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Good evening.

Thank you so much for watching HealthLine here on PBS Fort Wayne, I'm your host Mark Evans, thank you so much for watching and we hope that you'll call with some questions a very important topic tonight we're going to talk about wound care and the various kinds of wounds.

The type of care that they take might learn something if not for yourself, maybe a loved one or a friend.

Please call the number on your screen when you have a question.

The number is right there 866- (969) 27 two zero.

It is a half hour program.

We don't step down for commercials because we are public television so feel free to call any time our special guest tonight we have two in fact one an old friend of mine I won't say old because of age just we've been doing the show for so many years and if you don't mind I want to reach over you and shake this gentleman's hand.

Nice to see you, Dr. Jim.

Dr. James Adlen him round here we do call on Dr. Jim.

He's been a friend of ours for many, many years on HealthLine, a former colorectal surgeon but now after his retirement has gone into wound care wound care specialty and we're going to hear all about that in just a second.

And the lovely lady next to me is Brooke Randall.

>> She is a clinical nurse specialist and this is your first time on the program.

It's a piece of cake.

You'll get great.

It's so nice to have you.

So before we talk to Dr. Embleton about what he does, tell us what a clinical nurse specialist does.

>> Yeah, so I'm a clinical nurse specialist which is an advanced practice registered nurse, one of four different recognized in Indiana and my focus is really on wound care patients ensuring that they get what they need, meaning that the hospital has systems in place to ensure that they get the right things.

Also that the nurses feel comfortable treating wounds and that we are doing evidence based practice and are you parallelled against a nurse practitioner?

>> Are you about the same as far as education or maybe even more so?

>> Our education is very similar.

We take pharmacology, advanced assessment, our clinical hours are a little bit different and for a clinical nurse specialist you focus on a specialty population so mine is wound care.

There are also clinical nurse specialist in cardiovascular that work with the heart.

Those that work in the ICUs within the hospital.

So I am fortunate to be in a provider role so I am able to see patients just like a nurse practitioner would make very good.

>> And Dr. Adlen, you being in the colorectal surgery arena for so many years of course wounds are nothing new to you.

>> So I would imagine this was a fairly easy transition for you.

>> Yeah, we started kind of doing wound care.

I started doing wound care part time toward the last five years of my practice and so it was a natural transition and across the nation physicians who were in one care very often had another specialty that was related surgeons you know, if they no longer want to or can do surgery, you know, sometimes you get disabled and sometimes you just get old and you know, so for safety reasons and also I don't take call and I don't work weekends and so it's a lot easier on the old body but still I get to work do patient care and use the principles of wound healing are important for all surgeons and you work hand in hand.

Look, Brooke exactly.

Brooke is very helpful on a number of fronts.

One of the things she does for us is our telehealth help build our telehealth program and that became extremely necessary during the covid time and she also then does evidence based practice teaching it to nursing units because not all nursing units have the same level of expertize with wounds.

They don't see them all the time and then we also she also works in our clinics helping bring our new onboarding our new nurses and she's an invaluable source in terms of when I want a research project.

She's kind of got the chops to be able to help with the research projects and very important I've been so heavily involved clinically that research is kind of no longer a skill set that I have so and a typical day.

>> What is your day like about how many patients would you happen to go see?

>> We'll see.

You know we call it a panel and so half DLC fifteen patients and sometimes I do like a specialty referral that only a physician can do.

We have you know, most wound care centers are heavily nurse practitioner led and practiced and so we have not only nurse practitioner but clinical specialists and then when there's something that needs to be done by a physician for example, today I went and saw just two patients but they both took an hour and a half each.

Well yeah.

So they were like special things like that and you know and you know so I go to the various clinics and do that I'll fill in for people who need time off and that kind of thing.

>> I see.

And then when I get in trouble I colebrooke oh I see.

And then of course your job is to assist the physicians and also take care of the patients as well and upon the recommendations of the physician as well.

>> Can you explain what kind of a day you have?

Yeah so every day looks different for me some days are spent doing virtual consults with patients and one of our eleven hospitals community hospitals and other times I'm working directly with the nurses or the nurse practitioners in the clinic to make sure that a patient gets what they need.

Sometimes it's supplies.

