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Healing Wounds, Saving Limbs Webcast

(dramatic music) – And a good evening and
welcome in to MedStar Health healing wounds, saving limbs webcast. We are screening live right
now on Facebook and YouTube from MedStar Union Memorial Hospital right here in Baltimore. We have a jam packed
audience in our studio. You can clap, go ahead. (audience applauding) It’s not a clap track here. And also, I am your host Jaime Costello from WMAR ABC2 News. (audience applauding) Alright we are here to discuss
wounds that don’t heal. We are here to discuss
ulcers that become infected. Listen, these are topics
we don’t want to talk about but we are going to tonight because we’re out to save your life right here. And for the next 60 minutes, you can be part of our audience, you can be part of the
question and answer period with some of the best and brightest that we have to offer here at MedStar. So the floor is open, any
question you just fire away. If you’re a physician
or a physician assistant or a nurse practitioner, you can earn one hour of CME credit. I just found what CME, it is
Continuing Medical Education. I can get a credit tonight,
so all I have to do is watch. All you have to do is
post your name and email in the comment section on
YouTube or Facebook page and can you can get proper credit. Now if you have a loved
one with poor circulation due to diabetes, you have infection or Peripheral Artery
Disease, let them know that we’re doing this on
Facebook and YouTube right now. MedStar Health’s Facebook page is open or MedStar Health on YouTube. Give them a call right now. Use your cell phone and say, hey, I think you should listen to this
and watch it here tonight. Post your comments, your questions, click a like and be sure to
share the post so your friends can join in on the discussion. We wanna hear from you tonight, we got 60 minutes to go. Let us meet the team right
now that we have assembled. Doctor Paul Carroll is
a podiatric surgeon here in MedStar Plastic and
Reconstructive Surgery. Specializes in foot an ankle trauma and reconstructive surgery. We thank the doctor for
being here, Doctor Carroll. Doctor Tiffany Hoh, a podiatric surgeon who specializes in complex
lower extremity wounds and diabetic diabetic limb salvage. Doctor Hoh, thank you. Zachary Martin, the doctor
right in the middle. Plastic sur, it’s always great
to have a plastic surgeon in the audience here tonight. He’s with the MedStar Plastic
and Reconstructive Surgery and the medical director of the hyperbaric medicine and wound healing center here in MedStar Good Samaritan Hospital. Thank you doctor for coming. We have nurse practitioner Alayna Blazakis and she has a doctorate
of nursing practice and her specialty is in adult
and she is has certificates in wound healing using
hyperbaric medicine. We love her for being
here tonight, thank you. You’re gonna have the tough questions. You know they’re coming. And on the end, here right
here, you’re right here. I can touch doctor Kevin Brown. Vascular sur, thank
you, don’t go anywhere. Vascular surgeon with MedStar
Heart and Vascular Institute that treats all forms of vascular disease. Here they are, five wound care
and limb preserving experts ready to share information
on treating these issues and answer your questions. Again, go to Facebook
live, go to the YouTube, MedStar Health, type in
your question and send it and give us a like. Alright right now, let’s
get endocrinologist Doctor Malek Cheikh up
here to start us off. 1001, 1002, 1003, 1004, 1005, 1006 1007, 1008, nine, 10, I think you get the point. 17 seconds somebody comes up
with diabetes in this country. 17 sec, from the time it took
you from going from your chair up to here to get settled, diabetes. I want you to tell us about the impact on a wound to heal that wound. – Thank you Jamie. So I didn’t know that I’m
that slow to come up here. (all laughing) So yeah, it’s very unfortunate. So oftentimes we deal
with this on daily basis. So in the United States now, We have more than 30 million people who have type two diabetes. So in the last couple of decades, it’s very unfortunate that we
have more and more patients who are diagnosed with this nasty disease. And that’s mostly driven
by the obesity epidemic that we have in this country so we’re doing much better
job in controlling diabetes but because of the increased
in the number of patients who have type two diabetes,
we still have plenty of people who have problems with this disease. One of the most common
complications of diabetes is usually that happens
within the first five years of the disease if it’s not
very well controlled. Usually is the diabetes neuropathy. So, what that is, it’s nerve
damage, mostly happens, it starts with the toes
and starts to go up where the patient unfortunately loses the protective sensation of their feet. And that can increase
their risk of having trauma that would lead to an ulcer, a wound. And because the patient
may or may not know that they have this ulcer
and because of diabetes also can cause poor circulation to the feet. That wound does not heal. And I usually tell my
patients that bacteria, they love to be around sugar and because people who
have uncontrolled diabetes have high sugar by definition, bacteria is invited to be in that ulcer. And that eventually may cause
infection within that ulcer. And when that happens, it’s a
very very complicated process. The patient would need
usually IV antibiotics. They need surgery oftentimes, wound care, improvement of the blood circulation by surgical intervention. And if this disease is
not treated properly with a bunch of experts in their field, oftentimes, it can lead into
amputations unfortunately. – All right doctor, thank you. I think this is probably
more of your question. I’m gonna ask him anyway about this. Let’s say you’re sleeping
at night and you’re in bed, your body just falls. It’s like you get cramps below the waist. You can’t move. Is that something to be
