Throw Everything at Diabetes … But Don’t Throw in the Towel

Chronic nonhealing wounds are always challenging to treat, as they may be associated with multiple complications. And when that “typical” healing progression has been disrupted, it is the job of the wound care provider to determine why a wound may revert to or remain in the inflammatory phase. Of course, all wounds can become chronic in nature — but why do some become more challenging than others? Often, diabetes, and its complications, is to blame. We continue to hear the burden associated with treating these wounds as well as the significant impact that they can have on patients’ lives when standard of care is not provided. The longer a wound is in existence, the more likelihood there is for infection, amputation, and mortality. Patients who are living with diabetes have an additional increased risk of infection, and the longer the wound is open, the higher the opportunity is for amputation (not to mention the five-year mortality rate). Additionally, the odds of the contralateral limb being amputated increase within 2-3 years from the first amputation. Sometimes, wound care patients may fail to make progress because the clinician has not appropriately orchestrated a comprehensive plan or simply lacks the expertise to treat certain complex wounds. Remember the adage: “If it were easy, everyone would do it.” Not every clinician is prepared to effectively care for chronic wounds, especially when comorbid diabetes is present. We need to make sure we are “all in” at the time of the first patient encounter. With this edition of Let’s Be Frank, we will talk about what this should mean to wound care clinicians.

The “Difficult To Treat” Stigma
Some patients who live with complicated wounds are labeled as “noncompliant” when progress is not established and/or when acceptable outcomes are not reached. When it comes to noncompliance or adherence to the care plan, I wonder if most patients are truly noncompliant (which admittedly does happen for multiple reasons) or if we are generally too quick to characterize people. Do we always educate and communicate with the patients and their caregivers as well as we should be, consistently? We cannot rule out that patients may need more information. Throughout my career, I have witnessed many reasons for patients not achieving appropriate wound healing progress. The most frustrating may be when decisions are made without proper assessment or when there is a lack of adequate wound care knowledge. Let’s discuss two types of chronic wounds that carry the stigma as being “difficult to treat.” In the inpatient setting, pressure injuries (ulcers) may be somewhat challenging while diabetic foot ulcers (DFUs) can create havoc to outpatient centers when they are not properly treated. These wounds have multifactorial components that need to be addressed simultaneously, but it is essential for everyone involved in the care planning to know their roles and expectations — including the patients. Treating patients with these types of wounds, metaphorically speaking, can be compared to riding a roller coaster. There are costs associated with riding, the patients may be scared, and since they aren’t able to see all of the tracks ahead of time, they must trust that the operator will keep them safe. Living with these chronic wounds can produce similar feelings, and we must be reactive to the unexpected as well as proactive in doing what’s right for each patient who trusts us with their care. 

“Everything But The Kitchen Sink”
Another commonly used phrase comes to mind whenever I’m discussing DFUs and pressure injuries: Treat it with “everything but the kitchen sink.” The origin of this idiom is not entirely clear, but may date back to World War II, when valuable objects, especially metals, were needed for the war. At the time, sinks were made of porcelain, which was not in demand as a valuable material in the war efforts. This concept can be used when treating chronic wounds, as we want to give wounds our full attention, knowledge, and resources so that we can address obstacles encountered. The question with that, however, becomes do we know what we are doing and are we providing our patients with best practices while appropriately utilizing available resources and orchestrating the proper plan of care? So, what does “everything but the kitchen sink” mean when it comes to diabetes and chronic wounds? In my opinion, that means taking into account adequate nutrition, maintaining established glucose levels, establishing adequate arterial circulation, selecting the best method of debridement of nonviable tissue, recognizing and managing infection, offloading plantar wounds, seeking appropriate footwear, maintaining an ideal wound environment, and providing frequent wound and skin reassessment that is reinforced by patient education and a conversation about accountability on both the part of the clinician and the patient. Will patients benefit from hyperbaric oxygen therapy, cellular and/or tissue-based products, negative pressure wound therapy, and/or other advanced modalities? Unfortunately, today we must add “if they are approved by the insurance company” to the end of that last question. If the advanced modality is not covered by the payer, the proposed modality most likely will not be an option chosen by the patient. At that point, how willing are we to take the initiative to be an advocate for our patients and provide continued education and positive reinforcement in an attempt to heal wounds?  

Do Not “Throw In The Towel” 
Too often, patients and providers alike succumb to another idiom: “Throw in the towel.” This stems from the sport of boxing and occurs when a fighter decides to concede the fight — the trainer will literally throw a towel into the ring to signal the request to end the match. In this example, the motive may be to protect the human from serious injury, but we all know that isn’t the case when we don’t put up the full 12-round fight against a chronic wound. I was asked by a non-healthcare worker, “Why would a patient need to be seen specifically at a wound care clinic?” I answered that question by suggesting that, if his car was having problems, he would probably take it to an experienced mechanic and not just anyone telling him that they could fix the car. I try to avoid analogies that may inherently seem to trivialize healthcare by comparing patients to inanimate objects, but in this case the comparison feels warranted. When patients enter a wound clinic, they should be able to expect specialty service and nothing less than optimal results (with of course an objective, honest prognosis given based on comprehensive assessment).  

One Patient’s Experience
For full transparency, an interesting inpatient whom I recently met serves as the inspiration for this particular column topic. Let’s call her “Mrs. Knowbetter.” What appeared to be a “simple” wound was far from it, but her noted callous told the story. She has had a history of DFUs, but they have healed “every time on their own until now” and she is adamant that her arterial circulation is normal (a toe is missing from a previous surgery). Her neuropathic wound landed her in the hospital during her first wound care visit to our facility. Prior to being seen at our clinic, she was being treated at another center. Due to her infection and amount of ischemic tissue, a transmetatarsal amputation was performed by her surgeon, who also coordinated a revascularization procedure and initiation of advanced modalities. She was also malnourished, and her wound bed was not optimized. Our staff took the opportunity to discuss appropriate diet with her. Mrs. Knowbetter was at one point very resistant to accept the responsibilities of self-care that we proposed to her as part of her overall care plan. It took willingness from our team of clinicians to revisit her during her inpatient stay before she agreed to assume some accountability. Mrs. Knowbetter is unique in her own right, yet she represents the “typical” patient we see in our outpatient clinic — the type of patient who some may peg as “noncompliant.” Remember, every patient’s learning style is different, and we can never rule out barriers that may be present in one’s life when he or she enters our clinics. In order to achieve a treatment plan that allowed for this patient to be an active member of the care team, she had to fully understand her condition, the standard of care, the statistics involved, and the consequences to be expected if standard of care were to be ignored. This took more time and coordination from our staff than what should have been necessary, combined with knowledge of current best practices and education.  Sometimes, it is not what we as clinicians know best that we should rely on. Sometimes, it is seeking what is best to know. n

Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches.