Evidence-Based Care in Diabetic Foot Ulcers

My name is Alton Johnson. I'm a DPM, (and a) certified wound specialist as well. Currently, a clinical assistant, professor, podiatrist, pediatric surgeon, wound care specialist at the University of Michigan Hospital System - Michigan Medicine, currently working as a podiatrist and wound care specialist.

By the statement, "Not all DFUs are created equally," (this) simply means that no one wound is ever the same when it comes to diabetic foot ulcerations. That could be applicable to all ulcerations but in general, you don't know.

You don't know the patient's background when it comes to nutrition. You don't know the patient's background when it comes to Hemoglobin A1c. You don't know their situation at home, how many footsteps they have to take per day to ambulate, or if they have stairs in their home.

There's a multitude of factors that statement includes, but that's essentially what it is. It's basically knowing your patient before creating a treatment plan to heal those wounds because I can give patient A one treatment plan and it works out perfectly, but if I apply that to patient B, it also may not turn out as well, can make it worse. You have to tailor. It's tailored care.

The top tenets the clinician should keep in mind is essentially with that patient home environment, what is that patient's financial situation because when it comes to if insurance is only covering address and change three times a week, what's going on these other four days out of the week or next time they see you.

Sometimes it could work out to be a better follow-up period. You have to know that. Then, also you have to know the patient's education. Have an understanding or care, because they think now that they send a wound specialist or provider that treats wounds, that they're now in good hands.

Sometimes that's true because you can educate them but you have to let them know this is a long road. You have to prepare, have deep conversations with your patients as a clinician, and also you have to let them know the potential outcomes if you guys don't succeed with this care plan or treatment plan that you provided for them.

Essentially, being a good listener also. You have to know the patient and providing understanding and education to the patients. Then, even obviously, you can use your medical background or your specialty expertise to heal the wound. That's what you need to know. It's like a dance. It's you and the partner and the partner's the patient.

When it comes to DFUs and publications, paper resources, anything that I would say that's supported by the International Diabetic Foot Working Group, it's pretty much standard when it comes to trying to take care of DFU, specifically. Then, anything that the American Diabetes Association publishes as well, are supports.

Then, of course, I loved David Armstrong (DPM, MD, PhD), so anything his group [laughs] puts out there is definitely has been validated. There's a lot of good articles out there. Those are the ones when you say impactful. I would say those that are most impactful.

Feel like a first day out or you're trying to get into wound care, those are where you want to go to if you're trying to treat DFUs, which is a little different than other ulcerations.

Every DFU has complications. Otherwise, it wouldn't be a DFU if it didn't have complications. Unless there's a history of a trauma or something which still cause complications because now you're dealing with organisms that you normally would not have in the wound bed. Still could list it as a complication.

When it comes to properly treating it and how you would address it, I would say imaging. I love imaging. Whether it be X-ray, ultrasound imaging, or even the MRI which can be costly at times.

Also, appropriate wound cultures. There's times when you don't know what pathology you're dealing with or organism you have to battle when it comes to antibiotic stewardship. That's one of the issues to a diabetic foot ulcerations because not all ulcerations are affected but when it's complications it may be infected. You have to know.

Having a good infectious disease expert on your team that you can rely on to discuss these type of complications when it comes to DFUs is important. Then, also having a good vascular specialist, vascular surgeon, or a vascular medicine doctor that understands perfusion when it comes to complications.

You can put the latest and greatest technology on those wounds and they may not heal. They probably won't heal because you don't have the right situation to provide a proliferative phase for that one to go to the healing and that also can stagnate. I would say a good team is the true answer to that question.

Then, part of the steps of taking it is re-evaluating and going back to the ground zero. I call it so. The bird's eye view level or the ground level of what's going on with that particular wound. Whether it is there a perfusion issue. Is there a bioburden issue? Is there a pressure issue?

Sometimes you can be held in all of those steps but there could still be pressure causing them, preventing that wound from healing. That could be your go-to modality to solve that complication.

Also, going back, like I said, reiterating what the patient is going through at home. You never know, there may be some stairs that they're climbing that you didn't know about, adding extra pressure to that wound.

Even if you are offloading that property, put them in a Crow boot, TCC cast but they're taking 15 steps a day, and go take a shower or a bath. Could be the element that's preventing the wound from healing. Basically, knowing the patient essentially when it comes to complications and also having great team. That is the best way.

The biggest thing when it comes to wound care, and I don't know if we can say post-pandemic or [laughs] we adapted to the current pandemic, but it's the technologies that have evolved.

Telemedicine and the devices when it comes to demography, monitoring of all events in the last 18, 20, 24 months, will be 24 months with the pandemic. I think that alone will change how we treat patients when it comes to remote monitoring.

Then, even the other day I had a patient that usually would drive three or four hours to be seen, and they're able to just Skype in, but using HIPAA compliant video conferencing to assess their wound and how they're doing. They're pretty smooth with it and familiar with it.

Otherwise, they probably wouldn't have done it if it wasn't pandemic time. They wouldn't have had that experience. Wound care itself will have a step where involves more relying heavily on technology, just like any other specialty out there.