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Wound Healing
Steven Sparenberg D.O discusses wounds that do not heal. He shares information on the diagnosis of wounds, basic wound treatments and when it is important to refer to wound clinic for advanced help.
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Learn more about Steven Sparenberg, DO
Steven Sparenberg, DO
Dr. Steven J. Sparenberg is a family medicine doctor in Monticello, Illinois and is affiliated with Carle Foundation Hospital. He received his medical degree from Kansas City University of Medicine and Biosciences.Learn more about Steven Sparenberg, DO
Transcription:
Melanie Cole, MS (Host): Expert Insights is an ongoing medical education podcast. The Carle Division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please click on the link and complete the episode’s post-test. Welcome. This is Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we’re discussing wound healing and when it’s important to refer to the wound clinic for advanced help. Joining me is Dr. Steven Sparenberg. He’s a physician with the Carle Foundation Hospital. Dr. Sparenberg, it’s a pleasure to have you join us today. First I’d like to start with who’s really at higher risk for wounds that don’t heal on their own.
Steven Sparenberg, DO (Guest): That’s an excellent question. When I see people coming into our clinic, it sort of breaks down in a couple of different areas. People can have the non-healing wounds. You know the falls, the cuts, the injuries we get around in the kitchen, doing something in the garden, things of that nature. Then there’s another group. It can be post-surgical wounds. Maybe someone’s had ortho surgery, a foot or a knee, hip, back surgery. Maybe like a c-section. We’ve had a number of people have Mohs procedure for a skin cancer and it not quite heal. Then we have a group of people with venous ulcers. You may see folks running around with the big varicose veins. We’ve seen them out for a walk or in our shopping centers. Next would be like arterial ulcers, and then there’s people that have mixed ulcers. It can be arterial and have a venous component as well. We also have our diabetic friends. They can develop ulcers as they're prone to having wounds and things that don’t heal more than the non-diabetic group. Then we have think of people like in the nursing homes that can get pressure ulcers, but really that can happen to any of us. You can have somebody sitting for a long extended length of time in their job, maybe somebody doing phone triage. They can get a pressure ulcer if they're not getting up and moving. Then sort of the last group I think of are the post-radiation wounds—people that have had cancer. They’ve seen surgical oncology. They’ve had radiation. They're on their way to healing and then they just get this wound that just won't quite close.
Host: That was an excellent explanation Dr. Sparenberg. Thank you for that. So tell us a little bit about how you diagnose them and some red flags because people have their wounds and diabetics and feet and that sort of thing. When people are looking at their wounds, they don’t quite know what they're looking for all of the time to say, “Wow, I should go see a wound specialist.”
Dr. Sparenberg: As far as red flags, you always want to have in the back of your mind wounds that aren’t healing for four weeks. Maybe you’ve got some fevers or chills, you're having some puss or discharge. Maybe a bony prominence or maybe they think even a tendon is being present. That kind of thing. So we always have that in the back of our mind. Hopefully every clinician does that when we see patients for just general things of their health. As far as diagnose, you're old school. You want to do a good history. So you're going to listen to the patient. Do they have other chronic illnesses? Do they have diabetes? Heart disease? You want to think about what kind of chair or sleep surfaces they're on. Have they had prior rooms in those same areas? Do they have peripheral artery disease? You can sort of figure that one out by asking if you walk a short distance, do your legs hurt? Do you have to hang a foot over the edge of the bed to make you're foot feel better? Have you had a history of a blood clot? So that’s sort of the history portion.
Then the next would be the physical exam where you're going to lay eyes, put a pair of gloves on, touch, and look. You're going to notice the location of the wound. Is there a discharge? Is there a callous? Just sort of an FYI, at our wound clinic we assess these wounds every visit. We measure them every visit. We check a glucose on everyone. We check pulses. Something called an ABI which is an ankle brachial index. We also check for blood flow concerns. So that would be as far as the diagnosis and trying to figure out—going back to those categories—is it a venous ulcer? Is it arterial? Is it mixed? Is it a diabetic? Is it pressure? Is it post-radiation?
If you can't figure it out and you're thinking are there blood flow concerns, that’s when you're going to order like a venous duplex. Now venous reflux can be very painful, sometimes more so than the arterial ulcers. There's times you're going to need arterial doppler and duplex. Typically those would be a back looking eschar, almost like a tar wound. You want to make sure you have adequate blood flow. As I always tell folks, if you think of your wound like a garden, do you have the garden getting water—which would be like an artery? And do you have that garden being drained, which would be a vein draining things back and returning it into circulation. Sometimes we have to do wound cultures. Sometimes imaging. We may start with plain film x-ray, CT scan, an MRI. There's times we do biopsies and sometimes you do a wound culture if there’s a lot of discharge.
