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Melanie Cole (Host): Do you have diabetes? Are you careful about checking your feet? What would you do if you noticed a wound that didn't seem to be going away? My guest today is Dr. John Schwerd. He's a Foot and Ankle Surgeon with special interests in diabetic wound care, limb salvage, trauma of the foot, and arthritic conditions all at Saint Luke's Cornwall Hospital. Dr. Schwerd, tell us a little bit about foot health as it relates to diabetes and the risk of problems with the feet.

Dr. John Schwerd (Guest): With diabetes, this is due to impairment of circulation and impairments in sensation. Just about any diabetic if they've had the condition for long enough is at risk for foot ulceration.

Host: What is that? What's foot ulceration?

Dr. Schwerd: A diabetic ulcer is a wound that comes about really from a combination of two things. One, from a loss of sensation that comes from having the disease for a long period of time even if it's controlled — or more quickly if it's uncontrolled — and pressure points that we naturally have in the foot. In someone that doesn't have diabetes that has that sensation, this is something that would be painful and probably be addressed on pretty short order. Patients who don't have that feeling, who don't have that sensation, and who don't have pain from overworking these areas, the skin can break down and open up into ulcerations which, unfortunately, when untreated can lead to amputation and infections.

Host: We've all heard about that as a big scare of diabetes is foot amputations. What do you want patients to look for? If they're going to be really diligent about taking care of their feet what should they be doing? Should they be looking at them every night, checking underneath? What do you want them to be looking for?

Dr. Schwerd: Well, the first thing that they should do is see a Podiatrist because a Podiatrist — even if the patient is recently diagnosed can screen the patient for risk factors. If the patient smokes, we can assess them for any impairment of circulation. We can easily test how much sensation they have. We can check for deformities and areas that may become open wounds later on. We can promote the patient from that point on based on their risk profile how often they need to be checked in an office, protective devices that they can get, as well as even some minor preventative procedures.

As far as daily habits from day-to-day, checking the feet and strengthening the skin with moisturizing creams and things of that nature — which can be prescribed actually through that visit — is really the best way to prevent the worst of these things from happening.

Host: If they notice something — if they notice a wound on there, a thinning of the skin, and maybe they've gone to their Podiatrist — which, by the way, is really great advice. It's something that they should do on a regular basis just like seeing their eye doctor. If they notice something like that or if they notice a wound that really isn't healing, what are some of the treatment modalities that you might try?

Dr. Schwerd: Well, we assess every wound — I always say that diabetic wounds are equal parts mechanical and medical, meaning that even when they are medically assessed and we get you on all of the right medications if the pressure pattern of how you walk is getting in the way of it healing it's not going to have a great prognosis. What a Podiatrist can do is really combine both the medical knowledge necessary to get the wound to heal from a biological standpoint, but to also look at how you walk and look at your deformities and mechanically take pressure off of that area. If you don't do both at the same time and you don't have somebody putting those two pieces together the wound does not have a great prognosis to heal.

Host: Taking the pressure off — off-loading, staying off your feet — is that what you're meaning by that?

Dr. Schwerd: You don't have to necessarily stay off your feet or even be restrained from a lot of activities in order to take pressure off the area. We have a technique called total contact casting which can basically allow you to walk as if you have a regular pair of shoes on in between, which continues to take pressure off of it even as you walk. You don't have to be laid up. We have technologies that will treat these ulcerations while permitting you to walk and do basic activities.

Host: Let's talk about some of those technologies because HBOT has been in the media lately. Tell us about Hyperbaric Oxygen Therapy and how it can help with wound healing.

Dr. Schwerd: Hyperbaric Oxygen can definitely help with wound healing from the standpoint of being an accessory to those basic offloading techniques. Essentially, in addition to the basic things that we do — cleaning the wound up on a regular basis, using techniques that take pressure off of the area — Hyperbaric Oxygen Therapy can accelerate healing and also stave off recurrent infections. It has not been proven as yet to treat infections as they're happening. You still need antibiotics, and you may still need procedures to treat the infection, but as an accessory treatment and as a maintenance treatment in addition to the basics it definitely has shown significant promise in getting the wounds to heal at a more accelerated rate and preventing recurrent episodes of infections.

Host: For the listeners that may not even know what HBOT is, Doctor, why don't you give us a little lesson on it and really what it's intended to do. What does it even look like?

Dr. Schwerd: Hyperbaric Oxygen Therapy — the experience is they are daily, one- to two-hour treatments in our facility. We have individual tanks here at Saint Luke's Cornwall Hospital. What they are is they essentially put you in a position where the body is in a situation that is equivalent to somewhere between one and two meters below sea level. What that does is it increases the level of oxygen around the wound, and that is why it accelerates the healing rate. It puts it in a position where those additional resources can stimulation — in addition, the basic treatment plan provides additional resources for the body to repair tissue.

Host: Pretty cool when you hear about the ways and the technology for wound healing, but let's jump back just a bit to some old-fashioned healing. Clear up a little bit of wound information for us, Dr. Schwerd. Do we keep them open? Do we keep them dry? Should they be moist? Should they be covered? People don't know what you're supposed to do if you notice a wound on your foot and you're the one taking care of it first. Do you use Neosporin? What do we do with a wound?

Dr. Schwerd: Well, every wound really — even though they may look the same from person to person — really has multiple factors acting upon it being the circulation, its anatomical location with respect to how much pressure is being put on it, the size of it, how much it's draining, and people react to it in many different ways. Each wound really needs to have a tailored and individualized wound care plan from day-to-day, and it needs to be assessed by a physician — be it myself or another wound care specialist — to treat those risk factors and really attack it from its cause to treat a wound.

There was a very famous Podiatrist named David Armstrong who famously said, "It's not what you put on a wound. It's what you take off." If you address those risk factors and minimize what's causing the wound to begin with it really simplifies the plan going forward, but you really can't do that without an assessment by a doctor.

Host: What do you want people with diabetes to know about wounds, diabetic ulcers, when it's important that they visit their physician, and some best advice about hopefully preventing it, managing their blood glucose, and their other comorbidities that go along with their diabetes?

Dr. Schwerd: Well, what I would want every diabetic to know, whether they have a wound or not, is that they really should be enrolled with a Podiatrist at a bare minimum of once a year. If they're first diagnosed, they should be getting check-ups once or twice a year. When these things are caught early, the prognosis is so much better, and the chances of being admitted and developing open wounds are much worse.

If you have a wound already, it is not necessarily something that can't be fixed, and it is something that can be turned around. It just needs to be addressed, and it needs to be addressed intensively. Unfortunately, diabetics who have open wounds have a similar five-year life expectancy rate to people who have colon cancer and breast cancer even though it's not publicized as such. It is something that needs to be addressed from multiple angles even if the wound is small and not infected. It's something that needs to be addressed right away because even if the wound heals, there are probably some risk factors that need to be addressed that can save you time and trouble down the line.

Host: Such an interesting topic and the technologies for wound today is pretty cool stuff. Thank you so much, Dr. Schwerd, for coming on with us today and sharing your expertise. This is Doc Talk with Saint Luke's Cornwall Hospital. For more information, please visit SaintLukesCorwallHospital.org, that's SaintLukesCorwallHospital.org. I'm Melanie Cole. Thanks so much for tuning in.