very, and all of a sudden you feel like your feet are asleep. And oh, got that tingling sensation. And it goes on time and time again. Is that something to? – Absolutely. Oftentimes, in our diabetes population, this is a very common
complaint they may have because the disease may affect the nerves and typically that happens at night when they’re trying to rest. The tingling is usually severe enough where they they may not be
able to rest or fall asleep. So we get this complaint all the time. And that definitely can raise questions of uncontrolled diabetes, maybe
it’s very early sign of it. – Doctor Cheikh, now walk back. Let’s time, put on a timer. The 16, oh, he’s quicker now. Again, if you have any
questions, hit us up on Facebook hit us up on YouTube, here,
these doctors are right here for the next hour, they’re gonna be answering your questions. A common and serious complication
is diabetic neuropathy. Doctor Hoh is gonna answer that. What is that, diabetic neuropathy? – Doctor Cheikh actually touched a bit, a little bit about it. Diabetic neuropathy is
typically a nerve damage that happens in your
feet caused by diabetes. The most common side effects people feel is this numbness feeling in their feet, they lose the sensation of
what the floor feels like. Other symptoms are pins
and needles, tingling, sharpshooting pains, they wake you up in the middle of the night. You gotta shake your foot out before you can go back to sleep. Why is it so important to get
checked if you do have this is you can step on something
or you can develop a wound on the bottom of your foot
and not actually feel it. You won’t notice it
because it doesn’t hurt you and then it can be a source
for bacteria to jump on board and then cause an infection. – Are you saying can’t feel cold either? Can’t feel if you step on a fire, a log. – A hot summer, you go
outside barefoot on concrete. You can burn yourself and
then not be able to heal it. And cause a cycle of bad things happening. – Let’s bring Doctor Martin in. A patient stubs their
toe, steps on a nail. Maybe finds a blister’s
forming in their foot. it’s not going away. What’s the first step? They need to seek medical care. Particularly if they have diabetes or peripheral vascular disease or other complex chronic
medical conditions. And remember, there’s a
good number of diabetics that don’t know they have diabetes. So, these little wounds
can become big problems. And what we know is that the
best time for that patient is seek care is right
away because our chance to have a successful outcome is enhanced by getting early treatment. And we know that by letting time pass, that that ulcer can lead to
other complications in the feet that can then go ahead
and lead to amputation. – How long do you let,
this would hasn’t healed in three days, I mean how long could be– – A diabetic should not
wait should not wait on any wound in their foot. Because the infection can travel in a day. So we consider them all serious. And for the patient, they
know they have a wound but they may not know
why they have a wound or what’s the underlying
cause of that wound. So the good news for the patient is they don’t need to know. If they come to our
facility, they’re gonna get all the expert care that they need because it’s probably not just the wound, there’s probably some
underlying podiatric problem. There may very well be vascular disease. We may need to bring
in hyperbaric medicine to take care of this patient. So it really takes a team
to take care of this patient rather than one doctor. No one doctor all the expertise to take care of that patient. – Let me ask you, I think
we get to the basics now. The symptoms of diabetes are? – The symptoms of diabetes, we should get Doctor Cheikh to comment but– – Dr. Cheikh, come on. 23 24, let get to the basics. The symptoms, We’re watching it on
Facebook live right now. Somebody may feel dizzy. Their eyes may be going yellow. I mean is that? – So the most common symptom
of diabetes typically is frequent urination. So which is a result of elevated
blood sugar in the blood and the body is trying to
get rid of the extra sugar so people tend to urinate a lot which makes them feel dehydrated, thirsty. – Color of the urine? – Not, it usually depends
on what you drink. It’s usually just regular urine color. And then they may have excessive thirst, may have severe weight loss in the span of a couple of weeks. General tiredness,
fatigue and blurry vision that definitely can happen
within the first couple weeks due to the sugar coming to the eye lenses and make them bulge out and cause some blurriness in the vision. That’s usually very reversible
in that first few weeks. – Alright doctor, thank you. Le me go over to Doctor Carroll. Now that we’ve had the
wound, we’ve had it assessed. Where do we go from there doctor? – Yes, there’s many approaches to the treatment of an ulceration. One of the most common,
most reliable treatment for a wound is a debridement. There’s several different
types of debridement. The most commonly use is
called a sharp debridement or surgical debridement. This includes the use of a
scalpel, scissors, curette, or any sort of sharp instrument. The goal is to turn a chronic
wound into acute wound. And how we do this is by removing biofilm or build up of bacteria. Removing any dead cells and if we can, we can achieve a bleeding wound base. And this helps stimulate growth as well. New division of cells. In the picture down here,
I’m demonstrating sharp, I have a curette in my hand. I’m actually removing
any of the dead cells. Any sort of additional bacteria buildup. I’m trying to get a bleeding base. Most of our patients,
’cause they have neuropathy, this is a painless procedure for them. There’s several different
types of debridements as well. We can use autolytic which
is the body’s own enzymes to breakdown a tissue. Enzymatic is the use of creams or lotions that are commercially made with enzymes that breakdown tissue. And then sometimes certain patients, you can use biologic
