For the Love of Health

When Wounds Won't Heal with Dr. Jim Ley and Dr. Scott Reich

• ChristianaCare • Season 2 • Episode 8

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While most cuts and scrapes will heal themselves, some wounds can develop into a more serious situation.

In that case, you may need to see wound care specialists. Dr. Jim Ley, Medical Director of the ChristianaCare Wound Care and Hyperbaric Medicine Center, and Podiatrist Dr. Scott Reich talk to us about the kinds of wounds they see, the specialized treatments they offer such as hyperbaric oxygen therapy, and when to know if you might benefit from their care.

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Speaker 1:

If there's a wound that's not healing within a short period of time, it can often become a chronic wound that has more complications.

Speaker 2:

You're listening to For the Love of Health, a podcast about delivering care and creating health, brought to you by Christiana Care. And now here are your hosts.

Speaker 3:

Hello everyone, I'm Megan.

Speaker 2:

McGerman and I'm Jason Tokarski. Welcome to another episode of For the Love of Health, brought to you by ChristianaCare.

Speaker 3:

While most cuts and scrapes will heal themselves, some wounds can develop into a more serious situation.

Speaker 2:

In that case, you may need to see wound care specialists. Two of those specialists from the ChristianaCare Wound Care and Hyperbaric Medicine Center are joining us today. They're Dr Jim Lay, Medical Director of the Christiana Care Wound Care Centers, and podiatrist Dr Scott Rich.

Speaker 3:

Jim and Scott. Thank you both so much for your time today.

Speaker 1:

Thank you for having us. Thank you for having us.

Speaker 3:

Can you explain the specialization of wound care and why that may or may not be better for a patient, opposed to just going to a primary care provider to care for a wound?

Speaker 1:

All of us have had the experience of having a wound when we were young or growing up, or even in our adult lives, where we cut ourselves, we put a Band-Aid on it. It goes away. But there are wounds that are not like that and as we get older, as we get other diseases like diabetes, or sometimes when we have circulation problems, wounds don't heal. Sometimes, you know, when we have circulation problems, wounds don't heal, and so it's in those settings that the wound care center provides an expertise to help navigate those wounds and try to get healing out of them. Some people ask well, you know, how long do you have to have a wound to come to wound care center? And there's no hard or fast rule. Sometimes people say, well, if it's there for 30 days, you should come, but there may be some wounds that people come sooner than that. If it's a big, bad wound, that is going to need some help.

Speaker 2:

We're talking about this in terms of Christiana Care's wound care and hyperbaric medicine. Specifically, what sets Christiana Care apart, both locally and nationally?

Speaker 1:

I think Christiana Care has a wealth of clinical skill sets available for the patient. We have plastic surgery, we have vascular surgery, we have many podiatrists, we have infectious disease doctors, general surgeons, so there's a lot of resources available to employ these techniques that we do to get the wounds to heal. You know so some of our patients, you know, in certain instances will need to have a surgery done to restore blood flow, for instance to their legs, or they'll have. You know, people have heard of catheterizations, heart caths. Well, we do catheterizations on the legs and we can actually put stents in the legs and do angioplasty, which is the balloon kind of a thing where we open up arteries and all of those things go into helping a wound to heal. We also, of course, have two centers which are kind of geographically convenient for people, and both of those centers have hyperbaric oxygen capability, should that be needed for a particular case.

Speaker 4:

The Wound Care Center is a very specialized office where that's all we see are chronic difficulty heal wounds. We have a staff of wound care nurses who help manage these patients on a daily basis. We have a wide array of wound care dressings, compression wraps. We have access to HBO and we have access to numerous specialists that are required or needed for wound healing, like infectious disease, podiatry, general surgery, plastic surgery. We also have a very specific documentation system where we can monitor these wounds on a regular basis. We take accurate measurements, we take imaging every time a patient comes in, and that allows us to evaluate our progress or lack of progress progress, for that matter in which case we can easily change course or treatments.

Speaker 3:

You mentioned the hyperbaric chamber. Can you explain what that entails?

Speaker 1:

Hyperbaric oxygen is basically when you dive down under the ocean, for instance, there's a pressure that you experience, your body experience. We talk about pressure at sea level as being a certain pressure. We call that one atmosphere, and so when you go down under the ocean that number increases. If you go down to a certain foot depth, you know, you can be two atmospheres or two and a half atmospheres when you have this kind of pressure, or two and a half atmospheres when you have this kind of pressure.

Speaker 1:

What happens to oxygen or other gases is that they're compressed and some of those gases become liquid and so, with oxygen in the body, normally oxygen goes through the bloodstream, through a molecule called hemoglobin, and that's how it gets to the tissue.

