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Prakash Chandran (Host):    Thirty four point two million Americans, which is just over one in 10, have diabetes. If you have diabetes, you've probably noticed that wounds tend to heal more slowly and progress more quickly and some of them even turn into diabetic ulcers. We're going to talk about all of this today with Dr. Paula Pons, the Medical Director for the Center of Wound Care and Hyperbaric Medicine at St. Joseph's Health. This is St. Joseph's Health Med Cast from St. Joseph's Health. I'm Prakash Chandran. So, first of all, Dr. Pons, it's great to have you here today. I just want to start by asking a general question around people with diabetes and wounds. Talk about the relationship between both of them, and then maybe how wounds progress in a diabetic person.

Paula Pons, MD (Guest): Hi Prakash. Thank you for having me on today. You know, as you mentioned, 34 million Americans suffer from diabetes, I know it's important to know that about one in four of these diabetic patients will go on to develop a diabetic foot ulcer at some time in their life. So, taking care of their feet and inspecting their feet on a daily basis for ulcerations is very important.

One of the things that affect diabetic people is the sensation on their feet. It's called neuropathy and they're not able to feel their feet in a normal way. So, many times if they are wearing shoes that are too tight or too big or there's something in the shoe, they cannot feel it and it may happen that this goes on for two or three days before they realize that there is a wound developing in their feet. So, as I said, diabetic foot ulcers are very common in diabetic people and taking care of them is crucial, so they don't go into greater complications and affect their general health.

Host: So, before we get into the treatment of a diabetic ulcer, I want to understand a little bit more about how you get one. Is it based on weight? For example, a little overweight and you are diabetic, does it more commonly appear then? Talk a little bit about why diabetic ulcers appear and what makes them worse.

Dr. Pons: So, in diabetic patients, the biggest problem is, like I said before, the lack of sensation on their feet and of course weight can play a role, but it's not the most important factor in developing these ulcerations. One of the most important factors is keeping the blood sugars under control, checking their blood sugars daily, following a diabetic diet and making sure that they don't get too off on their blood glucoses and develop this neuropathy, this lack of sensation in the feet.

So, the relationship between the diabetes and the ulcer happens because since the patients cannot feel their feet normally you and I will have the blister because we have a new pair of shoes and a few minutes after that, we have to take our shoes off because it hurts so much. These patients can not feel that. By the time they take their shoes off, when they get home, now there is a hole in the foot, an actual wound an ulcer, that wasn't there when they put their shoes on earlier in the day.

Host: Wow. So, I was just going to ask you about how it progresses and from what you just said, it really progresses very quickly. So, from the beginning of the day, it could not be there. And then at the end of the day, there's a hole in your foot. Is that correct?

Dr. Pons: Correct, that quickly, yes.

Host: Okay. So, let's say there's someone who is diabetic that notices that they have a diabetic ulcer that has formed on their foot. What is the best course of action? And how is it most typically treated?

Dr. Pons: So, the best course of action is of course is to call your doctor or your practitioner and have it seen by a professional as soon as possible. Many times what we see in the wound center is that patients tried to take care of these wounds at home and use things like antibiotic ointment, or different antiseptics to wash the ulceration and a week or two go by and by the time they get to see us things are much worse than if they had come originally and they require a more extensive treatment. So, you know, going back to your specific question, as soon as they have an ulcer, they should call either their primary care or their podiatrist and have it taken care of, and if it is a little more complicated, they will be referred to us.

Host: I see. So, let's say they go to their primary care physician or a podiatrist and they then get referred to the wound care center. Can you talk a little bit about some of the treatments that you offer there and when hyperbaric oxygen therapy comes into the picture?

Dr. Pons: Of course. As a wound care center, we specialize in advanced wound care treatments, and that's a subspecialty, like any other subspecialty and we have more tools to treat these ulcerations than a regular physician office or a regular podiatrist office has. We have a number of different treatments that we can offer for diabetic foot wounds.

And depending on that severity of the wound we would use one treatment modality or another one. Specifically about hyperbaric oxygen, that is a treatment that is reserved for the more severe diabetic foot ulcerations. For the diabetic foot ulcerations that have advanced into infection, mostly deep infection that is already infecting muscle or tendon, or even has gotten into the bone and cannot be treated with just a regular antibiotic that you prescribe. It needs more involved treatment, including hyperbaric oxygen treatment.

Host: Okay. So, before we get into the mechanics of hyperbaric oxygen therapy, I want to understand a little bit more about the timeline from that first day where you're noticing something on your foot to when you actually are required to get this therapy that we're talking about.

Dr. Pons: You know, it can be anywhere from a couple of days to a few weeks. It really all depends how robust the immune system of a particular person is, how readily that immune system can fight infection and what is being done in the meantime for that diabetic foot ulcer. And that is why we encourage patients and referring physicians to send the diabetic patients early on to us, so we can catch that diabetic foot ulcer before it gets too complicated, and treat it at earlier stages and you know, not get that deep infection that will require a more involved treatment.

Host: Okay. Totally makes sense. So, let's talk about the mechanics of how a hyperbaric oxygen therapy works. Maybe walk us through the timeline of when a patient first comes in how long the treatment takes and what they can expect afterwards.

