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Wound Care
Some wounds that are chronic or difficult to heal require extra steps for recovery. Dr. Joseph Bivens, Medical Director at The Wound Clinic at Pioneers, explains what prevents wounds from healing and how to assist the healing process.
Featuring:
Joseph Bivens, MD
Dr. Joseph Bivens is a board-certified cosmetic and plastic surgeon and Medical Director at The Wound Clinic for Pioneers Memorial Healthcare District. Dr. Bivens completed his training in General Surgery at New York Medical College Westchester County Medical Center, Valhalla, New York. His Plastic Surgery training was done at the University of California, San Diego where he specialized in Reconstruction, Breast Surgery and Body Contouring. At The Wound Clinic, Dr. Bivens helps treat those suffering from diabetic wounds, spider bites, burns, surgical wounds and more. Transcription:
Prakash Chandran (Host): When we think of treating wounds, we imagine applying a bandage or possibly stitches for deeper injury, but have you heard of hyperbaric therapy and how it can be used to treat chronic or even difficult healing wounds? Let’s talk with Dr. Joseph Bivens, the Medical Director at the Wound Clinic at Pioneers Memorial Hospital. This is Pioneers Memorial Heath Talk, the podcast from Pioneers Memorial Hospital. I’m Prakash Chandran. So, Dr. Bivens, how does a specialized wound care center benefit a patient?
Joseph Bivens, MD (Guest): Well wound care is a very specialized area in that one of the things we try to do is to assure that the human body will heal itself. And what we do at a wound care center is that we analyze the human body, we evaluate all of the various things that are preventing the body from healing and we try to basically put them into the appropriate sequence.
In my plastic surgery training, and in my surgery training, we were always taught that all wounds will heal. The thing that stops them from healing, is either the patient, the environment, or something that the individual is doing to somehow interfere with the body’s natural tendency to heal.
Host: Okay. So, I have a layman question around this because I just cut myself the other day and I know there’s lots of different types of wounds, but I think that the natural inclination is to get Neosporin or some antibacterial spray to spread it all around and then put a Band Aid on it. Are we talking about things like that or are you talking about not doing anything and just letting the body handle it itself?
Dr. Bivens: That’s excellent marketing and I always tell my patients that the most important thing that you want to do is to keep the wound clean. Most circumstances do not require antibiotics. I’m sure you have heard of all of the different types of resistant organisms and the fact that the – you can go swimming and you can go into a pond and there’s this flesh eating bacteria et cetera; much of that is created by the unnecessary use of antibiotics.
So, what I tell my patients is if you cut yourself, clean it. Make sure that it’s nice and clean, try to eliminate as much bleeding or blood as possible and then you want to cover it with something clean in order to prevent contamination. And that’s it.
Host: Wow and so when you say clean it, is this just soap and water?
Dr. Bivens: Just soap and water. You don’t need antibacterial soap. You just need regular soap and water because it’s not necessarily the soap that does it all, it’s mostly the mechanical act of you using your elbow grease to scrub it. And that’s basically all you need to do.
Host: Wow, so don’t believe the hype here, just let it heal on its own. I’ve heard some people say the best thing to do is just let it scab and then it will – the scab will fall off and that’s the best way to let something heal. Is that accurate?
Dr. Bivens: Scabbing is a natural process. Now the scabbing also is indicative of the depth of injury. You have to be aware that the injury can be very superficial, in other words just the top layer of skin or it can be the top layer and the bottom layer of skin or it can be the top layer, bottom layer, fat and all the other structures that go down. So, the scab itself, is simply a combination of the layers of skin plus some of the protein that gets secreted as well as the blood and some of the plasma that ultimately comes up. So, it’s a combination of all those things and the depth of involvement will determine the thickness of that particular scab.
Now if you left the scab alone, yes, it’s going to heal, but sometimes, if there is contaminated material underneath the scab or around the scab; it can get contaminated. So, that’s why you want to keep it clean, cover it and monitor it very closely.
Host: Oh wow. I’m learning so much. So, let’s talk about what you do there at the wound clinic at Pioneers. So, what is the focus, what conditions do you treat? Talk a little bit about that.
Dr. Bivens: The focus is as I said before is to evaluate the total patient. Now there are many, many things that result in very, very slow healing processes of wounds. So, at a wound care center, what we do is we look at the wound and then we – we are investigators. I am your detective. I have to look at that wound and say wait a minute, why is this wound not healing. So, I then want to evaluate the patient’s underlying medical conditions. Number one, are they diabetic? Because diabetes will slow down the wound healing process because it tends to prematurely harden the small blood vessels that provide oxygen and food to that wound.
