Building a Limb Salvage Program

[Sabeen Dhand]
For trainees who are listening, what's your definition of limb salvage?

[Jihad Mustapha]
A limb salvage is a limb that is saved from amputation. It allows the patient to be independent of others, have a good quality of life, and return back to society to work and contribute. It’s also the ability to maintain the limb beyond three months. I say that because patients with critical limb ischemia, you can save their limb, but if you don't maintain it, it's not a limb saved. What happens after the procedure, what really counts the most as a limb salvage or limb save, is the maintenance of it. And we have patients now out to 8 or 9 years post limb salvage and they still have their limbs on.

[Sabeen Dhand]
Wow. Amazing. That sure beats the 2.1 year average lifespan of someone who's diagnosed with critical limb ischemia.

[Jihad Mustapha]
I'm glad you said that because that’s actually the reality we face. When we discuss the issue of mortality associated with critical limb ischemia, there's a lack of comprehension or refusal to comprehend the seriousness of critical limb ischemia. Many don't want to accept that having critical limb ischemia is deadlier than having an acute MI. But this is the reality. This is why we're talking and this is why we have to work together to raise awareness about the seriousness of critical limb ischemia.

[Sabeen Dhand]
Speaking of amputation prevention, you host an awesome annual AMP meeting in the summer and the slogan is "Leave your specialty at the door." What does that mean?

[Jihad Mustapha]
That is actually the resolution of the discussion between the co-directors and also the members of the CLI Society, board members, about the contribution of the different specialties toward the patient's outcome. Joining forces together allows us to provide a superior outcome to any patient that we treat versus a single entity, single specialty, or single physician. Leave your specialty behind is to push us to work together more. Any one of us might get to a point where we hit a brick wall and we don't have any more ideas or any other options to offer the patient. And, someone could be standing next to you and give you an idea that is so good and you'd be like, "Wow. That is simple. I can't believe I didn't think of it.” We found that if you combine the specialty effort together, the outcome for the patients is better. And we published a nice, large manuscript on that, showing that if patients were treated by any group, as long as they combine their efforts, the outcome is improved by 90%.

[Sabeen Dhand]
I agree, the multidisciplinary approach to saving legs and limb salvage is extremely important. What type of disciplines would you include under this multidisciplinary approach? Who all is involved?

[Jihad Mustapha]
We have our own independent limb salvage or amputation prevention center, and we have this direct relationship with our partners, vascular surgeons that work with us side-by-side every day. We have podiatrists as well. We also have deep relationships with infectious disease, wound clinics, endocrinology and any other primary care physicians that offer care for patients. We have this deep relationship with all of them together. What I've found to be extremely important is being able to pick up the phone and call someone and let wound care or the podiatrist know that you just opened the artery and it's a good idea to do something this week. I'm not sure if the communication between the operators, the surgical operation or in the vascular operation and with the primary care physician or a wound care specialist happen as much as they should. We found that we are unable to do everything, so we created a mid-level provider who is with us at the end of every case. We make a quick summary and send it to everyone involved in the care of the patient. I highly recommend everyone do this. Primarily, it's the wound care clinic and the podiatrist and the infectious disease doc if they're involved.

[Sabeen Dhand]
A second pair of eyes or something can just come up with another idea. Even just yesterday there was a lesion I couldn't cross and one of my partners thought of another idea that worked. Collaboration and more people who are highly involved can really help.

[Jihad Mustapha]
What you just mentioned right now is the reality of a collaborative effort between you and your partner, and your partner could be any specialty. We have multiple specialists in our practice. They can come in, put in a pedal sheath for you, pass the wire up, and walk away, and they just saved you an hour of hard work, right? We have to get to that level of telepathic combined work effort so the patient can get the best care from two physicians.

[Sabeen Dhand]
Yeah. It's leave your specialty at the door and leave your ego at the door, as well.

[Jihad Mustapha]
Absolutely. Leaving your ego is much better than leaving your specialty. Leaving both would be better.

[Sabeen Dhand]
One of the challenges I dealt with starting our program is competition and turf wars. What do you think about that? We talked about collaboration and multidisciplinary approach, but not to ignore the competition that's there.

[Jihad Mustapha]
In 2020, competition and turf war still exists, despite the fact that we know that collaboration also exists. You have to make a decision that you are not going to fall into this trap of primitive behavior and get side tracked. You need to rise above it all and focus only on what's important and that is the patients. This is how we fought our war. Yes, we do have our battles. But, everyone quickly realized that we are not a competition to any of our surrounding physicians because the patients that we're treating are patients that were scheduled for an amputation at each of the institutions around us. With this realization, we have less resistance. The turf war basically comes back to more of a claudication patient population and those we tend to manage, again, by using the same method.