STGEC ~ Wound Care: Diabetic Foot Ulcers (2013)

STGEC ~ Wound Care: Diabetic Foot Ulcers (2013)

fuck she was a doctor of Podiatric medicine and has been treating wounds since 2003 she is the owner and podiatrist of IDO wife's podiatry in precious burg Texas her past work history who's working with podiatry group of South Texas and being on the Memphis staff for the hyperbaric medicine and new care at Port Duncan Regional Medical Center she's a certified food specialist CWS of american cabin chemical management she's also a local as she attended Shriner University and also trained here through the VA and she practiced in British for eternity so let's give them welcome okay yeah I grew up in a Negro that's where I graduated from then I went to trainer so no Engram jokes and I did train in the VA but I was in Chicago South Dakota ears on that and I did some training gotta marry Elsa so it's kind of nice to be back home talking about of this stuff I deal a lot with diabetic foot ulcers and so a lot of these ulcers are preventable so that's kind of where my talk is living is more how can we catch these people before they ulcerate and fix the problem and offload the area that will ulcerate and help these people to get on with their lives so you have been talking about the different types of ulcers we have an air path the arterial venous all of these ulcers happen in the foot venous not nearly as frequently but they do happen the main ulcer that we see is air Pathak these are the ones that we can really prevent early and so 60 to 70 percent of all of our diabetics will develop neuropathy and one study showed that 7% of our diabetics on diagnosis of diabetes already have neuropathy so what's important about that as soon as they have their diagnosis of diabetes they should initiate regular diabetic could exams at that time it's better if these people come in to see us early rather than having diabetes for 10-15 years and now we're just starting on putting out your foot exams we can prevent a lot of problems if we can see these people early so clinically we call it protective sensation because if they step on a tack who will they feel it if they have and sticker in their shoe are they gonna feel it or are they going to notice at the end of the day when they take their shoes off that they're their shoes full of blood or maybe they notice blood in the floorboard of their car that's how they first met the soldier because they just can't feel anything on their foot and so we test this with the monofilament can you pass up I brought some show-and-tell since we're right before lunch to keep y'all interested so we use a monofilament and we test different points on but they should be able to feel this if they cannot feel this that's a big indication that they're not going to feel that tank is in their shoe so when they when the skin is injured or even you know it doesn't have to be a foreign body that's attacking the foot it can just be a callus on a sense8 foot a callus will be very painful and so these people develop calluses which are really appreciative lesion and then you really don't feel pain where they should when you don't feel pain you know when you buy a new pair of shoes and they have something bit right and you get blisters and everybody talks about breaking in your shoes and they'll get more comfortable so if you have feeling in your feet you'll eventually probably stop wearing their shoes because they hurt your feet and diabetic they don't stop wearing that she's because their feet don't hurt nothing that happened is causes pain so their gait cycle is altered their musculature is change they develop arthritis they walk differently but they don't really notice what's happening because that came free so it's kind of a blessing to be pain-free but at the same time it's a curse so when you see this on a patient's bed and you know you'll see this a lot more than we do because you're in there with these people you're talking to them so when skin exams are done calluses are a lot of times just looked over but this is a free alternative lesion so imagine every green lawn and if you take a piece of plywood and put it out on the green line leave it there for about two or three weeks when you remove that what happens the grass is yellow it's dead imagine that a callous system the same think to the skin it's there is friction in this area there is pressure whoops there's friction pressure the skin underneath this callus is dying so we need to remove that callus and find a way to prevent the callus from coming back and so neurotic bolsters the key science you're going to notice the hyper care Tata crane they will always have this hyper care time frame and that's because this this wasn't calloused to start with and if we can catch it at that point we can prevent this and so this ring that's right here it continues it caused problems with the skin and this one will not heal until all of this is to breed it and so that's why we really rely on heavy debridement these really are typically treated once a week if we can do that offload this then we can help that skin to heal it's never going to be as strong as the original skin if we can prevent it from ever happening at least they retain their planners again another common place on the great toe is that during toe off there's just a lot of pressure and when people have an altered gait cycle there's even more pressure and so this is a very common area and this is the one that I noticed that maybe dr. Brooks will notice this too this is the one people pick at you know they're as they're shown it to you that are pulling and yanking and it starts bleeding that's a really important thing to lift the patients know don't pick it anything on your foot because that skin is already dying over there they're pulling it off they don't feel that turning and now I have a new hole to deal with in there but many of the deletions we can offload debris get them healed get them into a good pair of shoes and wear a cake well we also have an arterial component there are bigger issues and I went to a dinner last night where