Essentials of Diabetic Limb Salvage (Part 1)

In this episode of Wound Care Wednesday, Dr Johnson joins guest speaker Dr Paul Kim, a podiatrist and Medical Director of the University of Texas Southwestern Wound Program. This episode explores diabetic limb salvage, focusing on a multidisciplinary approach to wound care.

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Dr Jonathan Johnson: Hello, how is everyone doing? Welcome to another Wound Care Wednesday. I'm Dr Jonathan Johnson, also known as Dr Wounds. And here, live at SAWC Fall 2024, we are here with the distinguished podiatrist and head of wound care at UT Southwestern, Dr Paul Kim. And today, we are going to focus on diabetic limb salvage, focusing on a multidisciplinary approach to taking care of diabetic wounds, and, most importantly, connect with you. 

So, sit back, relax, grab your coffee, grab your tea, grab your wine, and let's get started with another Wound Care Wednesday. And remember, this is sponsored by PolyNovo. 

So, I'd like to introduce Dr Kim. Dr Kim, thank you for joining us today. 

Dr Paul Kim: It's my pleasure, Dr Johnson. I'm really looking forward to this conversation.

Dr Jonathan Johnson: I mean, Dr Kim and I are great colleagues, known each other for a while. Couple fun facts; we're both from the great state of Colorado, and although he went to the University of Colorado, CU Buffs, if I would have went there it would have been 13th grade because I'm from Denver and all my classmates went there.

Dr Paul Kim: Huh, yeah.

Dr Jonathan Johnson: So we share that in common as well as being great wound care advocates.

Dr Paul Kim: Yeah, absolutely, I think your passion is clear. I'm really excited to talk, but I want to question something you just said.

Dr Jonathan Johnson: Mm-hmm, go ahead.

Dr Paul Kim: You called this “limb salvage.”

Dr Jonathan Johnson: Mmm. 

Dr Paul Kim: I got to tell you, that is not accurate. And I know people like to use “diabetic limb salvage” because it's sexy, it's interesting. But honestly, our goal is not to salvage tissue. Our goal is to preserve function. Sometimes you sacrifice tissue in order to preserve function, because one of the things that I see often in my practice—and I've seen now, this is my 21st year of practice—is that we do a lot of whittling pieces and parts, and they end up in the same place, but the patient's older and sicker, less likely to rehab.

So, I'm always concerned when people use that term, and I'm not picking on you Dr Johnson. You know better than that. 

Dr Jonathan Johnson: Mm-hmm, mm-hmm. Of course, of course, of course. 

Dr Paul Kim: But this idea of limb salvage has to die. We need to think of it as limb function preservation.

Limb salvage is a very physician-centric word, whereas limb function preservation is very patient centric, and we need to think about the quality of life. And I see these patients being tortured year after year, taking bits and pieces, and to what end? You've really ruined their quality of life over a longer period of time. 

Now, I'm not saying I know the answer, when to push for salvage versus earlier amputation, and that's a difficult debate, and I've been on both sides of that debate, and I'm not sure I have an answer. 

Dr Jonathan Johnson: Mm-hmm.

Dr Paul Kim: But I think we need to be thoughtful, individualized, depending on the patient's needs, what their expectations are for recovery. There's so many other complex factors associated with that.

Dr Jonathan Johnson: Got it. 

Dr Paul Kim: But anyway, I just wanted to lead with that. 

Dr Jonathan Johnson: No, that's a great point. And listen, clarification is always key. We're always evolving, always learning. 

Now, let's take a step back a little bit and talk about the aspect of diabetes. Specifically, we know it ravages our communities. It's a huge cost burden to our healthcare system. Tell us a little bit about diabetes and wound care and some of the foundational aspects we want to know. 

Dr Paul Kim: Sure. So, one of the things about diabetes that I think—especially diabetic foot ulcers, as that's kind of our discussion here—there is a notion that diabetes is a disease of gluttony, so it doesn't get the spotlight as, for example, cancer care is. But the cost of taking care of diabetic limbs exceeds that of cancer. So, I'm not sure where our priorities are. I think there's a lot of stigma attached to diabetes. And specifically, it's the stigma attached to obesity and diabetes, I think. 
What's interesting is I've been to every continent in the world except for Antarctica…

Dr Jonathan Johnson: Wow.

