Transcription:
The Latest Advances in Wound Care

Carl Maronich: And joining us today is Dr. Jeff Brown. Dr. Brown is a general surgeon with the Riverside Medical Group. Dr. Brown, welcome to the podcast.

Dr. Jeffrey Brown, MD (Guest): Thank you very much.

Carl: We appreciate you joining us, and today we're going to be talking about wound care and how significant and important that is. It might not be something people think a lot about, but we're going to talk about why it's important that they do think about it, should they have a wound. But before we get into that conversation, a little bit of background. I understand you're from the east in the United States, Boston specifically?

Dr. Brown: Yes, I'm from the Boston area. Grew up in the suburbs, been a general surgeon for eighteen years. Been involved in wound care for almost nine years at various hospitals that I've been working at. I was very excited to get into the Wound Center here and continue taking care of wounds.

Carl: Well it seems like general surgery and wound are natural companions in some way.

Dr. Brown: Yes.

Carl: I mean you're getting into the body, you're being invasive into the body, so you should have a good idea of how that should heal, and why that's important to heal. And so we'll talk a little bit about that, and for the conversation's purpose, let's define what a wound is.

Dr. Brown: Well a wound is any damage to the soft tissues of the body. They can be from surgery, where after an operation, you can have a wound problem if it doesn't heal correctly or fully. Wounds can be traumatic. People have accidents, walk into things, any kind of trauma that breaks the skin and can cause a wound.

Wounds can be from underlying diseases. People that have venous insufficiency, circulation problems, they can develop wounds from not enough blood flow, too much blood flow that gets backed up into the legs, causes swelling and tissue breakdown from there.

Carl: Wow, so really there's a lot of ways that wounds can develop.

Dr. Brown: Yes.

Carl: I'm in the garage working and I cut my hand, I rinse it out, think it's fine. That's a wound that hopefully in most cases heals after a couple days, but if there's an issue and that wound gets infected or bad things start to happen, that's not something that you're going to want to let go I would guess.

Dr. Brown: Correct. If people are injured, and over a normal course of time, usually one to two weeks, you should see some improvement in the healing of that wound. If that's slow for any reason or actually worsens, that's a good time to see either your primary physician, which is probably a good place to start, but also us at the wound clinic.

Carl: Yeah, you mentioned primary care providers. Again, I would think that would be the natural place to go.

Dr. Brown: Yes, that's usually the natural first step.

Carl: If you have an issue that's getting worse, and by getting worse, let's talk about some of the symptoms that would present if somebody has a wound that's starting to go bad, I'll say in my layman's terms. What are the first kind of indicators that people should really be paying attention to?

Dr. Brown: The two easiest ones are probably pain, which is very easy because things are getting more and more painful, redness is another one. Those are two that are easy to acknowledge, see, deal with. Some others are a little more subtle, but those are the main ones.

Carl: And what period of time- you know, somebody again, gets a wound of some kind, and then the normal course for the average wound that's pretty minor in nature I guess would be a couple or few days. But when- from a time standpoint, when should they be concerned if they're not seeing any improvement in the healing of a wound?

Dr. Brown: Over the first four days or so, the normal inflammatory process will start healing a wound, and you can have redness from that. Beyond that, if things stay red, or if pain gets better and then comes back and gets worse, redness spreads, you get any kind of strange drainage, pus, odor, things just aren't getting well, usually after four days and sometimes up to two weeks depending on whether or not you've seen someone.

If you've gone to see your primary physician, and it's been about two weeks and still no obvious improvement has come along, that's probably a good time to come see us.

Carl: And for those kind of more basic wounds that we're talking about, what would be the normal course of treatment for them?

Dr. Brown: In the Wound Center?

Carl: Yeah.

Dr. Brown: Our initial evaluation takes in the wound itself, plus all the potential patient issues; if someone has diabetes, poor circulation, histories of other diseases that can complicate wound-

Carl: Comorbidities they're known as, right?

Dr. Brown: Yes, the comorbidities.

