since when have you stopped drinking they say since yesterday after admission then alcohol also we have patients we had a patient called john karmalu from goa so he says john i said john you have diabetes and you drink he said yes sir so he says you know alcohol like diabetes is slow poison he says no first i asked him do you drink so he says doc is this a question or is this an an invitation so i said i just smiled and i told them you know like alcohol diabetes like alcohol is slow poison you know that said yes of course i know who's in a hurry yeah here's the page now again is the story is the patient who is in yes right he got a ride bike can you see that little ride by it and all his leg was swollen he did not know and the next three days he came with this path infected festered wood the same wouldn't see small thing here he had a pirate right here and then he had to lose this uh the foster he lost it yeah there's another patient who had come from distant suburbs in mumbai i don't know how many of you so here and here and here undergoing surgery by some surgeon i don't know but they have not done a good job so we had to clean it up we lost all these four or five doors here then we cleaned it up absolutely clean on the table it should look like this you know on table they're not a single island of unhealthy tissue should be seen on post-operative and this is the thing which is healed completely and the another patient who is who is from she was she was a farmer's wife she was working in a farm in somewhere near panvel and she she came with a little moon there which got festered she applied some people you know i don't know what it's called some local americans and then we got infected and then we excise it and if you see if you see if i open it say you can see there is not a single island of unhealthy tissue seen and this happened post-operatively she is healed completely another patient who had come she had a little wound on the little toe and we got an x-ray done and you can see osteomyelitis the entire little toe is gone there's the infection in the bone in the joint in all the bones we did no amputation and clean amputation and close it up and after after six weeks it was like this and this was a completely healed result very satisfying diabetic food is a very satisfying and gratifying experience well this i was told keep itself away from hot and cold objects this patient had gone to uh vaishnavi and see here no frostbite all the all the forefoot was completely gone so we had to do a four-foot amputation on both sides look at them this is called because excessive cold they don't know he must not have wound some warm clothing he must have gone in his slippers and you know this is this is frostbite he is a man to this right leg and to the left leg he he put his both his feet in hot boiling water i said what were you doing here what why this thing till this thing happened what happened what were you doing he said i was talking on the cell phone what a silly man he was and see what happened say right leg and left leg and what happened then he i told him that you get admitted he refused he went home and he was carrying on with some uh some treatment so he went to some other hospital he burst back washed up his leg ultimately he landed up with the baloney amputation on the right left side the same that it is a right foot of the same patient is the left foot now what is the goal of surgery aggressive radical debridement thorough drainage of infection and limited amputations are the essentials that is more important than choosing the right antibiotic combination preserve as much as possible early conservative amputation may prevent infection from gaining a foothold and propagating and hence a need for high level amputation can be avoided so when when the patient comes to me and i see i tell them this have to remove it neces he becomes very remorse and you know sorrowful and distraught i said see i'm looking at the larger picture i i'm not bothered about this story which is already gangrenous and but if you refuse to take that to off you might have an extra effect you might have for the getting the food affected the leg affected so your early conservative amputation is much better you will be much better off with that you know and there won't be any problem in walking the surgical skills what does the surgical surgeon require to be he must have must be he must have infinite gentleness in working diabetic foot also is uh can be where look can also look very artistic you know the knife of a surgeon you should work like a painter's brush you should be so delicate and so gentle and so light because especially in diabetic the tissues are more compromising so uh it's better to have very gentle do the surgeries very gently a purposeful effective movement and quiet movements you should one should not hurry doing the diabetic foot they have to do it very gently very slowly and very meticulously every operation should be executed not in the spirit of an artist working for the job but in the spirit of the artist who has something to interpret or create and this issue by small shoe bite giving rise to this you know festive also you can see that you can see that they get it to become gangrenous this is uh this is blistered and smelly food and the same food from the other side okay here they developed a gangrene of the toe he has lost history he lost his two opposed here it is he lost one to grade two and as i told you there should not be a single island of other tissue seen on the on the foot if the debridement should be so thorough in whatever material you use for most of you it is immaterial i don't use any local applications or medications or anything for healing of a wound because healing of a wood is not promoted by by local applications of antiseptic solutions but by nature this uh this is a lady who went to that mahakuma [Music] then she came with a little wound there and if you see that wound looks small from