Speaker 1:

But when you do hyperbaric oxygen, you can actually get oxygen into the liquid form, into the bloodstream and it goes to the tissue.

Speaker 1:

But when you do hyperbaric oxygen, you can actually get oxygen into the liquid form, into the bloodstream and it goes to the tissues much more efficiently.

Speaker 1:

When it arrives there it has a medical effect, a medicine effect, and those effects include helping to fight infection, promoting healing, encouraging the growth of new blood vessels so that the tissue can become more healthy, and one of the types of diagnoses that we treat that don't always have a wound involved is radiation injury. So we do a lot of hyperbaric medicine for radiation induced soft tissue injury and those diagnoses include sometimes, like when people have radiation to the prostate they'll have damage to the bowel or the bladder and they'll have bleeding or pain. That the hyperbaric ostrich can help to heal those conditions and reduce the pain and the bleeding or whatever they have. And we do it for radiation to the head and neck area where there's damage to the jaw or the teeth or different kinds of things. So it's really broad. And of course we also do it for diabetic foot ulcers of certain types that have to have a certain severity level and also bone infection. We'll do it for bone infections not responding to the normal kinds of treatment.

Speaker 2:

What sets ChristianaCare apart, both nationally and locally, in that service?

Speaker 1:

We are very careful to evaluate the patient, to have the appropriate patient into that treatment. It is an expensive treatment. It requires insurance approval. If you look across the country, there can be quite a few hyperbaric oxygen facilities that don't always pay attention to the evidence-based, what we call evidence-based medicine, which is, you know, what does the science say about the use of this modality and how does it work and who is it going to help and who is it not going to help? Because the last thing you want to do is put a person through a procedure and then they're not helped by it, you know. So there's that part. There are many wound care centers across the country, so I think most metropolitan areas have wound care centers, although I think it's very important to have that local resource available for people.

Speaker 3:

Can you explain why it's so important that you have this multidisciplinary team on staff at the wound care center?

Speaker 1:

If, say, for instance, somebody comes in with a foot wound, normally they might go to their community podiatrist and that person would see them and start to do care. But if they wanted to get that patient seen by, for instance, an infection doctor to deal with an infection issue, or perhaps vascular surgeon to look at the arterial supply or even just dealing with some of the specialty care that we do, it would take considerable time for them to get into those people. But when you have a multidisciplinary setting you have easy, quick access to these people. If I need a patient seen by, for instance, a vascular surgeon, quite often I can get that appointment within a week or two of the time that I decide they need that service.

Speaker 1:

Same with podiatry. We have numbers of podiatrists in the wound care center. So if I see a foot wound and say I'm the intake doctor because we use that term, the doctor that takes the patient into the care, does the initial evaluation I can know that Scott's gonna be there on Tuesday. Or he's gonna be there on Tuesday or he's going to be there on Monday or Friday at one center or the other and we can just say put them on Scott's schedule this Friday and they're right in there and we will often see patients within a week of the call for asking for an appointment.

Speaker 3:

And Scott, you could be that podiatrist that Jim was talking about. How does that work day to day?

Speaker 4:

So typically I see diabetic foot wounds at the wound care center, but it's, it's typically. I'm not the only person who would see these, these individuals. I don't usually just prescribe a dressing and and that's it. You know, we have to evaluate these patients from, say, their vascular status, and they go through a vascular exam and very commonly there's some vascular issues. So I'll send these individuals to our vascular providers at the center and then when they finish I'll see them back. They typically have imaging done and if there's an infectious process they'll go see infectious disease for help with the infection, whether it's antibiotics through an IV or oral antibiotics, and then if they need any kind of surgical intervention, I can usually help with that.

Speaker 3:

With all of those specialists within the wound care center. What are you seeing? It sounds like a wide array of wounds, then.

Speaker 1:

Yeah, I think we see a combination of diabetic foot ulcers. For instance, we see quite a few leg wounds, which we call venous stasis wounds. These are wounds that occur because of the veins that drain the legs and so there can be swelling in those legs and inflammation. So if there's a subtle injury, or even just no injury, a wound can appear and then start to drain and not heal. We also see sometimes wounds that are based upon just purely circulation, arterial problems, so that you know there's a wound that develops maybe on a pressure point and it doesn't heal because there's not good blood flow.

Speaker 1:

And another wound type of wound we see is pressure ulceration. So people who are less mobile or have some sort of neurologic injury can have pressure ulcers because of the way they're sitting or lying in bed. This can result in a wound, and so we need to figure out how to help them with that wound and get the pressure off of it. The appropriate action. So some of our wounds are infected, some of them are not infected, they're just open wounds. Some wounds are from skin cancer. Some wounds are autoimmune wounds, we call them. It's kind of a category of wounds which basically simply means if you have a wound that is there because the immune system is attacking the skin and you make a wound and it just gets worse and worse because the immune system is attacking it.