Host: That’s a very comprehensive approach to wounds Dr. Sparenberg. So let’s start with, before we get into more complex wound treatments, some basic wound treatments. Give us your best advice for general care for wounds of really any type because even healthcare providers are sometimes mixed in their responses whether they should be moist or dry? Open to the air or covered? Bacitracin or Vaseline? What are we doing for basic wounds?
Dr. Sparenberg: Those are really good questions. So if we think of people running around their home or office and they get something, you’d want to clean it. You can use regular tap water. You can clean it once with hydrogen peroxide. If you continue to use hydrogen peroxide that actually can be deleterious to helping heal a wound. So you want to stop that. If you feel there's a sign of infection, you may want to use an antibiotic cream for a day or two. Then after that switch to something like a barrier like Vaseline. Now if you have somebody that’s in a nursing facility and they're starting to get that little reddened area, you want to do a barrier cream. It can be Vaseline. It can be a zinc oxide. Sometimes we mix those two together. Then what you want to do with all wounds—say like on the body—you want to off load them. So if it’s on your foot, you don’t want to go barefoot and pound that foot that has a wound because that’s never going to heal. If it’s on your bottom, you don’t want to sit for 10 hours at a time. You want to set a clock, get up every 15 minutes, reposition, have a good seat cushion, a good pillow. If it’s on your leg, you want to make sure you're not having lots of fluid.
Again, I try to be visual with patients and say imagine yourselves like a water balloon. When we were kids you’d take a balloon and stick it on a hose and fill it up then tie it off and whip it at your brother or your neighbor. We’re sort of the same thing. Our cells swell, they sort of get leaky. So if you look at people that have a lot of swollen legs, those cells are just sort of ripe to be into that. Then you get a nick, you get something, and away you go. So you want to use something like a good compression. Those can be good support stockings. Thankfully now you can get them through medical supply houses. You can buy them off of Amazon quite regularly. The other thing is if you have a found, you want to have enough protein to heal it and people forget this. We’re made of protein. So general recommendations are you want 120 to 160 milligrams or protein in the diet a day to help get you moving in the right direction. If you're a smoker, stop.
Host: Well that’s certainly great advice all around. Now, for certain populations—diabetics and other—these kinds of wounds are really not healing. Now what do we do? Are you using hyperbaric oxygen? What are you doing to help treat these kinds of wounds?
Dr. Sparenberg: Good question. When people come in, we’re going to assess to make sure we label the wound correctly. That we know what type it is. Do a history to find out what types of treatment they have done. We don’t want to repeat what didn’t work. We want to debride. That can be with a scalpel, it can be a curette. What you're doing is you're removing the dead tissue. You're getting into some live tissue. By the way, we always use topical lidocaine and we monitor the patient’s pain. So we’re not inflicting things on them. If you see a callous, you want to make sure you get that callous off like on a foot or a bottom or whatever. There may be something underneath of there. That is what we’ve termed medical debridement in the wound clinic. Depending on if there's still a lot of slough or tissue or fibrin—a lot of gunk if you will—you may want to use Dakin’s, which is a medical bleach, for a while to help get that off understanding it can be aggravating to the surrounding healthy cells. Sometimes we use saline dressings. So that is something that can act as a debridement in between seeing us at the clinic.
Now there are other plethora of topical products. Silver products because silver—like AQUACEL Ag—has the ability to kill and keep down bacterial loads. Then there are collagen products that sort of give a format or a structure if you will almost like rebar and concrete. I tell folks that gives a structure for the concrete to adhere to. Collagen products can help let ourselves adhere to something to help promote healing. There's also living tissue like Apligraf that we can apply and those are for select patients like a lot of our diabetics. If you're getting to a point that they're just not healing, HBO is a consideration for diabetic as well as radiation wound subset of people. Again you're always—good protein in the diet, compression, stop smoking, exercise as tolerated, et cetera.
Host: What absolutely great advice. Wrap it up for us Dr. Sparenberg when you feel it’s important to refer to the wound clinic and really your best advice about keeping an eye on those wounds that don’t heal.
Dr. Sparenberg: As we always tell folks in primary care, if you're diabetic you should be looking and inspecting your feet everyday and applying a type of topical lotion. So that’s a barrier. So if you have people doing that, they're already getting a head’s up. If they find something, they can get int their primary. If you're treating somebody for four or five weeks and they're getting worse and not getting better, consider referral to wound clinic. Again, not smoking, exercise, getting diabetes under control. Those are all things that can help prevent further. If you have a chance to check venous or arterial, if you think it’s a blood flow problem, that can give a good leg up. By the time they see us in clinic, we already have that information. You need really to assess people for noncompliance at some point if they're not getting well. Are they using the dressing properly? Did we not communicate to them? Maybe they can't afford basic supplies. Maybe they're not offloading. Maybe they're still smoking. So those are things you can visit with people so that you're working together as a team to help them heal it.