out but such a huge thing inside the diabetic wound is like a tip of the iceberg this can you see that i have marked that area to form which has got infected so we have to do a debridement of this deployment over food here it is our anesthesia and this is giving local anesthesia we do most of our cases under local anesthesia we just we just anesthetize that part of the food which is undergoing surgery so we have she's anesthetizing the foot i asked this lady why did you go there right now it has to be thorough the thing is this yellow thing is not first it's the fat we opened her from top to bottom see you can see that our trip also is going from one end to the uh wound it's going into the thigh and one the leg is going to that in the one next to the knee joint we opened it up through and through and then we closed her not like available is not good a hypoprotein that mood is never going to kill and if the blood supply is not good never going to heal whatever you might do i said address the world but he is there he that's his he made the state statement 600 600 years ago and through even today because india has the highest rates of antibiotic resistance and rampant local general practitioners and all people give i've seen patients being a given and small antibiotic for such a small such a small not did not require you if you give antibiotics as a smallest incense instead then you do not allow the body's immune mechanisms to take part in the action is another patient who had come with her angry blister can you see that terrible we did a wild excision wide excision and it slowly started healing and this one you can say now it's absolutely all right and this is absolutely after six to eight weeks it got covered we allows the patient to follow i was suggested why can't why didn't you do a skin grafting but then the patient could not afford so i allowed it to heat my secondary intentions i we did not apply anything on the road just clean keep the clean cover clean covered and dry keep the wood clean covered in a ccd i would say cafe coffee day like you know clean covered and dry here is a good advice to practice go into partnership with nature she does more than half the work and as another field go in partnership with the nature nature is there to help you and nobody else the enormity of the global burden of diabetic food disease this much neglected but potentially devastating complication of a disease that is reaching epidemic proportions someone somewhere loses the leg because of diabetes every third 30 seconds every day so what are the indications for when do you decide that i'm going to when do i decide when i'm going to amputate the leg one if the it's going to cause death to the patient or second if the part is dead yeah you can see that one minute answer a lot of pus in his leg same foot on the leg on the other side here it is wbc count 30 000 uh created in 2.8 patient obviously in septicemia and then we did a baloney amputation we went home i did not struggle with this you know i don't like uh i want my patient to go back to my to do his duties as quickly and as expeditiously as possible i don't like people so i tell them yeah they had there was a farmer who had come from i told him do you want to listen to the truth he said yes he says doctor i told him sir arjuna you need a baloney amputation he'd only do it tomorrow so so i did an amputation with him here's a man again that same for what he smoker for 30 years see he has got gangrene over both his leg he underwent a bilateral application he used to stay in a small child type of a building i don't know how many people are from mumbai um small is a small room 10 feet by 12 feet there the whole family is staying there and it's a very difficult life actually so unfortunately he he did not survive for more he i think after two months he succumbed but it was more of a relief for him also and for the patient's relatives yeah again the other patient would come fermented leg operate upon outside trying to salvage his leg it was not possible to salvage it there's no point in struggling with this thing that the patient gets morally financially and uh and psychology i'm psychologically absolutely drained and sometimes it's better to do an amputation then i tell them when i do an amputation you do one thing you put where the best quality uh prosthesis that is joyful food so the patients are ultimately happy he did well i don't know i don't know where is he now is the same patient with the post up picture of the post of limb now personal experiences of 2018 patients up to 2009 after that i have stopped counting amputation and uh above the amputation is just three percent and five percent and we managed to salvage most of the patient this charge in drainage is 51 percent so ultimately if you look if you look back you're doing a quite a satisfactory job so never never never never give up we never give up but at the same time i i know where to stop when to stop and microsoft that is the basic qualifications pragmatism perseverance is pragmatic you must be persevered yes i understand but you must also be pragmatic so there's a story by which by officer sir winston churchill he was asked to give up convocation address at harvard not hero is him cambridge so he uh came to the he took his cane off he took his cigar off he took his hat off he uh held the podium in his hand and he thundered into the mic never never never never give up he picked up his skin he picked up his hat and went and started and sat on his seat that was the shortest uh convocation address ever given can ethical doctors be reduced basically actually these girls had asked me to talk on their this topic can ethical doctors be rich actually this is a topic which is essentially for medical student school debates you know uh it's a very difficult thing actually so i thought about i first of all my question is where is why should there be uh why should there be even a question that an ethical people