Foundations of Wound Healing: Exploring Cellular, Acellular, and Matrix Products (Part III)

In the third June WCW episode, host Dr Jonathan Johnson and guest Dr William Tettelbach discuss the evolution of the term "CAMPs" and how their use can help heal wounds, save limbs, and reduce healthcare costs.

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Dr Jonathan Johnson: All right, how are we doing everyone? This is Dr Johnson, also known as Dr Wounds, here on another Wound Care Wednesday. Now, we are live at SAWC, here in the beautiful and sunny Orlando, Florida. And, my guest today is the incomparable wound care expert, Dr Bill Tettelbach. We are super excited to have him on our show today, and we're going to dive a little bit into CAMPs—our skin substitutes, cellular tissue products. So we're going to talk a little bit about the basis of these type of products, but we're also going to have a fun educational conversation so that everyone can be engaged. Because remember, we focus on our patients as well as all of our colleagues.

So, with that being said, I would like to introduce Dr Bill Tettelbach. Dr Tettelbach, tell us a little bit about yourself, how you got involved with what you're doing now, and what makes it important about being here at SAWC?

Dr William Tettelbach: Well, it's a pleasure to be here. Thanks for having me.

Dr Jonathan Johnson: Great, great. It's my guy from a long time—we've known each other for a while, so…

Dr William Tettelbach: So, it's an interesting story, I think for all of us, how we got into wound care, because it wasn't what we—you'll hear it over and over again, it's not what we thought we wanted to do from day 1, right?

Dr Jonathan Johnson: Right. 100%.

Dr William Tettelbach: So my background really is infectious diseases.

Dr Jonathan Johnson: Okay.

Dr William Tettelbach:  And, I've been doing that for over 30 years. During that journey, at one point I started seeing wound patients. I was invited in by a healthcare system.

Dr Jonathan Johnson: Mm-hmm, okay.

Dr William Tettelbach: They were having trouble with length of stay, so they asked folks within the system to help them out. And then once I started doing wound care with these folks, I saw immediate responses, how, changing people's lives for the better, bringing them out of dismal situations and allowing them to go back to their hobbies, go back to their families in a way they thought they always wanted to where they were in situations where they couldn't.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: So that was back in Memphis, when I was in private practice then, and then I transitioned out of ID. I still do ID. It complements wound care very well. A lot of these wounds get complicated or even come in infected.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: And eventually I was courted away into the Intermountain System.

Dr Jonathan Johnson: Okay.

Dr William Tettelbach: And in Salt Lake, you know, so.

Dr Jonathan Johnson: Got to love the skiing, Bill’s a big skier, of course.

Dr William Tettelbach: But, my wife is from Utah, so that won the day.

Dr Jonathan Johnson: There you go.

Dr William Tettelbach: Of course, happy life.

Dr Jonathan Johnson: I hear you.

Dr William Tettelbach: And that just grew and grew, getting more and more involved, getting involved in how to effect governmental health policy, government affairs. And that has been—gone from regional to now where I work on a national scale trying to effect change, positive change.

Dr Jonathan Johnson: So you're a huge advocate for wound care,…

Dr William Tettelbach: Yes.

Dr Jonathan Johnson: …which is great. And really working on wound care on a national level, effecting patient policy, affecting clinical management, which is definitely key.

Dr William Tettelbach: Yes.

Dr Jonathan Johnson: So, the hot-button topic that we've all been talking about are cellular tissue products and skin substitutes.

Dr William Tettelbach: Right.

Dr Jonathan Johnson: But, you have a unique acronym, or what we call nomenclature, for our skin substitutes. Tell us a little bit about that.

Dr William Tettelbach: Yeah, so skin substitutes, that was from day 1, like 15+ years ago, we were using “skin substitutes” as a name because we were putting something on the skin, and we would close the wound and skin would cover it. We weren't necessarily ever, short of a graft,…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …putting a substance that substituted skin and replaced it, right?

Dr Jonathan Johnson: Right, of course.

Dr William Tettelbach: And so this has been an evolution of nomenclature. And then there's other things that are considered like a skin substitute, but it may not be cellular. But it transitioned from skin substitute to tissue—cellular tissue products.

