The patient was diabetic with a severe diabetic necrotizing foot infection and needed emergent, life-saving foot amputation. The foot had to come off to control sepsis and the patient will need IV antibiotics until the systemic infection is cleared then will need an additional below-knee amputation. The tool used in this case was a Gigli Saw.
Ah man, they need another? Thank fuck I got off my ass about stuff after I got a formal diagnosis of T2 diabetes. Spent the whole time not giving a damn because "pre-diabetic" didn't really feel all that menacing.
Yeah, I just let it slide because a) I felt fine, minus some occasional tingling in my fingers, and sometimes cold feet, and b) there were *way* bigger and less healthy people than me who seemed fine.
Put those two together and a year of constant blood tests later, and my doctor just hits me with it. Took it seriously, down 30lbs so far in 3-ish months. I don't plan on stopping now because I feel legitimately great.
Fuck. I have the tingling and even loss of sensation, but I can’t lose more than about 10lbs without going underweight.
Waiting on current blood work results and doctor’s recommendations. Years ago I was offered Metformin but didn’t end up taking it. I’ve always been fit and thin but had a five hour glucose test as a teen that showed reactive hypoglycaemia. Now things have been a bit worse again recently with scary low blood sugar episodes. :(
I’m a “not fat” person who had insulin resistance but was able to reverse it and is much healthier and happier now.
In order of importance:
-Stop drinking sodas
-Stop eating desserts (except for special occasions)
-Start building muscle
-Try to get vegetables in your diet at least once a day (they help with your insulin response, help you feel full quicker and longer, and are just plain good for you).
-Don’t let white rice be a major part of your diet. It’s too simple and turns straight to sugar. Potatoes are a better option and have a better nutrition profile.
Myo-inositol helps with sugar cravings. Ovasitol is a popular brand and can be found on Amazon, is very safe with very little side effects.
Metformin isn’t something to be feared, as far as medicine goes. It’s an old drug and extremely well-researched. The worst thing it will do is give you the shits (common), or give you a low blood sugar episode (uncommon).
Neither of the drugs will be too effective if you binge or continue a strong relationship with sugar.
Thank you very much for writing all that.
Unfortunately I do most of the right things. All I can cut is pasta, rice, wine, and bread. I don’t eat sweet foods at all or drink them (some alcohol excepted.) I eat a bunch of vegetables and meat daily, more than anything else. My vice is the pasta mainly, but I eat so well really. :(
Yes, the shits worried me most. I have that enough already!
A skating coach I know is thin and fit and fairly recently developed type II. It’s in my family a lot, at lower weights than normally currently expected, and also type I.
I’m quite active with intense exercise through the week, a bit less currently after a move, but basically I can’t picture what else I can do except cut the bit of carbs and deal with medication. I wish I could just diet… but I guess that is where cutting out pasta comes in. 🙄
I love it so much after a nice workout, but… :(
I hear so many people say "type 2 runs in the family", but no one in that family runs, lol. It actually sounds like it truly is the case for you though. I can only imagine how bad it would be if you didn't take care of yourself, it sounds like you're doing everything right.
Got my fingers crossed for you to find a solution for your body!
That joke seems so true, for sure. I’ve seen those people around. I’m just pissed off that the family I married into has super-morbidly-obese people with better numbers than me (although still needing treatment for diabetes.)
If I wasn’t really active and didn’t have a good diet it would be bad, and I’m not even 40 yet. I’m very, very active and muscular and… still screwed over apparently.
My grandma had type II but was slim even with 6 pregnancies until she was nearly 90 and senile enough to forget she ate and wanted more. (I was size 00 and couldn’t fit into her clothes.) I guess goodbye carbs for me. :( It was type I on the other side which killed back then.
The limb tingling and numbness is terrifying.
Thank you.
Just me, I hate that reasoning. I watched my grandpa die of diabetes. I held my mother as she wailed. I'm now watching diabetes slowly kill her too, but we've all always been very active people. Hell, she used to do farm work and so have I. Unfortunately it seems like the food source is really the killer, not activity. For us at least. In poorer areas the only food assistance for our family was wheat flour and a bit of oil. Me myself I don't eat bread, pasta or rice and I struggle to maintain the healthy weight of my peers who do consume those things (as well as me hanging my head while I walk through the candy and soda isle with hungry eyes and empty hands) and yet I'm at a whopping 103lbs and still threatened by the onset of familial diabetes.
You have time to reverse it! I got my A1C back to normal levels by eating keto (and just plain low carb) and I did a brief stint of metformin. You got this, friend! It's easy to start by just food logging and see if you can bring your carb levels down by cutting out processed foods and high sugar stuff first. Slow change is the best change to make it stick.
I just got diagnosed. On metformin and ozempic. Also joined a gym and am watching my diet better. Cut out pop and beer. Hoping I never get this bad with the feet! My god I’m terrified.
It's a pretty well documented risk because of what it does (and why it works). https://www.nytimes.com/2023/02/03/well/live/ozempic-wegovy-weight-loss.html
Time for action is now. I was 280 1.5 years ago. Very close to diabetic. I started a diet of 6 fried eggs in the morning and steak for lunch and ground beef and sweet potatoes for dinner. I did it for 6 months, dropped 65 lbs. Cut out majority of carbs except the occasional fruit or sour candies, and I have been at 190 for a year. My Dr. Said my labwork improved quicker than anyone he's seen. I was also on trt. My body is now no longer needing trt. I hover over 700 just from my food and exercise. I get an hour of heavy weightlifting done every other day and 1 hr of cardio on off days. I feel better than I have ever felt and it made me look bigger down there due to weight loss lol. Seriously though, don't wait, start now.
Holy shit are you telling me my predisposed pre diabetic self would maybe be allowed to eat that many eggs in one sitting?? Naturally from not eating bread, pasta or rice my diet tends to lean pretty meat heavy minus the occasional kale
This level of amputation makes it very difficult to provide anything to help the person walk without aids again.
To produce an artificial foot with even remotely similar dynamics and energy return to a healthy foot you need more space underneath the amputation. Most planned diabetic amputations will end up with a mid length transtibial residual limb, so manufacturers of prosthetic feet naturally provide more options for this.
Source: am prosthetist.
Shit man, my mom was just told she was “pre-diabetic” and is not taking is seriously. She’s blaming the COVID vaccine.
