diabetic wounds

>>lori casey: just ahead on this edition ofbeing well. we'll be talking about non-healing wounds and their treatment. our guest is dr.kelly jones monahan from sarah bush lincoln health system. we'll talk about what causesa non-healing wound, who's at risk, what are the symptoms, and what treatment choices areavailable including the use of a hyperbaric chamber. that's all coming up next on beingwell so don't go away. [music playing]>>lori casey: production of being well is made possiblein part by. sarah bush lincoln health system supportinghealthy lifestyles eating a heart healthy diet, staying active, managing stress andregular check ups are ways of reducing your

health risks. proper health is important toall at sarah bush lincoln health system. information available at sarah bush.org.additional funding by jazzercise of charleston. hello and thanks for coming back to beingwell i'm your host lori casey today our topic is advanced wound care.my guest is dr. kelly jones-monahan with sarah bush lincoln health system. a general surgeonand we've had you on this show before talking about gallbladders.>>dr. kelly jones-monahan: yes.>>lori casey: today is all about wound care and when wetalk about in this realm of wounds we talk about non-healing wounds. so what sort ofputs a wound into that classification?

>>dr. kelly jones-monahan:well obviously it's more than i just skinned my knee rollerblading.most of the wounds that we talk about that are non-healing have little improvement overfour-week period and are not completely healed at 8 weeks. so we're talking about somethingthat has been going on for a while. >>lori casey:so this is far beyond i scratched myself and it just doesn't heal.so it's a little more than that. so what disease or ailments can be associatedwith non-healing wounds? >>dr. kelly jones-monahan:the most common patients that we see in our clinic are patients with diabetes and whatwe call venous stasis ulcerations. and basically

that's the patient who has the varicose veinsbut it's beyond that were they have swelling, their darkening of the skin of the legs andthat causes breakdowns in the skin. those are the most common things we see.other wounds can be due to pressure ulcerations, and patients who may have neuro logic problemssuch as paraplegia. elderly patients who have sit or lay in aposition for long term or those are or immune problems.>>lori casey: so when wounds don't heal what is the bodynot doing or is unable to do? >>dr. kelly jones-monahan:well there's a couple things one is a lot of times there is debris in the wound thatjust prevents the healing process.

it's kind of like dumping garbage into a pondand expecting grass to grow over it, it doesn't really work.so and sometimes it's bacterial load. it may not be an infection but there's toomuch bacteria in a wound to allow the normal healing process to occur.>>lori casey: okay.why is it that we see diabetics are typically at higher risk for non-healing wounds?>>dr. kelly jones-monahan: well one thing we see is it's very commonin the feet. that's because many diabetics have what wecall diabetic neuropathy. the high levels of sugar in the cells actuallycause the nerves to short circuit.

so they tend to fell different types of painthan would be normal, but they also don't have good sensation.so they can step on a rock and not feeling it and get a deep bruise.then their healing process doesn't allow that to heal and then all the sudden they havea whole in the bottom of their foot. >>lori casey:that they don't even know. >>dr. kelly jones-monahan:they don't even know it. >>lori casey:is it too late then? >>dr. kelly jones-monahan:no it's not the big concern is that when they don't notice it how long do they let it gobefore they seek treatment.

there are concerns about infection that canascend into the bone and the deeper tissues. but certainly we treat a lot of diabetic ulcers.especially on the foot that heal with close personal attention, time, [unclear dialogue]that are cleaning up that wound, and other modalities as well.>>lori casey: so can normal healthy person be afflictedby non-healing wounds? >>dr. kelly jones-monahan:certainly we can see this. there tends to be some other issue going onfor example we may see it in someone who's fractured a leg or an arm.they may have hardware and pins or some other hardware that may make that a problem withhealing.

