When amputation seems inevitable, University Hospitals doctors team up to save limbs
Ideastream Public Media’s health team is connecting the dots to uncover solutions to the complex issue of health inequities.
Cleveland resident Maurice Edwards was told he may lose his leg. The circulation to his right leg was so bad that he was in pain, but he dealt with it. But one day in 2019, while riding the bus after work he couldn’t ignore the pain anymore.
“I couldn’t really sit down,” Edwards said. “I kept moving around on the bus like I’m on dope or something, you know? Because it was painful.”
He got back to his home in the Glenville neighborhood on Cleveland’s East Side and realized how bad the situation truly was.
“I took off my shoes, my foot was cold through my sock," he said. "Cold! Like, woah!”
One of his doctors, Dr. Mehdi Shishehbor, the president of University Hospitals Harrington Heart and Vascular Institute, said that was because Edwards was losing circulation to his leg.
“That can be very painful. The foot can become cold. You may get numbness and other feelings in your foot,” he said. “It would be like putting a tourniquet around your thigh and suddenly stopping the blood flow to your leg.”
The health disparities of amputation
Edwards is Black. That means he's at higher risk for amputation: Black Americans are four times as likely as their white counterparts to have a limb amputated, according to data from University Hospitals.
That’s why Shishehbor started the Limb Salvage Advisory Council (LSAC) in 2019 at UH. A recent study he published in Circulation: Cardiovascular Interventions from the American Heart Association shows it’s working to save limbs and address what some call an “amputation epidemic.”
The study looked at 19 patients between January and September 2019 who were scheduled for amputation. The panel reviewed each patients' situation and determined that all but three of those patients could have revascularization surgeries to try to prevent amputation.
The study found they were able to save the limbs of about 75%of the people they worked on, Shishehbor said. Without the Limb Salvage Advisory Council, all 19 would have lost their limbs.
Dr. Mehdi Shishehbor (middle), the president of University Hospitals Harrington Heart and Vascular Institute, gets a drill ready to break through calcification in a patient's artery in an effort to save her foot. [Lisa Ryan / Ideastream Public Media]
The panel brings doctors from many departments together to provide a second opinion if a doctor has recommend an amputation. If the panel decides a limb might be saved, Shishehbor might perform a revascularization to restore circulation to a patient’s leg.
One of the revascularization procedures redirects blood flow around blocked arteries. According to Shishehbor, UH is the only Ohio hospital to offer that kind of procedure, and one of only five centers in the U.S. to offer it. Edwards went through the LSAC review process, and the council determined they could try to save his leg. He was told it might not be successful, but the panel said they would give it a shot.
Three years later, Edwards says he's grateful to have both of his legs, even though they still sometimes hurt.
“I’m ok now,” he said. “I’m used to them being numb sometimes and aching sometimes, but they’re still warm and have blood flowing, and I thank God. And Dr. Shishehbor.”
People with lower incomes are also at higher risk of amputation, and Shishehbor started to tear up when he thought about the health disparities.
“These patients don’t have resources. They don’t understand their disease,” Shishehbor said. “Many of them cannot even come here to see us, because they don’t have transportation.”
Black Americans are more likely to have heart disease and diabetes than white Americans, diseases which can lead to amputations if not properly managed, according to the U.S. Department of Health and Human Services Office of Minority Health.
Heart disease runs in Edwards' family. He lost his father. Maurice Edwards, Sr., to the condition when he dad was just 43 years old. At 61 years old, Edwards has now lived longer than his father.
“When I turned 43, I was scared,” he said, tearing up at the memory of his father.
Amputations can lead to further disparities, according to Dr. Shishehbor’s research. A person who has a limb amputated might not be able to return to work, which then causes them to make less money. And rehabilitation for people who have lost limbs can be expensive. All of that can result in a person being less healthy and less financially secure than a person whose limb was saved, Shishehbor said.
Moving from one doctor's opinion to a multidisciplinary approach
Taking a multidisciplinary approach to amputation is something other hospitals are doing, including the Cleveland Clinic.
“For those patients who enter through our emergency department, we call it a ‘toe and flow’ model,” said Dr. Lee Kirksey, who works in vascular surgery at the Cleveland Clinic, on cases similar to Dr. Shishehbor at UH.
There are different ways a patient in danger of losing a limb arrives at the Cleveland Clinic: outpatient, emergency department, or referral from another hospital, Kirksey said.
“Maybe they have diabetes, maybe they have peripheral arterial disease, maybe they have both, and they have a threatened limb," he said. "All members of the team are called to initially evaluate that patient."
From there, the team determines the patients’ needs and decides how to treat them and attempt to prevent amputation, Kirksey said.
The clinic has been working in partnership with hospitals like UH to raise awareness of what Kirksey calls the “epidemic of amputation,” and how certain groups are disproportionately affected.
Shishehbor compares the interdisciplinary panel to cancer patients, who often meet with doctors across departments to determine the best route for their care, but this approach requires shedding the old way of looking at hospitals, he said.
“Unfortunately there are competitive forces that sometimes push us toward that silo-mindedness," he said. "It’s the leadership of the hospital, the leadership of the [heart and vascular] institute, to make sure we take away those fiduciary and silo forces and push the organization and the physicians to work more together around the patient."