Essentials of Diabetic Limb Salvage (Part 3)

In this episode of Wound Care Wednesday, Dr Johnson talks with guest speaker Dr Edward Lee, a clinical plastic surgeon in New Jersey and a Residency Program Director for the Division of Plastic Surgery at the Rutgers New Jersey Medical School. Dr Lee describes how he approaches discussions with patients who struggle with diabetic wounds, including incorporating innovative technology to improve patient compliance. 

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Dr Jonathan Johnson: Hello, and welcome to an awesome audio episode of Wound Care Wednesday. I'm Dr Johnson, also known as Dr Wounds, and today we have a very special guest with us to discuss a pertinent issue that we've had conversations with in the past, specifically diabetic issues, vascular access issues, limb preservation issues. And we're super excited to also have our sponsor, PolyNovo, today. And we're going to look at the topic of a multidisciplinary approach to diabetic limb salvage, integrating different medical specialties—podiatry, vascular, plastic surgery—and we've had a chance to really have informative conversations with each one of those specific groups and each one of those providers.

And we have the honor today of working with and having a great conversation with Dr Edward Lee. Dr Lee, welcome. Tell us a little bit about yourself and your passion about wound care.

Dr Edward Lee: Well, thank you. Thank you for that introduction. It makes me feel like I've done more than I actually have. It's fantastic. <laughing> Diabetic wounds and diabetic foot ulcers—what an amazing topic. This is actually what got me interested in plastic surgery. It's kind of an oddity, but where I trained, so I did my medical school down in Georgetown.

Dr Jonathan Johnson: Okay.

Dr Edward Lee: And in Georgetown, there's a guy by the name Chris Attinger.

Dr Jonathan Johnson: Of course, I know Dr Attinger well.

Dr Edward Lee: I think everybody in the wound care world and who's dealt with diabetic foot ulcers knows the guy, and his charisma, his passion for the subject and for his patients really is what got me interested in plastic surgery. What he said was that when you look at everything that we do as plastic surgeons, diabetic foot ulcers are one of the most challenging problems you can tackle.

Dr Jonathan Johnson: Agreed.

Dr Edward Lee: It needs all of that multidisciplinary care and approach. And if you don't have the technical skill and the, I guess the experience, and the ability to treat the patients for all of those issues, your patients will fail their reconstructions and they will lose their limbs.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: It's a difficult battle, because even if you do everything right, they may still lose a limb. And so it's incredibly challenging.

Dr Jonathan Johnson: Very true, very true. And one of the major issues working at a larger institution like you are and having a great academic background is the fact that you have the ability to work with a lot of different specialties. And that's one of the topics that we always want to discuss when we're looking at extensive comorbidities, like peripheral vascular disease as well as diabetes, and we want to look at a multidisciplinary approach. So, being on the academic side, tell me a little bit about how you work with different specialties, whether that's internal medicine, infectious disease teams. How do you integrate each one of those specialties to make sure the patient has the best care needed?

Dr Edward Lee: Yeah, I appreciate the question. Our focus really is every single patient gets your full attention. So it's the right patient, the right surgery, at the right time. And some patients, they really don't need any surgery.

So how do we incorporate all of these different viewpoints? First you have to identify who's going to be with you, right? Who's part of your multidisciplinary team?

Dr Jonathan Johnson: Right.

Dr Edward Lee: And, for an academic, it's a little bit easier because, well, we have a center for it, right? So you've got the vascular surgeon, you've got your orthopedic foot and ankle, you've got podiatry, you've got infectious disease, radiology, your pathologists, your microbiologists, you've got a whole team there.

Dr Jonathan Johnson: Okay.

Dr Edward Lee: And interestingly, I was in private practice for a couple of years, and you end up with a very similar team, but it's just not everybody's under one umbrella. You have everybody on speed dial, and that's the way it works. You call everybody up and you say, “Hey, look, I've got this guy, I need help.”

Dr Jonathan Johnson: Right.

Dr Edward Lee: And I think everybody, all of us as physicians, that's why we got into medicine, right? We're there to help. We're there to make things work for the patient.