debridement such as larva wounds and what you do with these
is you actually put maggots onto a wound and they actually selectively eat away dead tissue. We also can use of various
amounts of wound dressings. Wet to dries. Different types of
dressings such as alginates which are actually seaweed-based which help absorb of
chronically draining wounds. Or hydrocolloid dressing to actually retain moisture inside the wound which help promote debridement such as the autolytic debridement. We can also use HBO or Hyperbaric Oxygen, which will be talked about later. One of the medical equipment
that we use most frequently is something called a
negative pressure wound vac. Or just the wound vac. And what this apparatus
does, it applies a consistent negative pressure to the wound. It works on both the mechanical level as well as a biological level. On the mechanical level, it
actually absorbs extra fluid. It actually draws in wound
margins to help heal the wound. It also promotes granulation
tissue on a microscopic level. It actually promotes cell
division or cells to grow. It also promotes
angiogenesis or the formation of new blood vessels to the wounds. So these are some of the
techniques that we like to use in conjunction with
each other for treatment of these observations. – Like no patient’s the same. – Correct. Each patient gets their own
specific treatment plan, either with a surgical debridement mixed with wound vac hyperbarics. Some of these ones
unfortunately can come infected so you have to use antibiotics,
either oral or intravenously depending on if the infection
is a soft tissue infection just localized to the skin. Or in the bone or a combination of both. – Tell me about this VERSAJET. What’s this all about? – It’s a tool that we
like to use in surgery. It creates kind of water
with a suction type of device that can decrease the amount of bacteria, bioburden on a wound. It gets into the crevices. As you can see, kind of that
jet that goes through it with a little vacuum that suctions it out. It’s a great utilization
of surgical debridement to clean up a wound. It makes a nice flat
wound bed that you can see in preparation for
wound closure or a graft to cover over the wound. – If we’re at home and we have a wound, is there anything we can
do at home real quick before we even get here? – Take a look at it. If there is pus draining out of it, if there is redness, if
it does not smell good, you should probably have
someone see that soon. – Okay, thank you doctor. Alright HBO. And we’re not talking
about HBO that we buy. Doctor Blazakis is here. Explain to me what the HBO therapy is. – Sure, so HBO stands for
Hyperbaric Oxygen therapy. And it’s a therapy that involves
a high pressure of oxygen within an acrylic chamber. So at Good Sam, we have what’s
called a mono place chamber, meaning one patient per chamber. And then the nurse and the physician are treating that patient while
they’re inside the chamber. So here’s a visual of what a
hyperbaric chamber looks like. And the patient is undergoing
their treatment right now. – [Jamie] How long has this been around? – A long time. (laughing) So you know the the
indications for hyperbarics. So there’s primary
indications for hyperbaric and then there’s secondary. So the primary indications are things like arterial air embolism or
decompression sickness from doing like a scuba dive
and getting nitrogen bubbles. And then what we use it
for mostly, is for diseases that are more related to hypoxic tissues. So wound care, chronic
wounds, flaps and graphs that are compromised. Chronic osteomyelitis or
infection in the bone. And we also use it for
like radiation tissues that have gone undergoing
radiation that won’t heal. So those are the indications. We have lots of patients
that come in for wound care and the way that the hyperbaric works is when you’re in the
chamber and it’s pressurized, you’re now able to carry
oxygen to the tissues through your hemoglobin which
is how we all do it normally and also the oxygen gets
driven into the plasma. So it’s dissolving in the plasma and going to the area,
the target area now. So you’re getting up to 200%
more oxygen to that area that was hypoxic in the past. So that’s the mechanism of
the action of the hyperbaric. – HBO, there you go. All right, Doctor Brown, what
is Peripheral Arterial Disease and how does this all relate to chronic diabetes and chronic wounds? – Absolutely. As Alayna just alluded to, if
you don’t have enough oxygen getting to these tissues, they won’t heal. And Peripheral Arterial Disease basically is blockages in the arteries that don’t allow good
blood flow that hemoglobin Alayna has talked about
to get to these wounds, to heal them. Peripheral Arterial Disease
comes on a whole spectrum of severity depending on how
much plaque and blockages in the arteries there are and where in the arteries they are. Just like any artery, the
arteries in the legs supply blood to the distal portions of the leg and without that good blood flow, you can’t get the oxygen,
without the oxygen, you can’t get wound healing. As I said, severity, the symptoms of Peripheral Arterial Disease
aren’t always wounds. They can range from
just pain when we walk. That’s called something
called claudication. It all comes from a supply
and demand mismatch. So when you exercise,
you’re not getting enough of that oxygen due to these
blockages in the arteries and that causes pain in the legs. It’s the same Physiology as when you used to run wind sprints when you’re a kid, you get the side stitch. It’s the exact same Physiology, you’re just not getting enough blood flow to that muscle and that causes pain. As it gets worse, you don’t
necessarily develop wounds with Peripheral Arterial
Disease but if you get a wound, secondary to everything
we’ve been talking about, stepping on a nail, burning your foot, with diabetic neuropathy and so forth, you may have a wound that can
get infected and so forth. And you may have enough
