Conway McLean, DPM, Journal columnist

Modern medicine in the US is a complex entity, with multiple players involved in the provision of medical care. These include physicians, ancillary health care providers, the federal government, and the private, for-profit, health insurers. And, of course, the patients themselves. The private insurers are looking to make more from our health care, while the federal government is looking to control costs in the care of seniors and the poor. Many parties have their fingers in the pie which is American medicine.

The financing of US health care is hotly debated, differing as we do from all the other industrialized nations. The guiding hand of the billion dollar, private health insurance companies are an integral part of the complex, multi-faceted picture that is American medicine. Getting an accurate view is difficult, with so many parties involved. There are many cooks in this kitchen.

People with diabetes often get little attention to an area greatly affected by the disease, the foot, which experiences a unique constellation of complications. Some of these problems occurred to one diabetic individual, an elderly woman who we’ll call Betty. As occurs so frequently, Betty suffered a minor skin injury to the toes of one foot, which can have dire consequences in this population. Betty didn’t know it, but she was in a pickle.

Betty was quite elderly, but was fortunate to have the support of family nearby. She had been living alone until these sores developed. Betty was diabetic, but had never had a specialized foot exam. Like many with diabetes, she had neuropathy, meaning she didn’t feel certain kinds of pain properly. The result was Betty never felt the pressure on her toes from a particular pair of shoes.

Likely there would have been no consequences to this except Betty also suffered from peripheral arterial disease, as so many Americans do. Over time, this condition leads to thin skin, and difficulty with healing. Even the slightest trauma, irritation, or stress can lead to skin breakdown. And since the diabetic has difficulty fending off microbes, infection can necessitate amputation.

The sores on her toes worsened without proper care. Eventually she was seen by a specialist, who happened to be a general surgeon. Ever hear the one about everything looking like a nail when all you have is a hammer? This physician counseled for amputation of the foot and lower leg.

Would most physicians have recommended this? What about different specialties? Podiatrists tend to see many patients with chronic wounds: the majority of these wounds occur below the knee. Knowledge of the most effective practices and use of more advanced techniques allows many limbs to be spared. Could Betty’s leg have been saved? No one can say, but healing of these takes time. Too often, amputation is recommended since it’s definitive, one stop shopping.

Unfortunately, no one took care to maintain Betty’s blood sugar after the amputation. High blood sugars reliably cause problems with healing, and predictably, the amputation incision did not heal. Subsequently, despite the continued application of a dressing, the wound worsened. The physician’s suggestion: an amputation above the knee, claiming inadequate blood flow had prevented the wound from healing.

Betty’s family was not pleased and another opinion was sought; a physician board certified in wound care. A thorough evaluation revealed sufficient blood flow, adequate nutrition for healing, and, most importantly, no signs of infection. This means there was no rush to amputate at a higher level (above the knee). Wound care takes time and patience, vigilance, insight.

The wound had developed a yellowish, slimy coating at this point. To a lay person, it looked horrific, a yawning chasm. To the trained eye, this wound was clearly overrun with biofilm, which is a colony of various bacteria that often form on joint implants, bone fixation plates, and, pertinent to our tale, ulcers of the skin. Biofilm is tough and gooey. It’s produced by bacteria, but generally it does not invade the host’s tissues. The conclusion, after examination of the wound, was that Betty’s ulcer was not infected, just colonized. But biofilm blocks the steps to healing of an ulcer and is considered a tremendous impediment to closure.

For some time, the recognized standard of care for the treatment of chronic wounds has been debridement. This is the technical term for the removal of dead, infectious or foreign material from a wound. For most wounds, this is necessary for the wound to close. Yet, Betty’s amp site had not ever been debrided. This is a common finding since many physicians are unaware of the accepted wound care techniques and practices.

The options for wound care today are staggering. But these are recent developments when considering the state of wound care just twenty years ago. Keeping abreast of these new developments is both challenging and exciting. New methods of electric stimulation can bring blood to ulcers not getting sufficient flow. Cold lasers revive the skin cells in the region. Fish skin is being successfully used to heal these challenging problems. Placental tissues (from a planned C-section)  have produced marvelous results when injected into diseased tendons and ligaments, as well as being used on chronic wounds. Although there are exceptions, many of these resistant entities can be healed when the best techniques are used.

Betty’s wound is looking extremely good and no further limb loss is anticipated. But this scenario is re-enacted many times nation-wide, in various forms and manifestations. Ill-advised, inappropriate wound care is performed regularly, leading to unnecessary hospitalization, infection, amputation, even death. But it is not just knowledge that limits wound care practice.

Wound care can be expensive. Advanced wound care techniques can be pricey and some of the living skin equivalent products might be considered exhorbitant. Debridement is technically surgery and we all know that is expensive. But when compared to the cost of an amputation, the physical therapy required, the prosthetic fabrication, it seems a bargain. Yet many insurances limit what is covered for wound care to only the most basic (i.e. inexpensive) products.

Advantage health insurance plans are  those offered by the big private insurers for those who are eligible for Medicare. The marketing for these plans intimates it is the same as Medicare, but in actuality, they skimp here and there. One way to cut costs is to reduce access, especially to expensive items when something cheaper may suffice. For example, the advantage plans require the physician jump through many hoops to get the authorization allowing them to make use of these advanced healing materials. Multiple forms, reviews, prior authorizations each demanding hours of staff time, are demanded. Few will get through the arduous process, the result being the patient is deprived of the medicine or material.

Some would say there is too much specialization in medicine. But, in many areas, having a physician focused on some specific topic results in better care. The treatment of non-healing ulcers is certainly no different. Board certification in wound care is often the tell-tale, the indicator, that a physician is educated in the most effective, state-of-the-art techniques and technologies. It usually means an ulcer will heal faster and more effectively. That means better health and a better quality of life. Good goals all around. 

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments at drcmclean@outlook.com.