Dr Jonathan Johnson: 100%.

Dr Edward Lee: So how do we get these people involved? And really, first is respect, right? You have to respect everybody. Everybody has input into the team. It's how we look at our team approaches to care for, a top-down approach when you're looking at physician nursing, nursing assistants. Really everybody has an equal voice, because everybody's coming from a slightly different perspective and everybody needs to be able to say what they see and what they think and be able to contribute to the team. And that’s what we do.

Dr Jonathan Johnson: Got it. It's a great point, but you said something else that was very interesting. You said that when you were in private practice, your resources were a little bit different. Your outreach has to be a little bit different. Your communication and continuity of care with patients is a little bit different. So would you say that you have seen or are you seeing more patients on the private practice side as far as diabetic patients are concerned and diabetic wounds are concerned now or when you were in private practice?

Dr Edward Lee: I would say in the academic setting, I am seeing more patients with diabetic foot ulcers and other more complex wounds.

Dr Jonathan Johnson: Okay.

Dr Edward Lee: And part of that is when you look at the economics of it, wound care is very challenging.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: I think that there was a period of time where wound care was incredibly well remunerated, but I think that the challenges have grown for the field.

Dr Jonathan Johnson: Yes.

Dr Edward Lee: We have tons of products available, which is great. Now we have this panoply of options available to treat wounds, to try to bring in additional growth factors, to try to provide off-the-shelf type skin product. But what ends up happening is now the government is clamping down on some of the options that we have available.

Dr Jonathan Johnson: Yes.

Dr Edward Lee: Total amount of pay available is decreasing, all right? We're constantly looking at reimbursement cuts.

Dr Jonathan Johnson: Right.

Dr Edward Lee: And I think it's, honestly, as the cost of living has gone up throughout the country,…

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: …the amount of money that patients have for things like dressing supplies—where they were asked to buy a number of their dressing supplies before—patients are really suffering.

Dr Jonathan Johnson: Yes. Yes, 100%. If we're looking at the cost of wound care as an integral part of the cost of health care, it's in the billions. We're close to between $90 and almost $120 billion every year. Unfortunately, that has to be earmarked in the health care system in general just to pay for chronic wounds. So, having quality resources and working with payers is key because we need to continue to move, number one, our field down the road effectively, but we also need to make sure that we're treating patients as quickly as possible, because initial treatment is definitely key.

So, from a diabetic standpoint, how do you initiate conversations with some of your patients that come in that say, "Hey, listen, Doc, I know I'm supposed to stop eating Twinkies,” or whatever. “I know I'm supposed to offload and wear this special offloading device that you've given me as I ambulate and walk, but I just can't do it, Doc. So what do I do? How do I get better?” So, how do you initiate those conversations? It's always great to figure out how my colleagues, and obviously the listeners always want to know how to integrate those conversations into the patient encounter.

Dr Edward Lee: I love the question. I think this is the essence of what we do as physicians, right? You've got to walk into a room. And if it's a new patient, they say you have, what is it 15 seconds?

Dr Jonathan Johnson: Yes.

Dr Edward Lee: To make to make an impression and to make that connection with that patient so that they now trust you. What a difficult and challenging personal interaction that is.

Dr Jonathan Johnson: 100%. And the crazy thing is, not to cut you off, but the crazy thing about it is comedians actually get more time than physicians do to really form that common bond. And they do that professionally, which is crazy. <laughing>

Dr Edward Lee: And honestly, I think some of it is just really being who you are as a person.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: You walk in there and you want your patients to open up to you. You want them to tell you if they are not being compliant with their medications.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: So, I tend to move away from how I was raised, which is a rather strict Asian-American household, <laughing> where there's very definite rules and when you don't follow them, you get reprimanded, let's say. <laughing>

Dr Jonathan Johnson: Reprimanded.

Dr Edward Lee: Exactly.

Dr Jonathan Johnson: Me too, trust me, me too. I understand, trust me.

