Transcription:
Limb Preservation Program

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Evo Terra (Host): This is Palmdale Regional Radio and I'm your host, Evo Terra. Today we're talking about the Limb Preservation Program at Palmdale Regional with Dr. Kyle Hopkins, the Medical Director of the Limb Preservation Program at Palmdale Regional. Dr. Hopkins, thank you for joining me today.

Kyle Hopkins, DPM: Thank you for having me. It's a pleasure.

Host: So let's start with a broad overview of this limb preservation program. But I also want to say this, I mean, I gather that amputation is almost always the last choice for any physician, correct?

Kyle Hopkins, DPM: Yes, it definitely is. The whole important part of the limb preservation program is that, yeah, an amputation, especially a of the leg, like below the knee or above the knee does put a lot of stress on the body. You have a very increased cardiac demand with amputate amputations.

So, and that can, depending on the patient's heart which unfortunately is not the best to begin with, if they require an amputation that's extra stress that can increase what we call morbidity and mortality. So of course we do try to avoid that as much as possible, but in a lot of circumstances, it sometimes is unavoidable.

But yes, so the program is, in order to prevent that as much as possible, is to join all the little pieces that we have together, like getting all the cogs together so they run like clockwork. We have podiatry, which is my specialty, as well as vascular surgery to increase blood flow going to the leg, and limbs in general as well as wound care.

Now they do a lot of hyperbaric oxygen that has shown to increase blood flow to the area as well as oxygen. So sometimes even if they don't have the best blood flow to the area, their tissues are still getting oxygen. So, which will allow for wounds to heal and allow for maybe not the best tissue in the world to get a little bit stronger, a little bit more robust.

Now one of the things that we really need to focus on is, if there's wounds, we need to get them healed right away because that is an open door for bacteria and infection, especially in people who have diabetes or other comorbidities, other health problems. That is going to be a very detrimental thing. Because they have compromised immune response. So they don't have the best way of fighting off any infection. And I would say that infection is probably one of the leading causes of amputations besides gangrene due to poor blood flow or, trauma. Now we work all together. I mean, the other specialties that are a part of this, the big three of course were podiatry, vascular surgery, as well as wound care as I previously stated.

But the other people who are also involved with this, are infectious disease as well as a nephrology, the kidney doctors, as well as endocrinology. Pretty much as I like to say, in passing, if you name a specialty, it has its place in wound care as well as limb salvage, because it all runs together.

Evo Terra (Host): Right.

Kyle Hopkins, DPM: And a, a big thing with this, the wound care program as well, is going to be education as well. That's why I was so happy to do your podcast because the big thing will be educating patients of risk factors as well as what they can do to try to avoid amputations as well as any worsening of their health concerns with everything. But the main focus of this program is education because that will help with limb salvage.

Evo Terra (Host): Right. So we get people educated about the ways to take care of themselves. You mentioned there are many different modalities that are involved in this in the process of you know, what are we going to do to save this and preservation begins at home, obviously. But, but I'm curious about something. You mentioned a variety of reasons why this might come up. I would imagine that the reason someone gets here from chronic cases like diabetes are going to be much, much different than what the program or what the doctors will evaluate for emergency medicine situations. Am I correct?

Kyle Hopkins, DPM: Yeah. Traumas definitely will be something that we are trying to avoid for sure. For that we definitely have on-call trauma surgeons. I do some foot and ankle trauma as well. But no, the majority of that will be done by our orthopedic surgeons who do a fantastic job. But of course, sometimes the limb is so mangled that that needs to happen. The amputation is the only option at that point, and for that, we unfortunately just need to go in and proceed with that. And then another part of the program is support. Support groups as well as we at Palmdale Regional Medical Center, we do have an acute rehab unit that pretty much we are, we try to get all of our amputees in, so that they can recuperate. They have physical therapy. They've got pain management on top of that, as well as, support groups to discuss this, have talk therapy, social workers and all the mental health that we can of course support this because of course losing a limb is definitely a heavy blow to the mind and not just the body. Um, we've had a lot of people who have probably taken that worse than the actual trauma.

