Over forty medical professionals gathered to hear Maureen McShane, DPM, explain why a tiny blister could lead to a amputation – and how to prevent that.
“A little blister becomes a big deal in diabetic patients or those with peripheral artery disease,” explained McShane. “These patients typically cannot feel their feet due to nerve and vascular damage. So that little blister gets bigger and the wound gets deeper, without notice.” Ultimately, a blister left untreated can become infected, develop gangrene and make an amputation of the toes, foot or leg necessary.
McShane, a podiatrist with Palos Health, has been practicing medicine for over twenty-five years and seeing patients with chronic wounds for decades. She spoke to the collaborative health care group LEA-UP (Lower Extremity Amputation and Ulcer Prevention) at a meeting in Palos Heights.
LEA-UP was founded by Dr. Eugene Tanquilut of Vascular Specialists in Olympia Fields, New Lenox, Orland Park and Chicago. LEA-UP is an non-competitive, open group of primary care physicians, podiatrists, nephrologists, infectious disease specialists, vascular surgeons, plastic surgeons, nurse practitioners, and other medical professionals from area hospitals including Advocate South Suburban Hospital, UChicago Medicine Ingalls Memorial, Metrosouth Medical Center, Palos Community Hospital and Silver Cross Hospital. Quarterly meetings feature an expert speaker and a sharing forum of questions, answers, case studies and treatment options.
Wounds in the feet may be caused by rubbing, such as blisters, corns and calluses. Patients can develop ulcers from diabetic or vascular complications. Trauma, such as a scratch, puncture or slice, can also be the catalyst for a chronic wound.
“Preventing and healing wounds requires an interdisciplinary approach,” said McShane. “Podiatry is one part of a wheel. We find that when we use podiatry, vascular medicine, infectious disease, wound care, nurse practitioners, and physician assistants all working together patients improve much faster. The chance of amputation is greatly reduced.”
McShane explained that it’s not just the patient’s foot that is of concern, it’s the entire health of the patient. Blood flow is vital to healing, and when vascular health is compromised, wounds just don’t close. This condition could be caused by chronic venous insufficiency, by peripheral artery disease (PAD) and diabetes.
McShane explained how smoking a cigarette constricts blood vessels, and how those vessels won’t open up again for about forty-five minutes after the cigarette is finished. At that time, she says, most smokers will light up again, restricting blood flow all over again. “That means if you smoke a pack a day, you’ve gone an entire day without blood ever getting to your wound.”
Nutrition is always important, and this is where primary care physicians, nurse practitioners and physician assistants play a vital role. McShane says these health care providers can help guide patients to better diets and healthier choices. “We should refer to nutritionists who can help patients resolve protein deficiencies. Patients need to understand the importance of adequate vitamins, particularly A and C, in the body’s production of collagen that strengthens the skin.”
It sounds simple, but McShane stresses the importance of wearing shoes to avoid puncture wounds in the feet. She also explained that ill-fitting shoes are the culprits in the formation of blisters, corns and calluses. Dr. Jerry Chee Sing Chow, a plastic surgeon attending LEA-UP that evening, agreed. “A huge problem is bad shoes that cause rubbing and blisters. Patients need to get properly measured, choose shoes that fit well and consider inserts or custom orthotics.”
Education of patients is paramount in the quest to avoid amputation. Charcot foot, when foot bones fracture and the arch of the foot drops to form a “rocker bottom”, must be diagnosed and treated as early as possible to halt this deformity and avoid ulcers. Patients with neuropathy, significant nerve damage, should watch for warmth, redness and swelling in the foot, along with pain or soreness, and alert their podiatrist immediately of these symptoms.
McShane described a patient who, because of limited education about wound care, for twenty-five years, applied an over-the-counter topical antibiotic ointment to a wound resulting from a motorcycle accident. After just 4 weeks of proper, medically supervised treatment, his wound had shrunk to a fraction of its original size.
When a wound does occur, McShane said, the severity of the wound will dictate the recommended treatment. Medical professionals may consider debridement, which removes diseased tissue or wound V.A.C, which removes bacteria and infection and pulls the wound edges closer together. A variety of skin grafts may be used, either taken from the original patient, from a donor or with dermal substitutes. A soft tissue scaffold may be considered. Topical dressings, gels and ointments may be used to cover the wound and promote healing.
A further step to preventing amputations is consulting a vascular surgeon to see if the foot or leg can be revascularized to get blood flow reestablished. Tanquilut, a board certified and fellowship trained vascular and endovascular surgeon, said, “We try to get a “blush” into the toes, to get aggressive flow into the leg, open up the vessels as much as possible. Sometimes, though the smaller vessels are just shot.”
Unfortunately, there are occasions where patients face amputation. “No patient wants to hear they are losing their toes or foot,” said McShane. “But often, their quality of life will actually improve after an amputation.”
Director of Perioperative Services at Palos Community Hospital Diane Teresczenko was pleased with the information provided at LEA-UP. “I love working with Dr. Tanquilut and there is always more to learn about patient care, improve patient outcomes. I’m excited that this group gets together with a purpose, to interact with each other, learn from each other and share technologies.”
Wendy Valenti, a nurse at Palos Community Hospital said she was glad to find out about LEA-UP and intends to return. Maryann Merlo, Nurse Practitioner, said “I see a ton of diabetic patients that I often refer to Dr. McShane. I’m pleased I can ask questions and get answers from her experiences and knowledge.”
Chris Offerman, CWOSN at Silver Cross Hospital, said the interdisciplinary aspect of LEA-UP is extremely important and is grateful that Dr. Tanquilut runs the group. “We need to know about the latest in wound care to continually improve results for our patients.”
Tanquilut founded LEA-UP to, as he says, “help save limbs. It’s important that medical professionals in all disciplines share information, share results and share therapies so our patients don’t have to face amputation.”
LEA-UP meets quarterly over a sponsored dinner at Zachary’s Grill in Palos Heights. The events are open to any health care professional. Interested professionals should email jrivera@vascspecialists.org or call 815-824-4406 and ask for extension 130. Dinner sponsorship opportunities to introduce medical products and services are also available.