they cited a research study citing 50% of all their pet the posters are also have an arterial component so these people really should be involved with the basilar surgeon also we can offload we can use all of our fancy blue treatments but if they don't have a circulation it won't heal okay so and this is an example of that I see a lot of ulcers that come in and people have treated them you know if you look at the method of treatment everything has gone very well they've had a really good infection control they've had offloading everything has gone very well except that this is not a narcotic bolster this is an arterial holster so as we debride this whole series going to get larger and larger and larger and we're not going anywhere so this person means to see a vascular surgeon if you're going to save this foot and that's you know I don't know how or how many of they'll work with home health okay how many of y'all work in like a skilled nursing facility okay the rest of y'all are hospital based okay so sometimes I have I've talked to people that work in home health and nursing facilities where they'll just get an order or wound care there's no specific order for what type of wound care what product how to offload or anything and so it really is important that y'all are come into these courses and learning all these things because this is not an aerobatic all services arterial this person needs to see ask your surgeon and so it you'll see these things so much more than we do because y'all are changing the dressing so we really rely on y'all to give us a call and say hey this doesn't look so good and so noticing that this is arterial is key for this patient saving this one okay so I want to talk about just basic foot deformities these are the kind of foot deformities so that we can correct early on and save this patient a lot of trouble save amputations just save everything all the way around and with Medicare kind of know we're here in the VA okay what we're dealing with with Medicare on the outside everything is going for pay for performance so what is coming down the pipe is you will receive a set number of dollars and you have a set number of days to kill this wound if you don't have that healed in that time then that you have to continue taking care of the patient at your own expense and so one of the things that we can really do when we see a foot like this this patient is neuropathic this patient is diabetic they will ulcer it at some time so while this patient is younger healthier glucoses were well controlled maybe there are a little bit more compliant we can repair these toes so that we don't have these pressure points if we do that at this time when they have a circulation to heal the surgery then we have potentially prevented an amputation 15 years down the road okay with a hammertoe you'll notice that the tendons are very tight there may or may not be a corn on the top of the toe this is a site for illustration on the top of the toe sometimes the fifth toe will be rotated and you can see where the skin is a little bit darker there's a little bit of callus these are all pre on sort of leash diabetic guru neuropathic patient now there's also pressure at the tips of the toes because they are no longer walking on a flat surface the tip of the toe is pounding into the the shoe or the ground every step they taking since we live in tech with Texas everyone's wearing flip-flops and so it's even worse and then so here are some examples a normal callus is kind of yellow when your callus starts turning red Brown starts turning darker colors there's actually micro bleeding underneath the callus that's the skin dyeing underneath the callus that's a big concern most people are not going to see this as a concern until they see you know big red open wound and something more exaggerated kind of like the spider bite it looks like a little spider bite so that doesn't really seem that important they don't realize that there's it's not a spider bite there's so much bigger problem it's the same thing with these types of little lesions it doesn't look very important but it really is they also will get ulcers between the toes these are a big problem for offloading because until that hammer toes are repaired you're not going to ever be able to keep that ulcer away we can add it we can do different things but when this person's circulation goes down this is going to be the cause at the loss of that toe is not part of the foot and then a toe is very swollen here typically when you have this much swelling there's also bone involvement as far as osteomyelitis here Berta's also cause pressure and underneath the metatarsal heads and so this toe that's just almost dislocated on top of the minutes person can't pass up the foot models I'm like a magic show got a whole box of tricks here for you and so if you look at the way the boats are shaped on that on the foot look at the toes now imagine that the toe is sitting up on top of that long narshall so what it's doing is counting the metatarsal into the ground it's literally boring a hole through the skin to the ground so if we catch this person early on we correct their hammer toe and most of the time when we do surgery we address the deformity at the joint not just the toe so we don't have these high pressure points underneath the foot these are really really common sites for illustration but when we've encountered this patient they've already got vascular disease you know there's really a limited amount that we can do okay bunions ever ever just about every patient will tell you oh that's just my bunion and that's the way they put it that's just my bunion well it's a high-pressure point one of these phones move out of out of alignment they you know create a potent hiding spot on the foot and any pokey out a spot on them on the foot is gonna create an ulcer and can lead to amputation and underneath the first metatarsal that I don't think these moths have it there are two little bones there there that create a lot of additional pressure you called the says lloyd's and so many times we have says white