Evo Terra (Host): Mm Yeah. Likely so. But I know the goal of this program, it's called the Limb Preservation Program, so we're trying to preserve limbs before we get there. So, talk about the process we're going through here. And, and maybe thinking about this way, if we've got a patient in the hospital who's got some chronic condition who is a good candidate, who is clearly at risk of losing a limb, but we want to do the things necessary to help them not do that, what should that patient expect from this program? I mean, is it all done in the hospital on one visit and they can go home? Or is it an ongoing process?

Kyle Hopkins, DPM: Ideally, yes, we try to get this done. Let's say a patient comes in with a peripheral arterial disease, getting some necrotic changes where hopefully they're starting to get, they are new changes where the skin becomes a little bit mottled. They have dependent rubor meaning that if their leg is hanging on down, it turns bright red.

But if you raise it on up, it becomes pale. Or a cold limb, that's a new cold limb without real black change, like getting what I call mummy toes from gangrene or anything like that forming. Then what we do is this, we put in a stat consult to the vascular surgeon. The people who we're working with are Dr. Aziz and Dr. Makkar who do a fantastic job. They come in right away. They evaluate the patient, they get the appropriate studies done, and then hopefully we get them into the cath lab right away to increase blood flow. Let's say that this patient, they have some occlusions that are blocks to the blood flow that are newly identified. Where we go open those up and we get better blood flow at that time. Then we just monitor to see how the tissue does, because sometimes that tissue is from the lack of blood flow, from the lack of oxygen's been getting, and also from the new blood flow that's coming in, called reprofusion injury. There could be some either superficial or more significant tissue damage where then we then evaluate hey, can we treat this with local wound care or do we need to bring them into the operating room to clean some of this up.

Now, even if we do that, we, hopefully we avoid amputation and a more aggressive, debridement. But usually we can. At that point, let's say everything goes and they get maybe a little bit of reperfusion injury or hopefully none, then we just monitor them. If everything turns great, then it's more of an education.

It's like if you're a diabetic, you got to control your blood sugars. If you're a smoker, we need to have you stop that. If you're a dialysis patient, we need you to be on your game with going to dialysis every day. I would also say it's very important for these patients to inspect their feet daily.

It's a very simple thing. I pretty much tell all my patients who are diabetic or have neuropathy or have questionable blood flow, to inspect their feet daily. And that's just a quick look at the bottom of the foot, make sure that there's nothing out of the ordinary, or any new changes, that the color is the same, that we're not getting what's called as dusky appearance to the toe.

That, just anything out of the ordinary because just taking a look at the feet on a daily basis is going to be like, Hey, this is how my foot looks. That's not out of the ordinary. And if they do see something to let us know right away, we'll be able to then, assist the patient by saying, Hey, you need to go on in.

Or you can either come into Dr. Hopkins clinic or the wound clinic for evaluation. Definitely though if you see a foreign body in your foot, I that almost sounds like a joke, but we have had numerous patients come in with either thorns in their foot, toothpicks or even sewing needles or even diabetic needles from their insulin.

I always tell people to not walk barefoot in their house. People sometimes say, well, I have socks on. It's, we need something with a sole to the bottom of it. Like, so house shoe, house slipper. That's the best way to protect your feet as much as possible. But yeah, with the monitoring of the feet is super important because it will allow you to find things out right away where we can nip this in the bud, where we can take care of this right away before it becomes a big issue.

Evo Terra (Host): Yeah. That's when we want to get it right. We want to get it before it becomes that, that big issue you said?

Kyle Hopkins, DPM: Prevention is huge.

Evo Terra (Host): Yeah, yeah. Can you share a few success stories?

Kyle Hopkins, DPM: Well, right now, I mean, we've already had a number of patients who have been significant success stories. I mean, right now this is a relatively new program where we've probably had 20 success stories so far. So that's been huge. The one that comes to mind is a very nice lady who just loves her cigarettes, unfortunately. But, I remember seeing her in my clinic where her toes were getting what's known, like, I was saying, the dusky appearance as well as what's known as escar. Now think of that as a very thick and like almost leather like scab to the top of the foot.

and that's pretty much the beginnings of gangrene. Now these are definitely considered necrotic changes, dead tissue. But when I saw that, I said, okay, we need to get you to the hospital right away. And she says, okay. We send her over to the hospital where I'm literally thinking, I'm going to have to chop off part of this lady's foot.

