Had James Wilson's wife not taken him to the hospital a few days after he stepped on a nail at work this summer, he probably would've lost his foot.
Diagnosed in the late 1990s with Type 2 diabetes, Wilson is now in his late 50s and suffers from neuropathy, a nerve condition often associated with diabetes that left his feet numb. He didn't know at first that the injury had even happened.
He'd thought for years that he managed his condition well enough, but that August trip from his home in Pryor to the emergency room set him on a path that has taught him otherwise. It inspired him to get a better handle on his diabetes and make some lifestyle changes.
"You hear it all the time from your doctors and you say, 'Oh man, I don't want to do all of that,'" Wilson said. "But looking back, with all of this, I should've listened and done it."
With Wilson now on his way to recovery after months of treatment at St. Vincent Healthcare, his challenges underscore the hurdles faced by more than 63,000 Montana adults, especially within the American Indian population, diagnosed with diabetes and could serve as a cautionary tale to the hundreds of thousands more at risk of developing the disease.
As the number of diabetic Americans, and Montanans, has skyrocketed in recent decades, Wilson's experience shows there's cause for optimism.
"Diabetes can be controlled and managed, and for Type 2, you can even potentially prevent it from developing," said Jessie Fernandes, health improvement section supervisor for the Montana Department of Public Health and Human Services. "They can control their conditions."
A single nail
Wilson is a safety coordinator for the road department based out of Crow Agency on the Crow Reservation and drives more than 70 miles each way daily from Pryor for work.
This summer, he was out with a crew on a guardrail replacement when he had to return to the storage yard, and he believes that's when he stepped on the nail, although he can't be sure.
When Wilson returned home that night, he took off his boots and noticed a nail poking through the sole of one. Due to his neuropathy, a condition often associated with diabetes, he didn't feel a thing even though the nail went all the way through the insole. Upon checking his foot, he didn't see much of a wound and put the injury out of mind.
Within a day, his foot started bothering him. On Aug. 2 his wife rushed him to the hospital. The wound had closed enough that it couldn't drain and had become infected. He ended up at a walk-in clinic and, eventually, St. Vincent in Billings for surgery.
Doctors drained the wound and then stitched it at the top and bottom. They left it open in the middle to drain more and heal.
"That wound never closed for almost three months," he said.
With Type 2 diabetes, a person's body can't properly use insulin, which causes blood sugar to build up and can lead to other problems like heart disease, stroke, kidney failure and blindness. It can also lead to the need to amputate toes, feet or legs.
In Wilson's case, one of the consequences of his condition was poor blood flow to his feet and a reduced ability to fight infections there when he stepped on the nail.
Wilson has spent several months working with diabetes specialists at St. Vincent and had 40 sessions in a hyperbaric oxygen chamber — a sealed, pressurized chamber filled with 100 percent pure oxygen — in its Wound Healing Center.
Those 90-minute sessions in the chamber have over the course of eight weeks helped to drastically heal the wound.
"Pushing in that oxygen really helps it heal," Wilson said. "It doesn't feel like it when you're in there, but it's working. Your body really is taking it in."
Now he's healthier than he's been in years and he's getting a better handle on his condition.
While multi-disciplinary teamwork and training among staff at the Wound Healing Center is important to patient recovery, personal management is how patients see a real difference, said Mark White, director of the Patient Wound Care and Diabetes centers.
"What's going to get you out of here is well-controlled diabetes," he said.
Like many of the tens of thousands of Montana adults diagnosed with diabetes, Wilson's condition eventually put him at risk of amputation, in this case his foot.
Nationally, the disease is linked to about 80,000 lower-limb amputations. St. Vincent estimates almost 50 annual amputations within the diabetic population in its service area.
About 44 percent of the patients who come into its wound care center have diabetes. St. Vincent has seen the number of diabetes patients rise from about 2,400 in 2012 to almost 6,500 in 2015.
Wounds heal slower for those with diabetes, said Dr. Justen Rudolph, a St. Vincent diabetes care physician. So to prevent a wound escalating to requiring an amputation, "You need to check your feet every night if you have neuropathy."
Thousands of Montanans have the disease, and even more are at risk of developing it. According to DPHHS figures, about 7.9 percent of Montana adults had been diagnosed with diabetes in 2015, up from 6 percent in 2004 and 2.8 percent in 1990.
Nationally, 10 percent of adults had diabetes in 2014, compared with 7 percent in 2004.
DPHHS estimates put the number of pre-diabetic Montanans — those with higher-than-normal blood sugar levels that can increase the risk of Type 2 diabetes, heart disease and stroke — at around 38 percent of adults, or 300,000 people. That lines up with national statistics putting about one-third of Americans at risk of developing the disease.
Certain demographics, especially Native Americans, are more susceptible than others. DPHHS estimates about 20 percent of the Montana's Native population has been diagnosed with diabetes.
'Better than any pill'
Wilson, who is Native American, said many of his struggles with diabetes come back to diet.
Doctors point to diet as an issue for millions, especially those living on reservations.
"All the things they tell us not to eat are basically staples in our diet," he said. "Potatoes, pasta, gravy, things like that."
For years he knew he was overweight but checked his blood sugar levels twice daily, around his morning and evening meals, and believed that was enough.
He also thought he felt fine. But his recent experiences in more closely watching and treating his diabetes have changed his mind.
He has worked to change his diet and to check his sugar levels throughout the day to learn when they spike.
That meant cutting out many of the foods he'd eat at home, foods found at tables across the reservation every day. A meal for him now might be a serving of protein, like lean steak or chicken, and a mound of vegetables.
He no longer eats the fry bread and fried potatoes that are served, and he chooses whole-grain bread, checking the label to make sure it doesn't contain high-fructose corn syrup.
With all that work, he's lost 30 pounds, and he plans to keep those lifestyle changes.
"You need to change your eating habits, you need to monitor your sugars," he said. "It can be really hard because the right kind of food isn't always easy to find, or it's more expensive. But once you can overcome the food situation, that's half the battle."
Getting the entire family on board is also helpful, Rudolph said.
"Better than any pill I could ever give you, diet and exercise is going to do the most good for you," he said.
Fernandes, the health improvement section supervisor with DPHHS, said programs across the state can help people prevent and manage diabetes.
Chief among those resources are 20 on-site and 16 telehealth locations of DPHHS' Diabetes Prevention Program, which works to delay or prevent Type 2 diabetes and cardiovascular disease in Montanans.
It is a 12-month lifestyle program that, through education and hands-on group sessions, works to change behavior, implement healthy eating habits and set activity and weight loss goals, all facilitated by trained lifestyle coaches.
Community efforts can also help improve health by providing education opportunities and creating active options, like walkable and bikeable roadways, Rudolph said.
The biggest step is getting educated, he said.
"You can control diabetes. It doesn't have to control you," he said. "And taking care of yourself up front leads to better health down the road."
That's a lesson Wilson is taking to heart.
"It doesn't always feel like it, but it's working," he said.