problems in these types of ulcers and so we can heal this holster and this will be a really recurrent ulcer we'll get it he'll they could diabetics use the holster it comes back we get it held and we keep going through this process until they eventually end up with osteomyelitis and we have to amputate so if we can correct the deformity early on this is another case where we can save this foot great televisions I see a whole lot of these and unfortunately by the time I see them you nearly always have a vascular component and so when we go through a normal gait cycle we go through toe off a lot of patients I don't know if you all hear this people say well I'm wearing out the heel of my shoe I don't know why but I'm fitting my field first well that's a normal gait cycle people seem to think that they should walk on our toe first and it kind of bounce off their toes in a normal gait cycle they should have heel strike first they should roll across the mid-foot that's the stance pace and then they should toe off now this great toe joint so your big toe joint should have quite a bit of motion there so you can tell off what's happening with these people they have a little bit of arthritis and spurring this joint so they have almost no motion so when they come up there's just a lot of pressure on this toe this is a really easy deformity to fix early on but they these are the people that will have just a little callus it's not very big so when you're doing the foot exam you should notice on the big toe is there a little callus right here if there's a little callus right here this is the what this patient can potentially have happen and that's a really easy fix other foot deformities Charcot foot that one is is a bear to deal with because there's just really not many good ways to offload that and there are surgical Corrections for this but not everyone is a candidate and so these kind of lesions are very very prominent these people become very depressed because you're basically taking them off their foot and telling them you have to do nothing now and this is going to take months and months and months so the biggest key of the Charcot foot is recognizing Charcot in the acute face if you can catch a shark up but before it collapses you can save this foot I want to notice that I I read an article and I don't remember the exact percentage but there's a very high percentage of shark Cove but that go on to imputation there's a high rate of osteomyelitis in those patients now as surgeons you know we try and save as much as we can so people come into the ER and depending on what hospital you're at you might the vascular surgeon might do this the general surgeon or the podiatrist and so some of the thought process is let's see how much of this foot we can save but in the end we're not doing the patient any favors by saving this and so when we see a patient that has a foot structure like this it's completely by mechanically unstable they will also right here they will all serve underneath this metatarsal head but the scary part about this during this phase we've been able to save most of the foot if it gets infected again we may not be able to save that much of the foot so when I see a patient that has had this type of a surgery where the majority of the forefoot is gone I will take that person even if they don't have an open lesion take them to surgery and go ahead and amputate right here and create a state and walking service so we can save these feet we just have to do it preventative ly so offloading and there's a lot of different ways to upload I'm going I hate you that's okay you're right ahead of me okay so offloading they've come up with all these different devices to offload the biggest thing is we send them out of the wind clinic you know with one of the easily removed our pegs and everything looks hunky-dory and happy and then the next time you see them they come in and they're wearing this but it's bright new shiny and clean and looks like it's never been worn but they swear they've been wearing it and then they're wound has a large Palace around it so we know that they're not wearing it and so compliance is key with offloading if they're not being a compliant you're just with going nowhere in a hurry and with those patients I do a lot of education with the patients and home health nurses that I work with they do a lot of educational so you know they'll walk in and they'll give me a call and say you know like they just called me this week your patient is supposed to be strict non-weight-bearing in he's out in his garden with his flip-flops on with his wound back on with his walker walking through the garden and so you know those people we can try very hard we can use all of our every turn arsenal chest but you know walking in the garden on a planner wind that has a moon back on when they're supposed to be completely non-weight-bearing we just sew as much as we try we have offloading products but we have to look the patients to use them I like these because I will tell the patients to save them because we can put these little pegs back in and then when they develop another wound which the majority of people that have a diabetic ulcer will pull straight again we can put these pegs back in and offload where we need to and yet if people for my image of patients I don't know how many of y'all deal with those but a lot of the the thrift stores the hospice stores things like that we'll donate these and so I talked to them and though they can't resell them because it's a medical device so I will talk to them and say can you save anything that comes through three like this so we can get those two are integer patients custom molded shoes those are you know once the patient has had an ulcer they don't need a regular diabetic chute more likely than not they need a custom own tissue these are not you don't come by them very frequently the medical supply companies that do diabetic shoes typically do not do custom molded shoes and so what we see with this the difference between this and the diabetic she came to pester and the brown shoes if you look