Airing The Dirty Secret

Enjoy this preview of the August 2010 print issue of Today's Wound Clinic.

Note: TWC regrets that a few sentences from this Editor's Note were accidentally deleted from the print version of this article, so please read the complete version here.

  Since becoming co-editor of this journal with Dot Weir, I have aired some dirty secrets about my career in wound healing and here is another one. After beginning at the wound center at the University of Texas, Houston in 1990 (with a three page handout on venous leg ulcer care from Dr. Claude Burton at Duke), I received a call from the Chairman of Orthopedic Surgery.

  They had renovated their waiting room and were hoping that I would take over the diabetic foot ulcer clinic. It seems that wound drainage from diabetic foot ulcer patients was ruining the new waiting room carpet and the odor was discouraging the more lucrative clientele, specifically, the sports medicine patients. I protested that I really knew nothing about diabetic foot ulcer management and shouldn’t it really be done by orthopedic surgery? (I later learned that in the University setting, the best way to ensure that you are put in charge of a program is to have no credible experience in that area.) I was assured that they could easily teach me everything I needed to know, and most importantly, that I would have the services of the “casting technician.” This was good because I had no idea what a “casting tech” was or did. If only I could have had Desmond Bell’s TWC article on off-loading published in this issue, back in 1991!

  Since then, I have experimented with every possible solution to the off-loading question. For years I used the aforementioned “casting tech” but I had to share him with the operating room. Therefore, sometimes patients had to wait until he was out of the OR, causing patient care delays.

   “Surely I can learn to do this myself, but there must be an easier way,” I thought. I confess that I was grateful when Jeff Jenson showed me how to use his easy to apply kit. I love it! However, in the last few weeks I have casted an enormous man the size of a professional football player, and a very tiny woman the size of a child. Kits may not work for extremes of size.

  Also in this issue, Melodie Blakely discusses the pros and cons of “roll on” vs. custom TCC options. Perhaps you can save yourself a few years of frustration by absorbing what these experts have to offer in this special “podiatry in the wound care clinic” issue of TWC.

  I strongly believe that if you are not committed to off-loading in your clinic, you are NOT properly treating diabetic foot ulcers. A few years ago I developed a painful neuroma, and after I got tired of standing like a stork on my good foot, I finally went to see my own podiatrist. He introduced me to a computerized device, which assessed my gait (explaining why I always have to have the heel on one shoe replaced), special shoe inserts, and the science of footwear. His orthotist patiently explained what he did for all the patients I referred to him after I blindly scribbled a prescription for “footwear.” I had sent a lot of patients for this evaluation but never understood what it entailed. If you own a few pairs of uncomfortable shoes like I do, read Val Sullivan's article on gait assesment and why our diabetic patients really need this. The fact is, when I got started in wound care I knew absolutely nothing about general diabetic foot care or how to perform a basic diabetic foot examination. It is often the simplest things, which lead to limb loss in the diabetic--a callous ignored, a nail infection, a fungus allowed to get out of control. To continue the podiatry discussion, our September online issue will feature Shelly Burdette Taylor providing an excellent review of the basics of foot and nail care, exploring what is routine vs. what ought to be done by a DPM.

  Whenever we put an issue of TWC together, we ask ourselves what we wished we had known when we were getting our clinics off the ground, from both a patient care and a reimbursement standpoint. We feel sure that—as usual—Kathleen Schaum’s reimbursement feature on bioengineered skin and vascular screening will be a tremendous resource to make sure you stay on track in using these important modalities.

  There is one thing I did learn quickly about running a wound center. There are only a few catastrophic mistakes that a wound care clinician can make, but failure to diagnose arterial disease may be the “cardinal sin” in wound care.

  Desmond Bell has devoted most of his free time to the Save a Leg, Save a Life (SALSAL) Foundation. Amputation is one of the most fatal diseases in our society, with a survival rate worse than most cancers,
as I discuss in my article on vascular screening. Anything we can do to decrease the likelihood of amputation in our patients will extend not only their quality of life, but also their life expectancy. That is the second take-home message from this issue. If you are not committed to vascular screening in your clinic, you are not properly treating leg ulcer patients.

  There are three basic interventions, which are cost-effective, evidence-based and which save limbs and lives: vascular screening, adequate off-loading and compression bandaging. (See the Product Roundup section of compression products in this issue.) Commit to excellence in these basic things and you will have a superb wound center. Wound care is a team sport and podiatrists are integral to a successful team.

  Most of what I now know about the management of the diabetic foot I learned from my podiatric colleagues, so it seems fitting that we devote a special issue of TWC to podiatry. I wish I could have had this issue in my hand 20 years ago.

Caroline Fife, Co-Editor of TWC, cfife@intellicure.com