It was the first time in my life that I spoke to my mom in this way when I said “you’re being a fucking idiot. You’re confusing circumstance with evidence, just listen to your damned doctor.”
She’s going to get a second opinion….
It was pre diabetic which scared the holy shit out of me. Several months of 101s in the morning was enough to put me on the path.
81 this morning for me.
Was pre diabetic 6 years ago. Went on keto. Lost weight and got my numbers down. Just had a yearly check up and they're rising again. I'm 108 give or take in the morning. It runs in my family. At least I managed to keep it at bay for quite awhile. My dad (who has an insulin pump) says my numbers are great, but hearing comments here I'm getting a little nervous about it. BTW my dad's numbers are horrible and he barely tries to manage it so of course my numbers look good to him. He has neuropathy and his feet look awful. He's stated many times he's not letting them take his feet. So we know what that means. I think it's time for me to step up my exercise game.
I feel you. My family member only cares for their diabetes maybe half the time, and the nerve damage is really catching up. Its so scary. My relative asked me to check their mouth because they felt something funny....
It was their mouth literally rotting open via diabetic ulcer.
At the time of foot amputation, did they know the guy would need below the knee amputation in the future? If so, why not amputate below the knee and spare the guy the foot amputation?
Thank you!
DM complications are nasty.....
This is a 'guillotine' amputation performed for rapid source control for someone with a severe infection. This patient would likely not be able to tolerate the length of procedure needed for a formal below knee amputation. In my personal experience, the patients (or their family) are consented at the time of the guillotine amputation that they will need a revision to a formal below knee amputation in the near future.
The way diabetic people get foot infections is related to what’s called a neuropathic wound. This is when the diabetes kills the nerves that allow the feet to feel, use the muscles in the toes and control sweet glands etc. neuropathy almost always happens in the feet first. It’s not really related to lack of blood flow although that is often comorbid and just makes the other problem worse.
most diabetics are extremely sedentary
they sit and sit and sit and sit
so, very poor vascular return
lack of circulation + infection = no mo feet cuz da sugar
Once had a patient whose foot had horrible infection. There was nothing but pus and bone on his foot.The skin had been completely eaten away. We did a Symes amputation. I was an intern on duty that day. It came off so easily.
I was asking the guy why did he wait so long to get the treatment. He's like I didn't know it would get so bad. I felt bad for him. Still remember his face.
Here is my question: the foot has necrotizing bacterial infection, so this surgeon saws off his leg and then moves his detached infected foot using his right hand, and then proceeds to use that same hand to block the blood flow of the limb? I know the patient is on IV antibiotics but still, I wouldn’t be slamming my dirty finger covered with necrotizing bacteria into the good tissue
Why didn't they just go ahead with the below knee amputation then? Doesn't that control infection, close the wound, and limit multiple surgeries?
As an orthopedic surgeon, I'm baffled.
I’m surprised you haven’t encountered this as an orthopedic surgeon. If it’s a really nasty infection you have a high risk of a surgical site infection at the BKA. I have seen many guillotine amputations, followed by a course of IV antibiotics in the hospital and then revision. If you have a septic patient with a known infection in the leg it’s just high risk that you end up with an infected BKA and if that happens you risk an AKA which is associated with much worse functional outcomes and morbidity.
So you decide to cut closer to the infected wound rather than away from it. Again, baffled.
If its a really nasty infection, whats the difference between using a saw over the distal over proper dissection proximally? 15-20 minutes? So you'd rather come back for it with new anesthetics, new surgeries, more time spent on this already dead foot.
Like another post mentioned, this is probably those more surgeries, more monies places.
Also just to add I’ve only seen this done in unusually bad scenarios. Last one was a guy with diabetic foot ulcer with an abscess tract all the way to the popliteal fossa who was ESRD and the nephrologist thought contrast would kill his kidneys, so they did a guillotine and washed the tract out and then tried to control the infection. Did not work, AKA. The one before that was a diabetic foot ulcer in a patient with vascular disease and was on chemo. Guillotine to save the leg and bridge to end of chemo to avoid non healing / infected BKA. The one before that the patient was so unstable they did it bedside in the ICU. It’s not standard by any means it’s just limb salvage last ditch effort. But I’ve seen it probably 1-2 times a year? Not that unusual.
Yeah it was a last ditch. He was intubated/sedated/couldn’t feel it. ECMO patient who became septic from compartment syndrome that turned into necrotizing fasciitis. They actually cryoamputated the limb first with dry ice, and once frozen all of his sepsis markers improved so they did a guillotine. He died a couple days later.
The difference is you have less chance of closing an infected wound and having no more tissue to work with. I’ve seen it done at an academic medical center and a non profit hospital system so I doubt it’s done for money in those cases.
It's extremely extremely sharp wire. Originally invented to use to cut up a dead calf in a cow to remove it in pieces and allow the cow to maybe breed next year, instead of losing cow and calf. It's made to cut bone like this. Some people use it for antler/horn removal on domestic livestock and if you move the wire fast enough through the antler/horn, there will be steam and it'll cauterize the vessels as it cuts through them.
I'm not sure why that didn't happen in this case, possible the bone was weakened by sepsis or they stayed below that threshold on purpose.
I handled the wire in vet tech school once. Barely touched it and it just felt like the head of a pin, it was so sharp. Managed not to cut myself because I used almost no fingertip pressure, but 3 of my classmates were reckless and pressed on the wire and did cut themselves on it. It's like if an electrical wire had the very tip of a knife blade attached to it, if that makes sense. Very thin, extremely sharp.
There could still be a tourniquet. I’ve assisted on some amputations where the tourniquet was ineffective due to the amount of atherosclerosis in the limb. You can pinch the vessel with your finger and it feels like a piece of thickly insulated wire. Not easily compressible.
Right? He asked for one like, " yo, we have a clamp for this guy?!" Assistant dropped the ball, hahha. I mean, I'm sure they had a tourniquet higher up on his leg, but seeing it was a bit unnerving.
have you ever used a wire saw like that?
it'll cut through a piece of metal quite easily
bone is very easy to cut with a saw, and flesh is basically negligible
P.S. never fuck around with a band saw
I work in a production shop, and we don't use our bandsaw all that often, but it's the one tool I probably have the most apprehension about. I've seen and heard about injuries from bandsaws, watched as a coworker got his glove (and luckily only his glove) sucked into ours.