at this shape of the bottom of the shoe it's not the shape of a normal shoe and the reason it's not is that we actually take a mold of the patient's entire foot all the way up to the ankle and then this shoe is built around that mold and so when we have this recurrent ulcer that just keeps ulcerating we need to go ahead and do a custom shoe that's really the best way to offload now if you have somebody that has Creole sort of lesions they have hammer toes they have bunions we can go the regular diabetics shoe and we have some of those and you know the the biggest problem with diabetic shoes especially if you talk to our older women they're like it looks like a Frankenstein shoe and they're not interested they're not going to wear it so I brought some shoes because y'all see a lot of these people y'all can let them know you know the more people they hear this room you know it's a diabetic sheet they don't look like Frankenstein cheese anymore so I brought some examples of you know what some of the nicer diabetic she's literally so we can get more compliance out of that can you hold up the one that's I think it's on the bottom that's kind of cute it's brown I mean that doesn't really look that much like a diabetic shoe and so our little over ladies that want to make sure that they can wear something the church and where it goes nicely with their slacks they're not gonna wear the frankincense you there they will wear that okay these shoes are deeper than your average shoe there's different types of inserts that go into these shoes there's a heat moldable shoe insert and then there's a custom only shoe answer the biggest headache after getting an ulcer healed and I've gotten all the infection control this patient is ready to go out and start walking again they go get diabetic sheets somewhere and they come back and they have ulcers on their feet from the shoes and I'll ask them well when we went in for your shoes did they measure you and they say no no they asked me what size I wear well the majority of them don't know what size they were they're already wearing a smaller shape than what they should be and so what the companies are are supposed to do is actually measure them and so what I tell everyone that's going in for she and there is actually this is because you know patients talk to y'all about this kind of stuff you know I'm supposed to be private of shoes just throw it out there make sure that you have the measure of you and they need to measure the you understanding okay sometimes we have to actually make a mold a pivot question Medicare only covers certain height from that correct medicare covers diabetics she is not for every diabetic though so frequently you'll see a diabetic that doesn't come off of be there early fish maybe they're thirty six years old they haven't developed all these other complications they're not going to qualify for diabetic shoes Medicare will pay that they're very strict criteria they already left have a neuropathy and a callus so you're diabetic that has pretty healthy feet they don't have any calluses they might have a hammertoe but they haven't had an ulcer yet those people – I know it's a there are certain shoe companies that are certified to be covered by Medicare okay and so I'm sure there are some people out there that use plants that are not covered by Medicare but pretty much if it's a diabetic shoe that's listed as an acceptable diabetic shoe by Medicare which is what we all carry they're all covered they even come with a high-top boot there's a lot of different styles now many here will cover 80% if they have supplemental supplemental we'll pick up the rest Medicaid does not cover diabetic shoes Medicare there is a huge list and I don't know that Medicare actually has a list on their website but any state if you google diabetics use different companies are going to come up and they have to have a certificate for Medicare so anyone that saying that they are they have diabetic shoes they need to have that that certification from Medicare that they're in location and if they meet all the criteria is she designed these are all covered that's why except for the house shoes there I brought some posh shoes because I'll talk about that in a minute but all of the other ones these are all styles that are covered now some companies that do diabetic shoes they choose to you know they send you an entire shoe rack there's probably 60 or 70 different types of shoes some people will choose to only offer 10 in their office and you know they can certainly do that and if you're not satisfied with that selection there are other companies that do the same thing okay that's what I recommend for my patients that don't yet qualify for a diabetic shoe because sass is a really good shoe and I do a lot of Education with my patients in shoes selection and then it needs to have a furnace all new boy I taunt the prettier she was the worse it is for your foot and so if we can get a nice supportive shoe as far as prevention and since I send them there to make sure they're going to get a good shoe they had all these wonderful shoes and one of the ones that they promoted a whole lot was established she called the fisherman's sandwich I can imagine what style that was I was though it was the Medicare shoe fitted from the whole mold of the foot from the ankle down but it had bail throw across question and education of that company provided because the minority of patients require a custom molded shoe and if they already had an example there for you it was not it was just something for us to write but but at the same time if it's a custom of the shoe they wouldn't already on it's a sample because it's not molded to that patients but a lot of there's a lot of misinformation out there there's a lot of fraud and that's why I date my patients because they're they're going out there they're only entitled to one pair of year and so my concern is if it was a sample and probably if it was a sample it was now the question was not a diabetic sheet not a true diabetic shoe it might be there are some things that may be recommended for