Dr Edward Lee: But I tell the patients, “Look, I'd like to lose some weight. I've tried losing weight. It's really, really hard. You go home, you're hungry. You see, well, I've got some leftover pizza in the fridge, or I can spend my time making a salad. What am I going to do?” Well, there you go.

Dr Jonathan Johnson: <laughing> Of course, yeah.

Dr Edward Lee: But if you keep doing what you're doing, you're going to lose a leg. You're probably going to have a heart attack. Is that what you want to do to your relatives?

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: To your friends? To yourself? And if it's not, then let's find a way to make this work for you. And I honestly have not incorporated discussion of the GLP-1 inhibitors into my discussions with patients with diabetic foot ulcers.

Dr Jonathan Johnson: Mmm, I like that. I like that.

Dr Edward Lee: Yeah, that's a huge, huge new topic to discuss.

Dr Jonathan Johnson: Mm-hmm, mm-hmm, 100%. Because again, this goes back to the point of treating the entire patient, not necessarily just the primary dressing or the secondary dressing, or making sure that we're adequately removing devitalized tissue, it's treating the whole patient.

So, I think the common theme that's really important is education and communication. And I think having those conversations when the patient initially comes in, when they start treatment—whether it's academic, whether it's a large multispecialty group, whether it's private practice—is key because now you're initiating a plan, and you're hoping to decrease the cost of a chronic wound on the back end.

So, from an academic standpoint, are there educational programs that either you would like to implement or that you have at your department and at the hospital that you really found have been effective when communicating with patients?

Dr Edward Lee: I have to say, not so much. It's challenging.

Dr Jonathan Johnson: It is.

Dr Edward Lee: There are so many resources available, whether it's online, in print, individuals, support groups.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: A lot of it comes down to personal accountability. You can try to point people in the right direction, and I think that you have to, right?

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: The more resources you have available to point people in that direction, the better. And I think that's one of the wonderful things about social media, about the podcast world, being able to get that message out there.

Dr Jonathan Johnson: Yes.

Dr Edward Lee: And then the message is delivered in a slightly different way. And sometimes patients will latch onto it.

Dr Jonathan Johnson: Mm-hmm, okay.

Dr Edward Lee: And so you offer them everything that you have at your disposal, and something hopefully will click for them. And they’ll say, “Oh, that makes perfect sense. Now I know why I have to do this.” And you could talk 'til you're blue in the face, and if you're not saying it in that right way, they're not going to get it.

Dr Jonathan Johnson: 100%, yep. No, I agree. And I think that's a great segue to chat about another topic: New technology in treating diabetic and chronic wounds and treating ischemic ulcers, lower-extremity ulcers, etc. There's a lot of new technology that's out there. We're looking at types of fluorescent imagings. We're looking at ways of identifying and managing wounds. And we're even looking at virtual medicine as far as telemedicine is concerned, and that really helps us with an outreach standpoint. So, have you utilized any new technology? And have you found it beneficial for your practice?

Dr Edward Lee: Yeah. As an academic center, obviously, we often will get the latest and greatest of things.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: So we acquire a number of new technologies. And I have to say some of them are phenomenal. One of the ones that I've been playing around with more is the Polynovo product, BTM.

Dr Jonathan Johnson: Like that.

Dr Edward Lee: So there's a number of things. So, one of the things that you need to do is close off the wound, right? Once you get it clean, once you get the infection controlled, once you get it offloaded, it still needs to close.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: But if you can do that synthetically, one, bacteria don't like synthetic stuff.

Dr Jonathan Johnson: No.

Dr Edward Lee: So polyurethane is not something that bacteria eat. Two, if it closes it off so that the dressing change is a little bit simpler? So, for venous ulcers, you need stuff that's not going to hurt.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: Because those patients, they've been dealing with a ton of pain. And then you don't want things that are going to soak through, right? So that's one of the problems that I've always had with some other products, like some of the cultured cell products, is that they will produce a fair amount of fluid or an odor. I’ve got to say, I would not want that on my foot if I have something that smells bad.

Dr Jonathan Johnson: Of course.

