Intro: It's Your Health Radio, a special podcast series presented by Henry Mayo New Hall Hospital. Here's Melanie Cole.

Melanie Cole, MS (Host): I am so glad you could join us for It's Your Health Radio with Henry Mayo Newhall Hospital. I'm Melanie Cole. And we have Dr. George Barnes with us today. He's the Medical Director of the Henry Mayo Newhall Hospital Wound Care Center and Hyperbaric Chamber Medicine. He's here to tell us about wound care and hyperbaric chamber medicine, what is that?

Melanie Cole, MS: Dr. Barnes, I'm so glad to have you join us today. Your field is really such an evolving field and really an exciting time. Before we get into HBO, well, let's talk a little bit about wound care, why it's so important. What is it?

George Barnes, MD: All right. Well, thanks for having me, Melanie. Wound care is kind of an evolving specialty that is not a recognized American board especially, but it's moving towards that. There is actually a group in Chicago that's trying to get board certification for it. But at this point in time, there's a lot of people who practice wound care. One, because there are a lot of wounds. I think traditionally people have had wounds, particularly people that have diabetes and things like that, and they've led to sequelae, which people feel if they had had an earlier intervention, then it probably would've had a better outcome. So, we see a lot of wounds, mostly on the legs most commonly. And most commonly on the legs, the most common wound is related to people that have venous disease, which is usually undiagnosed.

Melanie Cole, MS: Well, that's interesting. So as you're telling us the type of wounds that you see in the wound clinic, why do people with diabetes have special issues when it comes to leg and foot health and wounds? How do some of those kinds of complications develop?

George Barnes, MD: Well, the problem with diabetes is, unfortunately, it's a systemic disease, meaning that pretty much any organ system from the skin to your eyes, your kidneys, your heart, blood vessels can be affected. Now, the particular problem that we have in the lower extremity is that, the further down you go, the smaller the vessels are. And diabetes in particular tends to affect, you know, the function of arteries, arterials, things that deliver the blood. So, people have unrecognized problems with their blood supply and they sometimes continue with the same behaviors that they've had when they didn't have diabetes, for example, going to the nail salon, having unqualified people that, say, weren't podiatrists cutting your toenails, things like that. Generally, unsanitary foot soaks, which meaning they're not clean, they're not sterile, so therefore your risk for getting infections are greater. Because, again, diabetes not only affects people's vascular supply, but it also affects their ability to fight infections, to heal, just a whole gamut of skin problems they can relate. And that's pretty much the reason why diabetes is such a significant diagnosis for wound health.

Melanie Cole, MS: And sometimes they don't even feel them, right? Sometimes they have that neuropathy and they don't even really feel those wounds so that they don't even know that they've got them.

George Barnes, MD: Yeah, and that's more importantly, again, back to behaviors people do before they know they have diabetes, meaning specifically, walking around outside without shoes, going to the beach, running in the sand, those kind of things. Because obviously, if you can't feel a wound, you know, you don't have your shoes sized appropriately, then you get friction and blisters and things like that. So, yeah, peripheral neuropathy, but that tends to be more of a late sequelae, not an early sequelae. So, people know they have diabetes. And if they've gone through the education and they know what to do, then they know they need to protect their feet. So, it's usually a little bit more likely that they would be running around on the sand without shoes on, that kind of thing.

Melanie Cole, MS: So Dr. Barnes, when should a person seek medical attention? We all get wounds for various reasons. Kids, adults, older adults, we all get these. How do we determine if a wound is healing properly? Can you tell us some of the signs that it may be infected or some things we should be looking for, red flags to tell us that a wound is not healing as it should?

George Barnes, MD: In terms of wound care patients, for the most part, we have patients which have chronic wounds, by definition means that the wound has been there for more than 30 days. Now, obviously, if you were a normal 12-year-old kid and you went out and skinned your knee, generally, it doesn't matter what your mother or your father put on it, it'll probably heal. But as we age and our skin tends not to be as healthy, it tends to be a little bit more frail, then things that were minor traumas when you're younger tend to not heal as quickly. So if you've had a wound, you've been treating it, giving it proper attention, 30 days, it hasn't healed, if all of a sudden, you know, you have more pain, drainage, the wound is red suggesting it might be infection, that's another area of concern where you might want to have your primary care doctor refer you to a wound care center.

And then, the other issue, obviously, if you know you have diabetes, anytime you have wounds on your feet, you have to be more diligent about followup. People that have problems with circulation and they know they have problems, whether it's a vein or an artery, then those kind of people at any point they get a wound probably should be more diligent and present to a wound care center earlier. But for the average person, scabbed, scraped your knee and it's closing in at two weeks, it's probably nothing that you necessarily need to run to a wound care center for. But if you have underlying issues that you know about from rheumatoid arthritis to sickle cell to anything like that, then those are the kind of patients that probably should present at wound care center sooner.

