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Diabetic Sensory Neuropathy/ Agent Orange |
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Diabetic patients with chronically elevated blood sugars tend to develop neuropathy, neurological changes that produce a variety of effects in their body. Most patients with diabetes are not familiar with the word neuropathy and further don't realize that there are three sub categories of diabetic neuropathy; autonomic neuropathy, sensory neuropathy and motor neuropathy.
Autonomic neuropathy results when the nerves that control the oil and sweat glands in the skin fail to function, creating dry, cracked and itchy skin and fissures. Sensory neuropathy is also caused by chronically elevated blood sugar levels and can cause BOTH pain AND numbness to the feet and legs AT THE SAME TIME! Motor neuropathy is also the result of chronically elevated blood sugars where the muscles in the foot fail to function properly resulting in bone and soft tissue deformities.
While each type of neuropathy has different negative effects on our body, sensory neuropathy is the co-morbidity, or result of chronically elevated blood sugars that has the most devastating results. Let's take a deeper look at Sensory Neuropathy. Patients with sensory neuropathy usually suffer from numbness and/or pain to the feet. The numbness results in loss of protective sensation (LOPS) and leaves them vulnerable to silent or painless trauma by mechanical, chemical or thermal origin. Painless trauma is the trigger that starts the process that can lead to amputation. There are several common reasons that a patient can develop sensory neuropathy. They include diabetes, exposure to heavy metals like lead and mercury, cancer and after chemotherapy, and tumors.
When we think about chemical trauma to the foot, the source most ofter discussed are topical over-the-counter medications that contain salicylic acid. These products are typically used to treat ingrown toenails, corns, calluses, and warts. Salicylic acid is dangerous for patients with diabetes to use on their foot because it destroys tissue painlessly.
But wait, what about other sources of chemical trauma?
An under appreciated reason for sensory neuropathy is systemic exposure to chemicals. Veterans who fought in the Vietnam War, had exposure to herbicides and defoliants almost on a daily basis. Some Veterans tell stories of leaking chemical drums, chemical spills, and accidental exposure to Agent Orange and its chemical cousins (Agents Purple, Pink, and Green), that often times covered their entire body. Some soldiers tell stories of having repeated exposures. These chemicals were used to deny the sanctuary of the jungle and food to the enemy. During the production of Agent Orange, dioxins were produced as a contaminant, which have caused health problems for those exposed to it during the Vietnam War. In a study by the Institute of Medicine, a link has been found between dioxin exposure and diabetes. Agent Orange was a 50-50 mix of two chemicals, known conventionally as 2,4,D and 2,4,5,T. Agent Orange was mixed with kerosene or diesel fuel and dispersed by aircraft, vehicle, and hand spraying. An estimated 20 million gallons of Agent Orange and other toxic herbicides were sprayed over six million acres of Vietnamese jungle. The earliest health concerns about Agent Orange were about the product's contamination with TCDD, or dioxin. TCDD is one of a family of dioxins, some found in nature, and are cousins of the dibenzofurans and pcb's.
The TCDD found in Agent Orange is thought to be harmful to man. In laboratory tests on animals, TCDD has caused a wide variety of diseases, many of them fatal. TCDD is not found in nature, but rather is a man-made and always unwanted byproduct of the chemical manufacturing process. The Agent Orange used in Vietnam was later found to be extremely contaminated with TCDD.
Captain T's Story.
Captain T had been a pilot in the Air Force, flying missions in both Korea and Vietnam. After leaving the military in his civilian career, he also flew Boeing 727's. The Vietnam missions included transportation of large quantities of Agent Orange. He was a seasoned pilot with thousands of hours of flying experience. When he arrived at my clinic he was piloting a 4 wheeled scooter, as he could not feel the floor with his feet, had a problem of losing his balance and falling, and worst of all, had chronic, unremitting pain to both legs and feet. Captain T has become diabetic due to his exposure to Agent Orange.
Once he got into my treatment chair with his portable nasal oxygen tank hanging over his shoulder he told me his story. "Doc, I want you to cut my left leg off," was his opening comment. "I have so much pain, I am going crazy." He then explained, "I flew many missions in Vietnam and a lot of them were transporting Agent Orange. Sometimes the containers leaked in the plane or there were accidents while loading or unloading it that left me and my fellow soldiers wet, covered in Agent Orange. But the worst experience I had was when I was shot down. I survived the landing but ended up laying in a pool of Agent Orange for two days until I was rescued. Over time I have developed numb feet and legs and the pain in my legs is unbearable. I am taking narcotics for the pain but they barely give me any relief. I have had so many tests, that I am sick of being tested. I am sick of seeing doctors, I am sick of taking medications that don't work and I am sick of hurting. I often think about going into my garage and taking a chain saw to cut my own leg off. I am sure that will relieve my pain." A desperate statement from a desperate man.
When I examined Captain T, his situation was one of the worst I had ever seen. The color of his skin was a mottled black/brown starting at his knees and going towards his toes. His legs were swollen due to retaining fluid. The skin was dry and taught. He had cracks in the skin near his ankles that were oozing blood. His feet were ice cold and totally numb.
I had watched him transfer from this motorized cart to the treatment chair. He was barely able to move his legs and had to hold on to a cabinet and then the treatment chair as he was so unstable he could not feel the floor with his feet.
Captain T could not feel my hand touching his foot, he could not feel the monofilament test. He could not feel me touch his foot or leg with a pin. In fact he was numb from his knees to his toes. He described the pain in his feet and legs as constant burning and shooting. He reported his pain level on a 0-10 scale with 0 = no pain and 10= the worst pain at level 15. At first I thought his pain might be from his back, or a nerve entrapment in his ankle or foot, but both of these causes were ruled out.
After I reviewed his chart and examined him, it became clear to me that there was nothing I could do to help this patient. I suggested to him that he should reconsider his request for an elective amputation as his health was so poor, that he might not survive the anesthesia and that even if his leg were removed and he survived the procedure there was no guarantee that his pain would be relived.
"Doc, I am ready for those results. If that's the way it goes that that's OK with me. I must have pain relief." I suggested that he visit with a psychologist or psychiatrist to discuss his situation before he made any final decisions.
While this is an extreme example of peripheral neuropathy due to chemical trauma, it serves to educate us to the extreme suffering that patients with diabetes can experience.
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