Dr Jonathan Johnson: It's had its names.  

Dr William Tettelbach: And that was a better, I think, title for that.

Dr Jonathan Johnson: Okay.

Dr William Tettelbach: That's been adopted within the, say, the CMS system. But the evolution now of these products include products that are cellular, that still have cells that can be cryopreserved.

Dr Jonathan Johnson: There we go.

Dr William Tettelbach: They can be processed but yet have the remnants of cells. So they have cell structures that are, but not living, like the ghost remnants.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: They can be completely processed where you wash out all cellular structures and you have a matrix, so it's acellular, right?

Dr Jonathan Johnson: Got it, mm-hmm.

Dr William Tettelbach: And then you have those that are matrix-like but are completely synthetic.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: So they can be, we have products that are made out of borate glass, we have products that are hyaluronic acid, but synthetically made hyaluronic acid, and so these are now matrix structures. So this is where the new, an acronym comes from: cellular, acellular, matrix-like products, so that's CAMPs.

Dr Jonathan Johnson: Got it.

Dr William Tettelbach: And that’s, I think, the most updated, in the modern version of what we deal with and how we treat our patients with these, because it allows for room of new products to come in…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …to still fall under this moniker and be appropriate.

Dr Jonathan Johnson: Sure, right.

Dr William Tettelbach: So now in our conferences, it's really caught on, everyone's really saying CAMPs.

Dr Jonathan Johnson: Right. So one of the major issues, and that's a great way to explain the different concepts because remember, and this is for our patient audience out there…

Dr William Tettelbach: Right.

Dr Jonathan Johnson: …and remember—during the podcast, everyone relax. This is a great conversation. Get your tea, get your wine, and get your coffee, and just listen to us, okay? So, remember before we spoke about our acellular, cellular, and matrix-based products, and really it's a conversation with your patient from a provider standpoint…

Dr William Tettelbach: Right.

Dr Jonathan Johnson: ...to make sure they understand which one is appropriate, which one can be used in their specific clinical situation, and which one they feel comfortable with.

Dr William Tettelbach: Right.

Dr Jonathan Johnson: So having the acronym helps to encompass all of those different types.

Dr William Tettelbach: It does.

Dr Jonathan Johnson: So, Dr Tettelbach, tell me a little bit about some of the great clinical situations that you've had using CAMPs, and tell us about an awesome patient outcome that you felt really comfortable about and the patient just loved you for.

Dr William Tettelbach: Well, it may not always revolve—I mean this is wound care, so you have passion, right?

Dr Jonathan Johnson: Right.

Dr William Tettelbach: But in wound care, and I think what we fall in love for what we go as a provider, doesn't matter what type of provider you are,…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …be it MD, DO, podiatrists, PA, nurse practitioner,…

Dr Jonathan Johnson: NPs, yep.

Dr William Tettelbach: …nurse, whoever's laying their hands…

Dr Jonathan Johnson: Everybody.

Dr William Tettelbach: …on the patient. These patients come in so consistently that we start to build a relationship that—folks who maybe only come in once a month, or they get a surgery and then you see them in 30 days—you're seeing these folks every week, sometimes twice a week.

Dr Jonathan Johnson: Consistently.

Dr William Tettelbach: Consistently, so you start to know who their grandchildren are,…

Dr Jonathan Johnson: Yes, yes.

Dr William Tettelbach: …what type of jobs they're doing, where they're going on vacation, what's happening with their dog. So you really, so there's this feedback network that comes out of it.

Dr Jonathan Johnson: Mm-hmm, yes.

Dr William Tettelbach: So you're always looking for something that can add on to that in the sense of improving their quality of life.

Dr Jonathan Johnson: Yes.

Dr William Tettelbach: Because you understand where their baseline typically is and where they were before they came in with this disabling, chronic wound.

Dr Jonathan Johnson: Of course, of course.

Dr William Tettelbach: So some of the things, really, I think what got me going is, when I was an ID doc, just doing ID, I would be called in to see a septic lower extremity, work it up, start an IV antibiotic, and they would start getting better and the surgeons were typically so busy during the week that…

Dr Jonathan Johnson: Surgeons. Busy.