blood flow to keep wounds from developing but you
don’t have enough blood flow to heal the wounds that were
brought on by the diabetes. We diagnose Peripheral Arterial
Disease generally speaking with noninvasive methods. If one of my colleagues comes in say, “I got a guy I’m not
sure if he’s got enough blood flow to heal this wound.” We bring in, we do different
blood pressure measurements on your ankles and
different parts of your leg to see how good the blood flow is in that portion of the leg. We will also do ultrasounds
to actually look at the specific arteries. See where the blockages are, see how amenable they are
to different treatments. Now for in terms of treatment, it’s also relatively noninvasive. There’s several different
modalities of treatment both open surgical
methods and endovascular. And by endovascular, I mean wires, stents, balloons, things like that. So generally speaking, we
would get access to an artery with a wire or a catheter. If we find a blockage, we
can we can blow up a balloon, open that artery up. If the blockage is not
responsive to the balloon, we can also do things like atherectomy. As you see, where basically,
we have these different devices that break up the blockages in the artery. And then we can come back and
do once we’ve gotten through the blockage, blow it up with a balloon or place a stent as you’re gonna see here. Once that’s all said and
done, so we can then assure that you have enough blood
flow to those distal portions to heal these wounds. Unfortunately, not all
blockages are amenable to these kinds of treatments
with wires and stents and so forth as you might imagine. And in that case sometimes,
we have to go and do a bypass where we’ll either take your own vein or a piece of plastic vein and basically bypass around these blockages
if they’re too severe. So there’s a broad range of
treatments and modalities that we can really assure that we’re gonna get enough, blood flow get enough oxygen to those tissues to heal these wounds. – They just got out of Med
school about five minutes ago. That is, wow you are something. Let me ask you this seriously. How many people are walking
around with this going on inside and they don’t know it? – That’s actually a really good point. I think there is a large
portion of the population. I’m not sure exact percentages. I don’t think anyone does. But I would say that a
lot of people walk around and they say, oh well I’m
getting a little older, I’m a little overweight,
my legs hurt and ignore it. And this could absolutely be
Peripheral Arterial Disease kind of lying in the shadows waiting to cause major problems. – All right let’s go to our question from, this is coming from YouTube. All right, here’s the question. I get a deep dry crack on my foot. What kind of cream should I use? My MedStar is in beautiful
downtown Bel Air. All right, who wants
to fill that question? What kind of cream should they use? – Well I’ll start and then
I’ll have my podiatrist colleagues back me up. But we we get really uncomfortable
giving broad-based advice because we know, I don’t know anything about this person calling
in but we know that even that crack could be really serious. And particularly if there’s
a history of diabetes. So I think to the extent
that there’s a question about moisturizing an unwounded foot, I think my colleagues can speak to that. But it’ll be hard for us
to wanna speak generically. These these treatments that
we give the patient are always tailored because they’re always serious. – OK so you don’t have to run down to local pharmacy right now. You didn’t do that tell
me how to fill my crack. Alright listen, if I had a family member or a friend with a wound,
how would he or she know if HBO treatment is appropriate? Sure, you can fill that one. – It’s a great question and we have people comment all the time for detailed consult. And we talk to the patients
about where their wound is, the etiology of the wound
or what caused the wound or what is the underlying factor that the wound will not heal. And then we determine whether the wound, or the patient is a candidate
based on what they have to undergo hyperbaric. And there actually are
fairly strict criteria for placing a patient
into hyperbaric therapy. And it is only one
treatment for the wound. So there’s many treatments
that we should be doing for a wound and hyperbaric
is just one of them. So if we’re engaging that patient with the multidisciplinary team and
we’ve got everything in line and their wounds will not heal, then we would place them in hyperbaric. – Alright here’s another Facebook. What is the best treatment for neuropathy? What’s the best treatment? – There are no great
treatments for neuropathy in the early stages. I don’t know if doctor, I
keep putting you on the spot but really, medical management
is the primary route and you may want to speak to that. There are some surgical techniques but after after medical management fails. – So the best treatment
for diabetes neuropathy is treating diabetes properly
and making the sugars under control because we
know that may help with reverse the acuity of the symptoms and taking the edge out of
the numbness or tingling or maybe the pain. We have some therapies
that have response to, some people respond to
them and some people don’t. There are some creams out there, there are some pills that we usually try. But the bottom line is, make sure that your sugar’s under control, make sure that your feet have no ulcers that can cause any of these things that we’re talking about today. – [Jamie] OK we’re taking a look at, what are we looking at right now? – This is an insulin
pump and this small pod has insulin that gets
hooked to a wireless machine that patients who have
diabetes can program it so the pump is giving
them the amount of insulin that doctors prescribe. – All right, Dr. Cheikh, thank you. Just stand right here OK? (all laughing) I want you right there back on call. You’re on call right here.