Carl: I don't know a lot of the medical terms, but I try to use all that I- when I have them, and when I have them right especially, I try to use them. So all these comorbidities factor into it.

Dr. Brown: That is correct. Yes, and then we'll assess that plus the wound and start treatments from there.

Carl: Yeah, and I know that the Wound Center has a degree of things they're able to do, all the way to the chamber that we'll talk a little bit more about. But the covering of the wound, to ointment, or some of those skills and kind of things are on the basic level of what treatments might be.

Dr. Brown: Yes, we have different treatments which sometimes it's just the dressing, sometimes dressings have medications within them, but we look to control the wound environment to give it its best opportunity to heal.

Carl: Yeah, and I've heard talk over the years when dealing with the Wound Center about debriding, that's the right term exactly.

Dr. Brown: Correct.

Carl: Making sure the wound is kept clean, and that might seem pretty basic and easy, but it can get complicated, and if it's not kept clean, very serious things can happen.

Dr. Brown: Yes, that's one of the mainstays of wound care is debridement, which is removing devitalized or dead tissue. You want to take that off the wound and leave healthy alive tissue there to give it the best chance to heal.

Carl: And when folks come in for the treatment of a wound, and you do your work and then it's bandaged again, do I change that bandage myself? Do I come back to get that changed? I suppose depending on the severity of the wound, that would kind of vary, but I know when I've had something I'm always, "Do I do this myself, or do I let the experts do it?" What general advice can you give on that kind of thing?

Dr. Brown: It varies. It depends on what the patient's comfortable with. We have a lot of patients who are quite comfortable changing their own dressings, and we will teach them to do that so that they can continue doing that between visits to the Wound Center. Other times family members may be interested, and we can teach them. Other times we will basically be flexible and adjust it to the patient. In the dressings we use, some don't need changing as often as others.

Carl: Medications get brought into the picture, I would guess, if there's an infection and antibiotics are needed possibly.

Dr. Brown: Yes.

Carl: And the use of antibiotics, I think we should talk a little bit about that as well. I know that's gotten some attention in some areas about the overuse and such of antibiotics. How do they play in the wound world, and what would your recommendation be to somebody who thinks about taking antibiotics on their own? Or what would your recommendation there be?

Dr. Brown: Best recommendation would be for someone to see a healthcare provider. It's sometimes knee-jerk to just throw antibiotics at something you see. We will culture wounds and actually look to get answers as to what might be growing and how much before we decide on an antibiotic. In addition, the other important part is how the wound looks. You can culture a wound and you'll get growth because bacteria naturally live on us, but you have to couple that with how the wound looks. If it doesn't look infected, I tend to be on the conservative side and not use a lot of antibiotics. But anytime they're needed, absolutely we use them.

Carl: Again, check with your primary care provider is probably the best course of action there.

Dr. Brown: Correct.

Carl: Now we've been talking about more what I'll call basic wounds. Let's move up the scale a little bit. And you talked about in the beginning wounds that may develop because of other issues, whether disease, or a diabetic whose wounds won't heal. I'm thinking particularly in the extremities, the hands and feet particularly I know I've heard can be especially troublesome for diabetics, and I would guess others as well. Is that indeed true, and how should those patients kind of take extra caution if that's even possible?

Dr. Brown: It is very true. Some of the most difficult wounds we have and some of the most chronic wounds we have are in folks with diabetes, what we call a diabetic foot wound or a diabetic wound. The class that comes right behind that is probably people who have what we call venous wounds, venous insufficiency wounds. People get varicose veins and blood flow kind of pools- fluid pools in the legs, causes all sorts of things. Those two are the most difficult. They can take months to get better. For a diabetic, the best thing they can do, control their sugar, control their diabetes, work with their doc on diabetic management.

Physically they should inspect their legs / feet wounds on a regular basis because a lot of times diabetics don't feel things as well, and you can have a wound that you don't know is there, and one day you take off your shoe and sock, and a toe is purple, there's a hole in it, there's pus draining, whatever it happens to be.

