Dr Rania Habib (Host): Welcome to MD Cast by Tampa General Hospital, a go to listening location for specialized physician to physician content and a valuable learning tool for world class healthcare. I'm your host, Dr. Rania Habib. Joining me today on MD Cast is Dr. Jeffrey Lester, a Board Certified Internal Medicine physician and the Director of Wound Care at the new Limb Preservation Program in South Tampa. He is here to share his vast knowledge on wound care. Welcome, Dr. Lester.

Jeffrey Lester, MD: Hello, thank you.

Host: Thank you so much for taking the time to delve into this very important topic.

Jeffrey Lester, MD: Yeah, great to be part of this.

Host: How did you get involved in wound care?

Jeffrey Lester, MD: I've been an Internal Medicine doctor with TGMG in the Sun City location since 2013. It's Sun City is a large retirement community and I was seeing a lot of older patients with wounds and over time I wanted make sure I tried to take better care of them and took some classes with wound care and got certified in wound care about five or six years ago, and then recertified just recently. And so we had a talk about a clinic for wound care, working with vascular surgery, originally in September of 2017 was our first meeting that we had about it, but were able to get everything together, and, open the Limb Preservation Program, which is in South Tampa.

It opened in March of 2023, so, been working here since March at the location in South Tampa and very excited.

Host: That is fantastic. So what types of wound problems do you treat in that clinic?

Jeffrey Lester, MD: So, certainly if somebody has an orthopedic issue, we send them to orthopedics, but we see venous leg ulcers, venous stasis ulcers, or problems with venous insufficiency. If a person has peripheral arterial disease in the legs causing wounds, we'll certainly see those.

We see diabetic foot ulcers, often. There are some other more atypical wounds that we sometimes deal with or sometimes get to the appropriate specialist. But we also have in our clinic, we have it's an 11 room clinic and we also have vascular doctors who are here during the week. We have podiatrists here during the week, so we consult a lot with them and also with other specialties to get people healed up as best we can to work together as a team.

Host: That's fantastic. So you're really using multidisciplinary care to take care of these complex wounds.

Jeffrey Lester, MD: Yes, for sure.

Host: What specific physical exam findings or patient complaints lead you to suspect vascular disease?

Jeffrey Lester, MD: So, if a patient has pain in their legs. Obviously, that's a big sign. If there's a wound, that's a big sign. Also, if a patient has shiny legs, or the hair on the legs is not there like it was before when they were younger. If the legs are discolored, discolorations of the legs, skin changes. Those are all things, that we suspect vascular disease, arterial disease in the legs. We are more prone to do some more investigation, ask more questions.

Host: Okay. So how do you, as the director of this clinic and, you know, wound care specialist, tell the difference between a venous and an arterial ulcer of the leg?

Jeffrey Lester, MD: Venous leg ulcers tend be larger. They tend to be superficial, but they can be deep sometimes. A leg ulcers, venous stasis ulcers because they have irregular borders to the wounds, there's also some tissue maceration. Sometimes our tissue gets kind of chewed up because of all the moisture. There can also be skin changes, discoloration in the legs, just above the ankles and the lower calves. You tend to see that's where we see most commonly discoloration of the legs, venous stasis dermatitis.

As far as arterial leg ulcers, they tend to be more round, usually, like punched out ulcers in the legs. Sometimes they can be deeper into the leg, and they tend to be also more painful. So if a person has a painful leg, they usually would more suspect an arterial problem in their leg.

Host: Okay. Besides peripheral vascular disease, what are some of the atypical wound problems that you might see?

Jeffrey Lester, MD: There's a condition called pyroderma gangrenosum, which is a genetic problem. The skin looks very tense to show in the legs. You have to be careful with those because if you debride those, they can get worse. That's more of a dermatologic issue. There can be also different types of aculities, different autoimmune conditions, so this is a host of different autoimmune type conditions that can manifest as different types of wounds in the legs.

We tend to get dermatology involved with some of the more difficult cases. Also, you can get a wound that's a skin cancer and you have to treat that carefully and do the right things with that. So we tend to send those cases to dermatology because it has a lot of special follow up, special treatments that involve skin cancers.