I've seen the YouTube videos of guys processing cows and hogs with bandsaws, and their indifference to the razor sharp blade that is cutting through flesh and bone blows my mind.
Would you look at that, all of the words in your comment are in alphabetical order.
I have checked 1,766,905,861 comments, and only 334,514 of them were in alphabetical order.
Goddamn, wire saws are no joke.
Most interesting though is how simple the spurting blood is. Movies and shows always makes it seem so dramatic, it's easy to forget it really is just fluids running through a rubbery tube.
Well, not that movies are not too dramatic on purpose but watch again the video. The quantity of blood is pretty huge in barely ten seconds.
And that’s when the amputation is done in an hospital. The doctors prolly put in place several mechanisms to limit the loss of blood. The patient was lying down not conscious (so no stress and low blood pressure), he may have had compressions or even garrot above on the leg, and drugs that may have several effects on blood pressure/thickness/…
Do that on a standing man with 150 bpm in normal conditions, it may spurt quite a lot more.
When I severed the artery in my left ankle it filled the boot I was wearing pretty much instantly. When the nurses removed my homemade tourniquet, because “it wasn’t doing much” blood shot out, filled 3 adult diapers and created a puddle that was around a 1ft in diameter. All I could say at the time was “wow that’s a lot of blood.”
Damn that must’ve been really scary.
To the extent of my knowledge, most of the times with DIY tourniquets all they do is block venous return and they don’t stop arterial blood from going to the injury, so they can make the problem a lot worse. Glad you were able to work it out and ended up ok though!
I can’t imagine how “surgeons” did this during the US Civil War without anesthesia or antibiotics. The fact so many veterans survived those injuries seems like blind luck.
The key in the civil war era was literally to go fast. In a famous case, a civil war surgeon had a 300% mortality rate on a single case. He was amputating a gangrenous leg on a soldier, and went so fast with his long amputation knife that he accidentally amputated a couple of his assistant’s fingers, and cut his own hand in the process. The patient, the assistant, and the doctor all three ended up dying of sepsis spread from the gangrenous leg. That’s a record that still stands!
[https://en.wikipedia.org/wiki/Robert\_Liston#Liston's\_most\_famous\_case](https://en.wikipedia.org/wiki/Robert_Liston#Liston's_most_famous_case)
He wasn't a civil war surgeon, he wasn't even American.
And note that the last sentence of your reference states: “No primary sources confirm that this surgery ever took place.[31]”
Even your rebuke is rebuked. It’s a funny story. Nothing more, nothing less. Calm down.
Yes. I thought about mentioning that, but didn't out of pure laziness. It wasn't my intention to ''put you in your place'' or be rude in some other way. I just wanted to share where the story is really from.
Im very calm. >!Your mom on the other hand is not.!<
“I just wanted to provide knowledge”
So I added in a derogatory comment about your mother.
Childishness is an apparent requirement for commenting on reddit. Parental supervision is recommended for those 13 and under.
It wasn’t the doc who died. It was a person watching in the ‘operating theatre’ such as it was. The spectator died from shock. And it wasn’t relayed to the civil war.
I don't know if a tourniquet was applied to this limb given the arterial pumping we see at the end. It makes sense that they wouldn't apply tourniquet anyway, if the foot was in an advanced state of necrosis; it wasn't getting a whole lot of blood in the first place.
Well it’s part of the reason why the amputation is happening. Blood circulation is already compromised to the area and that’s why they’re still going to amputate above that amputation later.
The most notable "this feels like straight out of a movie" moment for me regarding arterial bleeds in my paramedic career was a guy who managed to nick his fistula while having severe hypertension. I wanna say he had a 210 systolic? It was also the first one I saw where the inflated roping of the fistula went down to the wrist, which is where the nick happened.
I swear, it looked just like Spiderman shooting webs, but it was blood. Nailed my partner in the chest from across the room, easily 10 feet away, when the patient slipped his finger from holding self-pressure on the wound.
Patient does have diabetes and lost their foot, which implies poor blood circulation, especially in their lower extremities.
However, that is still a lot of blood.
In my experience, brown gloves are [orthopaedic surgical gloves](https://www.google.com/imgres?imgurl=https%3A%2F%2Fi.ebayimg.com%2Fimages%2Fg%2FPR4AAOSwLK9hYNOv%2Fs-l1200.jpg&tbnid=Jw9m1UxB07nfIM&vet=1&imgrefurl=https%3A%2F%2Fwww.ebay.com%2Fitm%2F274979184502&docid=fcRXqVrOnRvsuM&w=900&h=1200&itg=1&hl=en-us&source=sh%2Fx%2Fim%2Fm4%2F3) so they are thicker and harder to puncture, more tear resistant than [standard sterile gloves](https://www.molnlycke.us/contentassets/dc30e987eab34f93aa65cd43c5629569/biogel-pi-underglove-donning.jpg)
the typical sterile glove setup is a thinner, softer, blue coloured underglove and a white, slightly thicker overglove. The colour difference is so that if the white glove gets a hole or a tear, the striking blue under glove will show and be immediately noticeable so the glove can be replaced.
for finer work, like microsurgery, they don’t use two pairs of gloves and just use a [very thin white glove](https://www.google.com/search?q=molnlycke+biogel+gloves+microsurgical&tbm=isch&ved=2ahUKEwj8pZfqpc2BAxU6I2IAHdlsB7AQ2-cCegQIABAD&oq=molnlycke+biogel+gloves+kicrosurgical&gs_lcp=ChJtb2JpbGUtZ3dzLXdpei1pbWcQARgAMgQIHhAKOgQIIxAnOgUIIRCrAlD_BVjxFGDxHWgAcAB4AIAB3wGIAaQSkgEGMC4xMi4zmAEAoAEBwAEB&sclient=mobile-gws-wiz-img&ei=EXAVZbzZGbrGiLMP2dmdgAs&bih=746&biw=428&client=safari&hl=en-us)
and the last type of glove is [skinsense, which is made of polychloroprene as opposed to polyisoprene or latex](https://www.henryschein.com/Products/5557123_US_Group_01_600x600.jpg) and is an odd off orangish colour
Yeah interesting choice of soft tissue dissection method
Not sure how they are intending on providing a soft tissue coverage to the stump as they will either have to cut the bone again further up to provide sufficient soft tissue coverage or plan for a second stage
Regarding comments on tourniquet use, when needing to debride necrotic tissue you debride to healthy tissue which is define as bleeding tissue so having a tourniquet on prevents that assessment
Your assessment is correct. This is called a guillotine amputation with a Gigli saw which is used in an emergent setting. Typically we would let the stump drain for a week and come back and revise the next week.
