A Deeper Understanding of Wound Care - Episode 9
Perspectives on the optimal work-up for wounds and the setting where wounds would best be managed.
Peter L. Salgo, MD: More advanced wounds; I want to talk about how to treat them, and are there differences in procedures from center to center, practitioner to practitioner, and wound to wound? How do you begin to sort all this out? Anyone want to jump in on this one? How do you sort out a wound? I’m looking at this wound, how do I treat this?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: First and foremost, you have to do a complete history and a physical examination.
Peter L. Salgo, MD: OK.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Head-to-toe. You have to make certain that you’re looking at every aspect of their medical care, what their underlying comorbidities are, etcetera. Often we can use a checklist for that to at least guide us in the right direction so we don’t miss anything. We’re making certain that their vascularity is appropriate; whether they have problems orthopedically, neurologically, neuropathy, etcetera. Then once we make a diagnosis, we can go down a pathway utilizing appropriate evidence-based guidelines as they are known today, and sometimes they vary. By using that evidence-based approach, we can hopefully get a positive result.
Peter L. Salgo, MD: Are there acceptable different pathways for the same wound? It looks the same, you
get the history, maybe it’s subtly different in history. Are there different ways to get to the same end? Are they acceptable going in 2 different directions?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: The answer is, again, it depends.
Peter L. Salgo, MD: I knew that was the answer, I knew that.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: As an example, you may have a patient who you think has a diabetic foot ulcer who’s not getting better with appropriate therapy, offloading and debridement, and moist wound healing. You realize when you take a biopsy that they have this squamous cell cancer, or maybe they have a vasculitis.
Peter L. Salgo, MD: Well there’s a difference.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: You have to be able to have that knowledge base and have that flexibility, and understand what the evidence is telling you to be able to make those decisions.
Peter L. Salgo, MD: That’s another kernel that’s come out here, which never occurred to me, but should have, which is, if you’re doing everything right and it’s not getting better, look for what’s wrong, maybe it’s not what you thought. There’s something, a different pathology.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I had a mentor, Robert Warner, who unfortunately passed away, really an iconic figure in our field. His mantra, “If the wound is not getting better within 4 weeks, start over because you’ve missed something.”
Peter L. Salgo, MD: That’s amazing. I have a partner in the ICU [intensive care unit] who says, “If a patient isn’t diagnosed in 2 weeks, you’re in trouble.” It’s similar—you’ve got a real problem. If a patient goes to an emergency department for wound care, as opposed to a wound care center for wound care, and I’m assuming there are more emergency departments, in fact I know this, than there are wound care centers, is there a difference in the kind of treatment this patient is going to get? What do you think?
Samuel D. Young, MD, MBA, CPE, CHCQM: First of all, I would say that in the emergency department [ED] level, and you all can speak to this more than I can, I am not a podiatrist, I’m an orthopedic surgeon.
Peter L. Salgo, MD: We like them too.
Samuel D. Young, MD, MBA, CPE, CHCQM: We tend to defer these to our podiatry colleagues as well. But oftentimes, as you know as a physician, the ED, it’s kind of like a sorting point, you know?
Peter L. Salgo, MD: Sure.
Samuel D. Young, MD, MBA, CPE, CHCQM: Your ED physician tries to figure out what’s going on with the individual and then does a consultation. Do you even get definitive treatment, or are you even placed on the right track to definitive treatment at the emergency department level? You all can answer this better than I can. I would suspect, possibly not.
Peter L. Salgo, MD: With all due respect to emergency department physicians, they’ve got an impossible job. They’ve got someone with a wound over here; someone with crushing chest pain over there; somebody in DKA [diabetic ketoacidosis] and septic shock over there; and they’ve got to have 8 arms, they’ve got to be an octopus.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Remember, too, the ED physician is not going to develop a relationship with this patient. It’s a one-and-done scenario. Secondly, they’re not looking at the patient holistically. They’re focusing in on that problem at the time. Often they wind up leaving with an antibiotic that they may not even need and referred to an appropriate specialist, hopefully.
Michael T. Kazamias, MS, DPM: Or maybe the hospital-based outpatient wound care center that happens to be down the hall.
Peter L. Salgo, MD: Nudge, nudge, wink, wink.
Samuel D. Young, MD, MBA, CPE, CHCQM: We also have the confounding factor that if you do have an individual who is seeking the definitive treatment over and over in the emergency department, that individual’s probably not doing what they need to be doing to properly heal their wounds.
Peter L. Salgo, MD: Let me ask you the softball question. I’ll give this one to you. It’s 2 out, the bottom of the 9th—this is really softball—and you have a choice—an analogy, grant me this one—of going to a wound clinic or an ED for the treatment of your wound, what do you choose?
Samuel D. Young, MD, MBA, CPE, CHCQM: Knowing what I know, I’m going to a wound clinic.
Peter L. Salgo, MD: He swings, and the ball is heading over the wall. Yes, it’s obvious, right?
Samuel D. Young, MD, MBA, CPE, CHCQM: Right.
Peter L. Salgo, MD: You do want to go there.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: There’s something to keep in mind. The vast number of people who have wounds that require treatment don’t end up in wound care centers. They end up in primary care doctors’ offices, they wind up in a whole plethora of other specialty offices and not necessarily wound care centers.
Peter L. Salgo, MD: Is that a consequence of there not being any wound care centers, or because they’re going to the wrong place, or because there are a lot of places you can get good wound care?
Samuel D. Young, MD, MBA, CPE, CHCQM: Or they don’t even know where a wound care center is.
Peter L. Salgo, MD: Right.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: They don’t, but very often the driver is cost, particularly if they’re in a managed care plan or they’re in some scenario where that entry point, that gatekeeper, makes that decision.
Peter L. Salgo, MD: Got it.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Then very often that gatekeeper will hold onto that patient for a period.