Collaborating With Vascular Colleagues

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Jennifer Spector, DPM:
Welcome to Podiatry Today's Wound Care Q&A, our long-standing and well-read column that addresses timely topics in lower extremity wound care with leaders in the field. Today, we are hosting this call in a new format, through Podiatry Today podcast. We are thrilled to have Dr. Kazu Suzuki with us today. Doctor Suzuki is the clinical editor of the Wound Care Q&A, and the medical director of Apex Wound Care Clinic in Los Angeles. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles.

Jennifer Spector, DPM:
For this installment, Doctor Suzuki shares with us some key considerations and tips from his experience on collaborating successfully with our colleagues in vascular surgery.

Kazu Suzuki, DPM:
I always worked with the vascular surgeons when I started going to the conferences, I got to know the attendings, residents, fellows. I'm doing definitely a lot more closer collaboration with the vascular surgery colleagues, because I do the preservation and they do the preservations. I think that's only the thing for us to collaboration, and I do encourage people across the nation, across the board, to do more collaboration between podiatry and vascular surgery. We have a lot to give to each other, a lot to support each other, and there's only good things could come out from collaborating with others, for sure.

Jennifer Spector, DPM:
That's so true. Let's talk a little bit more about that. In your practice, can you tell us a little bit about what that initial referral to vascular looks like? I know it may vary from community to community, but what has been successful for you? Are you initiating non-invasive testing in the beginning, and then referring to vascular, or are you bringing them in right away?

Kazu Suzuki, DPM:
Actually, it goes both ways. Oftentimes, we have the same patients under our watch. It's almost like catch ball. They have, they see it, because it depends who sees first. Let's say a person has a wound. It's not healing. Sometime, they go to vascular surgeons first. They say, "Okay, your blood flow's okay, or your blood flow's bad, let's fix it. Okay, I don't know what to do with wounds. Go see Dr. Suzuki." I see cases like that. On the other hand, I see a new patient their wounds not healing, but they're doing everything right, but guess what? Their blood flow is bad. I have an ABI machine in the office. I can check their ABI in two minutes. If it looks bad, I'll send it to my vascular surgeon colleagues.

Kazu Suzuki, DPM:
I also see lots and lots and lots of venous leg ulcers. Actually more than half is probably venous leg ulcer disease, so vein disease of some sort, which I don't do, so I end up referring them to vascular specialties. I call it catch ball. I send them a ball and they give me the ball back. Yeah. It's a collaboration too. I email them, text them all the time, every single day. We're texting each other, collaborating with each other. Only good things will come out. I said don't be shy, if anybody's listening out there. Don't be shy. Reach out. They want to reach out to you, and make the first initiation.

Kazu Suzuki, DPM:
Reach out to them, "Hey, I've got this patient, can you help me? Hey, how's Mr. So and So doing?" The communication is a wonderful thing with other specialties.

Jennifer Spector, DPM:
Yeah, that relationship can be so beneficial, both for your practice and for the patients as well. What do you find has been successful for you for those patients where we know that the ABI can be unreliable, especially in patients with diabetes? Are there any other tests that you might initiate, or that your vascular colleagues prefer you initiate for those patients where the ABI may not tell the whole story, or who you may suspect have micro vascular complications?

Kazu Suzuki, DPM:
Yeah, we have this machine that checks ABI and also pulse wave recordings PWR. That's actually good enough for the screening purpose, and it takes me two minutes to do. I used to have SPP machines, skin perfusion pressure machine in office. I've published on it, I've lectured on it internationally. The problem is the company went out of business during COVID. I was told they're coming back, but they're not available now, so I'm not talking about it now. ABI, if you have an ABI machine, it should show you the pulse wave. That's really actually good enough to say, "Hey, this person has a vascular disease or they don't," more so than the physical exam.

Kazu Suzuki, DPM:
Again, have a low index of suspicion. If you believe this person has a vein disease, if this person has arterial disease, if you suspect it, just send them out. Send them out to referral for vascular specialties. They have their own vascular technicians with their own very expensive doppler machine. They can tell you, "Hey, hey, this guy's not too bad," or they might say, "Hey, this guy had a terrible vascular disease. We did an angiogram next day. thank you so much for sending this patient." Again, only good things will come out from making referrals and making contacts with the vascular specialty colleagues.