doctors have to be ethical why should we have one have to be unethical that is my question and the richness that which is so different for everybody so what to say yeah what it may be for me may not be for somebody else so when i said they told me richness i just thought about i said in more than riches i think i have been in i have been enriched that's what i would say one day i was giving a talk to one of the no i was speaking to somebody some resident of mine so i said when we were when our children were growing up we took them to for poetry session for music for everything but we really took them for movies i don't remember this then you said that means you have really enjoyed yourself i said no no i have not enjoyed ourselves we have enriched ourselves enjoyment is like going to london saturday and coming back on sunday that's in enjoyment but enrichment is lifelong so can ethical doctors be rich i'm not going to i'm just going to tell you what goes through my head when i start i when i practice i try to be as ethical as possible i don't think i have done anything which is unethical in my life i have not done any unindicated operation we have been very truthful to the patient so i will tell you how i go so what is ethical ethical is an adjective pertaining to our dealing with moral and principles of morality present pertaining to right and wrong in conduct and being in accordance with the rules and standards uh of of right kind of of practice especially in the standards of a profession so the what happens people tell me doctor this is your your yours is a very noble noble profession i said i always tell them it's not the probation which is noble the man who needs to be local so uh we had i had a patient he was horses with him and also he made a jewels it was filled his house was filled with jewels but with what he told me when you have side effect and contentment everything else is secondary now this uh covert has taught us that how simple you can live your life real rich means richness means that you are so rich that nobody can buy a character when all these thoughts i have written so that you also can go home some of you can go home and reflect on whatever i said the true terrorist of character is what you do when nobody watching when nobody what what you're doing i go there i've seen people who attended speak up masks quietly because nobody is watching but i have seen them and you are rich if and only if the money you refuse tastes better than the money you accept that's the most important thing my name is there manoj satay he was a chef champion vice president of nfbc something like that anyway uh he gives he is a good speaker what he told me uh he told me about wow increase it uh then third was it i don't know what's wrong anyway for fourth while what up in distribution don't keep it to yourself so wow wild one i don't remember third one third one is opera use it use your finances you understand so when a patient comes to me i am honored and humbled by the trust or hear she has shown in me and i am responsible for whatever that happens be it good or bad or complicated i am responsible some people tell me no doubt no sir you are involved more people so you have your responsibility responsibility will get distributed i said no my responsibility does not get distributed because i am the captain of the team and i am responsible for whatever happens to the patient good or bad or honored are complicated so when a patient comes to me and i'm humbled by the trust that he's showing and if i give him a wrong advice that it will be like betraying the trust that he has shown in you the art of medicine consists of amusing the patient when nature cures the disease most of the patient means most of the medical problems have no answer diabetes no answer blood pressure has no answer rheumatology has no answers but it's the nature which cures the disease a doctor should be humorous at heart scientists at brain and a mother at conscience that means a doctor should be cheerful insightful and caring have the courage to say no have the courage to face the truth do the right thing because it is right these are the magic keys to live your life with integrity there was a i was referring now i'm again telling you that i i might come but i that i'm not trying to brag but i'm just telling you my experiences we had i i i was referred a patient who had a gangrenous leg you know and the two toes were absolutely black so i said that this patient needs a below the amputation straight away no no two thoughts then the doctor is saying no no no you remove only two toes i said i am not going to do that that is not an operation which is indicated for you what is indicated is a baloney ambulation no no because i am saying you remove from toast you removed i said i'm not going to say that just because you're saying because that is not the right surgery he said that i won't send patients to you i said so be it i have not solicited patience for you from you i don't say i don't if you don't understand don't say no problem so i had the courage of saying no to me i did not want to be a yes man that might then my conscience would have tricked me look for three things in a person warrant buffet intelligence energy and integrity if they don't they don't have the last one don't even bother about the first two the hardest thing from about being in a doctor about being a doctor is that you learn from mistakes mistakes made on living people the urgent life and death decisions i make as a surgeon are based on lessons learned from bad experiences now coming to the examiner these days you find doctors they don't want to examine the patient they don't want to you know i go to the patient ask him what is the history if you just talking to talking to the patient he will give you giving you the diagnosis that's what william osler said just listen to the patient he's giving you the diagnosis now physical examination and the oldest and the most traditional