Melanie Cole, MS: Well, then tell us a little bit about your exciting field of work, Dr. Barnes. Tell us what HBOT is and how you determine the best course of treatment for wounds, because you've got quite a few tools in your toolbox these days. Tell us a little bit about some of those.

George Barnes, MD: For the most part, hyperbaric oxygen is a system where you undergo pressurized oxygen treatment a hundred percent, meaning that the greater the pressure, the more oxygen is dissolved in your blood, and the chance of delivering oxygen at a point where there's a wound is increased.

Now, hyperbaric oxygen have been known in a while. But hyperbaric oxygen is undergoing a lot of scrutiny and control now from a Medicare standpoint in the sense that there are very strict criteria that require for Medicare that would follow through. Obviously, one of the more common things that we see is diabetic foot ulcers, and that's one of the prime indications for hyperbaric oxygen therapy.

In addition to diabetic wounds, we also see a significant number of wounds that we don't have direct access to, meaning that there are wounds that are involving the bladder, which present with bleeding. And it usually happens in patients who've undergone radiation therapy for prostate, rectal cancer or cervical cancer in the past, and they present with hematuria. So in that situation, that's, in our clinic, one of the more common circumstances where we apply HBO therapy, because it's a proven and effective therapy for assisting urologists' treatment of the hematuria.

Other things, depending on location, necrotizing infections of the skin in hospitalized patients after debridement or circumstance, again, there's limitations in that your facility needs to be actually part connected to the hospital so that can happen. We treat people that have failed grafts, people that have undergo plastic surgery for closing ulcers or trauma to the limb if the graft gets ischemic, meaning it has a problem of blood supply, then that's another circumstance where we see patients where we can apply hyperbaric oxygen therapy.

There are more smaller or esoteric treatments for people that have hearing loss, things like that. But we don't as commonly treat those type of patients. But the most common thing we see are the, the cystitis of the bladder, failed grafts, people that have diabetic foot wounds. Those are the kind of typical things we treat. The process varies anywhere from usually six weeks to eight weeks, five days a week. They come in and the whole treatment experience is probably two hours total, but 90 minutes where you're actually in the under pressure in the chamber.

Melanie Cole, MS: Well, that's what I want to talk about next, doctor, because this is really interesting. And when I first learned about it, and it was because of divers or something, right? There was the pressure and it was something that helped divers breathe better if I'm correct, something along those lines. But I find it so interesting. Tell listeners what it's like in the chamber.

George Barnes, MD: When we first encounter a patient, the first question I ask them can they swim? And usually when you're kids and you're jumping in a pool, you swim to the bottom of the pool of 10 feet, and you know further down you go, the more you have to attempt to clear your ears. So if a person has done that and able to clear their ears, then that's a good sign. And obviously, some people are scuba divers and they know they can clear their ears.

Now, that's probably the most important thing, one, because that's the most common complication. If person has a problem in a tube, it's usually going to be because they have what's called barrel trauma, which means they can't clear their eustachian tube, so the pressure in their ear and their throat equalizes. And that's particularly people that have had like a problem with radiation of their jaw and things like that, which is another treatment where we give them some hyperbarics before you pull their teeth out. If they've had radiation to their jaw, then that side of the face could be scarred and they could also have a problem with their eustachian tube. So, that's another indication. But as long as they can clear their ears and they don't have any issues where they've had problems where they've had what's called blebs or little pockets of air in their lung that rupture and cause a problem, then that's usually the most common things that stop a person. In addition to, obviously, you have to be healthy enough in terms of your heart, meaning your heart has to function well enough that your ejection fraction's not going to be affected by pressure. And so as long as that situation's good, then you usually can take it.

Now, traditionally, obviously, this started from-- it's called the Undersea Medicine Society because people that had nitrogen narcosis, which is what the reason was when you go down, the more you go down underwater, if you're going down a hundred feet and you stay there so many minutes, then your body becomes saturated with nitrogen. And that as you come up, bubble out, and if you come up too fast or too much, then those are the situations where people get what's called the bends, and that was the primary reason why they started doing hyperbaric oxygen, was to allow them to equilibrate and have that come off without affecting, you know, their eyes and other kind of organs secondary to the nitrogen narcosis as they called it or the bends.

Melanie Cole, MS: Isn't that so interesting? Dr. Barnes, I'd like to discuss wounds for a minute with some real good practical advice. You've told us about HBOT. You've told us about the causes of some of these wounds, the complications, you know, what you're seeing most often in clinic. Now, there are people walking around with all kinds of wounds, and you are a wound expert. So, I'd love to tap you here and have you tell us about treating our own wounds. And you can start with nutrition for diabetes and the importance of monitoring their glucose levels and keeping their good nutrition under control because that does help with these wounds, yes? And then, we're going to talk about how we dress our own.