She sees Dr. Makkar. Dr. Makkar is able to improve her blood flow and in the clinic, I'm following her. And we're at the point right now where she required no amputations and no surgical, even surgical debridement, just local wound care. So that was a huge success. And then we also had another gentleman, who already had a below knee amputation and a prosthetic on one side, and what's known as a transmetatarsal amputation on the other side, meaning the front of his foot had to be cut off. Now this was a guy who started to get a wound forming with exposed bone. And he didn't have very good blood flow, and this was also a non reconstructible flow at this time as well.

So Dr. Makkar and his partners weren't able to do anything at that time. They said, oh, well there's unfortunately nothing that we can do. So I sat down with this gentleman at the hospital and said, Hey, here's the situation. What do you want to do? And he says, I want to try to save the limb. Do as much as I can because I'm a mechanic.

I need to have at least one good leg. I need to support my family. And I said, all right, well, this is what we're going to do. We're going to go in there, open this up, clean out all the infection that we can, try to promote good tissue growth as much as possible. Get you situated with the outpatient wound care program, where we can do hyperbaric oxygen to improve the chances of saving the limb.

And we went in surgery. I cleaned this on out. I closed it on up. The next day I took a look at it and it was looking what we call well perfused. So it looked like there was still good blood coming there. And in the OR, we had good bleeding of the tissue.

I told him, like, hey, it's looking good right now. We're going to be cautiously optimistic, but we need to be on top of everything. You need to control everything. You need to be on top of your blood sugars. And he said, yes, of course. And he went and saw the wound center. He did the hyperbaric oxygen. I was seeing him on a regular basis, as an outpatient in my clinic. And he healed up beautifully. And I remember the last time seeing him, uh, about a couple months ago, and he just, had a big old grin in his face. He's like, doctor, I'm all healed finally. And the limb was looking great and he was just nothing but appreciative and he actually told me this. He's like, you saved my life. And, that was pretty emotional. That was just like a, oh, wow.

Host: It makes it all make sense, right? This is it. This is why we're doing these things.

Kyle Hopkins, DPM: Oh, yes, it was totally worth it because you're not going to be able to save everything. Because sometimes it's either the leg or the person's life. So there are sometimes where unfortunately we can't save them all. Some, but we can at least try. We can only do our best.

Host: Exactly right. Exactly right. Is there anything else you wanted to share about the Limb Preservation Program?

Kyle Hopkins, DPM: Well, the main thing is that we are really going to try to do community outreaches and community educations, because unfortunately, especially here up in the Antelope Valley, but really I've done podiatry all over this country, in many, many, places and clinics and even the VAs and hospitals, but one of the biggest things that we need to educate people on is proper diabetes control, as well as the importance of not smoking, of keeping your blood pressure taken care of, all the important things with this. And now here in the Antelope Valley, we do have a high population who don't take the best care of themselves, unfortunately. We do have a lot of uncontrolled diabetics. We have a lot of people who have kidney disease on dialysis, and we got a lot of people who smoke, a lot of things, not just cigarettes. We do have a high population of drug abuse as well as methamphetamines and other substances as well. So we're dealing with a very high morbidity rate with our patients.

So I would say that the best thing that this program can do on the outside instead of just being in the hospital alone, is start really helping doing the outpatient programs; patient education, mental health like I was saying earlier, like, you name a specialty, it has its place with the limb salvage program.

But that is definitely, I would say is the most important thing, is that we need to change people's minds about healthcare. We need to have them be a more proactive force in making sure that they keep their legs.

Evo Terra (Host): I think that's an excellent place to end it then. Dr. Kyle Hopkins. Thanks for being on the show with me today.

Kyle Hopkins, DPM: Oh, it was my pleasure. Thank you very much for having me and I'd love to be on again, if you would have me.

Evo Terra (Host): And once again, that was Dr. Kyle Hopkins, the Medical Director of the Limb Preservation Program at Palmdale Regional. You can get more information on the program at palmdaleregional.com/limb. And that also concludes another episode of Palmdale Regional Radio with Palmdale Regional Medical Center.

Please visit our website at palmdaleregional.com for more information and to get connected with one of our providers. And please remember to subscribe, rate, and review this podcast and all the other Palmdale Regional Medical Center podcast in our library. I'm Evo Terra. Be well .

Physicians are independent practitioners who were not employees or agents of Palmdale Regional Medical Center. The hospital staff shall not be liable for actions or treatments provided by physicians.