most of the time we're looking for some underlyingproblem. most normal healthy people are going to heala wound in you know with normal wound care. keeping it clean, keeping it covered.>>lori casey: so what happens if someone has a wound likethese non-healing wounds and it's left untreated, what's the absolute worse case scenario thatcan happen if it goes too far? >>dr. kelly jones-monahan:certainly worse case scenario if you're talking in we deal with a lot of extremity woundsespecially feet. they can get an infection in the bone whichcould cause limb loss. in other words they could lose the toe, thefoot, the leg and those are worse case scenarios

obviously.in some situations they can get infections which we see this many times in the pressureulcerations in the back. where the tissues have died and then the infectionthen sort of what we call ascends and spreads elsewhere.then they can become very ill associated with that.>>lori casey: can those infections lead to like blood infectionsand infections i mean can it get really really bad?>>dr. kelly jones-monahan: it can spread elsewhere we do see some infectionsthat can spread to the spine. obviously the bacteria can spread into thebloodstream and could seed other organs that

can show up in the heart valves, pneumonia;we see a lot of urinary track infections with patients with pressure ulcerations.it's sometimes hard to tell which came first the chicken or the egg.whether the urinary track infection caused debilitation and then the ulcer or vice versa.>>lori casey: so are there you're a general surgeon andi know you do lots of different surgeries are wound cares are there specialized trainingthat people who deal with advanced wound care go through?>>dr. kelly jones-monahan: sure.when i went through general surgery residence this was not.you know we have rotations in a lot of different

things, but specific wound care other thandealing with burns, isn't a really focused on.wounds we don't want wounds we close things up so they should always stay closed.but what we do in our center is that we send the physicians to a wound care seminar insan antonio texas and that also includes hyperbaric oxygen therapy treatments.which we also get trained in so that we can do those therapies as well.>>lori casey: so run us through the process of someone youknow patients sees their general physician and they've got a wound that's determinedthat it's more advanced how does the treatment plan work when they come to see you?>>dr. kelly jones-monahan:

sure.basically i see the patient in the office. the nurses see them they take an extensivehistory then i go through a lot of their medical problems.do they have diabetes and what do their blood sugars run etc.i do a physical exam i evaluate how's their sensation.i look at the wound specifically and then from there usually it involves debrisment.that's the fancy word for i'm going to clean it up.that's usually the first day in. most of the time most primary care physiciansare not comfortable poking and prodding and scraping and so forth.fortunately we are.

we numb the patient with topical creams andwe'll do biopsies of wounds if appropriate. but basically is the first thing we do iskind of see what's underneath all of stuff on top.see what the wound bed looks like. get cultures if appropriate, send tissue topathology. then we make a plan decide what kind of woundis this? what kind of treatment do we need to startwith this whether it's compression when we are squeezing the legs to prevent venus pooling.whether it's getting their sugar under better controlled.whether it's off loading which means a lot of people we need to get them off of the bottomof the foot.

so they’re not walking on their ulcer.once you off load them and keep them clean a lot of times they'll start healing.>>lori casey: so talk about how the treatment has evolvedcause there's some new technology out there. you said you do some debrisment but what otherkinds of treatments do you do? >>dr. kelly jones-monahan:well in the old days we use to say keep the wound dry open to the air.doc shouldn't i leave this open so it will get some air to it.what we find is that cells actually walk across a wound bed better if it's moist.it's like tadpoles moving across a pond. they move across much easier if it's moistso we try to keep the wound bed moist.

so we use this like colloids which are fancynames for gels like ky is a colloid. keeps the wound soft.then we do certain types of topical dressings. we'll use honey, honeys actually been shown.regular honey it's a medical grade honey. but honey has antibacterial properties andhas some wound healing properties. there are certain dressings that we use thathave what’s called metalloproteases fancy names for enzymes that help cells move andbreakdown the bad stuff. finally hyperbaric oxygen therapy.which has been looked at in poor light over the years because it's been used for all sortsof craziness. such as michael jackson sleeping in a hyperbaricoxygen therapy chamber.