Let me just ask you here. I know what the audience is thinking. I’ve got a wound at home, I love it on North
Calvert, I love this place, it’s a beautiful hospital
but I don’t wanna come here for what looks like a long term. I mean, how long are we
looking at from coming in getting checked out, are you
gonna be able to go home? That kind of stuff. I think everybody is
concerned about the long term. How long is this gonna
take the wound to heal? Doctor. – The first one, we
don’t want them to stay away because they’re
worried about it taking long because it’s that delay and that happens. So I’m glad you’re bringing it up, is people are putting it off because they’ve heard
stories about what happens when you have a wound
and you have diabetes. But the most important point
to drive home to everybody is that now’s the time and
the sooner we get on it, the shorter that treatment
course is gonna be. In terms of predicting
healing time for a patient which I think it was at
the root of your question, we can say that for most
of the complex wounds that come into our center, 85% of them are gonna be healed by three months. But if you ask me on any
particularly one patient, we’re really not very
good at predicting that. – Okay doctor. All right doctor Carroll,
we heard that Doctor Martin mentioned charcot foot, right? Can you tell us more about that? – Yes so, charcot arthropathy
ownercan affect about five to 10% of the diabetic population. This condition is characterized
by weakening of the bones in the joints, as well as a soft tissue of the foot and ankle but
it can affect other joints. If this condition is left unprotected and patient continues to walk, the structural integrity of
the foot can be compromised and this can lead to collapse of the arch. This can make it impossible
or very difficult for patients to walk. Subsequently, patients can
develop ulcerations, infections and they can actually lead to amputations. A characteristic of the
arch collapse is seen in this photo up here of what they call the rocker bottom foot. And the patient with charcot continues to ambulate on a weakened foot. The bones of the midfoot can collapse causing a pressure point
as you can kinda see as an apex, almost down like a triangle at the bottom part of the foot that can lead to ulceration formation, infection, conditional osteomyelitis, which is bone a infection. and subsequently, can lead to amputation. So what we do for our
patients who are undergoing either charcot condition is we have. we could use conservative
treatments which includes bracing as well as protective boots. On the pictures up here,
in the center here, this is called a CROW boot or a charcot restraint orthotic walker. As you can see, it’s a custom made boot. It looks like a Terminator
boot by the size. It actually goes up close to the knee. It’s actually got a plastic
shell with a very soft, custom molded soft material in the inside which is custom built the to that specific person’s foot. It’s close and tight
fit to provide stability when the patient is walking. In some patients, a boot
alone may not be enough to treat the charcot and
they may continue to ulcerate or if the deformity is so severe that, they may lead to instability. And that route, we kind
of look at this pathology and may take a surgical approach. There’s 2 types of surgical approaches we can apply with this. One of them is uh procedure
called simple exostectomy which is actually just shaving off a bump. If you see on this picture here, down at the bottom of the screen, the foot, the front part of
the foot on the left-hand side is elevated and you can
almost see like a spike down at the middle there. And a patient who has a solid fused or very stable foot, shaving off that bump can actually alleviate the pressure. And that actually can be
one of the quickest ways to get the patients back on till they’re back into the shoes. Unfortunately when a
deformity is unstable, the bones keep moving, there’s
multiple areas of pressure regardless if we done exostectomy or shaving down the bumps. Bracing or boots, they
may need a reconstruction. And what that means is a
patient may undergo a procedure called an osteotomy or
infusion of a joint. Which is a osteotomy, is a
large bone cut through a bone and for these particular patients is actually removing out of
a substantial amount of bones and kind of shorten the foot and take away any pressure points. These are fixated with
either place or screws or external fixation or a giant cage to help protect the
bone while it’s healing. And other times, we actually
confuse direct joints around the affected area and this
will actually add as protection to the area of concern. – Alright thank you,
we have a question here from our Facebook watchers. Besides having diabetes,
are there any other pre-existing conditions that could prevent my loved one’s wound from healing? All right someone wanna buzz in? – I was hoping I could get you to talk about venous insufficiency. – Yeah, that’s actually
a really good point. So, just like arteries, veins carry blood. However, that’s about
where the similarities end. Arteries take blood from your
heart out to your extremities and to your organs,
veins bring it all back. Veins however have a
very different structure and veins have these little one-way valves that keep blood flowing against
gravity back to your heart. And oftentimes, what we
see is these little valves in the veins stop working over time. And this can be manifested
by a lot of different things. Probably the most,
people are familiar with is varicose veins. And it can be very benign,
annoying, unsightly, spider veins, things like that
but it can get severe enough where you have basically
high pressures in these veins due to blood kind of
pooling in the extremities. And it can result in ulceration. So not only is it important
to get good oxygenated blood to your extremities through the arteries but you really need to get
that blood that’s deoxygenated out of the extremities so that good oxygenated blood can get in. And oftentimes, that can result
in swelling, chronic edema and swelling that can then
lead to skin breakdown. And there’s different surgical
procedures that we can do from the vascular side of things to alleviate some of these vein problems and help these wounds to heal. They’re very rare
admittedly and thankfully. It’s very rare for venous
disease to get to that point but when it does happen,
it’s important to get in and get it evaluated so
that we can intervene and hopefully get those wounds to heal. – I wanna stay with you because I think we scratched the surface at the top here but here we are 35 minutes into this and I pay attention to
lingering cuts, scratches, sores on your toes, feet,
legs, control your diabetes and be mindful of symptoms of PAD. Tell me about that. – So again the Peripheral
Arterial Disease, depending on its severity,
can manifest itself in a lot of different ways. It can completely be asymptomatic where you don’t even know you have it. I’d say most people are that way, that do have Peripheral Arterial Disease. It can manifest itself
again as claudication where you have pain when you walk. And it’s very typically, like I said, it’s a supply and demand problem. So it’s a very reproducible pain. A lot of people say, oh my knee hurts or my hips hurt, my back hurts. But this is a very reproducible pain. You walk a certain distance. It hurts generally in the larger