George Barnes, MD: Well, in terms of our approach to a person that has diabetes, when they come in, we first order a basic lab set for us, which includes what's called a hemoglobin A1c. And a hemoglobin A1c is basically just a three-month measure of approximation of glucose control. Now, I mean, there's no data to suggest that just measuring the hemoglobin A1c is going to tell you whether it's high, low, whether the wound's going to heal, but at least you get a sense of whether they need some intervention from their primary care doctor in terms of better glucose control, which it does assist wound healing in the sense that if your blood sugar's uncontrolled, then your risk of infection, other things like that are higher. So, it's better to have a comprehensive approach.

The other thing we do in terms of nutrition is there are varied methods you can use, but I tend to use pre-albumin. And the reason I use that is just because it cycles in two weeks, so you're going to know if you're giving them protein or something, where at least you're registering the protein levels going up as opposed to albumin, which things like that, which takes like three weeks or more for the changes. And that's why we use the pre-albumin.

And then education, glucose education, meaning that they have a good sense. And if they don't, then you send them to a glucose or a blood sugar management clinic where they understand about measuring their blood sugar, what they should, shouldn't eat; in their circumstance, what makes their blood sugar go up and down, that kind of thing; the signs of hypoglycemia. And then, from there, you know, it's the standard wound care that we provide once a week for the person which involves debridement, which means we're trying to take off either frankly dead tissue or tissues that are aspects of the wound that will allow it to heal a little faster. And that's what we do with that.

Melanie Cole, MS: So for those of us that get wounds occasionally, and maybe they heal, maybe they take a little bit longer, but generally they do heal, can you give us some of your best practical advice? Do we clean with soap and water? Do we use Neosporin, bacitracin? Do we cover and keep them moist? Do we leave them open, keep them dry? Give us your best wound advice here.

George Barnes, MD: Well, the basic principle of wound care, whether you're at home or not, obviously, I personally ascribe to soap and water, washing the extremity, keeping it clean. And then, make sure that there's a moist wound environment, meaning that if you're a person that has a swollen leg secondary to venous disease, blah, blah, blah, drips, drains, then you want that to be less moist, so you would put something dry on it so it absorbs some of that fluid, as opposed to a wound that's dry, you want to keep that moist. So for the most part, whether the wound is dry or moist, you want to keep it covered. Because although scabs can still lead to wound healing, in our circumstance, you know, we're not trying to have patients with scabs on their wounds. We're trying to have a patient with an appropriate, clean, moist environment or appropriately dry so that the new skin can come across and cover the wound.

The other thing about wounds, again, I was saying the most common wound that's found in the lower extremity is a venous wound. In that circumstance, you need to make sure that if you know you have venous disease, which a lot of people do, that you wear the appropriate compression that was prescribed for you. And if your leg is swollen and you can't wear the compression, then that's when you would need to present to a wound care center where we can then take care of the wound and also start adequate compression, so it'll allow things to heal and we won't have the edema and things like that or slow down wound healing.

Melanie Cole, MS: This is so informative. You're a great educator, Dr. Barnes. Wrap it up for us with your best advice about wound healing, keeping an eye on them, checking even if someone has diabetes, keeping a watch on their feet, checking for these kinds of wounds that don't heal and when you want them, and feel that it's important that they visit the Henry Mayo Newhall Wound Care Center.

George Barnes, MD: I think, you know, as I tell people or that person who has diabetes, I mean, the first thing you need to do is come to the realization that your overall health is going to be at risk if you don't educate yourself about diabetes and particularly your feet, how to take care of your feet and follow up with the appropriate health professional, podiatrist, that's going to allow you to take care of your feet, as opposed to going to a spa where you know everybody's in a spa and your risk of infection is greater.

I think that, if you have a wound and you have underlying conditions that put you at risk, meaning arterial circulation issues, venous issues, then you need to have a more heightened sense of awareness of the need to follow up with your primary care doctor, who can then refer you to wound care center. And in our circumstance and probably most wound care centers, you can self-refer. So, you just have to have a wound, you don't necessarily have to have a referral unless you obviously have an HMO or something that requires that. But you still can come in to see us and self-refer, and we'll be happy to take care of it.

But I think for the most part, you have to know yourself, know your risk factors in terms of diabetes, arterial disease, things like that, you should know, and then you know that all those things can slow down wound healing and put you at a greater risk of limb loss and things like that, and that's when you should be more aggressive in following up.

Melanie Cole, MS: Thank you so much, Dr. Barnes, for joining us today. If you or someone you know has a wound that isn't healing properly, please call Henry Mayo Newhall Wound Care at 661-200-1525, or you can visit henrymayo.com/woundcare for more information. You can also visit the free health information library at library.henrymayo.com.

That concludes this episode of It's Your Health Radio with Henry Mayo Newhall Hospital. I'm so glad you could join us today. I'm your host, Melanie Cole. Until next time.