Carl: Now I guess those folks that have a lot of things going on, they may not put wound care at the top of their list. "I'm worried about I have to take this medication at this time, I have other things that I'm worried about with regard to my health," and again so wounds might not seem like they're something that should get a lot of attention, but obviously from what you're saying it's very important.

Dr. Brown: They can get out of hand and they can cause risk to limb or life.

Carl: And ultimately amputations is the big risk if things are left unattended, correct?

Dr. Brown: Yes. Yes, especially in diabetics, they are well-known for getting wounds on the foot, having a toe amputation or a partial foot amputation, but even worse either above or below knee amputations, depending on how bad things get.

Carl: And talking about the more severe cases, and you can correct me here because I likely will mis-speak about the use of a hyperbaric chamber, which is something the Wound Center has.

Dr. Brown: Yes.

Carl: And there's a lot of, from my understanding, very select patients that are able to use that or need to use that. Talk a little bit about just what that is for those that may not know, and how it's used in wound care.

Dr. Brown: The hyperbaric chamber provides oxygen under pressure, and that gets it into your plasma for better delivery of oxygen to a wound.

Carl: So it heals better ideally.

Dr. Brown: Yes. That's the ideal goal. It's very good and one of the actual indications is for diabetic wounds. That's probably top of the list, diabetics who have wounds that are not getting better, worsen, or for any other reason just to help it along. Chronicity, a wound that just won't get better over time despite everything else we might try.

Carl: Chronicity, not a word I hear a lot.

Dr. Brown: Long-term, something that's just not getting better over time. It's a chronic wound.

Carl: Chronic, there you go. Chronicity, I'm going to remember that. I'm going to use it in a sentence maybe today. Somewhere I'm going to work that word into a sentence. So the chamber is available for those- for special patients that need that.

Dr. Brown: Yes.

Carl: And it's not a one-time treatment.

Dr. Brown: No.

Carl: I understand there's a long course of treatment.

Dr. Brown: Yes, usually it starts as a first block of twenty, five days a week, weekends off so you can recover. And then after twenty sessions usually we'll re-evaluate the wound, see how we're doing, and potentially go for another twenty sessions.

Carl: How long is someone in the chamber or does that vary?

Dr. Brown: It varies a bit, but generally one to two hours.

Carl: So it's a pretty involved treatment process.

Dr. Brown: Yes, it's a commitment on the patient's part. Absolutely.

Carl: Yeah, and obviously it must be serious enough that they would need that. I mean it's not something that you're going to do for fun, so the wound- it's a serious matter when it gets to that point.

Dr. Brown: Yes, not only from the wound point of view, but we have an evaluation process we go through to make sure that the wound is appropriate, the patient is appropriate, that they'll be able to withstand it. It's not difficult to be in the chamber, but we have to worry about things like claustrophobia, people who get nervous in smaller places. It's not tight, but it is a tube that you're in. The most common thing is pressure in the ears, and we teach people how to clear their ears so they don't get the popping and pressure.

Carl: Yeah, it's similar to diving.

Dr. Brown: Exactly. We call it 'diving.' When we put patients in, we say we're diving them.

Carl: The pressure is similar to being under water.

Dr. Brown: Yes, it's like diving under water without the water.

Carl: And I'm going to let folks know that there is more information about that on the Riverside website that they can learn more about that. Doctor, if there's anything else- if you could say anything to folks regarding wound care in their own life, how they should deal with wounds, what would you want to tell them?

Dr. Brown: In general, most wounds are going to get better on their own with the person taking care of them like they would anytime. Beyond that, they can threaten life and/or limb, and if you have a wound that is not progressing as you think it should, seek higher care.

Carl: Let your primary care doctor know.

Dr. Brown: Yeah, your primary care doc, they can always send folks to us. You can always call us at the Wound Center directly.

Carl: Information on the Riverside website.

Dr. Brown: But get care.

Carl: Yeah, very good advice. Dr. Jeff Brown, general surgeon with the Riverside Medical Group, we appreciate that. And we just touched on wound care, but as a general surgeon, there's a lot of other things you deal with. We look forward to having you back to talk more about some of those.

Dr. Brown: Oh, thank you very much.