Speaker 2:

These sound like some really difficult and challenging situations that you have to deal with in treating these. What are some of the difficulties you're facing beyond that in these? You know you're talking about what it takes to get the wound. What are those challenges for treating and curing the wound?

Speaker 4:

One patient, compliance and managing other chronic conditions that are needed in order to heal these wounds and, for example, a lot of these patients we see with chronic wounds all have, many of them have other chronic conditions such as, as Jim mentioned, diabetes, peripheral vascular disease, neuropathy, which is numbness in the lower extremity, and these issues and these conditions need to be well managed and maintained in order for us to be successful. And you know, with that being said, oftentimes patients are very bogged down in managing their other chronic conditions and they sort of put their wound care on the back burner sometimes and it doesn't get enough attention and unfortunately this opens them up to things like infections, need for hospitalization, risk of amputation. So those are a couple of challenges that we face in wound care.

Speaker 3:

What is the patient response to that, when you're able to help them and with wounds that maybe otherwise, they've been told are maybe untreatable or just something they're going to have to live with?

Speaker 1:

You know there's many stories you could think about with patients who have wounds that are not healing. Come to the wound care center. You know I've had patients that come in with severe pain related to, for instance, what we call radiation cystitis. So it's kind of like having a urinary tract infection but you don't, and the antibiotic doesn't help you and you just have pain and discomfort, maybe some bleeding, and you just have pain and discomfort, maybe some bleeding. And we many times see patients by the end of their course of treatment. Their pain levels have gone down, they're reducing their pain medication, the bleeding has improved. So there's a lot of gratefulness that people have for this kind of treatment.

Speaker 4:

We had a woman who was dealing with a chronic wound on her heel for quite some time well over six months and was unable to be off of her foot because of work and family obligations.

Speaker 4:

We were able to see her and get her into a device called a total contact cast, which is essentially a device which allows people to walk while offloading or keeping the pressure off the bottom of the foot, and after all that time we were able to heal her and she'd been doing quite well. We had another patient we saw one evening in the ER who came in unfortunately after sustaining a traumatic lawnmower accident and losing his big toe and resulting in a large wound, and we were able to get him into the OR that night and clean the wound and effectively debride it into the OR that night and clean the wound and effectively debride it, create a flap to help close the wound. But unfortunately he walked on his foot a little too much after his procedure and the wound opened up. So we were able to follow him at the wound center on a regular basis and treat him with a biologic dressing called a skin substitute and over a period of time we were able to heal him and he's been doing quite well.

Speaker 2:

So if somebody is listening or watching this episode and feels like they're struggling with a wound that goes beyond their typical, I cut myself while making dinner tonight and they're having struggle with it. What advice do you have for them if they're looking for more advanced help?

Speaker 1:

Well, anybody who has a wound, who wants to seek medical attention in the wound care center, can just call the number and come, you do not need a referral.

Speaker 1:

Now, when I say that the caution is, of course certain insurances, you know, require certain paperwork to see a specialist, but we do not require a referral in terms of a person to be seen at the wound care center. We leave that up to the patient to know what their insurance requires. But they can come in for evaluation. We'll have some patients that come in and we look at the wound and we say you know, this wound is not so bad and we do something and they're healed within one or two visits. And then there are other patients, of course, that have a more complicated situation where it's going to take a period of time to deal with all the issues that Scott has been mentioning.

Speaker 1:

If there's a wound that's not healing within a short period of time, if you don't deal with it, it can often become a chronic wound that has more complications, bone infections. Then you start to getting into surgery and taking things off. That won't cure. You know there's just a lot of risk, especially with the diabetic ulcerations. They can be very challenging to treat and you know we've seen many patients that'll come in and say I've had this wound for two years and what amazes us is that something bad didn't happen in that two years. You know where a lot of other patients. They had a wound one week and something bad happened, so you can't always count on that, but the point is that we're there. We're available to help people with wounds and hopefully be able to give them good advice and chart a pathway forward to healing.

Speaker 3:

Jim and Scott. Thank you both so much for your time today.

Speaker 1:

It was our pleasure.

Speaker 3:

We'll have more information on the ChristianaCare Wound Care and Hyperbaric Medicine Center in our show notes for today's episode.

Speaker 2:

And don't forget to subscribe to For the Love of Health on Apple Podcasts or Spotify. And you can watch the video version of For the Love of Health on ChristianaCare's YouTube.

Speaker 3:

We'll be back in two weeks with another great conversation.

Speaker 2:

Until then, thanks again for joining us for the love of health.

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Megan McGuriman

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