Dr Edward Lee: Quality of life is an issue. So that's one product that we've been playing with that has provided a significant, I think, boost in patient compliance with their wound care and seems to create this really nice neodermis, which was surprising to me because…

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: …polyurethane foam? Why is that going to create a dermis? That makes no–

Dr Jonathan Johnson: I know.

Dr Edward Lee: But it does.

Dr Jonathan Johnson: Yep, that's key. Listen, from a microbiology standpoint, we have to create that scaffold, that foundation. We need the cells that are effective in helping to build granulation tissue. So, you know, as long as you can do that, you can help the wound edges reapproximate. It's 100% key.

So, we talked a little bit about the new technology side. Help me understand or give me your thoughts on accessing patients that may be outside of the health care system and how we can potentially reach them to really initiate those diabetic management conversations, ischemic injury conversations. Have you looked into any type of communication resources for that type of patient-physician and provider interaction? And if so, what have you found that's been beneficial?

Dr Edward Lee: Wow, it's really delving into the 21st century here.

Dr Jonathan Johnson: Yep.

Dr Edward Lee: I think we have a lot of tools at our disposal, and the question is: How are we going to get to these patients? We have here in Newark, New Jersey, it's a melting pot. We have, in our hospital at any point in time, we have probably 30 to 40 different languages being spoken by our patients.

Dr Jonathan Johnson: Wow.

Dr Edward Lee: And so it's a challenge, not just to reach them, but to be able to communicate effectively with them.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: And I think that is, we have invaluable resources in our translators, in our nurses and our staff who, some of them speak the language and understand the culture. Because really, the cultural nuances that exist are so challenging. So when you're talking about reaching out to a different group of patients, the fact that we have these food deserts within a city where the culture is to eat poorly and not nutritious food that's going to help their wounds to heal.

Dr Jonathan Johnson: Of course, mm-hmm.

Dr Edward Lee: How do you overcome that cultural barrier is an enormous task. And I think this is where we do look to the government for some help with this, right? We're looking for local governments, local chapters and charities to help with the education of not just our patients, but of the community as a whole.

Dr Jonathan Johnson: Mm-hmm. Yep. Listen, I think it's a large-team–based approach, as we've discussed—multispecialty, from the dietitians to physical therapy to obviously the providers, and even from a social work standpoint, right? Sometimes we need a strong social work case management team that is really effective in communicating with patients once they leave the hospital or the wound clinic or whatever academic or private setting you may be in. And having that foresight is key, because obviously we want to decrease rates of diabetic issues and decrease costs. So, we discussed a lot about that.

We looked at some new technology and really, from a biochemical standpoint, helping to propagate that wound, right? We know that wounds are stalled in the inflammatory phase. Our role as providers, as aggressively as possible, is to help the wound progress through those four stages, because it's stalled. So, we want to look at that.

We looked at some of the barriers—as far as systemic barriers, language barriers, location barriers—that can be an issue to, really, these diabetic wounds healing. And I think we've covered a lot today.

But what I wanted to do just briefly, because I know we have a little bit of time left, tell me—and we love to do this on Wound Care Wednesday when we chat with our different providers—tell us an awesome story that had a great clinical outcome or a clinical outcome that wasn't the best, and how did you handle it? What did you do?

Dr Edward Lee: Yeah, this is one of those stories where the technical aspects of it, we fail, right? An amputation, we feel like it's a failure at times.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: And what if that amputation then gets infected? And we move up from there. You start with the toes, you go to the BKA, then you're at the AKA, but the infection just keeps running its course.

Dr Jonathan Johnson: Yeah.

Dr Edward Lee: One patient ended up with a very high AKA. We were able to salvage it from there. But it was– The team approach to it was so profound and so cohesive, the patient really was okay with all of this, right?

Dr Jonathan Johnson: Amazing.

Dr Edward Lee: Their experience was a positive one. The patient ends up with a high AKA, ends up getting a prosthesis, sending us videos of him walking. He's turned his life around. Starts doing yoga.

Dr Jonathan Johnson: Wow.

Dr Edward Lee: He sends us videos, we're like, this is fantastic! <laughing> It's one of those where, really, like you're talking about: we're focused on the patient.