diabetics that don't already have complications Crocs have a recommendation but it's not a diabetic shoe but there are a lot of sales reps out there that are selling other sheets as diabetics you saw it and really careful and make sure that we go somewhere that they're actually certified to do this I was just curious exactly from foot injuries exactly that's not that's nothing more and it's not medically recommended and so a lot of it you know there are a lot of fly-by-night shoe companies right now and you'll go in there and maybe so that person minutes a certified shoe fitter certified shooter means they went to a one-day course and we all have a seat pet right back here in rank and it's significantly more training and so diving shoes that just come from the corner store that just set up shop and the person you just saw them working you know down the street and retail the week before they're they're not as knowledgeable as a see pet podiatrist a physical therapist other people that actually yeah unfortunately we can't control what people go out there and saying there's a lot of misinformation and so as the healthcare team it's very important than we educate the patients where is a good place to go traveling companies I'm always a little bit leery of I've seen prosthetic companies that will come in and offer a opposed prosthesis they're off-the-shelf that's just mean that's not a good policy to begin with and they always have a really fantastic sales pitch and you know they could sell ice to the Eskimos but it doesn't mean that it's the way it should be and so that's why you know I want you all to know these things because patients are going out there they just don't know any better and then they get their Medicare issues for the year and they get a terrible pair of shoes that either don't fit or the patient has been told that they're getting a custom insert and it's not a custom insert it's heat-moldable the difference between the custom insert a heat moldable this is tennis has this is an off-the-shelf insert so for your person that's never had an ulcer they'd show a callus on their foot they're diabetic their nerve haptic this is the type of people would sort we're going to give that patient but it shouldn't be dispensed just like that it needs to be heated up and rolled into the patient's foot but this is still not a custom now the most common thing that I see happening I order a custom in search and they then want to go somewhere to get their shoes we ordered our custom insert and then about getting a heat moldable insert but the company has built for my custom insert and so there's a lot of that going on you're going to see a lot of shoe companies being shut down for these reasons so it's very important that so when I prescribe a custom molded insert and then I go to section section give this shoe I always let them know they should take them all under foot and they should measure your foot if they're not doing those things get up and leave and go somewhere else that's the heat moldable you can put one of the inserts out of the brown shoes the custom is actually going to fit their foot it's actually gonna be it's a clear clear difference in how about like so it actually fits the palm mother but when you hold that in search of the bottom of your foot it just fits like a glove it doesn't look like your typical insert so you're standing up to use those at Walmart oh the the stand where you can stand on it and it you know you can go stand on that thing ten times and it's going to tell you something different every time it really is sometimes I feel like going and sitting a stack of my cards by the doctor tool machine because by the time people get too mean they've already gotten three or four pair of those and they're not cheap either so yeah that's you know there's a lot of little gadgets out there on the cruise ships they're selling what they're telling people are custom orthotics and they're selling them for anywhere from you know five to eight hundred dollars a pair and it's an off-the-shelf insert but you know as consumers we just don't know other than what people tell us and so that's why we try and educate so you know if it looks now like you know it's kind of questionable it probably is yes that's the custom yeah it's a process it's not something somebody's going to be doing out of the back of a van you know and there are shoe companies that literally have a van and drive around you know paying out their shingle diabetic shoes here and you know we think in our society that everything that is more convenient is the best and it's really not and so a custom molded insert anything a custom molded orthotic it's definitely different than a prefab actually like rather than and the other process that happens when the when they come to see somebody who is actually trained in this we're looking at more than their foot we're looking at how do they walk because this foot looks nice right here sitting on the table but when they get up and walk that foot mean wide differently and so there's more going on than just we're not shoe salesmen we're actually fitting the patient for what they meant or what their particular problem is and everyone's problem is different so if you see a company that pretty much everything looks exactly the same coming out of there there's a problem okay so custom molded shoes these are very expensive so the thing that y'all can doing l see these people on there you know tracking through you know cow manure remind them that these you know cost 800 to a thousand dollars of care take care of it because we won't get another pair till next year exactly the other thing that I see I'll see people that come in and they have what they're calling a diabetic shoe it's not a diabetic year they've paid 150 dollars $200 for this pair of shoes and the entire time they had coverage to actually get a diabetic she accustomed old issue they had the insurance coverage to get what they needed the ones that are really falling prey to these scans are Medicaid patients because they don't have any coverage at all but most of your