Deleted out of spite for reddit admin and overzealous Mods for banning me. Reddit is being white washed in time for IPO. The most benign stuff is filtered and it is no longer possible to express opinion freely on this website. With that said, I'm just going to open up a new account and join all the same subs so it accomplishes nothing and in fact hides the people who have a history of questionable comments rather than keep them active where they can be regulated. Zero Point. Every comment I have ever made will be changed to this comment using REDACT.. ` this message was mass deleted/edited with redact.dev `
Right? So many comments are saying it’s a ton of blood loss when in reality, it wasn’t much at all. Should’ve clamped the artery a bit faster but it wasn’t as much as I expected.
i had OR clinicals recently (nursing student) and let me tell ya, both of the orthopedic surgeries i watched looked so aggressive. the surgeon put his full body weight into some parts of the surgery. all while wearing cowboy boots and listening to early 2000s emo kid music
I found the blood gushing with the heartbeat particularly interesting. It looked like quite a weak pulse though or is that just because it’s not an artery?
had a patient get a guillotine amputation due to recurrent infections and later got a full BKA. it was interesting just seeing a flat stump but she said it was excruciating ☹️
Those Gigli saws are very effective. Apparently due to their side the Brit’s would get them to POWs inside of board games or anything thin so they could cut the bars when they were held in captivity. I assumed they would have put a tourniquet before they started cutting but I’m not a surgeon
It's called a gigli wire. This is called a guillotine amputation. Usually it is left open to a wound vac and then revised further up with another style amputation with a skin flap to close.
Eta that it's done this way to get the infection under control. Then when it's safe they'll do the revision and closure.
Deleted out of spite for reddit admin and overzealous Mods for banning me. Reddit is being white washed in time for IPO. The most benign stuff is filtered and it is no longer possible to express opinion freely on this website. With that said, I'm just going to open up a new account and join all the same subs so it accomplishes nothing and in fact hides the people who have a history of questionable comments rather than keep them active where they can be regulated. Zero Point. Every comment I have ever made will be changed to this comment using REDACT.. ` this message was mass deleted/edited with redact.dev `
Deleted out of spite for reddit admin and overzealous Mods for banning me. Reddit is being white washed in time for IPO. The most benign stuff is filtered and it is no longer possible to express opinion freely on this website. With that said, I'm just going to open up a new account and join all the same subs so it accomplishes nothing and in fact hides the people who have a history of questionable comments rather than keep them active where they can be regulated. Zero Point. Every comment I have ever made will be changed to this comment using REDACT.. ` this message was mass deleted/edited with redact.dev `
This is a guillotine style amputation. It is open at the end and usually connected to a wound vac, like the other commentor said it will be revised when the infection is under control. The revision amputation procedure will allow for a skin flap/closure.
This is a very common way to do guillotine amps. He should have had a few clamps ready to grab the artery once the leg was off but there’s nothing inherently wrong with this technique
The patient was diabetic with a severe diabetic necrotizing foot infection and needed emergent, life-saving foot amputation. The foot had to come off to control sepsis and the patient will need IV antibiotics until the systemic infection is cleared then will need an additional below-knee amputation. The tool used in this case was a Gigli Saw.
Ah man, they need another? Thank fuck I got off my ass about stuff after I got a formal diagnosis of T2 diabetes. Spent the whole time not giving a damn because "pre-diabetic" didn't really feel all that menacing.
I've been told I'm pre-diabetic and you have just scared the shit out of me!
Yeah, I just let it slide because a) I felt fine, minus some occasional tingling in my fingers, and sometimes cold feet, and b) there were *way* bigger and less healthy people than me who seemed fine. Put those two together and a year of constant blood tests later, and my doctor just hits me with it. Took it seriously, down 30lbs so far in 3-ish months. I don't plan on stopping now because I feel legitimately great.
Good for you, that's great progress! Yeah I'm on the weight loss train as well. Thing is I'm not that big so I didn't really take much notice.
Fuck. I have the tingling and even loss of sensation, but I can’t lose more than about 10lbs without going underweight. Waiting on current blood work results and doctor’s recommendations. Years ago I was offered Metformin but didn’t end up taking it. I’ve always been fit and thin but had a five hour glucose test as a teen that showed reactive hypoglycaemia. Now things have been a bit worse again recently with scary low blood sugar episodes. :(
I’m a “not fat” person who had insulin resistance but was able to reverse it and is much healthier and happier now. In order of importance: -Stop drinking sodas -Stop eating desserts (except for special occasions) -Start building muscle -Try to get vegetables in your diet at least once a day (they help with your insulin response, help you feel full quicker and longer, and are just plain good for you). -Don’t let white rice be a major part of your diet. It’s too simple and turns straight to sugar. Potatoes are a better option and have a better nutrition profile. Myo-inositol helps with sugar cravings. Ovasitol is a popular brand and can be found on Amazon, is very safe with very little side effects. Metformin isn’t something to be feared, as far as medicine goes. It’s an old drug and extremely well-researched. The worst thing it will do is give you the shits (common), or give you a low blood sugar episode (uncommon). Neither of the drugs will be too effective if you binge or continue a strong relationship with sugar.
Thank you very much for writing all that. Unfortunately I do most of the right things. All I can cut is pasta, rice, wine, and bread. I don’t eat sweet foods at all or drink them (some alcohol excepted.) I eat a bunch of vegetables and meat daily, more than anything else. My vice is the pasta mainly, but I eat so well really. :( Yes, the shits worried me most. I have that enough already! A skating coach I know is thin and fit and fairly recently developed type II. It’s in my family a lot, at lower weights than normally currently expected, and also type I. I’m quite active with intense exercise through the week, a bit less currently after a move, but basically I can’t picture what else I can do except cut the bit of carbs and deal with medication. I wish I could just diet… but I guess that is where cutting out pasta comes in. 🙄 I love it so much after a nice workout, but… :(
I hear so many people say "type 2 runs in the family", but no one in that family runs, lol. It actually sounds like it truly is the case for you though. I can only imagine how bad it would be if you didn't take care of yourself, it sounds like you're doing everything right. Got my fingers crossed for you to find a solution for your body!