but what hyperbaric oxygen therapy does isit increases the oxygen to the wound. >>lori casey:which is that what makes it heal? >>dr. kelly jones- monahan:that's what makes it heal. oxygen overall is the thing we are often lackingin many of these wounds. we talk about vascular wounds a great dealand people have low blood flow. even if you reestablish blood flow there'sonly so much it can do. which hyperbaric oxygen it's like pushingmore oxygen into the cells even more than all the blood could deliver.that increases the healing process and for some people who've had radiation therapy orwho have diabetic ulcers or who have vascular

ulcers this can be very helpful in healing.whereas other modalities alone wouldn't. >>lori casey:so how does the hyperbaric chamber work? we have a picture of it.it looks like a chamber of sorts. but how does it is it just like pure oxygenin there or how does it really work? >>dr. kelly jones-monahan:well it's a capsule it has plexiglas around it.you basically quote on quote dive. so what happens is the pressure in the chamberis increased to any where from 1.5 to 2 atmospheres. so in other words the pressure around youis like diving under water 15 to 30 feet. by doing that that develops more oxygen into the atmosphere and eventually into you

so you.>>lori casey: so does it get like you just breathing in?so it doesn't get like sucked into your skin you breath it in?>>dr. kelly jones-monahan: yes you breath it in then what happens isthe science of it is the oxygen is sort of forced into the tissues at that higher pressureand it gets to the tissues in a higher concentration. people talk time to dive or go down so thepressure is slowly comes up. it's like surfacing from underwater you can'tdo it very quickly because that can cause what we call barotrauma.some people as you know if you've ever dove your ears will pop.so some patients need ear tubes like we put

in kids to help equalize that pressure.some people will get some sinus pressure if they have problems with sinus and will useaferin to help open the sinus passages. worse case scenario is you can get a collapsedlung although that's very very rare. over time some people may notice some visionchanges which are reversible. >>lori casey:when we think of hyperbaric chambers you think of divers you know if they get if they comeup too fast from the water they've got to go in that to get pressure regulate or repressurized.so does a whole person go in there? >>dr. kelly jones-monahan:the whole person goes in. there's a couple different types of chamberswe have a mono chamber which means you go

in all by yourself.there are multi place chambers where multi people go in at the same time.actually the person who runs the chamber is also in with you as well.they dive with you and they come back up. there's advantages and disadvantages obviouslywe can get to patients very quickly there. in multiplace chambers the mono chambers arenice because there just private they are easy to deal with you don't need a huge room tomanage it. >>lori casey:so how long does someone dive or go in the capsule for?>>dr. kelly jones-monahan: most recommendations for are usually about90 minutes to 2 hours.

for our quote on quote dives.then treatment lengths can be anywhere from 20 to 40 treatments overall.on average it's about 30. it depends on their diagnosis and how wellthey are doing. >>lori casey:so is there is the person when they're in there do they feel any different other thanyou said some of the pressure in the ears and sinuses?>>dr. kelly jones-monahan: they notice a change in temperature they'llget a little colder so they may they usually have a blanket and then they get warmer asthey come up. because it's a higher pressure of oxygen weworry about fire so we basically keep there's

no make up, no lotions, no you can't bringyour ipad or a book in there. they have a blanket and their gown prettymuch. >>lori casey:so they just hang out in there? >>dr. kelly jones- monahan:watch television there's a television on the outside.a lot of them take a nap so and the time passes pretty easily most people do well.first off many people are concerned about the closeness of it about being in somethingenclosed. but most people find that they do well.we introduce them to the chamber have them look at it, get into it without diving.seeing how it feels and so forth to make them

more comfortable.>>lori casey: so if they have on average 30 treatments atwhat point in those treatments do you really start to see sometime significant in the healingon the wound. >>dr. kelly jones-monahan:usually after the first five to ten we definitely see an improvement.i've had a number of patients the diabetic wounds where we put them in the chamber andthey you know not a whole lots happened and then we really see all of the sudden a lotof improvement over time. a couple of them it's been amazing we putthem in and within you know we see them back in our office every one to two weeks and bythe time we see them again they've had seven