Host: That is great advice. Thank you so much Dr. Sparenberg for coming on and sharing your incredible expertise with us today. Thank you again. That wraps up this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at carleconnect.com for more information and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. Until next time, I'm Melanie Cole.
Melanie Cole, MS (Host): Expert Insights is an ongoing medical education podcast. The Carle Division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please click on the link and complete the episode’s post-test. Welcome. This is Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we’re discussing wound healing and when it’s important to refer to the wound clinic for advanced help. Joining me is Dr. Steven Sparenberg. He’s a physician with the Carle Foundation Hospital. Dr. Sparenberg, it’s a pleasure to have you join us today. First I’d like to start with who’s really at higher risk for wounds that don’t heal on their own.
Steven Sparenberg, DO (Guest): That’s an excellent question. When I see people coming into our clinic, it sort of breaks down in a couple of different areas. People can have the non-healing wounds. You know the falls, the cuts, the injuries we get around in the kitchen, doing something in the garden, things of that nature. Then there’s another group. It can be post-surgical wounds. Maybe someone’s had ortho surgery, a foot or a knee, hip, back surgery. Maybe like a c-section. We’ve had a number of people have Mohs procedure for a skin cancer and it not quite heal. Then we have a group of people with venous ulcers. You may see folks running around with the big varicose veins. We’ve seen them out for a walk or in our shopping centers. Next would be like arterial ulcers, and then there’s people that have mixed ulcers. It can be arterial and have a venous component as well. We also have our diabetic friends. They can develop ulcers as they're prone to having wounds and things that don’t heal more than the non-diabetic group. Then we have think of people like in the nursing homes that can get pressure ulcers, but really that can happen to any of us. You can have somebody sitting for a long extended length of time in their job, maybe somebody doing phone triage. They can get a pressure ulcer if they're not getting up and moving. Then sort of the last group I think of are the post-radiation wounds—people that have had cancer. They’ve seen surgical oncology. They’ve had radiation. They're on their way to healing and then they just get this wound that just won't quite close.
Host: That was an excellent explanation Dr. Sparenberg. Thank you for that. So tell us a little bit about how you diagnose them and some red flags because people have their wounds and diabetics and feet and that sort of thing. When people are looking at their wounds, they don’t quite know what they're looking for all of the time to say, “Wow, I should go see a wound specialist.”
Dr. Sparenberg: As far as red flags, you always want to have in the back of your mind wounds that aren’t healing for four weeks. Maybe you’ve got some fevers or chills, you're having some puss or discharge. Maybe a bony prominence or maybe they think even a tendon is being present. That kind of thing. So we always have that in the back of our mind. Hopefully every clinician does that when we see patients for just general things of their health. As far as diagnose, you're old school. You want to do a good history. So you're going to listen to the patient. Do they have other chronic illnesses? Do they have diabetes? Heart disease? You want to think about what kind of chair or sleep surfaces they're on. Have they had prior rooms in those same areas? Do they have peripheral artery disease? You can sort of figure that one out by asking if you walk a short distance, do your legs hurt? Do you have to hang a foot over the edge of the bed to make you're foot feel better? Have you had a history of a blood clot? So that’s sort of the history portion.
Then the next would be the physical exam where you're going to lay eyes, put a pair of gloves on, touch, and look. You're going to notice the location of the wound. Is there a discharge? Is there a callous? Just sort of an FYI, at our wound clinic we assess these wounds every visit. We measure them every visit. We check a glucose on everyone. We check pulses. Something called an ABI which is an ankle brachial index. We also check for blood flow concerns. So that would be as far as the diagnosis and trying to figure out—going back to those categories—is it a venous ulcer? Is it arterial? Is it mixed? Is it a diabetic? Is it pressure? Is it post-radiation?
If you can't figure it out and you're thinking are there blood flow concerns, that’s when you're going to order like a venous duplex. Now venous reflux can be very painful, sometimes more so than the arterial ulcers. There's times you're going to need arterial doppler and duplex. Typically those would be a back looking eschar, almost like a tar wound. You want to make sure you have adequate blood flow. As I always tell folks, if you think of your wound like a garden, do you have the garden getting water—which would be like an artery? And do you have that garden being drained, which would be a vein draining things back and returning it into circulation. Sometimes we have to do wound cultures. Sometimes imaging. We may start with plain film x-ray, CT scan, an MRI. There's times we do biopsies and sometimes you do a wound culture if there’s a lot of discharge.
Host: That’s a very comprehensive approach to wounds Dr. Sparenberg. So let’s start with, before we get into more complex wound treatments, some basic wound treatments. Give us your best advice for general care for wounds of really any type because even healthcare providers are sometimes mixed in their responses whether they should be moist or dry? Open to the air or covered? Bacitracin or Vaseline? What are we doing for basic wounds?
