By Dr. Bret R. Boyle
Although most skin wounds heal normally, there are millions in the U.S. with problem wounds that do not. Most occur on legs or feet and can fail to improve or worsen due to problems such as diabetes, peripheral arterial disease (reduced circulation), infection, peripheral neuropathy (reduced sensation) and chronic edema (swelling).
Leg ulcers associated with chronic edema affect over 600,000 in the U.S. and account for over 80% of all problem leg ulcers. Edema can result from a number of problems including congestive heart failure, varicose veins, previous episodes of infection (cellulitis), surgeries, or prior deep blood clots (DVT).
Diabetic foot ulcers improperly managed are the leading cause of leg amputations in the U.S., with nearly 100,000 occurring annually. Numbers are increasing as the occurrence of diabetes rises. Although other causes exist for leg and foot ulcers, these two issues of chronic edema and diabetes are significant sources of chronic pain, stress, disability, and infections leading to hospitalizations and even death.
Non-healing wounds are a big challenge for the vast majority of medical providers. As a result, a relatively new specialty has been emerging to confront these problem issues. Certified wound specialists with advanced training are available in populated areas where they direct wound care centers. The physician will evaluate the varied issues impeding the healing process, then initiate a plan for treatment. The specialist directs and oversees a “team approach” engaging other specialists to assist with improving conditions that may be affecting healing.
This advanced wound care specialty has evolved primarily from the “burn units” of major medical centers over recent decades. Experience and research have greatly advanced the ability to heal problem wounds––avoiding potential amputations and improving quality of life. Along with many new and advanced wound dressing products, some other recent developments are skin substitutes such as Apligraf and Dermagraft, which are both made from human skin cultured in a laboratory. They can be used much like a skin graft to help “close” a long-standing wound.
Because of the impact these disease processes can have on the body, odds are that many with one or more of the above problems will need help from a wound specialist at some point. However, there are measures that can be taken to help prevent the onset of leg and foot ulcers associated with chronic edema or diabetes.
Whether leg edema results from congestive heart failure, vein problems, or past injury to a leg, the connection between swelling and “dependent” positioning applies. In other words, while legs are positioned below the heart for the typical 12-16 hours per day, gravity will “pull” or “hold” body fluids down in the legs and swelling results. This fluid pressure outside of and around the smaller blood vessels significantly reduces blood flow to the skin, resulting in inflammation and ulceration. Sitting increases problems both because of the dependent position of the legs to the heart, and because of muscle inactivity. Walking causes calf muscles to act as a “pump” to help “push” some fluid out of the leg. For some, periodic elevation of the legs above or level with the heart can help reduce the effects of gravity. Diuretics or “water pills” can be a part of the treatment plan, but because they can be dangerous, should always be managed by your medical provider. Daily use of special “compression” stockings are an essential part of management, but again should be individually prescribed for proper sizing and a safe, effective level of compression.
Diabetic foot care is also a nightly effort involving careful inspection of feet for “red” areas and/or areas of callous. Both are indicative of excessive pressure or friction that can develop into an ulcer. Appropriate expert help at this stage can prevent a potentially devastating ulcer. Diabetic shoes are very important! There are variations; however they are typically a little larger than your normal shoe size, and have “extra depth” to allow for special thick, foam “inserts” that replace the standard cushion. These inserts redistribute the pressure more evenly across the bottom of the foot and will reduce or eliminate excessive pressure points. At the same time, the “well” or “depression” in the cushion helps to hold the foot in the center of the shoe, reducing pressure and friction points with the surrounding shoe. Toenail trimming or callous paring is a common cause of injury that can result in wounds, opening the door to infection and possible amputation of toes, feet or legs. Careful toenail trimming by a skilled and experienced professional every 60-90 days is very important for every diabetic.
There are a number of other scenarios where a wound care specialist can make all the difference. This article has touched on two more common problem areas. My hope is the information presented here may help one of you to make important changes that can prevent unnecessary and potentially life changing problems. I also hope that if you do need special care for a wound that you will do your homework and find a well trained and experienced specialist who can treat you well.
Dr. Boyle is board certified in family medicine, and fellowship trained/board certified in hyperbaric oxygen therapy/wound care from Duke University. His career includes 13 years military medical service. He has nearly 10 years of experience as a wound specialist and is medical director of Physician Wound Care Specialists of Utah, located on the 3rd floor of St. Mark’s Hospital, above the Emergency Room, 1220 E. 3900 S, Suite 3A, Salt Lake City, 84124. Dr. Boyle also provides consultation outreach services in 15 nursing facilities in Utah where he delivers at the bedside wound care. For information call 801-590-9064.
Time Does Not Heal All Wounds
“Dr. Boyle has been coming to our facility for a few years now and not only have I benefited from his visits, but so have the residents of our facility. Wounds can happen in matter of minutes as compared to healing time of days or months. Without the proper care, wounds can become chronic and sometimes limb or life threatening. I started following Dr. Boyle in his care to our residents about a year and half ago. I have seen many wounds diminish in size and heal. Time, patience, dedication and knowledge are needed in wound care and Dr. Boyle shows that with every patient he sees.
A specific example that comes to mind is a resident that is very petite in size with a recurrent moisture related wound to the buttocks. When she was first seen it took time and patience to figure out the right treatment that worked. After proper cushions, pads and treatment were in place, you could visually see the amazing progress. Caregivers were trained in maintaining proper positioning and placement. Nurses were trained in visualizing the treatment needed. Communication was a must between caregivers, nurses and Dr. Boyle.
What I take away from my experiences with Dr. Boyle is more confidence and judgment when I see wounds in various stages. I start to think the ‘Dr. Boyle’ way and ask myself, ‘what would Dr. Boyle do?’ Our facility and residents benefit from Dr. Boyle by having that collaborative teamwork and dedication that he possesses.”
– Lindsay, LPN
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