test any doctor can perform on a patient that is how we were grown up with we were taught physical examination these patients come with me with utterance sound and ct scan then i tell them do i have to treat your ultrasound report or do i have to see you i i first don't see the report first i will make an assessment of myself then i talk to the patient and the patient would come with constants she said she said she told me that she wants to undergo cholecystectomy i said why why do you want to undergo cholecystectomy because she said that ultrasound shows two stones and my doctor said i family physician said you need a cholecystectomy go to a surgeon and get it operated upon then she came to me i said why did you what happened what is happening to you why why did you let this sonography done he said no no because my son got it done i got it done but i said what's your issues i have no issue as i said if you have no issue then you don't have uh she had two stones small stone i said then you don't need a police system if you have any problem then we will see so examination can be performed by a pair of computer physician's hand and an astute mind can reveal important clues in any patient's illness another little story i would like to tell you is i was referred to patient in the in in intensive care for abdominal pain so i mentioned some other patient abdomen is actually required where and no examination is abdominal examination is complete without the examination of abdomen testing hernia sites rectum and the back so everything was normal when i so you know i lightly stopped on the left side of his uh left wrinkle angle he said ouch i said what will happen what's happening he said no no i've got too much pain then i said what's your urine exam i thought maybe he's got urinary you know urinary infection or pylon nephritis on the left side or something or diabetic so he's i said i thought i saw that your exam was normal then we say i said okay let's get a sonography done so now if you had already been done which was uh again normal i said okay let us get a ct scanner so he says ct scan is also normal then i saw the whole thing then i said something is going wrong there is something cooking in his left kidney we will get a repeat ct scan and we should turn the stimulus to the left regional artery and the moment he the next day he was posted for anthoplasty he did a bioplasty of the arena artery very well patient sensation completely now like in breast clinical examination machines mammography ultrasound magnetic imaging player powerful in detecting best breast cancers but so does touch 73 of breast cancers are detected by women who feel the brain feel the lump so human element twenty percent by mammograms and five percent by physicians ten thousand breast cancers are picked up every year making touch a surprisingly powerful tool full tool as well physical exam has uses which machines cannot replicate patients don't care how much you know until they know how much you care so caring what is caring true medical care is caring for the patient to cure sometimes to relieve often to comfort always that's our job that is what our principle is to cure sometimes we cannot cure the patient all the time but you can we can relieve him often but we can comfort him always that is supposed to be our job world is full of nice people if you can't one you can't find one be one so i can go through sides quickly so that you can uh you know read the read them and reflect upon them there's a book of book of i always like uh what to say um your quotes and you know there are great sayings by great people because it makes you think it makes you reflect lives of great men all repent as we can uh live our life sublime for departing they leave behind footprints in the sands of time so what the if you can't you it's better to be nice than to be important if we follow three rules in our lives one is uh be kind second is be kind and third is be kind a five wise physician said that the best medicine for humans is care and love someone asked him what if it doesn't work answer is simple he says just increase the dose so what you don't like to do for to yourself do not do to others that's a golden rule of humanity why there are most this was written centuries ago even centuries ago it was known that what is this translation oh physician i saw offer myself salutations to you you are the real brother of yamara mara yamaraj while reyamaraja robs a person only of his life you rob of him after both wealth as well as his life if now sometimes their neuropathy also the primary problem has no solution whatever you do i give three lectures in uh in the u.s and every time i asked them what do you do for neuropathy answers they said we have no solution for it if a problem does not have any solution it may not be a problem it needs to be solved but the truth which needs to be accepted another day i give like that sometimes i talk to my residents you know you must be involved you must get evolved from inside then i always tell them that you step yourself into the patient's shoe then you know you will know what is happening uh so if then like you they start thinking from inside if your egg is broken from outside force life ends but if it's broken from an inspired inside force life begins great things always begin from inside and he who knows often is wise he knows himself is enlightened a spiritual should have a recovery room attending the cashier's office because these days in private private hospitals the bills are so high that patient gets completely want to say shattered financially formerly when religion was strong and science was weak men mistook magic for medicine when now when science is strong and religion is weak men mistake medicine for magic [Applause] sonography everything can be done with with like magic a good physician treats the disease a great physician treats the patient who has got the disease i have to treat the patient i don't have