reputable companies will work out some sort of a payment plan with these people and that's what I do I work out a payment plan because they are expensive but I relate it you know if you can afford an iPhone then you can tuck some money back in and save up and maybe put that on your Christmas list ask the family to help you you know there's a lot of ways to get to this and I present it to all of our Medicaid patients it's you know I don't care where you get them it just needs to get a good reputable in place it's not optional it's necessary and I know it's not covered I wish Medicare and Medicaid would change but they all right this time or not and so I just you know let them know that this is necessary it's not optional before they get to the stage where they need to Medicare make most of them do but the policies are changing some policies people are changing maybe they have more budget maybe yeah they have different maybe they think they have more I coverage but they don't have as much this is health durable medical equipment they may not have as much durable medical equipment in their policy and that depends on what they're either their employer chose for their health plan or what they individually chose typically the health plans that are very very inexpensive don't usually have DME coverage so that really is case-by-case you know a really good area of people when they're working don't opt out for like the flexible spending plan or detect nobody get you're not yes absolutely and people that are really serious about taking care of their foot as soon as I see a problem and I see that this foot is potentially going to ulcerate and then this part that that automatically places this patient in a higher risk for amputation so I have a real serious to talk with that patient at that time sometimes they get very upset sometimes they cry but I tell them if we don't address this now you will be that person out on the waiting room with one leg and so when you put it to them that way it seems a little harsh but when you put it to them that way they they have to take responsibility of learning to take care of their feet early on if we can do that we can slow down all of this you know I hate to put the one business out out of business but you know that's what we're all striving for Xuan sorts like Kathy has I would have to cover the rest and honestly my insurance company pretty much I did whatever I paid even listening yeah so yeah I think when they call the insurance and they get the pre-certification you know what they can actually bill I think it's better reimbursement for the provider to do that it's that it's pretty uncommon at this point that anyone's insurance is coming covering enough on it and so we just pretty much assume they're not going to cover it because you know where they're making cuts and insurance orthotics DME seems to be one of the first things being a cut it is preventative and I don't understand it but that's the way the cookie crumbles but if you have a person or patient that this happened hammer toes that is not a diabetic are they still at risk for developing those ulcers if they ever develop a problem with their vascular flow yes so some of the arteria if you haven't heated vascular to flow then all of these pressure areas are potentially an arterial ulcer there's one of those is people to get hemorrhages it's a muscle imbalance it's partially hereditary partially the shoes we wear it's really a combination of things so you can't really necessarily prevent someone from getting them you can always recommend a young age that we we're better shoes but I mean you've been to pay less and you see anyway you can earn you play a factory yes it's in there there's a whole group of our entities that can you know worse than all these symptoms and so definitely so there's where she's and the other what I was talking about preventive lis this goes right into it so if we take this but this person's already getting the monster here this deformity is just not going to fit into a shoe and so at some point if their vascular supply goes down if they are her Pathak this is going to be a problem if this person is ever going to have an amputation this is why and so if we can catch this person while they have good circulation while there's still somewhat compliant is a as compliant as we can make anyone be and correct this deformity now this foot is much lower risk for any alteration so we can do a lot preventative ly so what did you do you go through before that and this whether than even my case but what we do is straighten these toes so usually we take a little piece of bone out of these toes we might use the bones to keep them straight depending on the type of hammer toe that it is sometimes it's a little bit dislocated at this joint and so we'll plantar flex the toe and drive a k-wire to it so these patients after surgery will actually the wire sticking out of their foot that will stay in there for several weeks and then we remove it as far as the bunion depending on the degree of deformity we might have to do surgery up here we might focus here or do surgery both places we remove the bulk of the bone create an incision completely through the bone and move and over when we move the head over the total street yeah it's I mean we can do a lot with these people when they have good circulation we're really limited when their vascular supply goes down or there's you know there are quite a bit older their skin is very a trophic you just can't hardly kill that surgical wound or like in our people that are osteopenia they weren't even osteoporosis as much as we're going to try and fix that if their bone is too soft to hold uh screw that we can't do anything we're very limited same thing here these toes are just kind of they've got a mind of their own right now and so if we can straighten them this foot is more agreeable to shoe gear that's the biggest problem if we want I'll watch barefoot all the time I think we're swimming all the time we wouldn't have these problems but we'd go to the store and we buy a shoe that is built for a normal foot