The waiting area on the third floor of the UT Health Medical Arts and Research Center quickly becomes standing-room only. Some men and women sit in wheelchairs with swollen, red legs and feet wrapped in gauze from the knee down. Others are on knee scooters so that their ulcerated toes and open wounds don't touch the ground.
All are dealing with complications of diabetes, the seventh-leading cause of death in Bexar County, and have come to seek treatment at a clinic that serves as a one-stop shop for patients who have lost – or are at risk of losing – a lower limb from the disease.
Once a month, a six-person multidisciplinary team of physicians and specialists comes together at the clinic. The group includes an interventional cardiologist, vascular and orthopedic surgeons, podiatrists, and prosthetists.
Led by Dr. Thomas Zgonis, a podiatrist with UT Health San Antonio, the team sees up to 25 patients on clinic days. Using the team approach to care for diabetic patients allows treatment decisions to be made faster, reducing complications and helping to avoid amputations. In a city where as many as 2,000 lower-limb amputations occur annually, the clinic aims to serve as a bulwark against San Antonio's stubbornly high rates of diabetes complications.
“We are losing legs on a daily basis in San Antonio,” Zgonis said. “One of the biggest reasons for diabetic amputations is the delay of treatment. [The clinic] sees patients who in any other health care system will go to appointments at different clinics on many different days for weeks, sometimes months.”
Patients at the Preserving Ambulation and Limb Salvage (PALS) clinic may spend several hours there, seeing as many as four specialists. First, a podiatrist inspects the patient's wound and depending on the severity of the patient's symptoms, directs him or her to vascular intervention to increase blood flow and complete stress testing, and then to radiology to get X-rays or MRIs.
On a recent visit to the clinic, 40-year-old Sergio Martinez met with Zgonis, vascular surgeon Mark Davies, and cardiologist Shah-Hinan Ahmed for his first appointment at the clinic. He was referred there by University Hospital after the cuts and broken bone in his toe – the result of a piece of marble being dropped on his foot – failed to heal properly.
Diagnosed with Type 2 diabetes at age 13, Martinez struggled to manage his symptoms and had a major heart attack in 2012. Because of his cardiac history, peripheral vascular disease, and poor blood supply, operating on Martinez would increase his risk for infection, Davies said.
Doctors performed a CAT scan and ordered vascular studies. Martinez will remain under team surveillance as the wound heals and was told to avoid putting pressure on the wound.
“What’s hiding behind the foot ulcer is uncontrolled diabetes, coronary heart disease," Zagonis said, "and in a year or two, [the person] might develop heart issues, and possibly have a stroke. We need to look into all of these things before we make any decisions.”
Type 2 diabetes is largely preventable, yet it accounts for nearly 95 percent of all diabetes diagnoses in the United States.
It is the the No. 1 cause of adult-onset blindness, kidney failure, and lower limb amputation, according to the Centers for Disease Control and Prevention (CDC). Nerve damage, or diabetic neuropathy, makes people less aware of foot injuries and ulcers, which left untreated may cause severe damage to tissue and bone. More than 80 percent of amputations result from untreated foot ulcers.
In Bexar County, 113,009 residents have been diagnosed with Type 2 diabetes – nearly 12 percent of the population – but doctors and other health experts believe many more have the disease but have not been diagnosed. Nationwide, nearly 24 percent of adults with diabetes don't yet know they have it, according to a CDC report.
Zgonis said it is not uncommon to see people under age 25 at the clinic with foot complications – cracking skin, thick calluses, ulcers on the ball of the foot or on the bottom of the big toe, and gangrene – that led to a Type 2 diabetes diagnosis.
“The majority of the patients we see were [previously] undiagnosed, and the first time they learn they have diabetes, they lose part of their foot or their leg,” Zgonis said. “Lack of education about the disease makes people delay treatment, and early-on treatment is the key to success.”
While there are diabetes treatment centers at hospitals and clinics throughout the city, the PALS clinic is only one in the city taking a team approach to treatment, Zgonis said. He compared the PALS clinic's collaboration to that used by the Mayo Clinic, where more than 4,700 physicians and scientists work together across clinic campuses to ensure a comprehensive look at a specific disease.
“If we had 10 freestanding diabetes wellness centers in San Antonio where patients could go to both learn about their diagnosis and see a range of necessary doctors all at once instead of waiting for an appointment, we can prevent diabetic complications,” Zgonis said.
Zgonis said that similar diabetes complete-care clinics exist in states such as Louisiana and Arizona, where there are large Hispanic populations.
Having more comprehensive care clinics also would reduce the cost of caring for patients with Type 2 diabetes, costs that have risen to $327 billion annually in 2017 from $245 billion in 2012, according to the American Diabetes Association.
In Texas, total charges for hospital stays with any mention of diabetes as either a principal or coexisting condition were $29.05 billion in 2012, over 27 percent of aggregate charges for overall stays, according to the Department of State Health Services.
The PALS clinic also operates once a month with University Health System, offering its multidisciplinary services to low-income patients who use Medicaid and CareLink, the income-based financial assistance program for Bexar County residents who do not have public or private health insurance.
"Nobody is turned away," Zgonis said. "We provide comprehensive diabetes care to anyone in the community."
Juventino Lopez Jr. brought his 81-year-old father to the PALS clinic for a checkup appointment following a toe amputation. Both father and son are patients of the clinic; the younger Lopez was diagnosed with Type 2 diabetes in 2009 after developing an ulcer that left a hole in the bottom of his foot. After treating the wound for five years, he decided to have the leg amputated and use a prosthetic.
He now works with the PALS team to manage his diabetes symptoms, with regular check-ins to ensure that he is not at risk for additional complications.
"My dad had been seeing a doctor at another place, but I brought him here when he started having trouble because of the type of care I got," Lopez Jr. said. "Sometimes you will be here for a long time for your appointment, but Dr. Zgonis gets to know you and he really cares about helping you and he listens."
In the years leading up to his toe amputation, Lopez Sr. experienced few diabetes symptoms or complications, but he struggled to manage his blood sugar levels after undergoing a tracheotomy and small woulds often failed to heal properly.
“Having [Type 2] diabetes is like the body has rust: It is a systemic disease, it affects everything, and you cannot get rid of it you can only treat or control for the symptoms,” Davies said. “Education and prevention are the only keys to success.”
Patricia Anderson, 51, lost her right leg due to diabetes in 2016 when an infection became too severe to treat. The PALS team has been monitoring her for a prosthetic for her right leg while she works to slowly put weight on her left leg, which is covered in a hard-shell boot cast to protect it.
For some patients, follow-up care may be necessary for years, Zgonis said.
"Living with diabetes is very hard, especially with all the health problems I have and the specialists I have to see," Anderson said. "It takes a lot of work to stay healthy and I'm not healthy, so it's hard."