Number two, I want to look to see is there anyway that the blood vessels themselves, the arteries that come to that area, are being compromised. Number three, I want to look to see whether or not the veins which allow the blood to return back to the heart are somehow under high pressure. So, we have venous insufficiency, we have arterial insufficiency, we have diabetes, and there are other things that can also cause wounds to be delayed in healing.
And so, that’s one of the things that the wound care center will do. Now sometimes, patients will come after they’ve had surgery and the surgical wounds themselves can be compromised either because they’ve been very, very weakened because of the patient’s underlying condition. Many times when patients have had surgery, or they’ve had a condition that leads to surgery; they are malnourished. So, I’ve got to evaluate the patient’s nutritional status. Can they produce protein? Are they compromised because their bodies cannot build immune cells to fight off bacteria.
So, there’s a lot of things that we have to do when that patient comes to the wound care center.
Host: I really like the structured approach that you have with everything. So, I want to transition a little bit to the advanced treatment that I’ve certainly never heard of this hyperbaric therapy or using hyperbaric oxygen to benefit wounds. Talk a little bit about this.
Dr. Bivens: Hyperbaric oxygen just like it’s defined, hyper means excessive, baric means pressure, oxygen of course we know what that is. That is the O2 or oxygen that’s in the air. So, hyperbaric therapy basically it started from the military. And what they were doing was that when patients or soldiers were deep sea diving and they’d end up having what’s called the bends. They’d get nitrogen gas in their joints. And they put them into a chamber that was high in oxygen, 100% oxygen and it was under pressure. Meaning the atmospheric pressure would be increased to probably about two or three times and that process would drive oxygen into the joints and drive the gas out of the joints. But in so using hyperbaric oxygen, they realized something. Part of the healing process uses oxygen and it’s a process known as respiration. Respiration means oxygen creates water and carbon dioxide. So, if you want something to heal and you give the area oxygen; the oxygen process is going to cause the development of collagen and part of the healing process is in the tissues and in the cells.
So, that’s a basic concept as to what happens in a hyperbaric chamber.
Host: Okay, that really goes into the detail about how it works, which I love, because I’m a nerd. But I think that for just someone listening to this, it really does sound like a way to accelerate the healing process using that hyper pressure and oxygen. Is that correct?
Dr. Bivens: All wounds need oxygen. All wounds need glucose. And in the process of using oxygen and glucose; the body expels carbon dioxide. Hyperbaric medicine or hyperbaric treatment definitely they accelerate that process so that you end up getting a much more efficient healing process. So, in essence of what you said is it’s very accurate. The only issue is that the person, the patient cannot be in that chamber for 12 hours. They can only be in that chamber for about one maybe two hours or else there are other issues that can develop.
So, during that time period, yes, it’s accelerated. But we do it – it’s what we call a dive. So, the person goes into the chamber once a day, let’s say for up to about two hours and many times in some of our wounds it may take 30 treatments, it may take 10 treatments, it may take 20. So, we have to assess the injury and decide how long. But during that time period; it is an accelerated healing process.
Host: Okay thanks for that clarification there. So, I’m actually kind of curious about what patients would benefit most from this hyperbaric therapy.
Dr. Bivens: Right now, the most common treatment is for what we call DFUs and that is a diabetic foot ulcer or VSUs, venous stasis ulcers. So, diabetics and patients that have varicose veins or severe varicosities are the most commonly treated patients for HBO, at least in a hospital setting. Now in the military, you are looking at barotrauma meaning pilots who have high G forces or those deep sea divers that are coming up too fast and they end up having what’s called the bends.
Host: I think this has been so eye opening for me today just to hear about the general discipline and practice of wound care and really just letting the body heal on its own really just using that soap and water to keep it clean and then for things that are more advanced you have that hyperbaric oxygen therapy to help out. That just seems like something from the future. I’m just curious, I always like to ask what do you enjoy most about working at the wound clinic?
Dr. Bivens: Well, as I mentioned earlier, I’m a detective. And I like to unravel the mystery behind the delayed wound healing process. And you’re probably a little bit too young to know this show Columbo. I used to love this –
Host: Of course I know Columbo. Come on now.Host:H
Dr. Bivens: I used to love that show and I love his investigative spirit and so when I see a patient coming in to the wound care center; I start – I look at the wound, I look at the patient and I love it when the family comes because I then look at the dynamic between the family, the patient and the wound. And miraculously, it tells you a lot about what’s going on. Because it’s not always the metabolic processes but so often it’s the dynamic that’s going on. And that to me is very, very exciting.