Dr William Tettelbach: Yeah, right? We only had, so Memphis is a mid-sized town. So there is still, today, there's a chronic shortage…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …of general surgeons in the mid-sized cities.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: So these guys were to the wall all week. Come the weekend, they’d get around to seeing this stabilized patient. And I’d be off for the weekend, and I’d come in Monday, and the leg is gone, right?

Dr Jonathan Johnson: Right, right.

Dr William Tettelbach: Even though they were getting better.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: But then when I was actually sort of put in charge of the wound care, I could put some guard rails up like, don't take this patient to surgery, this is not necessarily your patient anymore.

Dr Jonathan Johnson: Got it, got it.

Dr William Tettelbach: I'm consulting you instead of me being consulted by you, right?

Dr Jonathan Johnson: Right.

Dr William Tettelbach: So now we started saving limbs.

Dr Jonathan Johnson: Mm-hmm.

Dr William Tettelbach: And we had patients who literally were going to the OR, they refused, we got them into the outpatient clinic, and we used everything. I mean from maggot therapy to debridement to negative pressure, then CAMPs, right?

Dr Jonathan Johnson: Right, everything, the whole the whole gamut.

Dr William Tettelbach: The whole gamut.

Dr Jonathan Johnson: Right, right.

Dr William Tettelbach: And saving their leg.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: And you talk about people who were doing the happy dance after we did that, that's kind of what turned me on.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: But then later, years on, we did a study. We did a prospective study at the burn center at Valleywise, so in Phoenix.

Dr Jonathan Johnson: Okay.

Dr William Tettelbach: And these burn centers, it was a community center, so they take everything from traumas to burns to necrotizing fasciitis. And we did a 1-year prospective study where anyone that was being put on the OR schedule for amputation of an extremity, any extremity…

Dr Jonathan Johnson: Had to have a preliminary review first.

Dr William Tettelbach: They literally had to be on the schedule.

Dr Jonathan Johnson: Very important.

Dr William Tettelbach: The PI was Mark Matthews.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: He would go in, evaluate the patient. if they had any semblance of blood flow or could actually be reperfused…

Dr Jonathan Johnson: You would take them off the list.

Dr William Tettelbach: We would take them off the list.

Dr Jonathan Johnson: Got it.

Dr William Tettelbach: We put them into our limb salvage pathway, which…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …they would go in and trephinate the bone. So these were folks literally who were being amputated because there was no steps in the reconstructive ladder left.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: In other words, there was exposed bone, exposed tendon, and they weren't flap candidates. They felt like it wasn't going to happen with secondary closure.

Dr Jonathan Johnson: Right. Secondary intention, mm-hmm.

Dr William Tettelbach: There was no primary option.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: Or tertiary, so we would bring them in and we would do the same thing like this first patient we did, but he would trephinate, take out, lay down a CAMP,…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …and then bolster that down with a VAC.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: We had 17 patients in 1 year we took off the list.

Dr Jonathan Johnson: Wow.

Dr William Tettelbach: I think it was 24 limbs at risk, because some of these folks had bilateral arms, bilateral legs,…

Dr Jonathan Johnson: Mm-hmm, mm-hmm.

Dr William Tettelbach: …there was necrotizing fasciitis patients who are diabetic, we had traumas in Phoenix, we had folks who went into an arrhythmia, fell down on the pavement, and started having third- or fourth-degree burns.

Dr Jonathan Johnson: Issues.

Dr William Tettelbach: Yeah.

Dr Jonathan Johnson: Of course.

Dr William Tettelbach: So, we had a 92% limb salvage rate,…

Dr Jonathan Johnson: Wow.

Dr William Tettelbach: …where that would have been a 100% amputation rate. That was using CAMPs to granulate in where no flap could have worked.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: And so this was a plastic surgeon or a trauma surgeon, so they would finish off with a split thickness.

Dr Jonathan Johnson: So what I gather that you're saying is utilizing our treatment regimen and methods, our CAMPs, skin substitutes, cellular tissue products, etc, is key, right?

Dr William Tettelbach: Yeah.

Dr Jonathan Johnson: Because what we don't want to be is to a point where we say listen, there's a wound, let's just be drastic in our treatment, in our measurements.

Dr William Tettelbach: Right.

Dr Jonathan Johnson: We need to be progressive, and this goes to the point of having the passion behind wound care to make sure we're treating them effectively. Those are major issues.

Dr William Tettelbach: We mostly think of using CAMPs in outpatient and stalled wounds, but these were situations where they can be deployed in the OR setting…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …and then transitioned out into the outpatient.

Dr Jonathan Johnson: Mm-hmm.

Dr William Tettelbach: So they have benefit everywhere.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: So I just want to, I gave that example, but this is where, if you're aligning yourself, because it's a multi-specialty specialty.

Dr Jonathan Johnson: Of course.

Dr William Tettelbach: You’ve got to get all the specialties on board.

Dr Jonathan Johnson: You have to. And then we've discussed this multiple times in the podcast, you have to get every single specialty involved, right?

Dr William Tettelbach: Yeah.

Dr Jonathan Johnson: Because we're not only making sure the patient has what they need, but we're cutting costs in large healthcare systems, and we're also making sure our payers, our federal payers, are not being overcharged for services.

Dr William Tettelbach: Right.

Dr Jonathan Johnson: That's very important. Take care of the patient, reduce costs, and heal wounds. That's our plan.

Dr William Tettelbach: Yep.

Dr Jonathan Johnson: And really that aligns with our CAMPs and our cellular tissue products and utilizing these effectively to make sure we're healing wounds. What we don't want to do is see a patient that has a primary venostasis or a diabetic ulcer, and then the next week we see them getting amputated.

Dr William Tettelbach: Yeah.

Dr Jonathan Johnson: It's just not a functional way to practice medicine or wound care, and now we have a resource with our CAMPs to be able to mitigate against some of that drastic clinical measures.

Dr William Tettelbach: Yeah. So this is, you tie on with the CAMPs and bringing, tying everyone together, so this is part of that journey I talked about in a sense of local, regional, and to national. When I was at Intermountain, Intermountain Health now, they had no wound care system. It was just a scattered group of folks, they had 1 or 2 clinics within the city. So what we did is we actually were able to create a service line…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …that now had jurisdiction over every region that they had hospitals in. And we grew that from a 4-clinic system to, like, a 12-clinic system.

Dr Jonathan Johnson: Growth.

Dr William Tettelbach: We put in guidances on CAMP utilization, when to deploy it appropriately. And, we've published Medicare data now, and I've had the opportunity to publish Medicare data and show the cost effectiveness as well as improved outcomes. But here, even on regional level, we did our own internal audits and showed that with us using these advanced products we were off loading their own ED,…

Dr Jonathan Johnson: Mm-hmm.

Dr William Tettelbach: …so there were less ED visits.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: We knew there were less readmissions. We were—not just CAMPs, but if they came infected we manage their infections, we put PICC lines in. This is the beauty of having an organized wound structure.

Dr Jonathan Johnson: Very important.

Dr William Tettelbach: And CAMPs is a key part in the sense of closure, because if you don't close these, especially in diabetics, their risk of complications…

Dr Jonathan Johnson: Huge.

Dr William Tettelbach: …is through the risk, I mean, their risk, they get infected. A wound that's there for 30 days, the Lavery data is part of this but…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …they are closed over 55% more increased, or 55 times more likely to be admitted.

Dr Jonathan Johnson: 100%.

Dr William Tettelbach: And there are over 150 times more likely to be amputated.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: So that's where the CAMPs come in. The only way to get rid of this cascade…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: And so what happens if you get amputated in a diabetic? What's their mortality rate?

Dr Jonathan Johnson: It exponentially goes up, obviously.

Dr William Tettelbach: It's over 50%.

Dr Jonathan Johnson: It's huge. 100%.

Dr William Tettelbach: So the only way to get this down-spiraling cascade…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …eliminated is to close the wound.

Dr Jonathan Johnson: Right, right.

Dr William Tettelbach: And to close it in a stalled wound, you need something more, and that's where CAMPs come in.

Dr Jonathan Johnson: 100%. And remember, the whole point of what we're talking about here is establishing a wound care program or a system that, number one, encompasses all the specialties,…

Dr William Tettelbach: Right.

