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Melanie Cole: Minor wounds such as blisters or cuts can cause complications if left on unattended. And even more so in people with diabetes. This is Doc Talk presented by Montefiore St. Luke's Cornwall. I'm Melanie Cole. Today's topic is the prevention and treatment of wounds in diabetic patients. My guest is Dr. Timothy Fishman. He's a Podiatry Specialist in New Windsor, New York and he specializes in Podiatry and Podiatric Surgery. He's also affiliated with Kappa Podiatry and Montefiore St. Luke's Cornwall. Dr. Fishman, I'm so glad to have you join us today. Tell us a little bit about why diabetics and people with diabetes are more at risk for wounds that do not heal?

Dr. Fishman: So regarding our diabetic population, unfortunately they are more predisposed to certain types of ailments of the foot and why that is the case is because as the disease progresses and even not so, cause we have people that are walking around undiagnosed who are also accumulating these types of things over time, people become what we call neuropathic. And essentially what neuropathy is a loss of nerve sensation, especially to the extremities. When this occurs, people don't feel certain pressure points. They might step on something, hit something the wrong way, have an area that rubs against a shoe, any kind of thing that might occur in the course of their day that unfortunately, opens up the skin. And if untreated can cause serious infections that can lead to amputations and even loss of a limb and life.

Host: Well, since sometimes they don't even know that they have them or they don't feel if they've done something to their foot, what should they be on the lookout for? What are some red flags of a wound that isn't healing? What would you like them to know about checking their feet?

Dr. Fishman: Well, sure, and some people might be walking around with calluses on their feet, which they've had for their whole lives. But unfortunately, callouses can be areas that are essentially precursors to having wounds. These types of calluses in a regular person can be shaved down, no issues at all. In a diabetic, if they're not shaved down, they eventually become a little pressure areas where if untreated, essentially think of it as like we were walking with a rock in your shoe. Eventually that rock is going to start to cause an abrasion to your foot and eventually start to open up an area of your foot to an opening, an open sore or a blister or anything of that nature. So some warning signs or red flags would include having callouses already. You know, if you're in an area where you're predisposed to certain types of shoe gear, if you're working in hard steel toe boots all day, if you're somebody who's going to be on their feet for several hours every day, you should always monitor, inspect your feet just to make sure nothing has hit it, nothing has that you've stepped on or anything at all that could have happened during the course of a day. But essentially the people with the biggest warnings I would suggest would be people that already have calluses or people that are on their feet all day.

Host: And I know this may seem a weird question, but when we cut our toenails, some people do it wrong and that can cause wounds in itself, right?

Dr. Fishman: Oh, absolutely. I've had a number of patients, I can't even begin to describe how many come in here who have tried to cut their own toenails, end up cutting open their skin. Unfortunately it becomes an infection. They end up going to an amputation and some of them fairly quickly. You know, I've had patients tell me, but Doc, this just happened yesterday? And of course it not have, it may have happened sooner than that, but yes, if you cut your own toenails incorrectly, you can take a piece of skin off of there. And if left untreated, I could lead to severe outcomes.

Host: So what can you do for them if they do have some wounds and they've noticed some of these red flags and they've come to you. Tell us a little bit about what you do for one of these wounds and the different types of treatments that you have available.

Dr. Fishman: Well, sure and I'd begin by saying prevention is always the key. A patient coming into the office on a regular basis is less likely to have these types of issues because they're being treated on a consistent basis by us. There are people that come in here, we catch things early, we note things more quickly than they would have or even their primaries would have been unfortunately because so often our primaries don't always look at the feet, but they do, but not as much as we would like. So prevention is always number one, but essentially once these things happen, there's a lot that goes involved with the care and treating an ulcer is of utmost importance from the direct onset. If you fail to treat it right away, you're going to lead to a lot more of these poor outcomes. But essentially if you have an ulcer, if you notice something that's open at that point, seek a Podiatrist's help immediately. A wound care center is always a place to start because we're more specialized at a wound care facility. But essentially you want to get over to those types of places first so that we can start our management of the wounds.

Host: So then speak about that. Some nonsurgical things. You might try the different dressings or do you, can you use antibiotics, revascularization? Tell us about some of the things you might try.

Dr. Fishman: Well, sure and antibiotics would be indicated in an infection. You know, I can tell you from my experience, what we usually do, I mean when a person gets the wound center for an initial evaluation, whether we know them or not, one of the first one we were doing was we're taking a swab culture to make sure there's no bacterial growth in the wound. If it does look infected, we'll start them on antibiotics until that culture comes back and then change it based on those results. But the main, the biggest thing about treating a diabetic foot ulcer that's more important than anything you put on it, is taking the pressure away from the area of the sore. If you have a pressure ulcer on the bottom of the foot or any kind of diabetic foot ulcer on the bottom of the foot, you need to do something where you offload that wound. In order to offload it, there's certain types of devices that people wear whether it's a surgical shoe at first or a cam Walker boot, which might be a little more offloading or venturing into what we call a total contact cast, which is kind of what we call the gold standard. It's essentially a cast that you walk on, but the whole point is that any type of pressure removal is of utmost importance in treating a diabetic foot ulcer. If you remove the pressure from a sore, if you disperse the pressure around it, you give it a chance to heal. I like to give people the analogy that if you have a bump on your head and you hit your head at the wall a thousand times a day, the bump on the head is not going to get better. The same situation is with the diabetic foot ulcer. When people walk on their foot all day, as soon as you hit pressure on it, put pressure repeatedly, it's going to eventually cause the wound not to get better. So the key really is to offload a wounds. We then perform different types of nonsurgical procedures at the wound center, including things of dressing types of different types of dressing changes as well as other modalities which we can always get into as well.