Host: Okay. That makes sense. I love that. Again, you're getting all these different specialties involved to optimize care for your patient. When the patients come to you, what types of studies do you typically order in wound care?

Jeffrey Lester, MD: Ankle brachial index is one of the common tests we do, to look at the pressures in the arms and legs. That's an arterial test for the legs that we typically do. Also, arterial duplex study of the legs if the ABI, the ankle brachial index is abnormal, that's the next test we would go to.

That can tell you where in the leg the problem is. Also at the venous duplex or venous doppler, if there's any a swollen leg with a painful leg, we can suspect like a deep vein thrombosis. So also they can look for vascular, um, venous hypertension, venous insufficiency or valve problems in the veins of the legs.

If, a test is abnormal, we would go to like a CT angiogram of the legs, and certainly, referral to vascular surgery if there's significant disease, you know, moderate, severe disease we would definitely consult vascular surgery and get them involved.

Host: Okay. So what are some of the treatment modalities used for healing wounds?

Jeffrey Lester, MD: If it's a diabetic wound, certainly taking a chronic wound and changing it to a new wound, assuming that the vascular status is good enough for us to go through these things. We would do like a debridement of the wound with a sharp curette. I think it's a chronic wound that's been there for months to a new wound, getting a lot of junk and bacteria off, and to expose the wound bed. Also, we would do, it's a diabetic foot ulcer, a total contact casting, to basically offload the foot and get the pressure off of the wound to help it heal faster so there's less shear forces to the wound. We do compression wraps onthe leg for mild arterial disease in the legs causing wounds or venous disease in the legs causing wounds.

We would do wound vacs in some cases if it's a larger, deeper wound. So those are all the different modalities that we use. Those are the common things that we use to treat wounds.

Host: Now, I know you mentioned two specific for diabetic foot ulcer. You said wrapping the leg to take the pressure off and then debriding it to get new blood supply. Are there any other common approaches to managing specifically a diabetic foot ulcer?

Jeffrey Lester, MD: You have to make sure you get the sugars controlled. The gold hemoglobin A1C level, well gold is below 7%, but if usually if it's A1C level is 8.5% or higher, you're going to have poor wound healing, because a person is in an immunosuppressed status. So, getting those, the fasting sugars below 130 is really important.

Diabetic diet, proper nutrition is important. They may need a new diabetic medication. Some more aggressive medication for the patient. You have to have the patient work with their primary care doctor. Or sometimes a pharmacist or an endocrinologist to get their sugars controlled. So, a lot of what we see is an obese patient, with A1C levels is very high.

And because of their obesity has led to the diabetes, and then due to poor control, poor compliance, or maybe not getting the right education, they come in and their sugars are very high, their A1C levels are high, and we have to help them work on losing weight with their other doctors, get their sugars controlled to help them get to lose weight.

Also, another thing that's come up in the last five years or so is, continuous glucose monitor on the skin is a big deal because with that, they can maybe get 10, 15 readings a day, and they can be much more aggressive with their insulin and following their sugars and working with their doctors to get things controlled.

So, I'm a big advocate of continuous glucose monitors if we need to get them in the right direction.

Host: Of course, and I'm sure that the patient seeing those values right in front of their eyes really helps them understand the sugar spikes as well to help them get that under control.

Jeffrey Lester, MD: It takes time. You can't fix diabetes in a day. I mean, these things take months to to get going the right direction and get under better control. So, I just tell the patients, once the sugars are consistently controlled day to day, every day, this will start to heal.

So in some cases, if things go really well, I can heal them in four weeks or six weeks. With diabetic foot ulcers, in some cases, it may take months to heal with casting every week. Other times, if it's a very complicated case or there's more going on or whatever, they may never heal or we may need to do more advanced therapy and get the other specialists involved as well.

Host: Now, for patients who maybe aren't healing well, could you describe the new advanced therapies for wound care?

