Late last year, 53-year-old Miguel Hernandez went to the doctor after ulcers started taking over his right foot. Hernandez is diabetic, and the doctor told him that at least part of his foot, if not all of it, would have to be amputated.
"I told him, please, try to save it," Hernandez, a restaurant cook, recalled. "I have to work, I have to support my family."
The doctor referred Hernandez to Dr. Gabriel Halperin, who runs a podiatry practice out of a narrow sliver of an office tucked between a real estate agency and a Mexican bakery in East Los Angeles.
The practice, called New Hope Podiatry, specializes in limb preservation, and on most days every bed and exam room is taken by a low-income diabetic patient, who, like Hernandez, is hoping to save a limb or part of a limb.
One day last week, Hernandez was among them. In January, doctors from New Hope removed two large chunks of infected tissue from his foot. Seven months later, the wounds are still healing, but Hernandez’s foot remains intact. He comes in for follow-ups several times a month.
Nationally and statewide, the number of diabetes-related amputations has fallen in recent years. But a UCLA study published last week found that disparities persist. Diabetics in low-income neighborhoods like East Los Angeles are up to ten times more likely to have a toe, foot or leg amputated than diabetics living in wealthier, west L.A. neighborhoods.
The study’s authors theorized that one of the reasons for that disparity is the simple fact that poorer people are less likely to have their diabetes controlled, which leads to complications.
But Dr. Halperin said another big factor is that many doctors tell patients that amputation is necessary when in fact it’s not. That's what happened to Hernandez, he said, adding that unlike Hernandez, many patients don’t seek a second opinion.
"Our Latino patients have a tremendous amount of trust in the doctors and the medical community," Halperin said. "So they have a greater chance of going along with it than somebody on the west side who will question what the diagnosis is and ask for second opinions."
Halperin said that in almost every case, the limbs of patients who show up at his office can still be saved.
But part of the problem is that because of the cost, many doctors don’t try. Healing an infected limb can be expensive. It can require bypass surgery to increase the flow of blood to extremities that’s been impaired by diabetes, surgery to remove dead tissue, and almost weekly follow-ups to keep new infections at bay.
By contrast, Halperin said, "amputations are easy, fast and relatively inexpensive," which is why many doctors recommend them to patients who lack insurance or whose plans resist paying for treatment.
Wound care centers like New Hope can address that disparity. But while they’re common on L.A.’s wealthier west side, there are only a handful elsewhere in L.A. And Dr. Halperin said many choose to treat patients based on what their insurance will cover.
New Hope officials say only about 25 percent of its patients have private insurance.The rest are on Medicare, Medi-Cal or are uninsured. So to make up for the low margins from treating those less profitable patients, the practice has to treat a lot more of them.
Traffic jams are a constant in the office’s narrow hallway, with patients in various stages of treatment and recovery waiting to see a doctor.
Reymundo Hernandez, no relation to Miguel, lifted the hem of his pants to reveal three large scars where Dr. Halperin had treated ulcers that Hernandez feared might lead to amputation.
"They're fine now," he said. "But they used to look like hamburger meat."
Another patient was David Duran. He has had diabetes for ten years, but is uninsured, and so hasn’t been seeing a doctor to manage his disease. He isn’t even on insulin. Duran came to New Hope after a stubbed toe on a camping trip turned into an ulcer that became infected and began to spread.
"It just kind of got out of control," Duran said.
Dr. Charles Ananian, one of Halperin’s partners, numbed Duran’s foot. Then, with a pair of what looked like tiny bolt cutters, he carved a hole into the end of Duran’s toe. When he reached the bone, he began removing small bits of it and placing them on a surgical tray.
"It was starting to get infected, and the thing with bone infection is, it spreads really easy," Ananian told Duran as he worked. "So if we don’t do anything now, it’s going to go down to the toe and the rest of the foot. So this is a preventive thing."
The procedure took only a few minutes. By the end of it, Ananian had removed about an inch of bone. But, he told Duran, the toe was saved.
"Can I make that bone...a necklace?" Duran asked.