It’s a big part of his job as a vascular surgeon, but David Kopriva doesn’t particularly like amputating the feet.
For him, and many other surgeons, the aversion is philosophical.
“Some of us see amputation as a failure,” says Dr. Kopriva, who practises at Regina General Hospital. “Our job is to save the limb. If we can’t do it, we’ve failed.”
Between 2021 and 2023, Dr. Kopriva and other surgeons across Canada amputated about 7,720 lower limbs annually associated with diabetes, according to a report released by the Canadian Institute for Health Information last month. A disproportionate number of those life-altering surgeries are conducted on First Nations patients, often unnecessarily. Research shows about 85 per cent of all diabetic limb amputations could be prevented with adequate screening and rapid limb-saving treatments. In Canada, that translates to around 6,000 feet.
Fighting the phantom: For First Nations, diabetes takes a devastating, oft-preventable toll
A handful of new clinics and health care providers are focusing on the problem – and may be able to save feet by overhauling an overlooked area of health care.
Any fix has to start at the local level. Stewart Harris, a professor in the Department of Family Medicine at Western University, has spent more than three decades working with First Nations on local diabetes projects. In one community alone, Sandy Lake First Nation, Dr. Harris and other researchers discovered the world’s third-highest recorded rate of diabetes in the 1990s. He worked on programs to stock and promote nutritious food in the grocery store, create a diabetes school curriculum, build a six-kilometre walking trail and open a diabetes summer camp for youth, among many other programs.
Did any of it work?
“Kind of,” Dr. Harris says. “But if we did the same study in Sandy Lake that we did in the early nineties, you’d find the same rate of diabetes and a horrific complication burden.”
Eventually, Dr. Harris embraced a health care concept called Quality Improvement (QI), in which local teams experiment with homegrown solutions to diabetes. In one First Nation where men refused to show up for their diabetes appointments, the local QI team created a footcare program targeted at men. “Everyone with diabetes is terrified of amputation, so they used that as a strategy to get men into the clinic,” Dr. Harris said. “They wouldn’t just check their feet once the men came, they would do their whole diabetes care. And it worked.”
In other First Nations, QI teams created diabetes registries so that local medical staff could track patients, families and the broader spread of the disease.
“It works,” Dr. Harris said. “After a career of working with Indigenous peoples of Canada, it’s the first thing where we have demonstrated improvement. It’s community-driven, community-owned, which is a perfect scenario for the success with First Nations communities.”
In Manitoba, 23 First Nations are taking community ownership to another level, setting up an organization called Keewatinohk Inniniw Minoayawin (Cree for Northern Peoples’ Wellness) that is negotiating with the federal and provincial governments to take over health care delivery for First Nations in the province’s northern reaches.
The organization’s chief executive officer, Barry Lavallee, says a First Nations-led health authority will approach diabetes and diabetic complications with First Nations medical staff who understand and empathize with the unique needs of Indigenous patients.
“That’s really the crux of the work that we’re doing here, trying to make this new health care system respond to the needs of First Nations patients in different ways, like trying to change the system so that we don’t have so many below-knee amputations or new dialysis starts,” said Dr. Lavallee, a member of the Métis community of St. Laurent, Man., and a descendant of Duck Bay and Lake Manitoba First Nations.
But local health facilities lack the capacity to treat all diabetic wounds. Because diabetes impairs circulation and hastens infection, a simple-seeming wound can easily become limb threatening without specialized care.
In Alberta, the Zivot Limb Preservation Centre, opened in 2016, has stepped in to fill that need. Based within Calgary’s Peter Lougheed Centre, the clinic now sees around 8,000 patients a year and, according to a 2019 study that compared amputation rates between Calgary and Edmonton, is responsible for a 45-per-cent reduction in major amputations.
The clinic operates under a “toe and flow” model, in which podiatric and vascular surgeons work together on each patient. The podiatric surgeon has a greater understanding of the foot’s biomechanics, while the vascular surgeon can work on blood flow, which is impaired in roughly 65 per cent of diabetic foot wounds.
Zivot has managed to save so many feet – and so much money by eliminating unnecessary surgery, hospital stays and rehab programs – that Alberta Health Services is launching a second facility in Edmonton next year.
“The idea is that if we make sure there’s good blood flow to the foot and we give them good wound care, we can save a lot of these limbs,” said John Toole, one of the Zivot podiatric surgeons.