Jeffrey Lester, MD: One of the common ones that we do is, we typically try to heal the wound the old fashioned way with offloading and, and debridement and, all of those things that we've mentioned before. So if it's a wound that's kind of a newer wound, we try to go with typical stuff first, basic wound care. But if it's more involved, more difficult, or it's been there for more than a month or so, and it's not really progressing well, the wound is not healing, week to week, there's a platelet derived growth factor gel that we use.

It's quite expensive, but we get it through the insurance if we can, and that's speed wound healing applying to the wound. Also, skin substitutes are a thing that's come out the last 10 years. There's a placenta derived skin substitute, which is very common, that we used.

 So skin substitute placenta is really most commonly used, but it's also for skin. Skin substitute products, there's also other products that contain live cells. So if we get these, these are all expensive, like a 1000 dollars for application per visit, or more, but we get them approved through the insurance if it's a chronic wound that's difficult to treat.

Also, there's wound vacs that we use, which can be advanced therapy. There's also, if all these things have failed or in certain cases, we would refer patients to plastic surgery for a skin graft to the wound. They have to have enough blood supply, it depends on where it is and also patient compliance, if that's an ideal thing to do.

Also hyperbaric oxygen therapy is a modality that's used for more difficult to treat cases. So that's certainly an option as well.

Host: Now when you are choosing these advanced therapies, do they require any additional lab workup for these patients?

Jeffrey Lester, MD: So, labs that we typically order are blood count, comprehensive metabolic panel, hemoglobin A1c level, also thyroid testing. Also testing for like albumin, prealbumin, protein levels. Also in certain cases, you might suspect autoimmune diseases that can certainly, cause skin problems as skin ulcers, to test for anti nuclear antibodies, and other inflammatory markers as well.

So those are the common tests that we do. Part of that is, metabolically optimizing the patient, good nutrition, all good things like that.

Host: So obviously the knowledge required for wound care is very vast. If a healthcare worker is interested in learning more about this topic, what resources do you recommend?

Jeffrey Lester, MD: There's certainly a lot of good PowerPoint presentations you can go online and get to learn more. Some of them are more basic and some of them are more involved. There are dozens and dozens of different diseases that can cause wounds. A lot of them are rare, but they certainly are out there.

So, there can be, basic wound care things that you learn, but there also can be a lot more atypical or more involved, training and PowerPoint presentations. There's books you can learn on wound care, some of them more basic and some of them more involved, with more rare findings, more rare cases.

There's also online classes you can take. You can also watch videos on YouTube. There's some good videos on YouTube you can watch on Wound Care Basics, Wound Care Information. There's also different levels of training. I've worked with them a lot over the years. So they have a certification for MAT level, they have a technician level, they have an RN level, and they also have the provider PA, MD level as well. So there's lots of ways to learn.

Host: That is fantastic. Now, you've shared a ton of information about this Limb Preservation Program that you've started in South Tampa. What major take home points would you like to share with our audience on wound care?

Jeffrey Lester, MD: So big things are not smoking. If you smoke, stop smoking for sure and do whatever you can to get some patches or whatever with your doctor. So, no smoking is a big deal. Also losing weight and making sure you're an ideal body weight, getting closer to an ideal body weight, you know. So, body mass index 30 or above is obese. So, we want them to get closer to 25, which is a normal body weight. That's super important in avoiding vascular disease and avoiding wound problems. And also if you're diabetic, making sure your diabetes is controlled, making sure your fasting sugars are below 130, getting that hemoglobin A1C level down below 7%. So checking your sugars every day. Diabetic diet, regular exercise, making sure you have good diabetic control. Those are the main things to keep your blood vessels in your body and your legs healthy and avoiding wound problems as you get older.

Host: Thank you so much for your expertise, Dr. Lester.

Jeffrey Lester, MD: Thank you so much for, doing this. This is terrific.

Host: Thank you for listening to MD Cast by Tampa General Hospital, which is available on all major streaming services for free. To collect your CME, please click on the link in the description. For other CME opportunities, including live webinars, on demand videos, and local events offered to you by Tampa General Hospital, please visit cme.tgh.org. Thank you so much for listening. This is Dr. Rania Habib wishing you well.