Dr Paul Kim: …investigating wound care and how it's been provided by different limitations of resources, the people that populate those areas. And what I'm finding is that the highest group– what I recently found, before the pandemic shutdown, I was in China. And that area has the highest new incidence of diabetes in the entire world. 

Dr Jonathan Johnson: Hmm.

Dr Paul Kim: And I was in a diabetes hospital, visiting a diabetes hospital. They have these diabetic hospitals where they take care of wounds because their reimbursements are different. There's lots of reasons for it. 

Dr Jonathan Johnson: Right. 

Dr Paul Kim: But anyway, what I found was they're not fat, but they have type 2 diabetes. So, I think there's a genetic link to this. There's a lot of social influences that are part of that.

And so, I think there's a lot of confusion about diabetes and diabetic complications, as you pointed out Dr Johnson. Diabetes impacts every part of the body. Every system is impacted. 

Dr Jonathan Johnson: Right.

Dr Paul Kim: When you talk about the diabetic foot ulcer, what it is is simply a sign of the disease. 

Dr Jonathan Johnson: Mm-hmm.

Dr Paul Kim: So, we're really doing symptom-sign management rather than trying to find a cure. The underlying disease is pervasive, especially in our most at-risk populations, the minority populations of African Americans and Hispanics. And it's interesting, I was at Georgetown University Hospital practicing for almost 10 years, largely African American population I was serving there. When I came to Dallas, it was a largely Hispanic population. Same socioeconomic pressures, same limitations to healthcare resources. And it's largely the working poor that we're talking about here. So, I was just as a side story, do you have another question or do you want me to keep going? 

Dr Jonathan Johnson: No, no, no, go ahead, go ahead. Well, I was going to…

Dr Paul Kim: Because I’ll go on forever.

Dr Jonathan Johnson: Trust me, I was going to lead in with another one, but go ahead. I love the energy, keep it up.

Dr Paul Kim: What's interesting is I was invited to an FDA panel, this was a couple of years ago, discussing the FDA's role in looking at new—whether it's devices, biologics, or drugs. And it was an interesting conversation. There was real patients there giving their input. And the FDA asked me, they said “What can we do as the FDA as far as trying to encourage innovation in the space by industry? How can we help?” And I said, “You can't.” I said “If you can't solve poverty, this is going to persist.” Because the highest at-risk populations are our poorest populations in our cities and rural areas, by the way. Because now, being in Dallas, we have a lot of rural communities with no health care available to them, and they drive hours to come into UT Southwestern to not only see me but other health care providers as well. So, I think this is endemic of social issues rather than the development of new technologies. 

Now, has new technologies helped? Absolutely it has. 

Dr Jonathan Johnson: Okay. 

Dr Paul Kim: I'm not saying it hasn't. But, ultimately, it's about inequality in access to health care. It's about social biases and norms that have really stigmatized diabetes, specifically. And so, I think this is a very complicated thing. 

By the way, Dr Johnson, I have no answers for any of these problems. 

Dr Jonathan Johnson: Well, exactly. 

Dr Paul Kim: I can pick problems out and say that, I can point my finger, but I can't come up with a solution. So, to me, it's not very helpful when people don't have solutions to problems there. 

Dr Jonathan Johnson: Well, no, Dr Kim, first of all, that's great. And I want to pick at a couple points that you've said, because I think they're really important for the audience to summarize. Number one, we're looking at a multispecialty approach to diabetes, right? And from you working in UT Southwestern and running the Wound Care Center, you're working with endocrinologists, vascular surgeons, podiatrists, plastic surgery; it's a multispecialty approach, number one. 

And then the other important concept is access to care. If we can't figure out a way to reach impoverished or marginalized populations, there's always going to be an issue. 

And then the last concept that I want to summarize, that I think was amazing, is new technology. 

Dr Paul Kim: Yeah.