to ten treatments.wow it's you can really tell. >>lori casey:so a non-healing wound is something that it takes it's been around for at least four weekswe said? dr. kelly jones-monahan:four weeks. >>lori casey:how long does it take for one of these wounds then to heal once you've kind of got the treatmentplan going? >>dr. kelly jones-monahan:well this is the thing about wounds is that most of these patients have a chronic diseasethat we're not going to be able to cure. so it takes a lot of vigilance outside thewound center as well.

some of them tend to occur vena stasis especially.>>lori casey: which is what?>>dr. kelly jones-monahan: that's when the blood pools in the legs theyoften times the patients get a dark pigmentation of their legs.they'll have what we call brawny edema it's really sort of thick woody almost and thefluid pushing into the surrounding cells and then leaks out and then they get ulcers fromit. that once those things happen you can't reversethat problem so you have to sort of be vigilant to prevent it.we will often see someone heal a wound when we start seeing them within one to three months.it sounds like a long time but many times

we see patients who've had these wounds muchlonger than even 1 to two months. >>lori casey:that's what i was going to ask are you seeing is that you're seeing people pretty far intothe disease process? >>dr. kelly jones-monahan:i think it's getting better now that we are here and people are more aware of it.i think what had happened originally were that physician said okay we'll give this atry and didn't really know where to go from there.so now that we are seeing that we're aware that they're available we're seeing them alot sooner. makes that a lot easier for us.>>lori casey:

so if you're a person that is at high riskfor advanced wounds or maybe you're a caregiver of a person what signs and what sort of thingswould you recommend they look for or kind of a practice to get into?>>dr. kelly jones-monahan: sure.my every diabetic should be told about foot care.you should never walk around barefoot ever if you're a diabetic.even if you're getting up in the middle of the night to go to the bathroom you need ahard souled slipper or shoe to slip your feet in.you should check your feet everyday. to make sure that you haven't stepped on somethingthat there isn't something new.

for pressure ulcers caregivers need to watchrotation. you need to really rotate people so they don'tstay in one place. neurologic patients or elderly patients whodon't have that sensation to move need that help.for vena stasis what we say is compression you should be wearing a stocking somethingthat's going to keep the blood from pooling try not to stand long periods of time, walk,keep you legs elevated. higher than your heart is you can.it's sort of an upside down position but really compression is the most important thing forvena stasis. >>lori casey:so if debrisment doesn't work the hyperbaric

chamber doesn't work, is surgery the lastoption to kind of get in there and cut some of that out?>>dr. kelly jones-monahan: in some situations yes.we do some debrisment in the office and again that's those are things that obviously thepatient can manage and handle from a pain standpoint.sometimes we need to take them to the operating room as they become more aggressive.sometimes it requires revascularization where we find that the blood flow is not enough.so they might need a bypass where you're reconnecting some blood so that we can get blood flow.finding those things and in some situations we can't heal an ulcer.then we talk about what we do for that and

for some people it's limb loss unfortunately.we try very hard to help prevent that as much as we can.but it's a multi modality. i do way more internal medicine in this jobthan i ever do as a surgeon because i'm asking all these questions.what is your sugar today? what has it been running?what is your diet like? what shoes are you wearing?what's your blood pressure today? those sorts of things.>>lori casey: so really the patients or the caregiver reallyneeds to kind of top of it on a regular on a daily basis.so at what point when should somebody really

seek medical help do you think?>>dr. kelly jones-monahan: for my standpoint for us of course i see thecontinuity of this i have a blister today to a wound i've had for six months.so for my standpoint if you have something that is not healing and it's not healed ina couple weeks you need to seek your physician. whether or not it's ready to go to somethinglike that a non-healing wound could also be a sign of other things like skin cancers canpresent as non healing wounds such as melanoma or [unclear dialogue]it looks for an underline problem of is there an infection?is there a deeper infection? so a couple weeks of high i got this somethingand its not getting better or wound that get