muscle groups in your legs. – [Jamie] Every day. – Everyday, every time you walk. It’s a very very reproducible thing. So people too typically have
true claudication will say, I can walk however many feet. I can walk 20 feet, I can
walk 50 feet, whatever it is. And I get severe pain in
the larger muscle groups generally the calves, ’cause
they’re further from the heart. I stop, that supply and
demand mismatch goes away ’cause you stopped exercising The oxygen balance gets
better, the pain goes away and you can walk exactly 50 feet again. And so that’s kind of where it starts and that’s where those symptoms start. But symptoms, as you get further along, can be much more severe. In other words you can
get that claudication even at five, six feet and these people are severely debilitating,
they can’t function, they can’t walk, they
can’t enjoy their lives. And ultimately that can lead to deconditioning heart disease and so forth. In addition, you can get
to a point where you have essentially what we call rest pain. In other words that supply demand mismatch never goes away. You never have enough oxygen
to really support your tissues. And that manifests itself as pain similar to diabetic neuropathy at night but it’s generally an
ache, a real dull ache generally in the foot or in the toes. And strangely enough, it often gets better when the patient stands
up or hangs their foot off the side of the table or
the bed, in this instance. Because that little extra
pull of gravity gets enough blood flow those tissues
to reduce the pain. And it’s extremely
important that gets into when you start having
rest pain and so forth, that’s when wounds really
start to become a problem. And amputation rates skyrocket. – Let’s go to Doctor Hoh on that. The goal of treatment is
to prevent amputation. I mean that’s the last resort here. And preserve the limb function. What are the considerations
you have to make as a surgeon when a patient has a foot
wound that has become a limb threatening infection Doctor Hoh? – Yeah, when they come in, a
lot of times the first thing we think about is actually
controlling their infection. By controlling their infection,
you’re actually making them feel better, they aren’t feeling as sick, they don’t have as many fevers and then after multiple surgeries, we have to think about
how we can give them a functional foot without
losing their limb. A lot of times patients will be fearful of the word amputation. They’ve lost one to
already and this infection brought them to losing a second toe. And they don’t want to hear
that they’re about to lose all their toes but that might actually be the most functional outcome where they have a foot
that they can walk on without a wound, without something that’s gonna cause them to come back with another infection. So someone who’s lost one or
2 toes like in this X Ray, you have to think about, is
this foot actually functional? Can they actually walk on this
when you close their wound? the problem is their
toes start to dislocate. They can potentially get fractures. Like on the next slide,
if you were actually to complete their amputation,
removal of their toes, they actually have restored what’s called the normal parabola. This is a midfoot foot amputation called a transmetatarsal amputation. It’s something that’s very functional. Patients will be fearful
because the word amputation, they’ve lost half their foot. But this is something that
allows them to wear shoe that has a toe filler. They can walk, they can go
back to their normal lives and people won’t be able to see it when they’re wearing shoes. It’s not without complications. So in the next slide, because
they’ve lost half their foot, they can develop what’s
called an equinus contracture where the achilles is
pulling their foot down. Their foot is no longer at a
90-degree angle to their leg so they can get a repeat ulcer at the end of their amputation stump. So we do a simple procedure
like on the next slide where we have three small
incisions in the back, lengthen their Achilles so they
can actually stand straight and continue walking and going about It’s important that they
still keep coming back to make sure they get their foot checked because the other rotational
plane problem that happens like in the next slide. And this is somebody who has restored their normal 90 degrees. The next slide shows
the foot kind of rotated where the front part of their
foot starts to pull up higher and the outside part of
their foot turns down. You can get rubbing on
the inside of the shoe so they get ulcers on one side or if the other side is lowered down, they get a wound on the bottom. So you can easily do
other things to balance this foot out like in the next one. So that they’re nice and perpendicular. And this way, their foot
stays flat 90 degrees through their leg, they have
their shoe that they can use and not have any problems
that they come back with. – We’re about 20 minutes
away from wrapping this up but if you have a question, go to YouTube, you’re on it right now. And also go to Facebook
live, you’re on it right now, fire off a question. I know you’re at home,
you may be suffering. This is your chance to ask a question. I’m gonna ask doctor Cheikh again. Diabetes, of fight it off, what should we be doing right now? – So, the most important thing is to know that you have the disease. So screening is super important because like Peripheral Vasc Disease, many people would be walking down the streets without knowing that they have diabetes. So screening is very important
especially if you have risk factors for diabetes. If you’re overweight, if you
have somebody in your family who has type two diabetes, that increases your risk of having it. So, an easy blood test
that most of the doctors are gonna do it then, the second thing is gonna be lifestyle. And I cannot emphasize the
importance of exercise, weight loss, following
a well-balanced diet. I usually tell my patients
to have a dinner plate that half of it is vegetables,
a quarter, a starch and a quarter, a protein. And that, by just trying
to diversify the diet and not eating too much processed food. Food that is high in starch or fat, that can definitely decrease
the chances of weight gain and then also decrease the chances of them encountering this nasty disease. – On Facebook we have a question. How do I refer a patient
for hyperbaric therapy? How do I do that? – You had another question
about hyperbaric therapy earlier and it is very challenging
for referring providers and for patients at home to really know, am I truly a candidate
for hyperbaric therapy? It’s a very complicated
analysis that we have to do to make sure that we’re offering
them the right treatment. So the thing to do is
to is to call our center and we can get you in quickly and you really won’t be just
seen for hyperbaric therapy because we really have to
look at the whole picture and figure out how hyperbarics might fit into your care plan. – And from YouTube, can I use a foot soak if I am a diabetic? – Tough question to answer just based on the stages of diabetes you
have, if you have neuropathy, any open wounds, what you