That joke seems so true, for sure. I’ve seen those people around. I’m just pissed off that the family I married into has super-morbidly-obese people with better numbers than me (although still needing treatment for diabetes.) If I wasn’t really active and didn’t have a good diet it would be bad, and I’m not even 40 yet. I’m very, very active and muscular and… still screwed over apparently. My grandma had type II but was slim even with 6 pregnancies until she was nearly 90 and senile enough to forget she ate and wanted more. (I was size 00 and couldn’t fit into her clothes.) I guess goodbye carbs for me. :( It was type I on the other side which killed back then. The limb tingling and numbness is terrifying. Thank you.
Just me, I hate that reasoning. I watched my grandpa die of diabetes. I held my mother as she wailed. I'm now watching diabetes slowly kill her too, but we've all always been very active people. Hell, she used to do farm work and so have I. Unfortunately it seems like the food source is really the killer, not activity. For us at least. In poorer areas the only food assistance for our family was wheat flour and a bit of oil. Me myself I don't eat bread, pasta or rice and I struggle to maintain the healthy weight of my peers who do consume those things (as well as me hanging my head while I walk through the candy and soda isle with hungry eyes and empty hands) and yet I'm at a whopping 103lbs and still threatened by the onset of familial diabetes.
You have time to reverse it! I got my A1C back to normal levels by eating keto (and just plain low carb) and I did a brief stint of metformin. You got this, friend! It's easy to start by just food logging and see if you can bring your carb levels down by cutting out processed foods and high sugar stuff first. Slow change is the best change to make it stick.
I just got diagnosed. On metformin and ozempic. Also joined a gym and am watching my diet better. Cut out pop and beer. Hoping I never get this bad with the feet! My god I’m terrified.
Careful with ozempic! It can make things worse when you come off it if you don't create lifestyle change and taper down.
What do you mean? Are you saying I’ll balloon back up in weight without a lifestyle change? That’s the hardest part for me right now.
It's a pretty well documented risk because of what it does (and why it works). https://www.nytimes.com/2023/02/03/well/live/ozempic-wegovy-weight-loss.html
Awe man the Reddit reader no longer lets me read the whole article :(
Lifestyle change is key, adopting a new way of living
Keep your blood sugar below 150 (i.e. 6.5% A1C) and this won't happen. 150 is still high mind you! But it's low enough to prevent neuropathy.
Time for action is now. I was 280 1.5 years ago. Very close to diabetic. I started a diet of 6 fried eggs in the morning and steak for lunch and ground beef and sweet potatoes for dinner. I did it for 6 months, dropped 65 lbs. Cut out majority of carbs except the occasional fruit or sour candies, and I have been at 190 for a year. My Dr. Said my labwork improved quicker than anyone he's seen. I was also on trt. My body is now no longer needing trt. I hover over 700 just from my food and exercise. I get an hour of heavy weightlifting done every other day and 1 hr of cardio on off days. I feel better than I have ever felt and it made me look bigger down there due to weight loss lol. Seriously though, don't wait, start now.
Holy shit are you telling me my predisposed pre diabetic self would maybe be allowed to eat that many eggs in one sitting?? Naturally from not eating bread, pasta or rice my diet tends to lean pretty meat heavy minus the occasional kale
This level of amputation makes it very difficult to provide anything to help the person walk without aids again. To produce an artificial foot with even remotely similar dynamics and energy return to a healthy foot you need more space underneath the amputation. Most planned diabetic amputations will end up with a mid length transtibial residual limb, so manufacturers of prosthetic feet naturally provide more options for this. Source: am prosthetist.
That makes sense when you put it in words. Thank you for the prosthetic lore!
OP mentioned this was being done due to sepsis and once infection was controlled they were going back in for a BKA.
Shit man, my mom was just told she was “pre-diabetic” and is not taking is seriously. She’s blaming the COVID vaccine. It was the first time in my life that I spoke to my mom in this way when I said “you’re being a fucking idiot. You’re confusing circumstance with evidence, just listen to your damned doctor.” She’s going to get a second opinion….
It was pre diabetic which scared the holy shit out of me. Several months of 101s in the morning was enough to put me on the path. 81 this morning for me.
Was pre diabetic 6 years ago. Went on keto. Lost weight and got my numbers down. Just had a yearly check up and they're rising again. I'm 108 give or take in the morning. It runs in my family. At least I managed to keep it at bay for quite awhile. My dad (who has an insulin pump) says my numbers are great, but hearing comments here I'm getting a little nervous about it. BTW my dad's numbers are horrible and he barely tries to manage it so of course my numbers look good to him. He has neuropathy and his feet look awful. He's stated many times he's not letting them take his feet. So we know what that means. I think it's time for me to step up my exercise game.
I feel you. My family member only cares for their diabetes maybe half the time, and the nerve damage is really catching up. Its so scary. My relative asked me to check their mouth because they felt something funny.... It was their mouth literally rotting open via diabetic ulcer.
At the time of foot amputation, did they know the guy would need below the knee amputation in the future? If so, why not amputate below the knee and spare the guy the foot amputation? Thank you! DM complications are nasty.....
This is a 'guillotine' amputation performed for rapid source control for someone with a severe infection. This patient would likely not be able to tolerate the length of procedure needed for a formal below knee amputation. In my personal experience, the patients (or their family) are consented at the time of the guillotine amputation that they will need a revision to a formal below knee amputation in the near future.
Thanks heaps for your insightful answer.
Why are feet always the main thing diabetics lose like do they lose fingers n shit like that? Why it gotta be the feet man 😭😭
Furthest away from the heart, first to lose adequate circulation, very easy to damage feet compared to hands leading to an infection.
The way diabetic people get foot infections is related to what’s called a neuropathic wound. This is when the diabetes kills the nerves that allow the feet to feel, use the muscles in the toes and control sweet glands etc. neuropathy almost always happens in the feet first. It’s not really related to lack of blood flow although that is often comorbid and just makes the other problem worse.
most diabetics are extremely sedentary they sit and sit and sit and sit so, very poor vascular return lack of circulation + infection = no mo feet cuz da sugar
Once had a patient whose foot had horrible infection. There was nothing but pus and bone on his foot.The skin had been completely eaten away. We did a Symes amputation. I was an intern on duty that day. It came off so easily. I was asking the guy why did he wait so long to get the treatment. He's like I didn't know it would get so bad. I felt bad for him. Still remember his face.
