Interviewer: You have a wound on your foot, or your leg, or someplace else on your body and you've tried everything. You've even seen your primary care physician, and it's not going away. What can you do?
Dr. Troy Madsen from University of Utah Health, first of all, what's going on when you have kind of this chronic wound that's not going away?
Dr. Madsen: Yeah, Scot, this is something I see all the time. So I do emergency medicine, and then I do wound care as well. So it's kind of two ends of the spectrum. I'm taking care of emergencies, and then I'm taking care of these people who I see who have had a wound on their foot or on their leg, and it's just this hole there that will not heal.
They may have been to a primary care provider. That primary care provider may have tried different dressings on it, saying, "Well, let's try this. Let's try this ointment on there. Let's put this bandage on there," and it just has not improved at all.
I've seen people who have gone through this process for over a year, and it is frustrating for them because the wound limits what they can do. They can't go swimming because they're told, "You've got to keep it dry," or they're told, "You've got to keep it elevated." So they've been going around on a knee scooter trying to keep it up, things like that, and they're incredibly frustrated.
So what can often happen with these wounds, once they get to a certain point . . . So let's say you get a wound on your foot or your leg, and you may have an underlying issue, say, diabetes, or peripheral vascular disease, or something that affects your ability to heal that wound, and the wound just stalls. It just sits there. And it sort of just gets in this comfort zone where it says, "Well, we're doing all right. We're not going to close up. We're just going to stay this way."
And unless something else happens, it's just not going to heal. You get bacteria that sit in that wound. Sometimes infections can affect it. And so you really need to get to a point where you can see someone and get some additional help to try and get that wound healed.
Interviewer: And what do these wounds kind of look like? Describe what somebody is seeing.
Dr. Madsen: So the classic wound in someone with diabetes is a wound on the soles of their foot. It's often overlying the joint, right where the toe meets the foot or maybe it's on the toe itself, and it just looks like a hole there. And maybe it's got kind of a dusky appearance to it, kind of a gray appearance in the base of it, maybe some drainage, kind of some clear or yellowish drainage out of it.
People who have vascular disease often have wounds on their lower leg, so down below the knee, often from the mid calf down through the ankle. These wounds are very painful. They're very sensitive. Again, they kind of have that appearance. The base of the wound, if you take your bandage off, you look at it, that wound just kind of looks gray in the base. It's not a healthy pink tissue.
And again, most often, they just have not seen any change. People have taken pictures of their wound to look for progress over months, and you'll look at the picture from a month ago or two months ago and now, and it's not any better or it's even worse.
So they're just not healthy looking tissue. They're gray. They're kind of this dusky appearance, some drainage maybe with it. Maybe they have a bad smell to it as well. And it's just . . .
Interviewer: Are they kind of scabbed over? Or is that a completely different thing?
Dr. Madsen: Sometimes, they are. Sometimes, on the lower leg, they may just have a scab that's sitting there and the scab just never seems to fall off and the wound never seems to heal beneath it. So that's definitely the case as well.
Interviewer: All right. Then what are some things that you can do to help kind of get things going again if that wound is not healing?
Dr. Madsen: Well, certainly, if you're in that situation and you haven't seen a doctor yet, go to your primary care provider. And sometimes just trying some different bandages, getting some ointment on there, something to maybe moisten that wound a little bit better is going to help it to heal, or at least kickstart that healing process.
But again, a lot of these patients I see, the large majority, have been seeing a primary care doctor and have been trying these things and aren't seeing any progress.
So there are clinics throughout the Salt Lake Valley or wherever you live that are dedicated to wound care. And this is what these clinics specialize in, people with chronic wounds.
And the process of going to that clinic . . . once you go there, a lot of the process is saying, "Okay, is there something underlying here that's just affecting this wound so it's not healing?" So if you have diabetes, how well controlled is your diabetes? If you have peripheral vascular disease, is there anything we can do to help these veins so you don't have fluid just backing up in your legs and leading to these wounds that just won't heal?
So that's a big part of it, is saying, "Okay, let's not just focus on the wound. Let's focus on your health and some of the other issues we can do to improve those things to try and help this wound to heal better." If your diabetes is not controlled, if your blood sugars are high, the wounds are not going to heal. If you've got fluid . . .
Interviewer: No matter what you do.
Dr. Madsen: Yeah. It's really not. You can try all kinds of things. If you have peripheral vascular disease and you've got lots of fluid building up in your legs, that just makes your skin so much more fragile and it causes it to break down. It causes new wounds. It affects the wounds that are already there. So you've got to address those things first. So that's a big part of going to the wound clinic.