Dr Jonathan Johnson: So, tell us something a little bit about new technology and how we can use that to fight the epidemic of diabetes. 

Dr Paul Kim: Yeah. Well, I want to lead into that by answering one of the thoughts- I understand this is a multidisciplinary discussion we're having. 

Dr Jonathan Johnson: Yes. 

Dr Paul Kim: And honestly, that term has been so morphed. And I hear it used a lot, especially in the wound space, and then you start to dig, and it's really not multidisciplinary. And I'll give you an example. 

Dr Jonathan Johnson: It should be. 

Dr Paul Kim: It should be.

Dr Jonathan Johnson: It's not, but it should be. 

Dr Paul Kim: But people say like, “Oh yeah, I do a day or a day-and-a-half in the wound center, and then I go back to private practice.” That's not a multidisciplinary wound center. Multidisciplinary truly means an integrated approach where there's cohabitation of providers and nurses and everywhere else. That way there's a continuity of care. And then you involve the right people instead of having the patient wait for each individual appointment that could be scattered throughout the community. And so, I think that delays care, and the communication is not there. If you're cohabitating in a space, you are forced to talk to each other. 

One of the easiest things is an EMR that's shared. That allows for quick access to information and efficient delivery of care because everybody is sharing the same database. The other piece is that we're all linked through pagers and Epic chats and all this stuff. So, I think that communication is very important. 

So, I just want to say that multidisciplinary care has been shown to not only reduce costs but increase the quality of an efficiency of care that's delivered. It's important. I'm just not sure we're doing it as well as we could be. 

Dr Jonathan Johnson: Right.

Dr Paul Kim: Now, it's hard to do. I've got 2 papers, just Google or PubMed search me. I wrote 2 papers on this multidisciplinary approach. 

Dr Jonathan Johnson: Nice. 

Dr Paul Kim: It's not easy. You really need people that are passionate and on the same page of how to do it right with a patient in its center. There's a lot of distractions, including economic pressures, the pressure to increase your RVUs, all that stuff. It makes it hard.

Dr Jonathan Johnson: Right.

Dr Paul Kim: And it's not the easiest thing, but it is a goal that we should go for. But we should be careful when we talk about multidisciplinary care to understand what that actually means. 

Dr Jonathan Johnson: Right.

Dr Paul Kim: Because I think it gets a little bit confusing when people describe what they're doing. And I'm like, that's really… “Oh, we have a vascular surgeon there,” like, “Do you ever talk to them?” “No.” “How do you communicate with them?” “Well, through the nurse.” Well, that's not really good direct communication discussing the patient.

Dr Jonathan Johnson: Let us know or help us understand some of the new technology that's helping us fight diabetes. 

Dr Paul Kim: So, it's interesting that technology—not just in medicine and healthcare, but in all aspects of life—have made our lives easier. I think everybody could agree to that. 

Dr Jonathan Johnson: Yeah.

Dr Paul Kim: Although access to that technology is not always there. 

Dr Jonathan Johnson: That's the issue. 

Dr Paul Kim: That includes internet, like high-speed internet, and those sort of things. But I am excited about a few things. 

One of the things is we're right now trialing something called ambient conversation capture. Now what is that? It's not Dragon. It's not dictation. But you're having a conversation with a patient, and AI is picking up the relevant parts of that discussion and automatically putting it into the note. And let's say I say, "Mr. Smith, I also want to order x-rays." X-rays are ordered without me touching a keyboard, because what's been happening is technology– we've been kind of leashed to it, typing away in front of the patient or spending hours after the visit trying to catch up with notes, which you don't even remember half of what you saw or talked about with the patient. So, this allows more freedom, more time to spend with the patient and education and not just in treatment. So that's one piece. 

Dr Jonathan Johnson: Yep.

Dr Paul Kim: The other thing is remote monitoring. People have been talking about it for ages. The problem is there's so many different devices, and each has a cost related to it, and it seems to me if my telephone can record video, can take pictures, can search the internet in a small little portable device, I don't know why industry hasn't moved to a singular device that encompasses all the remote monitoring that is capable that's already out there. 