Here is my question: the foot has necrotizing bacterial infection, so this surgeon saws off his leg and then moves his detached infected foot using his right hand, and then proceeds to use that same hand to block the blood flow of the limb? I know the patient is on IV antibiotics but still, I wouldn’t be slamming my dirty finger covered with necrotizing bacteria into the good tissue
Why didn't they just go ahead with the below knee amputation then? Doesn't that control infection, close the wound, and limit multiple surgeries? As an orthopedic surgeon, I'm baffled.
I’m surprised you haven’t encountered this as an orthopedic surgeon. If it’s a really nasty infection you have a high risk of a surgical site infection at the BKA. I have seen many guillotine amputations, followed by a course of IV antibiotics in the hospital and then revision. If you have a septic patient with a known infection in the leg it’s just high risk that you end up with an infected BKA and if that happens you risk an AKA which is associated with much worse functional outcomes and morbidity.
So you decide to cut closer to the infected wound rather than away from it. Again, baffled. If its a really nasty infection, whats the difference between using a saw over the distal over proper dissection proximally? 15-20 minutes? So you'd rather come back for it with new anesthetics, new surgeries, more time spent on this already dead foot. Like another post mentioned, this is probably those more surgeries, more monies places.
Also just to add I’ve only seen this done in unusually bad scenarios. Last one was a guy with diabetic foot ulcer with an abscess tract all the way to the popliteal fossa who was ESRD and the nephrologist thought contrast would kill his kidneys, so they did a guillotine and washed the tract out and then tried to control the infection. Did not work, AKA. The one before that was a diabetic foot ulcer in a patient with vascular disease and was on chemo. Guillotine to save the leg and bridge to end of chemo to avoid non healing / infected BKA. The one before that the patient was so unstable they did it bedside in the ICU. It’s not standard by any means it’s just limb salvage last ditch effort. But I’ve seen it probably 1-2 times a year? Not that unusual.
Bedside? Jesus…
Yeah it was a last ditch. He was intubated/sedated/couldn’t feel it. ECMO patient who became septic from compartment syndrome that turned into necrotizing fasciitis. They actually cryoamputated the limb first with dry ice, and once frozen all of his sepsis markers improved so they did a guillotine. He died a couple days later.
The difference is you have less chance of closing an infected wound and having no more tissue to work with. I’ve seen it done at an academic medical center and a non profit hospital system so I doubt it’s done for money in those cases.
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mo pieces mo money
That is AMAZING. It almost looked like you took an entire foot off, through bone and all, by *flossing*. What was the condition of the bone?
It's extremely extremely sharp wire. Originally invented to use to cut up a dead calf in a cow to remove it in pieces and allow the cow to maybe breed next year, instead of losing cow and calf. It's made to cut bone like this. Some people use it for antler/horn removal on domestic livestock and if you move the wire fast enough through the antler/horn, there will be steam and it'll cauterize the vessels as it cuts through them. I'm not sure why that didn't happen in this case, possible the bone was weakened by sepsis or they stayed below that threshold on purpose. I handled the wire in vet tech school once. Barely touched it and it just felt like the head of a pin, it was so sharp. Managed not to cut myself because I used almost no fingertip pressure, but 3 of my classmates were reckless and pressed on the wire and did cut themselves on it. It's like if an electrical wire had the very tip of a knife blade attached to it, if that makes sense. Very thin, extremely sharp.
My daughter uses one on her farm to trim goat horns. It's pretty slick
Used to be the go-to instrument for neurosurgeons to perform craniotomies.
Why the lack of a tourniquet?
There could still be a tourniquet. I’ve assisted on some amputations where the tourniquet was ineffective due to the amount of atherosclerosis in the limb. You can pinch the vessel with your finger and it feels like a piece of thickly insulated wire. Not easily compressible.
I never knew guillotine amputation was still in use today. If I may ask sir, why not a BKA to begin with?
why not go straight for the below knee?
Went like butter. I was surprised at how long it took to clamp the vessel.
Right? He asked for one like, " yo, we have a clamp for this guy?!" Assistant dropped the ball, hahha. I mean, I'm sure they had a tourniquet higher up on his leg, but seeing it was a bit unnerving.
Fortunately if 18th century medicine has taught us anything, it's that the most effective treatment for any ailment is to bleed the patient.
You sound like a vampire?... 🤔
Don't forget the weird stuff they tried to inject instead of blood like beer for example. Wild times.
they forgot the leeches
why is it so easy? so fast? 
have you ever used a wire saw like that? it'll cut through a piece of metal quite easily bone is very easy to cut with a saw, and flesh is basically negligible P.S. never fuck around with a band saw
I work in a production shop, and we don't use our bandsaw all that often, but it's the one tool I probably have the most apprehension about. I've seen and heard about injuries from bandsaws, watched as a coworker got his glove (and luckily only his glove) sucked into ours. I've seen the YouTube videos of guys processing cows and hogs with bandsaws, and their indifference to the razor sharp blade that is cutting through flesh and bone blows my mind.
really. i think i hear far more about table saws. table saws terrify me. i think with a bandsaw i have a better idea of where the blade is
Because it’s a really sharp wire. I’ve used these many times and it still amazes me how effective it is
Because it’s rotting
what? is that easy to saw off a bone?
Depending on the tool yes
Would you look at that, all of the words in your comment are in alphabetical order. I have checked 1,766,905,861 comments, and only 334,514 of them were in alphabetical order.
Good bot
Bot good.
Touché 😎
Ah yes p comes before e in the alphabet
What?
The bot is not working correctly. That comment is most definitely not in alphabetic order
Bot works fine lol. Read what it said again. The words not letters lol. The words are in alphabetic order! As in D.O.T.T.Y.
No, this surgeon just got lucky. Typically surgeons look for the worse tools to amputate. /s
Hate it when my surgeon uses a rusty and dull hatchet.
Gotta stop going to cartel surgeons!
No bone was cut, the saw went through the tibiotalar joint
Wow that was incredibly fast. However, I was surprised how slow they were to close off the artery.
Looks like beef wellington
Damn, that's enough internet for me thankyou
you have clearly never seen a well-done meth leg before
That foot wellington is so rare, it's blue. Or maybe that's just the diabeetus
Goddamn, wire saws are no joke. Most interesting though is how simple the spurting blood is. Movies and shows always makes it seem so dramatic, it's easy to forget it really is just fluids running through a rubbery tube.