Dr. Pons: So, hyperbaric oxygen treatment like the name says you're breathing a hundred percent oxygen under pressure. So, mechanically how it works is the entire patient goes into a chamber that gets pressurized to twice the pressure or two and a half the pressure of the atmospheric pressure. So, what I tell my patients is it kind of feels like when you get in an airplane and the cabin starts to get pressurized, sometimes you feel your ears are popping and you can feel that pressure. That's how it feels. But as opposed to an airplane, in the hyperbaric chamber, you are breathing a hundred percent oxygen during the entire treatment.

What happens when you breathe a hundred percent oxygen at higher pressure is that the oxygen is able to dissolve in the liquid part of the blood, as well as in the red cells. That it's where oxygen normally goes through in our body. And it reaches all the tissues in our body. So, that oxygen not only will go to the wound that we're trying to treat, it will go everywhere else. But more importantly, with a diabetic foot ulcer, that oxygen that reaches the wound is able to jumpstart a healing cascade that otherwise will not happen. So, not only will the oxygen get in more on the wound, it will help treat infection because of that concentration, oxygen is toxic to germs, to bacteria, to microorganisms, and also will help regenerate some of the tissues and some of the blood vessels that have been destroyed by the ulceration or the wound.

So, hyperbaric oxygen works at very many different levels in wound healing in a diabetic patient. Now the treatments are quite intense. They are they are given daily to the patient, five days a week. So, Monday through Friday, they take about two hours of their day. And during those two hours, they're laying inside this chamber where they're breathing a hundred percent oxygen under pressure.

Host: You know, it's funny, it really sounds like it's something from the future, having this technology where you can walk into this chamber and have it create this environment where your body can effectively heal much faster. So, I just think it's so cool to hear about. Still though we've talked about how intense it is five days a week, two hours a day. There's going to be people listening to this that are potentially a little apprehensive in getting this treatment. And I think it's probably because they're going into a space that is foreign and maybe they're thinking about well, how is my breathing going to be? Is it uncomfortable? So, can you maybe speak to some of those concerns?

Dr. Pons: Yes, of course like any medical treatment, there are potential side effects. And we work up our patients very intensely to make sure that we reduce the chances of getting any of those side effects. The most common side effects that we encounter during treatment is problems with pressure. So, just like in an airplane cabin, sometimes your ears can hurt because of the change in pressure. The same thing, getting happen in the hyperbaric chamber. So, we educate our patients. We teach them how to decompress their ears, so that pain doesn't happen. And sometimes we have to do part of the things is to good tubes inside the years, just like the kids get tubes when they get ear infections, when they're young, the same procedure.

And we have them do that, so that pressure doesn't happen inside the ear and the pain that can happen and that tube it stays in for them length of the treatment, which is about two months, by the way. And once the treatment is completed, the tubes can either be left in or removed. That's the most common complication. There's other complications that can happen that are more rare, but oxygen, you know, it's like a medication, it can have some side effects.

Host: And what is the success rate for doing this hyperbaric oxygen treatment? You know, after the two month period, what percentage of people have their wounds completely healed?

Dr. Pons: The majority of the people will heal. And I want to make clear that hyperbaric oxygen treatment is not the only treatment that is given to the patient when they have these kinds of complicated wounds. Hyperbaric oxygen treatment is just one more tool together with antibiotics, sometimes antibiotics have to be even in an IV, home care to change dressings. Serial debridements and cleaning of the wound to make sure that any dead tissue or any infection that could be still present on the wound gets removed. So, hyperbaric treatment is just one more thing. It's like taking antibiotics, it's doing hyperbaric oxygen. So, when you combine all those different things that we do at the same time with a patient, you get the greatest success in healing the wounds. And like I said, the vast majority of the wounds do heal. But it's quite intense treatment. And of course it means that the patient has to be very compliant with the treatment too.

Host: Just as we close here, you know, as the Medical Director of the Wound Care Center, I'm sure you've seen a lot of patients that are potentially coming in a little later than you'd like. So, if you could share a message, one message that you wish more people knew before they came to see you, what might that be?

Dr. Pons: That they need to come in early, as soon as their wounds happen. The longer a wound has been present, the harder it is to heal. It's that's been, you know proven time and time again, not only with diabetic foot ulcers, but with any kind of ulcerations that the longer a patient takes to seek treatment, the harder it is to heal it. And in, in diabetes, there's not a lot of wiggle room. I would say as soon as you see a blister, you should call your doctor or call your podiatrist. It is never a good idea to try to take care of these ulcers by yourself, at home. Even if you were successful in treating an ulceration before.

It may be a different thing this time. And what we're trying to avoid here is not just the ulceration, is the awful complication of having an amputation and losing the leg to a diabetic foot ulcer. And the sooner that ulcer gets healed, the faster we prevent those complications.

Host: Well, Dr. Pons, I think that is great advice. I hope everyone heeds your call to really just call their primary care physician if they notice anything on their foot, because the sooner you can get to it, the better it's going to be. So, thank you again for your time. That's Dr. Paula Pons, the Medical Director for the Center of Wound Care and Hyperbaric Medicine at St. Joseph's health. For more information, please call (315) 329-2600 for an appointment. Or visit our website@sjhsyr.org/wound care. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been St. Joseph's Health Med Cast from St. Joseph's Health. Thank you so much, and we'll talk next time.