Dr Jonathan Johnson: Mm-hmm.

Dr Paul Kim: I think the government needs to perhaps invest in a more cohesive plan on what actual remote monitoring is, because that is the future.
 
Dr Jonathan Johnson: Yes. 100%.

Dr Paul Kim: If patients can't get to your office, you can go into their home virtually, right? And during COVID, as you know, telehealth was supposed to help. It was terrible, especially in wound care, because wound care is about touch, smell, and feel, and you can't do that through a screen. And so I think there were a lot of disasters that occurred because of the fact that we weren't able to be face-to-face with patients. In fact, patients didn't like it either. They said, “I really want you to see me.” 

Dr Jonathan Johnson: Right. 

Dr Paul Kim: Because they understood the importance of that as well. But having said that, I think there is some technological advances where we're going to be able to smell the wound remotely, where we're going to be able to use all these sensors, including perfusion sensors and pressure sensors, to make a more accurate assessment and then a treatment plan. But a part of that is there's too much information. 

Dr Jonathan Johnson: There's a lot of information. There’s a lot.

Dr Paul Kim: This is why generative AI is the answer for that, because generative AI has such capacity, they can collate information into the essential necessary things. 

Dr Jonathan Johnson: Mm-hmm.

Dr Paul Kim: Because I open a chart, and we use Epic, I open a chart, and there are notes from every other discipline. And I don't have time to go through every single one trying to understand my patient’s situation. 

Dr Jonathan Johnson: Right. And that's going into that multispecialty concept that we think would work. 

Dr Paul Kim: Sure.

Dr Jonathan Johnson: So, what I'm hearing is that, number one, diabetes is an ongoing process from a wound care standpoint that we need to continue to make sure we're treating effectively. We're going to use technology, help to increase access, and make sure that we work as a team…

Dr Paul Kim: Yep.

Dr Jonathan Johnson: …to decrease the rate of a cost-burden-based diagnosis that's more progressive and more costly than most cancers.

Dr Paul Kim: Absolutely, and just a step further, if you think about having a patient visit with all the disciplines at the same time with that patient, and you can do that remotely…

Dr Jonathan Johnson: Mm-hmm, that’s key.

Dr Paul Kim: That's a lot of cost savings. It's a lot of resource savings for everyone.

Dr Jonathan Johnson: Very true. So, one of the great things we like to do on Wound Care Wednesday with our guests: Tell me a great patient outcome experience and tell me why you're passionate about wound care and what got you into the field—in 2 minutes. <laughing> 

Dr Paul Kim: Yep. I'll do the best I can. One is, I don't remember my successes, I remember my failures. 

Dr Jonathan Johnson: Okay.

Dr Paul Kim: So, I can tell you what I did wrong for many different patients. But what really got me interested in wound care is, as you know, Dr Johnson, it's the Wild West. 

Dr Jonathan Johnson: It is. 

Dr Paul Kim: And we're very product heavy in reliance. And I think we've gone away from using our brains and talking to our patients and understanding their situations. And so, I think there's so much we don't know. I liken it to cancer research. We're about 20 years behind them as far as cancer. 

I'll give you one example. If you look at their customizing of medications that are genomically profiled, so specifically looking at their genetic profiles. We don't do that in diabetes. We just throw things against the wall and hope something sticks.
 
Dr Jonathan Johnson: Mm-hmm.

Dr Paul Kim: So, we need to rethink how we do this and who influences us on how to make decisions. 

Do I rely on technology? Absolutely. Do I rely on products? Absolutely. But if we could have some more time to do more thoughtful investigation of what we should be doing, and identifying what we're doing is not working and moving on to something else, I think that'd be tremendously helpful. 

Dr Jonathan Johnson: 100%. And listen, that's exactly what our concept and thought process here on Wound Care Wednesday is. Dr Kim has been a great and excellent guest. We'd like to thank you for coming on. And most importantly, we want to make sure everyone tunes in for the next Wound Care Wednesday. We are, again, sponsored by PolyNovo. And, we are super excited that everyone has joined us. We will see you on the next Wound Care Wednesday.