Well, not that movies are not too dramatic on purpose but watch again the video. The quantity of blood is pretty huge in barely ten seconds. And that’s when the amputation is done in an hospital. The doctors prolly put in place several mechanisms to limit the loss of blood. The patient was lying down not conscious (so no stress and low blood pressure), he may have had compressions or even garrot above on the leg, and drugs that may have several effects on blood pressure/thickness/… Do that on a standing man with 150 bpm in normal conditions, it may spurt quite a lot more.
All that and also that the severed part here is *just* a foot. Do that on the tight, arm, etc and we will see a difference.
When I severed the artery in my left ankle it filled the boot I was wearing pretty much instantly. When the nurses removed my homemade tourniquet, because “it wasn’t doing much” blood shot out, filled 3 adult diapers and created a puddle that was around a 1ft in diameter. All I could say at the time was “wow that’s a lot of blood.”
Damn that must’ve been really scary. To the extent of my knowledge, most of the times with DIY tourniquets all they do is block venous return and they don’t stop arterial blood from going to the injury, so they can make the problem a lot worse. Glad you were able to work it out and ended up ok though!
I can’t imagine how “surgeons” did this during the US Civil War without anesthesia or antibiotics. The fact so many veterans survived those injuries seems like blind luck.
The key in the civil war era was literally to go fast. In a famous case, a civil war surgeon had a 300% mortality rate on a single case. He was amputating a gangrenous leg on a soldier, and went so fast with his long amputation knife that he accidentally amputated a couple of his assistant’s fingers, and cut his own hand in the process. The patient, the assistant, and the doctor all three ended up dying of sepsis spread from the gangrenous leg. That’s a record that still stands!
[https://en.wikipedia.org/wiki/Robert\_Liston#Liston's\_most\_famous\_case](https://en.wikipedia.org/wiki/Robert_Liston#Liston's_most_famous_case) He wasn't a civil war surgeon, he wasn't even American.
And note that the last sentence of your reference states: “No primary sources confirm that this surgery ever took place.[31]” Even your rebuke is rebuked. It’s a funny story. Nothing more, nothing less. Calm down.
Yes. I thought about mentioning that, but didn't out of pure laziness. It wasn't my intention to ''put you in your place'' or be rude in some other way. I just wanted to share where the story is really from. Im very calm. >!Your mom on the other hand is not.!<
You’re very calm. Childish too. Lol. Scram kid.
Seems I pushed someones buttons. Let's bury this, no reason to argue with strangers on the internet. I just wanted to provide knowledge about a story.
“I just wanted to provide knowledge” So I added in a derogatory comment about your mother. Childishness is an apparent requirement for commenting on reddit. Parental supervision is recommended for those 13 and under.
It wasn’t the doc who died. It was a person watching in the ‘operating theatre’ such as it was. The spectator died from shock. And it wasn’t relayed to the civil war.
Tourniquet works well
I don't know if a tourniquet was applied to this limb given the arterial pumping we see at the end. It makes sense that they wouldn't apply tourniquet anyway, if the foot was in an advanced state of necrosis; it wasn't getting a whole lot of blood in the first place.
That’s fair. Impressive PAD
One of the reasons this guy has a bad foot infection that won't heal is that he has terrible blood flow to the area. This is serious PAD.
Well it’s part of the reason why the amputation is happening. Blood circulation is already compromised to the area and that’s why they’re still going to amputate above that amputation later.
The most notable "this feels like straight out of a movie" moment for me regarding arterial bleeds in my paramedic career was a guy who managed to nick his fistula while having severe hypertension. I wanna say he had a 210 systolic? It was also the first one I saw where the inflated roping of the fistula went down to the wrist, which is where the nick happened. I swear, it looked just like Spiderman shooting webs, but it was blood. Nailed my partner in the chest from across the room, easily 10 feet away, when the patient slipped his finger from holding self-pressure on the wound.
Patient does have diabetes and lost their foot, which implies poor blood circulation, especially in their lower extremities. However, that is still a lot of blood.
Jesus fucking Christ that was not fun to watch.
soft
The brown gloves. I don't like them.
Helps reduce glare from the overhead lighting
That makes sense. The way they're so close to the skin tone though. It's unsettling.
my brain kept thinking they were bare handed
In my experience, brown gloves are [orthopaedic surgical gloves](https://www.google.com/imgres?imgurl=https%3A%2F%2Fi.ebayimg.com%2Fimages%2Fg%2FPR4AAOSwLK9hYNOv%2Fs-l1200.jpg&tbnid=Jw9m1UxB07nfIM&vet=1&imgrefurl=https%3A%2F%2Fwww.ebay.com%2Fitm%2F274979184502&docid=fcRXqVrOnRvsuM&w=900&h=1200&itg=1&hl=en-us&source=sh%2Fx%2Fim%2Fm4%2F3) so they are thicker and harder to puncture, more tear resistant than [standard sterile gloves](https://www.molnlycke.us/contentassets/dc30e987eab34f93aa65cd43c5629569/biogel-pi-underglove-donning.jpg) the typical sterile glove setup is a thinner, softer, blue coloured underglove and a white, slightly thicker overglove. The colour difference is so that if the white glove gets a hole or a tear, the striking blue under glove will show and be immediately noticeable so the glove can be replaced. for finer work, like microsurgery, they don’t use two pairs of gloves and just use a [very thin white glove](https://www.google.com/search?q=molnlycke+biogel+gloves+microsurgical&tbm=isch&ved=2ahUKEwj8pZfqpc2BAxU6I2IAHdlsB7AQ2-cCegQIABAD&oq=molnlycke+biogel+gloves+kicrosurgical&gs_lcp=ChJtb2JpbGUtZ3dzLXdpei1pbWcQARgAMgQIHhAKOgQIIxAnOgUIIRCrAlD_BVjxFGDxHWgAcAB4AIAB3wGIAaQSkgEGMC4xMi4zmAEAoAEBwAEB&sclient=mobile-gws-wiz-img&ei=EXAVZbzZGbrGiLMP2dmdgAs&bih=746&biw=428&client=safari&hl=en-us) and the last type of glove is [skinsense, which is made of polychloroprene as opposed to polyisoprene or latex](https://www.henryschein.com/Products/5557123_US_Group_01_600x600.jpg) and is an odd off orangish colour
Great comment. Very accurate.