well it wasn't built for this foot and it wasn't built for this foot so if we can fix this early honey we can prevent more problems um a couple of things that y'all might see there are more medical emergencies and just like you can have a DVT of blood clot sometimes we have a micro in Malloy and it comes down in the shower and it just goes to all the end vessels all the end arteries and basically plugs up all these teeny little capillaries and so you end up with with this dark watching of parents this person used to see a vascular surgeon ASAP not next week they really need to get into Summa someone right away this is typically pretty painful and so this is not something you know you might see this and say well we'll get them in to see someone they're too they need to be seen today or tomorrow this is a case I had never dealt with cows until axis I only have one case of it and so this patient actually it looked like this but these areas were very black very hard this is a dialysis patient in any dialysis patient that you have if you start seeing small black card lesions on the foot on the abdomen anywhere on the body and there's a multiple lesions they need to be seen right away it's calcify Laxus very very high er a high group of these people are dialysis patients and the one patient that i have died within two days because all of these will emboli that are going out to the skin are going to the organs and so yes and then you have multi organ failure and it will kill the patient the patient that I saw luckily I had just finished a winged horse but is in residency I'd never saw a case of this and I thought oh my gosh is this could this be so we got them to San Antonio got them to Methodist they did everything that they could they started amputating I think the patient had three amputations within two days and then died and so medical emergency don't assume that it's nothing it's always better to assume it is something and then it turns out to be nothing and these these come on very suddenly it will be one day it's not there the next date is there and it's painful I'm gangrene sometimes you're going to pull off the bandage and a toast going to come off with it and that's dry gangrene two types of gangrene dry and wet so when we start to see parts of the foot completely become necrotic that are dried out they may be a little bit macerated these are reasons that we need to get them back to whoever's taking care of the wound or establishment care or care of the vascular surgeon pretty quickly sometimes you'll have small areas of the toes and we typically don't right away because we have to see how this is going to travel this tow is starting right here but by the time it's all finished and demarcated and it's probably going to go up to here so we're going to have to amputate higher don't you worry a lot about surfaces oh absolutely that's why we need to get these people into the hospital if it's a dry gangrene who usually don't worry about sepsis as much you know we do a full workup but if it's whitening green we immediately go in the hospital and immediately take them to surgery now this is a bigger case you know when you start seeing you've got gangrene but you have all this macerated tissue wet tissue it's easy its weepy this is gonna smell really bad a big problem okay and the next picture like I said so if the front of your foot falls on them it's real bad so the toes you know the disease that you can see with the eye is down here but we can't create a non-weight-bearing but we have to amputate more proximal so that we do have a good blood supply and so that's one thing when these people you know they're going to say how much are you going to take we have to go high enough up to save what is left okay so here's a different kind of a case y'all are going to see this multiple times throughout your career you've gotten a diabetic patient then with red hot swollen foot they don't have a winner there's nothing draining there's no open lesion they don't have fever they're completely a fever all labs are normal so what do we do with this patient so big key factor here if there's no wound there's no signs of infection other than it's red hot swollen this is what an acute Charcot foot it looks like if you catch an acute Charcot foot we need to immediately offload this person that rocker-bottom deformity how many of you have actually seen a sharp of foot the deformity okay rocker bottom foot we can catch them in this stage completely offload them and that means no weight on that foot at all we can let this disease process go through what it needs to go through it's going to go on for a while there's a lot of micro trauma that it goes on with walking so the nerves are sending the mixed signals so we start to send a lot of blood flow to the foot it washes out the buttons the bones become almost like sand so then when this patient continues to walk it collapses now wherever it collapses or whatever it position it's in by the time this Charcot episode is over that's how it's going to stick that's how it's for the state so when you see red hot swollen foot you can make them an appointment with their primary care their podiatrist or the whoever it is that you're going to send them to but the number-one thing is they have to be completely unwavering because between now and the time they get that appointment they've already walked on it they've bottom doubt their foot now we have a lifelong deformity that it will most likely lead to amputation okay so this is the bone structure but just kind of a normal foot arch this is how it should look you can see the clear definition between the bones all the joints all of these bones are you know neatly defined in the Charcot foot it just becomes this great big ball of bone with no definition is it's just like sand it collapses however it collapses that's how it's going to stay and so that's why Charcot reconstruction is very very involved this is something that is done more frequently now assured of reconstruction it's very very involved because you have to basically go in and recreate the entire mid-foot