Dr. Sparenberg: Those are really good questions. So if we think of people running around their home or office and they get something, you’d want to clean it. You can use regular tap water. You can clean it once with hydrogen peroxide. If you continue to use hydrogen peroxide that actually can be deleterious to helping heal a wound. So you want to stop that. If you feel there's a sign of infection, you may want to use an antibiotic cream for a day or two. Then after that switch to something like a barrier like Vaseline. Now if you have somebody that’s in a nursing facility and they're starting to get that little reddened area, you want to do a barrier cream. It can be Vaseline. It can be a zinc oxide. Sometimes we mix those two together. Then what you want to do with all wounds—say like on the body—you want to off load them. So if it’s on your foot, you don’t want to go barefoot and pound that foot that has a wound because that’s never going to heal. If it’s on your bottom, you don’t want to sit for 10 hours at a time. You want to set a clock, get up every 15 minutes, reposition, have a good seat cushion, a good pillow. If it’s on your leg, you want to make sure you're not having lots of fluid.
Again, I try to be visual with patients and say imagine yourselves like a water balloon. When we were kids you’d take a balloon and stick it on a hose and fill it up then tie it off and whip it at your brother or your neighbor. We’re sort of the same thing. Our cells swell, they sort of get leaky. So if you look at people that have a lot of swollen legs, those cells are just sort of ripe to be into that. Then you get a nick, you get something, and away you go. So you want to use something like a good compression. Those can be good support stockings. Thankfully now you can get them through medical supply houses. You can buy them off of Amazon quite regularly. The other thing is if you have a found, you want to have enough protein to heal it and people forget this. We’re made of protein. So general recommendations are you want 120 to 160 milligrams or protein in the diet a day to help get you moving in the right direction. If you're a smoker, stop.
Host: Well that’s certainly great advice all around. Now, for certain populations—diabetics and other—these kinds of wounds are really not healing. Now what do we do? Are you using hyperbaric oxygen? What are you doing to help treat these kinds of wounds?
Dr. Sparenberg: Good question. When people come in, we’re going to assess to make sure we label the wound correctly. That we know what type it is. Do a history to find out what types of treatment they have done. We don’t want to repeat what didn’t work. We want to debride. That can be with a scalpel, it can be a curette. What you're doing is you're removing the dead tissue. You're getting into some live tissue. By the way, we always use topical lidocaine and we monitor the patient’s pain. So we’re not inflicting things on them. If you see a callous, you want to make sure you get that callous off like on a foot or a bottom or whatever. There may be something underneath of there. That is what we’ve termed medical debridement in the wound clinic. Depending on if there's still a lot of slough or tissue or fibrin—a lot of gunk if you will—you may want to use Dakin’s, which is a medical bleach, for a while to help get that off understanding it can be aggravating to the surrounding healthy cells. Sometimes we use saline dressings. So that is something that can act as a debridement in between seeing us at the clinic.
Now there are other plethora of topical products. Silver products because silver—like AQUACEL Ag—has the ability to kill and keep down bacterial loads. Then there are collagen products that sort of give a format or a structure if you will almost like rebar and concrete. I tell folks that gives a structure for the concrete to adhere to. Collagen products can help let ourselves adhere to something to help promote healing. There's also living tissue like Apligraf that we can apply and those are for select patients like a lot of our diabetics. If you're getting to a point that they're just not healing, HBO is a consideration for diabetic as well as radiation wound subset of people. Again you're always—good protein in the diet, compression, stop smoking, exercise as tolerated, et cetera.
Host: What absolutely great advice. Wrap it up for us Dr. Sparenberg when you feel it’s important to refer to the wound clinic and really your best advice about keeping an eye on those wounds that don’t heal.
Dr. Sparenberg: As we always tell folks in primary care, if you're diabetic you should be looking and inspecting your feet everyday and applying a type of topical lotion. So that’s a barrier. So if you have people doing that, they're already getting a head’s up. If they find something, they can get int their primary. If you're treating somebody for four or five weeks and they're getting worse and not getting better, consider referral to wound clinic. Again, not smoking, exercise, getting diabetes under control. Those are all things that can help prevent further. If you have a chance to check venous or arterial, if you think it’s a blood flow problem, that can give a good leg up. By the time they see us in clinic, we already have that information. You need really to assess people for noncompliance at some point if they're not getting well. Are they using the dressing properly? Did we not communicate to them? Maybe they can't afford basic supplies. Maybe they're not offloading. Maybe they're still smoking. So those are things you can visit with people so that you're working together as a team to help them heal it.
Host: That is great advice. Thank you so much Dr. Sparenberg for coming on and sharing your incredible expertise with us today. Thank you again. That wraps up this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit our website at carleconnect.com for more information and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. Until next time, I'm Melanie Cole.