bigger.that started small and now they're getting bigger you should seek medical attention.>>lori casey: so if you do have that just basic wound carejust keep it covered? >>dr. kelly jones-monahan:yes. >>lori casey:with some sort of like antibacterial something on it or just lightly covered with gauze?>>dr. kelly jones-monahan: from a standpoint of you know if you havei just cut myself i have a wound it's not something i necessarily need to seek medicalattention. wash with soap and water, you can apply anantibiotic ointment to it and then a cover

of some sort.usually we recommend that you change the cover everyday.most people can shower and let the water run over those everyday.hands are a difficulty because when you are washing you hands soap so frequently the dressingsget wet. so you need to change those fairly frequently.but keeping it covered is the most important thing.>>lori casey: so the opposite of what the olds wives taleletting it breath and keeping it open. dr. jones want to go ahead is there anythingelse we need to know that we haven't covered today?>>dr. kelly jones-monahan:

you know i think from a standpoint of educationwe i'm always very surprised when i tell patients that they need to monitor their medical problem.i said you should never walk without shoes and they look at me like really no ones evertold me that. blood sugars should be maintained less thantwo hundred because white blood cells don't work.so i think education is a big part of this telling people how to take care of themselvesand how to prevent this? i think is the most important.>>lori casey: before they have to seek more advanced care.well thank you so much for coming back to being well.we'd love to have you on again.

>>dr. kelly jones-monahan:thanks so much for having me. >>lori casey:thank you. â >>music>>kean armstrongâ  if you're one of those people at the grocerystore who only reads the front label on food packages, listen up.â â you might not have a good understanding of what you're getting.â â in today's health minute, holly firfer explains. grocery shopping can be about getting in,getting what you need, and getting out. but are shoppers buying what they think they'rebuying? if they're only reading the front of the package,many times they're not.

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and trans fats.. many manufacturers have removedthese 'bad' fats from foods, but not all of them have done so.â â just because a foodsays zero by law, it can contain up to a half gram transfat and still claim zero on the label per servingyou want to look in the ingredients for the words "partially hydrogenated oil" - the majorsource of trans fat - and steer clear of those items.being a proactive and informed shopper can go a long way.for today's health minute, i’m holly firfer. >>kean: januaryâ is cervical cancer awarenessmonth.â â cervical cancer was at one time the most common cause of cancer death foramerican women. but after 1955 the death rate

from cervical cancer went down. the main reason?â â betterscreening.â â  even though more than 12-thousand americanwomen were diagnosed with cervical cancer last year,â it is still the easiest femalecancer to prevent, because of two main tests. the first is the pap test or pap smear, whichdetects pre-cancerous cells in the cervix.â â  it's the gold standard of cervical cancerprevention the pap test is recommended for all womenaged 21 to 65 years, although the cancer has a tendency to show up in mid-life.the second is the hpv or human papillomavirus test-- which looks for the virus.â â almost99.9% of cervical cancers are caused by hpv if you get an hpv test with pap, the cellscollected during a pap smear, will be tested

for hpv in a lab.â â talk with your doctor whether an hpv test is needed.in some cases, an hpv vaccine may be recommended. but keep in mind, the pap test and the hpvtest only screen for cervical cancer.â â neither test detects for ovarian, uterine or vaginalcancers. for today's health minute, i’m holly firfer.production of being well is made possible in part by.sarah bush lincoln health system supporting healthy lifestyles eating a heart healthydiet, staying active, managing stress and regular check ups are ways of reducing yourhealth risks. proper health is important to all at sarah bush lincoln health system. informationavailable at sarah bush.org.

additional funding by jazzercise of charleston.