And then the next piece of it is actually taking care of that wound and treating it. Like I said, a lot of these wounds are kind of . . . it's like the wound is in this comfort zone. It's just like, "I'm happy being a wound. I'm not going to do anything about it." So you've got to do something about it.
And part of what we do in the wound care clinic is debriding the wound. And what that means is actually putting some cream on the wound to numb it up, some lidocaine cream, and then once it's numb, scraping at the wound to get rid of that dead tissue.
As you get that dead tissue out of there, then you've got this bacteria that builds up in the wound, you get that bacteria up. That process then stimulates the healing process. It gets all the bad stuff out of the way. So then you're getting down to the good tissue. Then as you're treating that good tissue, this process kicks into play again, this process of healing and producing the growth factors, everything that's necessary to try and get that good tissue built up again.
So we go through that process every week of re-evaluating the wound, doing the debridement, getting rid of the dead tissue. Sometimes, it takes weeks or months to get a lot of that nasty dead tissue out on some of these really big wounds.
But as you do that, it's just remarkable to see how these wounds heal, to see that base fill in, to see this healthy red tissue in the base. And then as that fills in and fills in the base of the wound, to see that skin, that epithelium just kind of work its way across the wound until it's finally healed.
Interviewer: So what you described is scraping away some of that old dead material. Why is it a good idea to go and see a professional and have that done versus . . . That sounds like something that maybe anybody could do at home. Why is that a bad idea?
Dr. Madsen: Well, Scot, a lot of it is about maintaining some sterility using sterile instruments and then also really cleaning that wound well, which typically we're doing before we're doing that debridement. So I think that's a big reason to not necessarily try this at home, but go to a wound care clinic where they have the instruments and also the skill to do this.
A big piece of it too is that in debriding a wound, it's kind of like a balance. And I've heard it compared to sculpting. You can always take things away, but you can't put them back. So, as you're debriding the wound, you're trying to get rid of that dead tissue, but you've got to be careful because you don't want to take away the good tissue.
So, unfortunately, if you are trying to cut into your own tissue at home, there's a potential that you could really slice things up there, cause a lot of bleeding, and really make things a whole lot worse.
So it's a tough balance. It's a skill you develop over time in terms of doing these debridements. It's something I love doing, really cleaning these wounds up well. And you're really best to have a professional doing that.
Interviewer: It must be really satisfying when somebody comes in and has gone through all this frustration of just a wound that won't heal and the inconvenience it causes in their life, and spending . . . It sounds like it can take some time, but it sounds like it's really worthwhile.
Dr. Madsen: It really is. And quite honestly, it's just such a rewarding thing because I see these patients week after week. And to see that healing process, and to hear them talk about their frustration and the limitations and even embarrassment that wound has had and the impact on their lives prior to this, and then to have it heal, and then to see the healing process.
We do so much as doctors where we are healers, but to actually just watch that healing process is incredibly rewarding. So it's something I thoroughly enjoy doing. I love the people I'm able to work with. And it's always great when they are healed. Then they have a bell in the clinic. They actually let them ring the bell once they're healed and they leave, and that's always fun. So it's a great thing to see.
Interviewer: And for somebody looking for a wound care clinic like this, do they tend to be only in bigger cities or do most towns have them? I mean, where do you even start to find one?
Dr. Madsen: You're probably going to find them primarily in larger cities. So usually small areas, rural areas, it's typically not something you're going to see in smaller towns. So you're probably going to need to be looking more in an area . . . the same city in your region that has the referral center for other conditions. So it may mean traveling a bit.
We've had people travel from a couple hours away to be seen in our wound care clinic simply because they just haven't had the resources or haven't been able to get the help they need in their hometown, but they've wanted to do that and have certainly appreciated being able to do that to get their wound healed.
Interviewer: And being able to find that, is that something you would talk to a primary care provider? You go to the internet? What would be the first step to actually finding that clinic? I suppose Googling it.
Dr. Madsen: Yeah, you could Google it. Google "wound care clinic." Certainly, you can talk to your primary care provider. It's been funny, though. Sometimes I think a lot of primary care providers aren't aware of the resource or haven't utilized that resource before. So sometimes it may be a matter of even just contacting your insurance company, seeing what's in network.
They may require a referral through your primary care provider. But I think if you've had a primary care provider dealing with your wound for months, they're probably just as frustrated as you are and would be more than happy to refer you to a wound care clinic to try and get some additional help.