of the of the foot and then when we do this we create risk for another Shopko episode and so it's easier if we can catch these people before they have mid foot collapse okay and then the other another promise Charcot foot once they've had an ulcer if they have any hint of bone infection or if they ever have they are never going to be eligible for a Charcot foot reconstruction so it's a very difficult foot and the more has the episode oh it can last three to six months or more this this patient needs to be prepared to be completely non-weight-bearing for in a long time very frustrating it's very depressing by the end of this episode these people are usually just a basket case because they have not been able to participate in anything they're already depressed their diabetes is out of control maybe they were using an exercise program now they can't do anything so their glucose is out of control it's just a cascading process and it's very very sad to watch these people go through this process because they just are very depressed okay and you know when you when you're trying to keep take care of yourself and then you become depressed our chances of doing any good really go down so we're pretty fortunate nowadays you know my residency director when he started they were doing Dayton's solution which dry and betadine that was basically their tool chest for wound care any amputation and they he told me that when he started their goal was never to heal and it was to prevent an amputation so they just already expected that this will be a long-standing word we're just going to try and keep it from getting infected and save your foot they never anticipated so we've really really kind of full circle now we're preventing wounds we're using a lot of different products so that we can heal these wounds and so we use routine diabetic foot care dr. Armstrong and it does a lot of research with diabetic foot infections all these types of things and one of the the studies that they just published and I don't remember the percentage bird knows that I'm trying to remember what exactly it said basically if we can get somebody in for routine foot exams routine diabetic foot care early the the dollar amount that you save her patient is just as amazing because we're preventing amputations were preventing ulcer you're preventing all these chronic problems that take this patient to a you know a non weight-bearing status once a patient has an amputation odds are they're not going to live another five to seven years so we're shortening the lives when we start amputate but if we can prevent the ulcer that's started then we can prevent this whole process we need to I saw that John were talking about nutrition that's perfect everyone has to have their nutrition assessed vascular status needs to be assessed and control any infection that's there offloading we most definitely have to do that and then we have a lot of you dressings I use a lot of skin substitutes so if I have a one that's not healing hasn't closed fifty percent in one month then I typically will go to a skin substitute I could I use derma graft a lot I use that word Wrexham and so we have a lot of tools but we need to see those patients early once that patients had only for six months it's harder to heal so if we get those patients earlier we do a lot better and we're trying to make sure that we're after we heal this wound now we need to worry about how we're going to keep it from coming back so that's where we need diet cheese or pesto mold issues some people will need an AFO to prevent pressure on the forefoot and so that's just a hold of grace that goes completely at the patient's leg there's a lot of devices that we can use to help these patients but we just need to see them and unfortunately as much as we try and offer other people I thought this was funny at Google offloading and this picture came up and so you know we can offload we can give them every tool offload but when they're going home and they're you know they're uploading in their way okay okay it's lunchtime and we have lunch provided for you you have the choice of either chicken or beef fajitas there on the side here and just grab a box you come back to the table eat or somewhere else we can unfortunately we can't use a classroom back there like we did yesterday because the vendors are setting up for the product fair for the sector noontime we have drinks in the back water and then there sodas for $0.50 okay thinking oh we also like to thank our sponsor today for freshness a chip O'Donnell from high-tech rehab solutions and also che cose from shark region common sense of using sponsors just don't thank you enjoy a lentil but someone has torn it apart she's taken

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4 thoughts on “STGEC ~ Wound Care: Diabetic Foot Ulcers (2013)

  1. HiI have had Diabetic ulcers for almost 15 yrs and lost over 5 pieces of bones in my both foot.What saved me and now 2 yrs and no more ulcers under my foot was I avoided Wheat and anything that's related to wheat products. What really weird is the ulcers started to heal very fast. as soon as I've stop eating wheat…… my blood sugar very stable    4.2 mmol average in 30 days…taking 1/2 my medications  only….blood pressure normal even if I'm a smoker.You could try this but it takes a strong will cause I've missed my wheat products…and every-one around us is addicted to it. and eats it daily….But for me and a few people I've met who had ulcers are a thing of the past for us.If you tried this and your feet heals Spread the word. You have nothing to lose but gain your health…But it will take at least a few days for the liver to deplete all the wheat it holds incase of starvationMy Question why do you do a test group test to prove that I'm correct about this No believes me but a case study could save  people from this illness and lots of money and health costs…. Mesalt and aqua-cel Ag are quite expensive…..but you still need to wear foot  ortotics for you feet

  2. Natural treatment for diabetic foot ulcers

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