Jennifer Spector, DPM:
Absolutely, I think very few people would say they regret making such a referral. It's certainly usually the other way around. If you're inpatient, if you're dealing with an inpatient who needs revascularization, and you're also waiting to take your turn to help this patient through debridement, et cetera, how long after that vascular intervention do you find you usually need to wait before you can get in there and debride? Assuming that we don't have any limb-threatening infection that takes precedent at this point?

Kazu Suzuki, DPM:
I usually don't wait that much. Number one, the hospital doesn't want you to sit on your hands too long. The hospital always want you to treat the patient and get them out of the house, which is understandable, because the hospital's always over capacity. That's one thing. Another thing is there's another concept of strike the iron when it's hot. If the patient's blood flow's fixed, let it by bypass, angioplasty, doesn't matter. When the blood flow's good, you want to take care of it right away.

Kazu Suzuki, DPM:
Usually day after. Usually day after the bypass, day after angioplasty, we do something about it, be it debridement, amputation, or skin grafting, that's usually what we do, even though there is some arguments to be made. There's some literature that, hey, you might want to wait 24 hours, 48 hours, 72 hours to let the blood flow come back. There's that concept there, but they may not be practical. We usually try to intervene as soon as we can.

Kazu Suzuki, DPM:
There's another component of it is I've seen so many cases where a patient comes in with a black toe, the classical, dry, gangrene, black toe. Let's say this person's big toe is completely black, and dead, and dry. Okay, so he needs angioplasty. He gets angioplasty. The patient's home. The patient comes back two days later, that dry, black toe turn into wet gangrene, and came right back to the hospital two days later.

Kazu Suzuki, DPM:
We see a lot of that, not to anybody's fault, but we see that all the time. That goes to show you that one thing I learned over the years is the ischemic limb doesn't get infected very much, because it actually takes blood flow, oxygen, and nutrients for the bacteria to thrive. The "dry" ischemic limb doesn't get grossly infected, almost never. On the other hand, when you increase the blood flow all of a sudden, the infection can blow up. Again, that's probably yet another argument for intervening as fast as possible, at least next day or the day after the vascular intervention. That is my philosophy. That's how I practice.

Jennifer Spector, DPM:
After the patient has had their revascularization, and they've had your intervention as well, and hopefully that patient is discharged home with no incidents, and they're following up in that wound care clinic, how do you collaborate with vascular in the post-operative period, or in that follow up period where you're trying to keep them in ulcer remission?

Kazu Suzuki, DPM:
I kind of have protocol in my head, in that I risk stratify the patients, in terms of at risk limb in high risk, moderate, low risk. If the patient's low risk, I see them every two months for follow up, two, three months, even. If they have no problem whatsoever, okay. Young diabetic guy, 50 year old, just diagnosed with diabetes, I might see them twice a year. I think that's the American Diabetes Association recommendation. The more at risk patients who have had an ulcer before, I'd probably want to see him every two months. Then there's really high risk patient who gets ulcer left and right. Patients like that, I might see them more often, let's say, I don't know, every four weeks or every two months, or every week when they have active ulcer.

Kazu Suzuki, DPM:
I kind of risk stratify in my head. When the patient realize their limb loss is at stake, they're usually pretty good about coming to see me in the regular intervals. The vascular guys, they usually have their own schedule, in that after they do interventions, I think every surgeons may differ, but they usually have their own schedule and say, "Hey, come back in four weeks for doppler, and if it looks good, three months, then six months, and six months thereafter." They usually have that kind of schedule. That may be actually in the literature already. They usually have their own schedule to bring the patients back for doppler exam. As long as they're plugged into the system, I'm comfortable with that.

Kazu Suzuki, DPM:
Again, communicate and collaborate. I'm always on texts and emails, and sending pictures to my vascular colleagues. They text me back saying, "Hey, I got this patient who just had an ulcer. Can you see this patient?" I of course bring them over. We always texting and communicating with each other. Keep your communication lines open. Tell them to give them your personal cell number. I don't care, text me any time. Give them your email. Just make sure that you're accessible would be my advice to everybody.

Jennifer Spector, DPM:
Thank you so much for being with us today, and sharing your experience and insights with us. We look forward to future Wound Care Q&As, and other episodes of Podiatry Today podcasts, which you can find on PodiatryToday.com, Apple Podcasts and more of your favorite podcast platforms.