Host: Well Detective Bivens, I really appreciate it. That’s Dr. Joseph Bivens, the Medical Director at the Wound Clinic at Pioneers Memorial Hospital. Thanks for checking out this episode of Pioneers Memorial Health Talk. Head to www.pmhd.org or call 760-351-4848 to get connected with Dr. Bivens or another provider.
If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library of topics of interest to you. Thanks and we’ll see you next time.
Prakash Chandran (Host): When we think of treating wounds, we imagine applying a bandage or possibly stitches for deeper injury, but have you heard of hyperbaric therapy and how it can be used to treat chronic or even difficult healing wounds? Let’s talk with Dr. Joseph Bivens, the Medical Director at the Wound Clinic at Pioneers Memorial Hospital. This is Pioneers Memorial Heath Talk, the podcast from Pioneers Memorial Hospital. I’m Prakash Chandran. So, Dr. Bivens, how does a specialized wound care center benefit a patient?
Joseph Bivens, MD (Guest): Well wound care is a very specialized area in that one of the things we try to do is to assure that the human body will heal itself. And what we do at a wound care center is that we analyze the human body, we evaluate all of the various things that are preventing the body from healing and we try to basically put them into the appropriate sequence.
In my plastic surgery training, and in my surgery training, we were always taught that all wounds will heal. The thing that stops them from healing, is either the patient, the environment, or something that the individual is doing to somehow interfere with the body’s natural tendency to heal.
Host: Okay. So, I have a layman question around this because I just cut myself the other day and I know there’s lots of different types of wounds, but I think that the natural inclination is to get Neosporin or some antibacterial spray to spread it all around and then put a Band Aid on it. Are we talking about things like that or are you talking about not doing anything and just letting the body handle it itself?
Dr. Bivens: That’s excellent marketing and I always tell my patients that the most important thing that you want to do is to keep the wound clean. Most circumstances do not require antibiotics. I’m sure you have heard of all of the different types of resistant organisms and the fact that the – you can go swimming and you can go into a pond and there’s this flesh eating bacteria et cetera; much of that is created by the unnecessary use of antibiotics.
So, what I tell my patients is if you cut yourself, clean it. Make sure that it’s nice and clean, try to eliminate as much bleeding or blood as possible and then you want to cover it with something clean in order to prevent contamination. And that’s it.
Host: Wow and so when you say clean it, is this just soap and water?
Dr. Bivens: Just soap and water. You don’t need antibacterial soap. You just need regular soap and water because it’s not necessarily the soap that does it all, it’s mostly the mechanical act of you using your elbow grease to scrub it. And that’s basically all you need to do.
Host: Wow, so don’t believe the hype here, just let it heal on its own. I’ve heard some people say the best thing to do is just let it scab and then it will – the scab will fall off and that’s the best way to let something heal. Is that accurate?
Dr. Bivens: Scabbing is a natural process. Now the scabbing also is indicative of the depth of injury. You have to be aware that the injury can be very superficial, in other words just the top layer of skin or it can be the top layer and the bottom layer of skin or it can be the top layer, bottom layer, fat and all the other structures that go down. So, the scab itself, is simply a combination of the layers of skin plus some of the protein that gets secreted as well as the blood and some of the plasma that ultimately comes up. So, it’s a combination of all those things and the depth of involvement will determine the thickness of that particular scab.
Now if you left the scab alone, yes, it’s going to heal, but sometimes, if there is contaminated material underneath the scab or around the scab; it can get contaminated. So, that’s why you want to keep it clean, cover it and monitor it very closely.
Host: Oh wow. I’m learning so much. So, let’s talk about what you do there at the wound clinic at Pioneers. So, what is the focus, what conditions do you treat? Talk a little bit about that.
Dr. Bivens: The focus is as I said before is to evaluate the total patient. Now there are many, many things that result in very, very slow healing processes of wounds. So, at a wound care center, what we do is we look at the wound and then we – we are investigators. I am your detective. I have to look at that wound and say wait a minute, why is this wound not healing. So, I then want to evaluate the patient’s underlying medical conditions. Number one, are they diabetic? Because diabetes will slow down the wound healing process because it tends to prematurely harden the small blood vessels that provide oxygen and food to that wound.
Number two, I want to look to see is there anyway that the blood vessels themselves, the arteries that come to that area, are being compromised. Number three, I want to look to see whether or not the veins which allow the blood to return back to the heart are somehow under high pressure. So, we have venous insufficiency, we have arterial insufficiency, we have diabetes, and there are other things that can also cause wounds to be delayed in healing.