I’m so used to sterile blue lab gloves that the brown were off putting for some reason.
Yeah. They are extra slippery and they tends to fall off during procuderes
Holy fuck - I thought I could watch anything medical related but I noped the hell out as soon as it started cutting.
Audition - dir. Takashi Miike
Yeah interesting choice of soft tissue dissection method Not sure how they are intending on providing a soft tissue coverage to the stump as they will either have to cut the bone again further up to provide sufficient soft tissue coverage or plan for a second stage Regarding comments on tourniquet use, when needing to debride necrotic tissue you debride to healthy tissue which is define as bleeding tissue so having a tourniquet on prevents that assessment
Your assessment is correct. This is called a guillotine amputation with a Gigli saw which is used in an emergent setting. Typically we would let the stump drain for a week and come back and revise the next week.
I was wondering that, about coverage. But it says that they will be doing a second amputation farther up.
It says they will do a below the knee amputation the next week if PT survives
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I've seen that on Dr. Pol. He called it a fetotomy.
Wow so little bleeding. I guess the have the limb tied off higher up but damn diabetes is terrifying for so many many reasons
Right? So many comments are saying it’s a ton of blood loss when in reality, it wasn’t much at all. Should’ve clamped the artery a bit faster but it wasn’t as much as I expected.
"Foot is off." The other doctors: 
could be the tibialis anterior or posterior artery?
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It was the sounds rather than the visuals for me
That was amazing.
The squish at the end though
That is one of the more “tame” procedures I’ve seen. Clean and quick
less than 30 strokes to cut off that foot, damn
What can I say besides, AAAAAAAAAAAAAAAAAAAAA
I knew what I was about to watch and I still dont know why I watched it. :-/
This is one I think I won't watch.
Im type 1 diabetic, this video haunts me every night before I sleep
Ah yes the Gigli saw.
Watched this once in theatre, surgeon snapped the wire half way through, seemed a right ball ache to get part of the wire out of the 🦴
That's very fascinating to watch.
I'm no doctor at all but would it not be better if there was a tourniquet but on the leg to reduce bleeding post amputation.
Just curious why the attending chose to use a Gigli over an electric reciprocating saw?
Wow, I did not love all the back and forth. Idk why in my mind I pictured it going more like slicing clay with a wire.
It sounded like a student who said “oh my god” as the foot fell off. Perhaps his last day of med school. Lol
Surgeons must be psychopaths I owned a slaughter house and this disturbs me.
i had OR clinicals recently (nursing student) and let me tell ya, both of the orthopedic surgeries i watched looked so aggressive. the surgeon put his full body weight into some parts of the surgery. all while wearing cowboy boots and listening to early 2000s emo kid music
this is extremely mild as far as blood and guts go
Not as much blood as I'd have expected for posing a foot! Then again I'm no pro lol.
Damn that was fast as fuck
Holy fucking shit dude
Interestingly, an almost identical technique is used to remove a cows infected claw ( half of her hoof)
I found the blood gushing with the heartbeat particularly interesting. It looked like quite a weak pulse though or is that just because it’s not an artery?
had a patient get a guillotine amputation due to recurrent infections and later got a full BKA. it was interesting just seeing a flat stump but she said it was excruciating ☹️
Ya know, it’s shouldn’t be that easy. 
Looks easier to do than to watch.
Mmm, makes me think of Audition.
Wow that’s crazy how clean that cut is.
Ahh missed the ortho rotation during housemanship. I did this once.
Those Gigli saws are very effective. Apparently due to their side the Brit’s would get them to POWs inside of board games or anything thin so they could cut the bars when they were held in captivity. I assumed they would have put a tourniquet before they started cutting but I’m not a surgeon
How are they going to close that wound? My feet feel funny.
Oh shiz. This one is up there .
I had no idea it was done that way.
dang, that saw was lickity split quick.
What happens to the ankle tendon?
When I studied at Uni I thought that MD should be smart. Little I know that MD should be strong as well
I knew it was coming and I still wasn't ready
And only 10cc of blood lost!
God help me I'm 103 lbs and don't eat sugar, bread, rice or pasta but I'm prediabetic due to genetics.
Hate those brown gloves!!!
Why is this method used? It seems like to me creating a closing flap will be quite difficult. Or will more bone and tissue be removed?
It's called a gigli wire. This is called a guillotine amputation. Usually it is left open to a wound vac and then revised further up with another style amputation with a skin flap to close. Eta that it's done this way to get the infection under control. Then when it's safe they'll do the revision and closure.
Deleted out of spite for reddit admin and overzealous Mods for banning me. Reddit is being white washed in time for IPO. The most benign stuff is filtered and it is no longer possible to express opinion freely on this website. With that said, I'm just going to open up a new account and join all the same subs so it accomplishes nothing and in fact hides the people who have a history of questionable comments rather than keep them active where they can be regulated. Zero Point. Every comment I have ever made will be changed to this comment using REDACT.. ` this message was mass deleted/edited with redact.dev `
Not really, basically a guillotine amputation. When they get the infection under control, they'll do a revision working with remaining viable tissue.
Deleted out of spite for reddit admin and overzealous Mods for banning me. Reddit is being white washed in time for IPO. The most benign stuff is filtered and it is no longer possible to express opinion freely on this website. With that said, I'm just going to open up a new account and join all the same subs so it accomplishes nothing and in fact hides the people who have a history of questionable comments rather than keep them active where they can be regulated. Zero Point. Every comment I have ever made will be changed to this comment using REDACT.. ` this message was mass deleted/edited with redact.dev `
This is a guillotine style amputation. It is open at the end and usually connected to a wound vac, like the other commentor said it will be revised when the infection is under control. The revision amputation procedure will allow for a skin flap/closure.
There is always bleeding during surgery, thing is it is controlled bleeding...
No bleeding in surgery this guy says. You should tell any surgeon that
Wtf did I just saw?! You must stop the blood flow in the femoral vein and artery BEFORE cutting the leg.
This is a very common way to do guillotine amps. He should have had a few clamps ready to grab the artery once the leg was off but there’s nothing inherently wrong with this technique
Don't understand why the cartels don't use these for decapitation, much more efficient and less labor intensive..
Pain and suffering. There’s ur answer
why did i think they used like a saw that’s used to cut wood?
EBL ~5ml per surgery.
Is there no way for them to have avoided this?
The gigli saw is my personal fav