plan to soak the foot in. If it’s just warm water
and salt or if its soap or if it’s hot water. So it depends. My recommendation is to check
with your medical doctor ahead of time to determine
if what solutions or what compounds you wanna put
on your foot is appropriate. – My grandmother is no
longer here but I think that came from her. I mean they all did, just put
it and we’ll soak it in water. I wanna go down the line. We’ll start with you doctor. I want you to tell me your
greatest success story. One of those stories about a
patient that keeps you going. In walking the halls
and making sure people are taking care of. What is that one story that sticks out that will always live with you. – That’s a great question. I actually had a patient that came over from the Eastern Shore. He had Peripheral Vascular Disease. Previous partial foot amputation so he lost his fifth toe as well as part of the metatarsal behind. I had seen several podiatrist, several other vascular surgeons that yield a baloney amputation. He came all the way to our
Good Samaritan facility and he said, “You gotta save my foot.” So through the use of, we threw
out (mumbles) sink at him. Surgical debridements,
hyperbarics on several occasions, wound vac, skin grafts,
even some local tissue flaps of just rotating the skin around and we actually were able
to save this person’s foot and he is so grateful. He still comes to me and that’s probably one of the most greatest
success stories I’ve had since I’ve been in practice. And we used every single
technique that we’ve discussed up here to save this guy’s foot and he’s so happy that
he’s out walking on a foot. – Happy that he’s ran into you. There you go, Doctor Hoh, one question that keeps you in your white coat. – The multiple patients who,
they come in with an infection, they may not have known they had diabetes, their sugars are out of control and they have a horrible infection that is about to not only take their limb but could potentially take their life. And you come in with your team
of everybody who helps them, you save their limb and when I see them for that final follow up where
they’re back in their shoes, they’re actually walking. And they see me and they say hi to me is what’s really rewarding
that keeps me there. – That’s great. Doctor Martin, tell me
a tell me that story of telling that person that
sitting right across from you the worst and then seeing the best. – Yeah I mean, these are the
stories that that keep us going and I hope I hope our
enthusiasm for this work can come across in this forum. But yeah, this is a rollercoaster ride. The patients come in and we say
they have a limb threatening infection, that’s what they come in with. And this team basically
is called into action because the case that Tiffany
was describing earlier about the patient that
comes with a bad infection, all these things we’re doing are happening almost simultaneously. So we’re having a surgery
to control the infection. We’re having Doctor Brown come in and restore the circulation. The plastic surgeons
and podiatric surgeons are conferring about how do
we get the best structure around this foot so that
this person can walk? And often, we’re getting
hyperbarics involved too to try and get our best outcome. So we have to start with
a very frank conversation with that patient because the reality is when they come in, we
don’t we don’t know yet where we’re going with this. So, and we have to be
direct with the patient because our credibility
is gonna be so important going forward because we
need a lasting relationship with this patient because
it’s multiple surgeries and once we get past the crisis point, we need to keep them on task because there’s other
things they need to do in terms of the rehabilitation. So in some ways it’s that
it’s that roller coaster that can be so exciting for
us because we feel the depths when the patient is upset about the information we’re giving you. And then and we’re sharing these patients so when we have a success
we’re sharing that together. There was a video there
of an event that happens every evening where we’re rounding that they were just showing
but it’s working together, solving these life-changing
problems for patient that really keeps us going. – All right, Doctor, what keeps you going and also I’m attack on why this field? Why in medicine? What was it that drew you into this? – Wound care? Well I think that you
know what everyone else has already touched on is that, you have such a serious
you know initial visit and then you see the outcomes and you see people getting
back to functioning. And the fact that there’s
so many components to the multidisciplinary team. There’s so many people involved and it’s a great team to work with and so I just I love that
there’s so many components and so many professionals
working to make that person get back onto their feet. – Yes, you’re stumped
at home, you come in, all of a sudden you get it. What’s that feeling like? – All of a sudden, hey let’s try this. – Oh yeah, I will be at home
and I will be thinking about a patient and you know what
we can do to help them to heal and then I’m excited the
next time that they come in to try something new and a
lot of times that it works. It’s a great feeling. – Alright doctor, alright come on. Tell me that one story. Always lives with you. – I think one of our group
greatest success stories was a gentleman that I got to participate, I don’t get to participate
in every single one of these patients care. Because they don’t all have bad blood. I know, I wish. No but we had a gentleman who
came from another hospital and he was told that
he would need bilateral above knee amputations. And they had him on the schedule to do so. And he said no way. I hear there’s a limb salvage
program at Good Samaritan, I wanna go check it out. I want a second opinion. And he came over I think, I
hope you guys remember him. He had significant wounds. He had knee contractures
because he had been in a wheelchair for a long time but you know, it’s all
about risk to benefit ratio and yes, we’re probably not gonna do these massive bypass surgeries
on somebody in a wheelchair but at the same time if
there’s something we can do to improve his blood
flow, to heal his wounds, there’s no reason he needs to
have a bilateral amputation and sure enough, I did the
stens and the angiograms and so forth on both of his legs. And I think he needed
some minor amputations but he kept both his legs. – He was right to come. I want that second opinion. We have a question on Facebook. I’ve heard about a wound vac. What does it do? – Yes the wound vac, the
negative pressure wound vac is a device that provides a
constant negative pressure or sometimes it can be
inconstant pressure. Think of a picture up
here and what this does is works on two levels. It works on the biological level as well as the microscopic level. On the biological level,
or the macroscopic level, what this does it actually
sucks out any fluid, any sort of material that
could potentially be infectious and also kind of draws in our wound edges. So we’re trying to slowly
close the wound in over time. As well as promote tissue
called granulation tissue which is essential for wound healing. At a more of a microscopic level, it actually promotes