Host: That was a great analogy. Dr Fishman, a really great analogy.

Dr. Fishman: I use it a lot on my patients, some of them do appreciate it.

Host: Well, it works really well and it makes perfect sense that way. What would you like people that do have diabetic foot wounds to know about care at home? I should they be dressing these and if you've done something a debridement, you've done one of these things. Should they be cleaning and changing the dressings? What should they do?

Dr. Fishman: Well, it all depends. There are some patients, and it's always specific to a type of population. You kind of have to pick the patient and know who they are and what they're capable of. There are some patients that I have them cleanse the wound every day with saline and put certain types of medications that I prescribed for it. There are others that we don't have them touch them at all. We have dressings and different types of things that we use at the wound care center that can stay on for a week at a time. So we essentially tell our patients to leave it alone, don't touch it. The more that some people expose it to the air, the more likely they are to have bacteria settle on the wound and cause an infection. So we tell some patients not to do anything at all whatsoever. If you're somebody who's at home and not been seen for the first time, I would urge you not to put peroxide and alcohol on it because that seems to be the formula that everybody wants to employ. Unfortunately, alcohol and peroxide kill good cells also, and you're kind of undoing some of the good things that your body is trying to do to heal. So you know, that's what I would tell people, at least initially. Don't do that. If anything, even if you just put Neosporin or a bacitracin on it, just to have something on it until you're seen as okay. But don't do peroxide alcohol.

Host: And what about some do's and don'ts when it comes to general foot care? Socks? You mentioned certain types of shoes that can predispose people to not knowing what's going on with their feet, but what about certain socks or materials? Do any of those things make a difference?

Dr. Fishman: Well, it kind of depends. I, you know, some people come into my office and I'll say, Hey Doc, I bought these diabetic socks. I mean, are they good for me? And sure. I mean they might be fine. The idea is they're certain types of conditions, some people need more breathable socks if their feet tend to sweat more, which can cause them to get more blistering or more athletes foot infections. Some people need a thicker sock, like a wool sock, which might give them a little more cushion. It all kind of depends on the person. I find it more important to have some kind of insert or some kind of offloading support within the shoe that might help them more than just the socks. So for instance, a lot of our diabetic patients will have what we call diabetic shoes. And diabetic shoes, you know, back in the day people would say, Oh, they're just these big clunky orthopedic shoes. And some of them are, but a lot of them are designed more trendy nowadays. And what they contain are certain types of material inserts, which are a lot softer and take away a lot of the blow from an average step. So not so much the socks that I worry about, but so much the insert in the shoe is more important.

Host: What great advice as we wrap up, what would you like the listeners to know about diabetic wounds and specifically wounds of the feet and what they should be on the lookout for and even how important it is that they do things like monitor their blood glucose, and other health problems that they take care of to make sure that they're in good shape.

Dr. Fishman: Well sure. And to best summarize that, I can give you a quick anecdotal story from what just happened this past weekend. To make it a quick story, I had a 43 year old patient presents to St. Luke's on Saturday night. He had a two week onset of foot pain to his right foot, didn't treat it, didn't do anything about it until the point where his wife started to notice a smell, and she asked him to take the sock off and she saw what she saw. Essentially he had an abscess to the bottom of his foot, which eventually the infection itself took a choke-hold on the area around the outside of his foot by his fifth toe, turning his fifth toe black, completely gangrenous necrotic. He had that for about a week at that point, still didn't treat it, so came into the hospital, had an immediate incision and drainage amputation of his toe, and now he's gone back to the operating room twice so far this week for additional clean outs and washouts and removal of that tissue. So I guess the point of that story is to suggest to people that they don't want to sleep on something. If you see something, say something, right, like the New York city subway adage. Because if you don't do something on it right away, you're going to end up with a bigger problem. This gentleman, nice guy, good background, intelligent. He's a school teacher in York city. He's not somebody of a lower socioeconomic status that some people associated with these types of issues.

He didn't think about doing this sooner. It didn't think about addressing it. Ignorance is bliss. And now he's facing the possibility that if we can't get this under control that he can lose his leg. And that's unfortunately the real things that happen in life and people don't always think about those outcomes. So the whole thing is prevention or at least addressing something on an immediate basis. These things are going to happen and if you don't address it, it's going to eventually get worse. In terms of blood sugars, it's of utmost importance to keep your sugars under control. The more the people keep their sugars high and the more predisposed they are to circulation issues, which can impede healing, the more predisposed they are to neuropathy. And the more likely those people are not to heal. If you have high blood sugars and impedes your body's ability to even heal. So if you're somebody who's walking around with a hemoglobin A1C of 10 and a foot ulcer, it's going to be a lot harder to have you healed than somebody with a hemoglobin A1C of seven. Essentially the sugars control how the body responds to things. And if your body can't respond, it can't heal.

Host: That is such great advice. What a great guest you are. Dr. Fishman, thank you so much for joining us and sharing your incredible expertise with us today. And that wraps up this episode of Doc Talk presented by Montefiore St. Luke's Cornwall. For more information on diabetes and wound care, please visit our website at montefioreslc.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Montefiore St. Luke's Cornwall podcasts. Share this show with your friends and family. I'm sure you know somebody that could really benefit from this great information we got today. Thanks for listening. I'm Melanie Cole.