to treat the disease i have to take a holistic review of my patients i have to see what his requirement is i have to see how his finances are i'm not supposed to be doing anything for my finances i want to do for him be humble it's the humility which separates separates the good and the very good physicians from the great physician so you have to be very humble best index to a man's character how he treats those who can can't do any good and how he treats those who can can't fight back there was a one young resident of mine which who shouted this sister this happened last weekend shouted at the sister i told him why did you shout at him sir sir because he she was not listening to me i said same thing you could have told her politely you know why did you shout at her just because she she can't answer back you're talking to her like this never do that i said it's not going to take you too far prima non no cherry again first do no harm when a patient comes to you further do no harm i always tell i i would rather have you to i tell the patient i would rather tell you the truth and hurt you then tell you a lie and comfort you i'm never good i always tell truth to the patient whatever it is he has to face it because if he comes to know that doctor is lied to me which is she's not going to like he might feel bad on the first day he came but i i that's why i'd rather have you hurt me with the truth then then comfort me with allah i never tell a lie to the patient 10 of all conflicts are due to difference of opinion 90 percent are due to wrong tone of voice i've seen patients uh young residents shouting at uh what was like hey lightweight i said why are you saying like that yeah you can always request it to come there there are lights [Music] that you know if you want to you have to be nice to people i you can't talk like this one of the first duties of the physician is to educate muscles not to take medicines i don't of a young doctor starts ends it starts trusts for one disease and he's ends his life for one drug for 20 diseases i don't give any medicine post off never nothing no experience physicians use fewer drugs i hardly use any drugs another thing for the physicians saturn is the progress if you have a patient in the icu cardiology kidney specialist neurologist surgeon physician intensive now my child my grandson was in elementary school in california see how they teach their young children this is the motto of live oaks elementary school so i thought i will wrote it down i wrote it down and i thought i will share it with everybody who would like to talk listen to me that motto says i am in charge of my life i will listen and follow directions i will do my best at all times i will tell the truth even if it is difficult i'll accept responsibility for all i am in charge of my life i listen follow instruction and i do best at all times i will tell the truth even which is if it is difficult and i accept responsibilities for for my actions even my mistakes as i said in the first slide whatever happens to the patient good bad or complicated i am responsible so i will go back now to the little bit of diabetic food and the diet of course you know what is that how important is diet in in diet and exercise so it's work for 40 minutes every day at least five times a week then keep it straight control in your diet and do neck exercises so people ask me what are neck exercises so if we will give you samosas and a then with your neck you just said no no i don't want so so after two year loan to the united states michael angelo david was returned to italy his proud sponsors were mcdonald's kentucky fried chicken final i believe that if life gives you lemons you should make a lemonade and try to find somebody whose life has given them vodka and then go have a party thank you very much for listening to me thank you yes sir you have a lot of comments in the comments section uh everybody has enjoyed the sessions right from diabetic food to your take on ethics uh we learned a lot from your uh experience really on both the topic yes whoa yes i hope you're not saying that so that i feel nice no not at all not at all we hope you do come again uh but i'm not saying that for you to come again people are still listening or only you're listening no yeah we have people uh listening uh in the audience in my uh in my spare time during this i wrote a lot of stories yes it said well about 12 of them and i like a lot of reading yeah so we will definitely get our feedback from our audience and i'm sure they'll uh like having you on the session uh talking about one of your stories uh so on world diabetes day netflix has actually made a small poll related to diabetes so we give sir a break for a couple of minutes and we'll just run through the poll uh so here you go that's the first question um do what in and it's just a fun poll from our end to me just for me yes sir you can also participate in it so you'll get the question and the options on your screen [Music] okay uh sadly no mumbai is not known as diabetes capital of india it's actually bangalore [Music] um let's go to the second one yes i i just picked this up this morning it was surprising and yes and it was i think very common in the younger population as well uh so here's the second year i know because of this yeah because it is because of these terrible diets you know yes yes sir otherwise why should they be and basically we are also ramen is also here he's passed on from above yes okay that's the correct answer uh 1920. when was insulin discovered 1921 so we finished 100 years of insulin today this year rather um and so we have a third pole um okay this is more on opinion it's an opinion baseball so let's see what people have to say about this [Music] that's nice nice to know that we'll also have non-medical options for diabetes and that would be i guess the first option um thanks for participating in the polls um so we can take up a few questions from the comments section i'm