Dr Jonathan Johnson: Okay.

Dr Edward Lee: And so create these teams. We create these support networks. We bring in all of this technology, all of this skill to try to fix what's going wrong. And at times it's the effort and the care, the emotion, that counts more than anything else.

Dr Jonathan Johnson: Agreed, and yep, no go ahead, go ahead, Dr Lee.

Dr Edward Lee: No, no, and so, I'm just, I'm very grateful for you asking that question and being able to share a story about a patient where technically you could look at it as a failure.

Dr Jonathan Johnson: Mm-hmm.

Dr Edward Lee: But really the patient, I think, felt that it was a huge success for him.

Dr Jonathan Johnson: And that's a major point that I think our listening audience, whether you're a provider or just interested in wound care, student, etc, the key is communication with the patient. Because I've had clinical experience with specific cases where, just like you, from a surgical standpoint, I thought we didn't do the best we could have done. But through continued communication with the patient, explaining to them what the clinical course was going to be, explaining to them even the technicalities of the surgery, reaching out to extended family that may be their POAs, and just continuing to stay engaged with the patient and answer their questions. And even at the end, they're like, “Hey, Doc, you did a great job. I feel amazing. I'm walking. My quality life has improved.” And you're thinking yourself like, that was a difficult case, and it's one that I would put in the back of my head to do some more reading about or figure out maybe an alternative way. Not saying that it was a bad surgical outcome, but just, it took you on a path surgically that you didn't think you would go down. Because rule number one is: Do the easy things first, when you're in your case, and then work from there. That's what you're taught in training.

So, it's great that you also have had that experience and just speaks to really the point of staying engaged with the patient. Communication is key. And then just verbal continuity of care is what I call it. So, the more you do that, the better.

Dr Edward Lee: Yeah. Like we just said, the relationship with the patient is so important. And we've been talking about the teams and all of the people involved in the teams, and one group that I totally forgot to mention are wound care nurses.

Dr Jonathan Johnson: Oh yeah, of course.

Dr Edward Lee: Oh my gosh, we can't do anything without them. And they spend the most time with our patients and really are the heart and soul of what we do in the wound care world.

Dr Jonathan Johnson: Could not agree more. Could not agree more. They're the foundation, and a lot of times, they're the first ones to see the cases, give you great clinical tips about, “Hey, I had a conversation with this patient. This is their thought process. This is what they expect. Just nursing in general. But us being obviously biased, being in the wound care field, we cannot have strong, adequate clinical teams without the excellent job of our wound care nurses, so shouts out to them. They definitely need a month. We need to figure out a month. Yeah, everyone has a month these days. You’ve got to figure out a month, so.

But listen, Dr Lee, I would like to thank you for taking your time out. I know you're very busy from a clinical standpoint. We appreciate everything you do on the wound care side. And we know that you'll continue to do great things. And we are happy that you were able to be a guest today. And I wanted to give you a last couple seconds to say whatever you wanted to say to the audience.

Dr Edward Lee: Well, I just wanted to say thank you very much, Dr J. Thank you for Wound Care Wednesday. And I appreciate the voice that you're providing to the physicians and to the patients and the resources that you're creating for them. So thank you very much.

Dr Jonathan Johnson: I appreciate it. And as always to our audience, thank you so much for joining us today. We continue to be elated with our ability to have this platform to continue to speak about the efficacy and treatment of wounds and to have excellent guests that really share their personal clinical missions and their management styles, which really helps us all grow as a field and a specialty.

So again, Wound Care Wednesday was sponsored by Polynovo. We want to thank them for really providing three great interactions and discussing the diabetic issues and some limb salvage issues with our colleagues.

So again, we'd like to thank Dr Lee for his expertise. And again, please join us on the next Wound Care Wednesday. We appreciate everyone tuning in to learn about the efficacy of wounds, how we treat wounds effectively, and to really be engaged with our excellent guests and their ability to really understand the foundation of wound care. So again, I'm Dr Jonathan Johnson, also known as Dr Wounds, and this is another Wound Care Wednesday.