Recently we wanted to start using a new product in our clinics.

It's called Fishkin and that helps heal wounds.

It's a novel product and so I went through the channels necessary in our organization to bring that on board and to be able to utilize for our patients.

>> I see very good.

Well we have all this knowledge here and we're here at your disposal if you will just give us a call and will answer your question.

First of all, let's just get to the beginning of things what is classified as a wound in the medical profession so we have brought some slides.

OK, so a wound is a disruption in the integrity and function of tissues in the body.

We go to the second slide I can now we divide wounds into chronic and acute the acute wounds by and large there's some basic principles and we can often close them primarily I think if you look back to the historical things in the civil war they didn't close wounds they didn't you know by and large because wounds would get infected if they did so our wounds are not closed nor are they closable.

So we have to employ strategies to get the wounds to close.

So that's basically what we do if we have the next slide clinical practice is because most people in a busy practice might see one or one week in a primary care where internal medicine practice we can see these patients weekly and give them the attention they need and there's a host of things that are required to to manage a wound nobody normally gets a chronic wound.

>> There's always some problem and it involves coordination of care among multiple specialties in multiple communities resources.

>> I'd like Brooklyn to talk a little bit about the coordination of care that she really is very helpful with.

>> OK, before you go into that brook, what kind of wounds are we talking about?

Are they surgical wounds?

Are they gunshot wounds?

What kind of the majority of wounds we see are diabetic wounds or due to venous what we call venous insufficiency venous leg wounds?

OK and we see you know, you've been out and seen people with with the very close the Burkle's veins as those go on they get worse when you get injured back your shin slamming in the car door, get a bee sting, get a spider bite with a chainsaw.

These are things that happened.

The wound won't heal if you have venous insufficiency the blood gets down there and won't go back.

Another thing that happens is the blood might not get down there and then the wound won't heal.

So the arterial supply is important just the same as you get arterial supply problems to your heart and it's the leading cause of death in the United States.

Blood supply to your legs is often compromised in a wound.

One of the things about arterial insufficiency is the wound won't heal.

One of the things about venous insufficiency wounds won't heal sometimes they'll have a cancer taken off and there's a wound and it won't heal.

>> And then so that's where we come in.

We come in and take care of the wounds we're talking about the various ways wound can be treated.

>> Yes.

And then you know, the treatment of the wound implies that you also identify the various risk factors.

The diabetes is a huge thing for everyone.

So diabetic foot ulcers are huge.

People with diabetes lose the ability to feel a sore so they don't limp and you get a sore on the bottom of your foot.

You don't know it.

You get a Lego in the bottom of your foot.

You don't know it and you know I mean these are things I've seen Jackson are another really dangerous thing and they get embedded in there and they don't know it because their feet are numb.

About half of all diabetics in just thirty eight million diabetics in the United States now adults and so about half of them will have some level of what is known as neuropathy and so neuropathy leads to wounds which can lead to ulcers which can then lead to infection and the infection can get into the bone and you know, you can lose your leg.

>> Well, and I'm not trying to keep you out the conversation.

There's one more question I want to ask.

You said some wounds cannot be closed.

>> Why is that?

Well, you don't want to close a wound that's been open too long.

When I worked one of my many lifetimes I worked in emergency room and after 12 hours you did not want to close the wound.

>> You know, you wanted to let it heal by secondary intent, OK?

And that's in the civil war and before then the wounds were left open treated as chronic wounds.

>> They will heal much better if you have good blood supply, you good blood drainage, you take proper care of the wound.

You don't keep walking in those kinds of things.

>> OK, very good.

I'm glad we had that sidebar there.

Yeah, very informative.

>> And then we're going to talk about clinical practice with you is that right?

So what's up for grabs next?

So go right ahead.

You have the floor.

So when we're thinking about what type of treatment that we want to do for the wound, we ask those questions like Dr. Allen was talking about those that have blood supply and then the coordination of care comes in play.

Do we need to get a cardiologist on board and then we're looking at if it's a diabetic wound and they're walking on it, do we need to get a podiatrist on board because people with diabetes that have the neuropathy walk differently and their bones change in their feet and so those areas that are prone or predominant sometimes there are procedures that a podiatrist could do to help relieve the pressure from there.