Dr Jonathan Johnson: …puts the patient as the number one priority, but also focuses on cost cutting, right?

Dr William Tettelbach: Right.

Dr Jonathan Johnson: Because we understand the cost burden on our overall healthcare system is in the billions for wound care, right?

Dr William Tettelbach: Right.

Dr Jonathan Johnson: And that's venostasis ulcers, pressure injuries obviously, and diabetic, not to mention our atypicals and some of our other dermatologic issues that we see.

Dr William Tettelbach: Right.

Dr Jonathan Johnson: So it's important to make sure that we're number one, treating them effectively to decrease costs, so–

Dr William Tettelbach: So now we got, I'm at Restorix, which is, that's the national component.

Dr Jonathan Johnson: Okay, right?

Dr William Tettelbach: So I just started there, like, 9 months ago.

Dr Jonathan Johnson: Right.

Dr William Tettelbach: So we're just getting started,…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …and doing everything that you just talked about.

Dr Jonathan Johnson: And programs are really important on a local and national stage because at the end of the day, it's communication with the patient.

Dr William Tettelbach: Right.

Dr Jonathan Johnson: And so if patients have communication resources that are local and national, then they have the ability to talk with their providers and figure out how they can heal faster.

Dr William Tettelbach: Yeah.

Dr Jonathan Johnson: Which is definitely key.

Dr William Tettelbach: And to circle back, you mentioned about being able to talk to patients. So on these CAMPs, there's a lot of them out there, right? But the ones that have the evidence,…

Dr Jonathan Johnson: Right.

Dr William Tettelbach: …the ones that you can discuss the evidence with your patients,…

Dr Jonathan Johnson: Yes.

Dr William Tettelbach: …that's where the discussions get much easier.

Dr Jonathan Johnson: 100%. And we literally here at SAWC just finished up our Alliance of Wound Care Stakeholders meeting…

Dr William Tettelbach: Right.

 Dr Jonathan Johnson: …and had a chance to speak with one of the medical directors of one of the MACs. That is pivotal in these discussions and these decisions. And the number one thing we took away from this was reasonable and necessary…

Dr William Tettelbach: Right.

Dr Jonathan Johnson: …and understanding how to utilize that effectively in our patients. But we want to make sure that we're treating our patients effectively with the right product.

Dr William Tettelbach: Yeah. We have to think of everything.

Dr Jonathan Johnson: True.

Dr William Tettelbach: So, out of this alliance meeting, reasonable and necessary. They mentioned that they look at, in other words, what you're using is the right thing, the evidence supports…

Dr Jonathan Johnson: True.

Dr William Tettelbach: …it's necessary to close,…

Dr Jonathan Johnson: Yes.

Dr William Tettelbach: …but as clinicians, we have to think of—I work mainly in a hospital basis. So I have to think about, I have to keep my patients…

Dr Jonathan Johnson: Always.

Dr William Tettelbach: …physically healthy, mentally healthy, and financially healthy.

Dr Jonathan Johnson: Right. And stay within our standard of care,…

Dr William Tettelbach: Right, at the same time.

Dr Jonathan Johnson: …make sure the documentation has what we need.,

Dr William Tettelbach: So you're always trying to find…

Dr Jonathan Johnson: It’s the back and forth.

Dr William Tettelbach: …what is reasonable in all those realms, right?

Dr Jonathan Johnson: It's the back and forth. So listen guys, what we want to take away from our Wound Care Wednesday podcast for the day: Number one, focus on treating your patient correctively, effectively. Make sure you have that communication because remember, we have our acellular, our cellular, and our matrix-based products, but make sure that we focus on what your specific patient needs. And if we can utilize these, we can mitigate against some of the drastic clinical issues like we’ve discussed here with Dr Tettelbach on the amputations, hospitalizations, to decrease our cost.

Dr William Tettelbach: Yeah.

Dr Jonathan Johnson: So I want to thank Dr Bill for coming on today. He's been a great guest and an excellent resource in wound care, and we will see everyone on the next Wound Care Wednesday. And remember, see the wound, heal the wound. We'll see you next time.

Thank you. This Wound Care Wednesday podcast is sponsored by ExtremityCare and is for your educational purposes only.