And so, that’s one of the things that the wound care center will do. Now sometimes, patients will come after they’ve had surgery and the surgical wounds themselves can be compromised either because they’ve been very, very weakened because of the patient’s underlying condition. Many times when patients have had surgery, or they’ve had a condition that leads to surgery; they are malnourished. So, I’ve got to evaluate the patient’s nutritional status. Can they produce protein? Are they compromised because their bodies cannot build immune cells to fight off bacteria.
So, there’s a lot of things that we have to do when that patient comes to the wound care center.
Host: I really like the structured approach that you have with everything. So, I want to transition a little bit to the advanced treatment that I’ve certainly never heard of this hyperbaric therapy or using hyperbaric oxygen to benefit wounds. Talk a little bit about this.
Dr. Bivens: Hyperbaric oxygen just like it’s defined, hyper means excessive, baric means pressure, oxygen of course we know what that is. That is the O2 or oxygen that’s in the air. So, hyperbaric therapy basically it started from the military. And what they were doing was that when patients or soldiers were deep sea diving and they’d end up having what’s called the bends. They’d get nitrogen gas in their joints. And they put them into a chamber that was high in oxygen, 100% oxygen and it was under pressure. Meaning the atmospheric pressure would be increased to probably about two or three times and that process would drive oxygen into the joints and drive the gas out of the joints. But in so using hyperbaric oxygen, they realized something. Part of the healing process uses oxygen and it’s a process known as respiration. Respiration means oxygen creates water and carbon dioxide. So, if you want something to heal and you give the area oxygen; the oxygen process is going to cause the development of collagen and part of the healing process is in the tissues and in the cells.
So, that’s a basic concept as to what happens in a hyperbaric chamber.
Host: Okay, that really goes into the detail about how it works, which I love, because I’m a nerd. But I think that for just someone listening to this, it really does sound like a way to accelerate the healing process using that hyper pressure and oxygen. Is that correct?
Dr. Bivens: All wounds need oxygen. All wounds need glucose. And in the process of using oxygen and glucose; the body expels carbon dioxide. Hyperbaric medicine or hyperbaric treatment definitely they accelerate that process so that you end up getting a much more efficient healing process. So, in essence of what you said is it’s very accurate. The only issue is that the person, the patient cannot be in that chamber for 12 hours. They can only be in that chamber for about one maybe two hours or else there are other issues that can develop.
So, during that time period, yes, it’s accelerated. But we do it – it’s what we call a dive. So, the person goes into the chamber once a day, let’s say for up to about two hours and many times in some of our wounds it may take 30 treatments, it may take 10 treatments, it may take 20. So, we have to assess the injury and decide how long. But during that time period; it is an accelerated healing process.
Host: Okay thanks for that clarification there. So, I’m actually kind of curious about what patients would benefit most from this hyperbaric therapy.
Dr. Bivens: Right now, the most common treatment is for what we call DFUs and that is a diabetic foot ulcer or VSUs, venous stasis ulcers. So, diabetics and patients that have varicose veins or severe varicosities are the most commonly treated patients for HBO, at least in a hospital setting. Now in the military, you are looking at barotrauma meaning pilots who have high G forces or those deep sea divers that are coming up too fast and they end up having what’s called the bends.
Host: I think this has been so eye opening for me today just to hear about the general discipline and practice of wound care and really just letting the body heal on its own really just using that soap and water to keep it clean and then for things that are more advanced you have that hyperbaric oxygen therapy to help out. That just seems like something from the future. I’m just curious, I always like to ask what do you enjoy most about working at the wound clinic?
Dr. Bivens: Well, as I mentioned earlier, I’m a detective. And I like to unravel the mystery behind the delayed wound healing process. And you’re probably a little bit too young to know this show Columbo. I used to love this –
Host: Of course I know Columbo. Come on now.Host:H
Dr. Bivens: I used to love that show and I love his investigative spirit and so when I see a patient coming in to the wound care center; I start – I look at the wound, I look at the patient and I love it when the family comes because I then look at the dynamic between the family, the patient and the wound. And miraculously, it tells you a lot about what’s going on. Because it’s not always the metabolic processes but so often it’s the dynamic that’s going on. And that to me is very, very exciting.
Host: Well Detective Bivens, I really appreciate it. That’s Dr. Joseph Bivens, the Medical Director at the Wound Clinic at Pioneers Memorial Hospital. Thanks for checking out this episode of Pioneers Memorial Health Talk. Head to www.pmhd.org or call 760-351-4848 to get connected with Dr. Bivens or another provider.
If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library of topics of interest to you. Thanks and we’ll see you next time.