cells to divide or grow. It also promotes the
formation of new blood cells which allow more cells to
come to the wound healing. It also allows for us to kind of irrigate or clean out the would
in a specialty device called a V.A.C. VERAFLO
which actually uses sailing, can be infused into irrigated
went to clean it out and then later gets sucked
out through the vac sponge as you can kind of see on
this particular image here. So there’s many different
functions of the wound vac and we use it for multiple
different applications such as if we wanna put on graphs, we use it over graphs. Split thickness skin grafts,
it works great for us. Synthetic grafts, can be used over tendon, you can use over bones. So there’s many
versatility to this device. – Listen, we’re still open. You can get us on
Facebook live and YouTube. Fire off a question here,
if you’re watching us, please, fire off because
these are the experts here. This is a great question here. This is almost like a wrap up. When should I call you
if I have a problem? We said that at the top
right away, right now. – You worry maybe you raised the alarm and then all of a sudden you
get a bunch of people coming in that don’t really have problem. It just doesn’t happen. I mean, our center’s been
around for close to 20 years doing wound care and it’s
quite uncommon for a patient to come in that they were just
being a little overreactive. I mean, for the most part
patients are really good about knowing when to come in
and we rarely see somebody where were like, oh no, you can be fine. You don’t need our help. I mean, most people we can bring value to. – Can I shower? – Can you shower? – I can answer that question,
I’m not even a doctor. I could answer that. – There are there are
certain circumstances where we discourage it
immediately after surgery but generally, showering is OK. It’s usually, many patients
are told the opposite of that. People are told to keep
their their wounds dry but we generally like to
have the wounds cleansed. And so the challenge
really for showering is, can they stay off their
wound when they’re doing it? Can they use good technique? But for the most part, we approve of cleansing the wounds in the shower. Here’s another Facebook question. What items are allowed
inside of the HBO chamber? – It might be easier to explain what is not allowed
inside of the HBO chamber. No synthetic material, no cell phones. Nothing that would cause a fire. no electronic devices, no paper. But most wound dressings are OK so when the patient comes
in and they have a dressing on their wound then that’s fine. That can go in the chamber. We ask the patients when
they come in to change out of their street
clothes and put on scrubs that we give them that are made of cotton. We allow the patient to
have a drink in there which is in a plastic container. – Can I exercise? Well it depends on the
pain and severity, right? – So with limb salvage, the whole purpose is to keep people moving. So when people stop moving they can suffer other medical conditions. So, it’s an equivocal
answer because most of our immediate attention is to
taking pressure off of wounds. So if it’s on a foot, it may
be difficult to exercise. We have one of the best
rehab centers in the state. And one of the nice things is we can get our patients in there
that maybe are not allowed to put pressure on their foot but they can get them
exercising in other ways and mobile other ways ’cause really, important to keep moving
while still protecting all the work that we’re doing. – I think everybody that watch
us tonight on Facebook live and YouTube feels there’s
a team effort here and doctor Hoh, just talk about the team that we have assembled here. – These complex are, these
patients are so complex. Their wounds are complex,
they are sick patients who have a lot of other things. One physician cannot
handle this on their own. You require a multi disciplinary team. Doctors from various
specialties, podiatric, plastics, vascular, endocrine, you
require PAs and MPs to help you. And Good Samaritan is
building this beautiful team to help you get back on your feet. – Doctor? – Yeah, I mean, teamwork is everything, we see it in lots of aspects of medicine. The reason for that is the benefits have been so good for the patients. If last century, a code team
was invented in hospitals because they realized that when
people were having a crisis in the hospital, the
nurse wasn’t able to wait till a doctor was
available, they had to call a code blue team and this was
a team of health professionals all with different skill sets, all tasks with descending on that patient at a moment’s notice so that
patient had all the benefits of all their skills so
they could get treated and have the best possible outcome. And that’s essentially what we’re doing. You show up at our
facility and we’re trying to bring all these forces to bear at once because we know that
that’s our best chance for a successful outcome. – Look at this on Facebook right now. You’ve inspired somebody in Med school. This is great, thank you for
the inspiring work you all do. Do you perform surgery on
structural abnormalities? Bunions, hammertoes to prevent
ulcers in high risk patients? Can this cause more harm than good? – That’s a good medical statement. – And I’m so happy we’re inspiring you. In a high risk patient, you worry that they have to come back in. You have to look at
the patient as a whole. Are they medically optimized,
how are their blood sugars, what is their vascular status before you actually make that decision. So study hard and
hopefully, you’ll understand when you’re standing in
front of that patient. – Or you’ll be up here on this
pretty soon, that’s great. I wanna bring up Brad Chambers who is the president of
MedStar Good Samaritan and MedStar Union Memorial Hospital. He is the president. – Thank you, I’m right here. Thank you, I appreciate it. On behalf of everyone
across MedStar Health. In particular, our wonderful
family and colleagues at MedStar Good Samaritan Hospital. I want to thank all of you
for joining in tonight. A special thanks to Jamie
and our media partner WMAR. They’ve been on this journey
with us for many years supporting our webcast series. But more importantly,
congratulations and thank you to this wonderful panel of people. Doctor Cheikh, you know, you always off, running back and forth here. Thank you. We’re very proud of our
wound and limb saving program at Good Samaritan. Tonight was really just a
flavor of the wonderful things that we’re doing. Please reach out to us. The number is provided here on the screen and we really, on behalf
of MedStar Health, thank you for tuning in
tonight and supporting Good Samaritan Hospital
and the wound care program. – Thank you Jamie, I appreciate it, thank so much. – Hey listen, I think we encouraged you tonight, didn’t we? And I know you may be shy
to get on Facebook live or YouTube you but here’s
the number to call. 443-444-4275. Doctors, you were wonderful. Thank you for your time, your expertise and for saving our limbs and making sure our wounds are healed. Thank you for joining us here tonight from MedStar Union Memorial Hospital. Great job. (dramatic music)

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