ready uh there are a lot of uh good comments for you for the session i'll just unable to read it yes so if you can see comments on the right hand side of your screen you see present polls and comments so you can uh scroll through that and see the comments there yeah uh if anybody would like to come up on stage and talk to sir and answer get your questions answered by sir you all can also do that or the raise hand option would be available on the right hand side of your screen so you can click on that and come up on stage hello sir yeah yeah good hello yes sir uh good morning sir yes sir good morning sir it's it was a very good session sir and uh yeah i got uh some good information from your slides so i want to ask you one doubt sir nowadays uh even in diabetic food even after the treatment of a ulcer over the legs sometimes what happens is uh the patient is getting ulcer again again all the same position so what can be done for that regulations hello hello yes sir can you hear me sir yeah i can i can't hear you so what happens is one of my patients actually he was from mumbai only so what happens is he was getting ulcer over his small toe at the end of the two so once it was treated again after a time of six months again it recurrence was there's a one after healing also after uh six months again recurrence was their set so what can be done for that sir actually no sir he doesn't have sir actually or the wound heals her actually so what can be done sir you know actually he wears his socks and he he walks with a socks only so that uh it never uh touches the ground directly sir so i'm telling you what to do okay sir where are you from where are you from i'm from kerala i'm from kerala so you know the so far the people who make sofas sorry sir people who make sofas sofa sets yes sir yes sir they have those they have those sponges with they stuff them inside remember yes sir so you can ask him that person to collect you know two inches by two inches and wherever that uh that little toe is touching on the only chapel fix that uh with a favorite quick or something so it will be like a little padding okay sir and if he has no osteomyelitis then there's nothing to worry about it doesn't have actually last time it was almost to osteomyelitis but with the moon management uh it goes crazy thank you so thank you very much sir you're most welcome yeah thank you so much um we have dr anjali um taking you up on stage there's one interesting question from kumar we [Music] so my question was for being a surgeon do we need long fingers because i have heard my professors say that you have to be very quick and you have no no no no [Music] you don't have to need you don't need long singing you should be ready to sacrifice your life work very hard at any time of the day and night and if you can't do that then you should read the profession and you should have an application for being a surgeon because being surgeon is very hard work and you know uh you have to take the right and left right decisions in for the patient and for that you should be very discriminating i'm not going to do anything at first do no harm if you want to become a surgeon so we could take up that question uh by dr kumar the breitman cut off point yeah the department cut off point is he there okay i can talk yeah so you can talk he's there yeah you must cut cut off till you get a good blood supply that is one criterion and second current indian debridement should be so good that not a single island of unhealthy tissue should be seen kumar can you get it are you getting it uh and and thirdly there is some you know when you do a diabetic food there usually a stench stench stench you know what i mean then one at one point that sunstein suddenly goes away that is the end point then you can feel a stink stink there i hope that answered your question dr kumar i hope so so then there was another question right towards the beginning actually what is the role of maggot therapy in the road and uh what are your views on prophylactic antibiotics for diabetic products not required okay i'm very clear on that okay i think you also covered that in the session [Music] because there is obviously infection in the body but once that thing uh infection gets is it removed part is removed the patient becomes can you see me yes i can feel you the patient wow one day we had a patient who was in the icu and had fulminating like for a minute and very bad chest condition also you know so i did his billony amputation under local anesthesia wow so next day his name was doshi so next he was in icu so next day i went to meet him i asked if you can understand gujarati yes i can answer so i think most of the people would know i said [Music] i am all right sir they they they're so happy and proud delighted yes that's the best feedback a surgeon can get from their patients yes exactly yeah um so there's one more question what would be what is the role of conservation management for diabetic foot households what do you mean i don't understand conservative management uh maybe it would say diabetic food answer if it is infected take it out simple as that give what i did you go back up till up to a level where you see a normal blood supply so there is no question of conservation okay uh we have dr muskan so the nail infection being common presentation for diabetes what are the other causes for nail infection fungus combination fungus in diabetes or then if you if the guy who's got anything if he's not cut his nails properly if sometimes what happens diabetic cannot see you know so the i asked his relatives to cut the nails for them because they cut it and they cut it hard they'll go through the skin which i don't want to happen yeah so i asked his relatives will you cut his knees because there there were cataracts and they got retalipathy they are not able to see like in our house in our hospital when the patients are talking to me i said whatever you want to ask you can ask i never lose my patient and if four or five people are there i ask them do you want you have any question you have any questions you have any questions till they get satisfied i never live i leave the patient and i give my full attention to the patient you know who is the most important person in the hospital the patient the patient is the most important patient person in the hospital nobody else yeah you are we are there for him nobody knows not for any we will do it because it is convenient for him i said no no i we must do whatever is convenient for the patient the patient is the most important person in the hospital yeah uh so we have questions on how to dress the bone [Music] ccd clean covered and dry don't put any medication and if you are deprived very very good nothing is required okay get really clean keep it covered and keep it right i always tell them do you apply some antibiotic solution i said if you going to apply any sure a packet with some you know betadine soap or gauze piece i tell them how long will that bitter didn't remain there one hour two hours four hours after that what after that wound is rivaled you know so why do you want to use that better team that is my question yeah uh so we have a few more raise hands so dr manasir i'm accepting your request so please turn on your audio video when prompted doctor manager we've accepted your request you have to turn on your audio and video thank you sir for your excellent talk hello are you listening thank you thank you very much thank you i'm honored sir i will i'm azusa and i want to share something with you um please about this honey uh i have found in my practice very very useful number one number two in one of my case when i was working in saudi arabia he was a patient he used to just sleep when i discharged and whenever he comes with maggots he was having madra food fungal infection so i have i used to see a wire what is this like natural department this has happened with me third one of one of the doctor asked about long term no you need lady's finger lion's heart and eager side as a surgeon this i want to share with you yes a heart of a lion i have been you know hands of a lady thank you very much very interesting sir oh thank you very much well i mean i must hear you i will share one thing just a minute i i heard i read one wonderful quote today the truth is the highest virtue correct but higher still is truthful living yes exactly i am absolutely truthful to my patients i do anything hanky banking nothing the problem is the problem no idea the doctors are treating pocket first and patients afterwards but you and me i like too much we cheat the passion first then pocket and we never we never treat the reports scattered information not the report your clinical recommends more important most of the time correct let's compare to a scan record sorry thank you sir these kinds of uh thoughts are good for old farts like us replacing thank you so much for coming up on stage um i think we've gone through uh most of the questions in case we have skipped any uh we'll surely collect them and we'll send them to sir and then so can answer and we'll get back to you with those answers uh thank you so much everyone for coming in and thank you so much sir for taking time out on a sunday morning and coming to netflix we really enjoyed the session uh the knowledge part of it yes the clinical knowledge but more so the knowledge that we got through your experience and on all fronts so thank you so much sir and we really hope to have you on our platform again surely i will yeah so go ahead ah yeah we'd like to know what exactly do you cover the world with right now uh dr harinas from chennai i am only 79 years old surgeon oh 79 years young you mean 79 years dental surgeon like you yeah i completely agree with you regarding our approach to the ethical uh this one by hippocrates and all those what material do you use no no one stage one stage that's what i wanted to know that patient does not have to come to the opposition table again and again if that has happened there is something wrong with me with me if that thing happens one stage how would you give the permanent cover do you have to use uh services of a plastic surgeon or you do yeah you can do you can do but that because but then you know doing this in private hospital it will cost patients a lot of more money as it is the patient is financially drained because dread because of yeah so i allow it to heal my secondary intention instead of four weeks it will take two weeks it takes four weeks that's the only thing yeah thank you and i never make it wet because i always tell tell people you know okay if you go for a bath you will you take a diet novel with you or you take a moist oven obviously you're going to so that all that those discharges can get absorbed so we want those discharges to get absorbed and how will they get absorbed and if you don't put it right or drive a gas piece you put thank you very much that is very nice uh hearing your experience and uh i am honored sir it is also very i'm also honored to be to be with you over there uh sharing all the curls of your experience and wisdom thank you very much thank you very much yes sir thank you so much for coming up on stage how how is the rain in chennai uh i should have asked him that [Music] uh so i guess uh no more questions i guess we can uh yes i think we can wind it up and we look forward to you for more such sessions and thank you so much everyone for joining in on a sunday and happy birthday wonderful to be interacting with you ladies thank you sir thank you so much okay all right thank you so so much thank you sir and thank you everyone for coming in today

SPEAKERS

dr. Sunil R Vaze

Dr. Sunil R Vaze

Senior Consultant, General Surgery, SL Raheja, Mumbai

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dr. Sunil R Vaze

Dr. Sunil R Vaze

Senior Consultant, General Surgery, SL Raheja...

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