And then other things we look at is is there infection?

Do we need to engage infectious disease doctors to ensure we have the right antibiotics on board?

Nutritionists nutrition plays a huge part in wound healing.

We want to ensure that if they're diabetic their agency is well controlled also if are that they're getting the nutrients that they need so certain vitamins there are products out there that you can take specific to wound healing, daily vitamins and other pieces.

Does the patient need assistance with their dressing changes and so do we need to engage home health care and other agencies.

So all of this coordination of care is typically happening through the nurses.

The providers are saying this is what I want and then the nurses work together to ensure that all of these things are happening, that patients have the dressings that they need.

We order them sometimes they're covered by insurances and sometimes we have to get creative.

So we do a lot of meeting people where they're at to ensure that we're checking all these boxes and that their wound heals.

>> Do you ever have situations where you have somebody with a foot ulcer comes in and they don't realize they have diabetes?

You ever have situations like it's an enormous problem, was that right?

>> I would say that at least twenty five percent of people with diabetes don't know it in the United States and it's clearly some areas are worse than others.

>> And you know, there's large areas of the United States where they're underserved and that's our population is people who are under under insured in the rural areas.

You know, they can't get to the doctor and you know, so our weekly visit sometimes are every other week.

There's no way for them to get there.

So if you can't even get to the doctor, you're not going to know you have diabetes.

Right.

And diabetes is insidious in the sense that it creeps up on you and you can have it.

You know, the first symptom of diabetes is often numbness of the feet and they go and they see that my feet are burning and and you work it up and you find out they've been probably diabetic for eight to ten years.

Oh wow.

And that means there's already damage damage done only to the sensory nerves.

But as Brooke said to the nerves of the muscles, the muscles there would hold the bones in shape and there's twenty one bones in the foot and they get mal aligned and you begin to walk funny and then you've got an ulcer because you're walking funny and you know if you're on an hourly job with very little health care coverage, you know you can't be off of that foot.

>> You got to keep working.

Oh absolutely.

And so that's that's a huge problem for our patient population and that's where coordination of care comes in to play.

You know the reason that the most popular shoe that I see out there is the one where you don't have to bend over and put it on as most of us can't reach our feet after a certain period of time and that's our patient population.

>> They can't reach their feet to do the dressings.

Wow.

So we need lots of lots of community involvement with home health care and other resources to help us get taking care of these patients.

>> We say it takes a village to take care of a wound care patient.

Oh wow.

Yeah.

Well let me get into maybe a little darker area here because I think it's necessary.

What if you don't have these wounds taken care of ?

I mean what's what's going to happen?

Well, if you don't get some help if you're not being proactive about yeah.

So if wounds go untreated, especially diabetic foot ulcers then you're at risk for amputation or loss of toes sometimes half the foot the whole foot even up to the knee.

And we know there's been robust research that shows if a patient with diabetes gets a high level amputation that their morbidity or chance of dying is similar to that of a cancer diagnosis or even worse.

Yeah, and we don't want to get to that point.

So if you have any issues with your feet especially I mean that could be a warning sign.

So get that checked out because you certainly don't want to get to that area where even I mean not to take business away from you but you know, really if it's not necessary, why can I get to that stage?

>> You know, we're very big on prevention.

We preach prevention.

>> Absolutely.

So checking your really why we're on here.

Yeah.

Yeah.

Oh exactly.

That's what the show's all about and we thank you for being here once again.

All right.

Well you have several slides.

We love to see those.

>> Where would you like to go from here?

Well you know we were actually originally going to talk about hyperbaric oxygen.

Yes, but hyperbaric oxygen is important part of wound care.

But it is an adjunctive therapy.

So if you are not actively treating the wound and treating the wound properly, it's not going to be covered by CMS or any of the third party carriers and hyperbaric oxygen has a very important role.

Here's what it is.

It's defined as a pressure of one point six atmospheres or more with 100 percent oxygen.

We do it in specialized chambers that are designed to be safe.

>> We have a big around this.

We have a big safety program.

You can imagine the fire risk with one hundred percent oxygen.

So you know the fire department is in the national fire safety organizations have to certify our chambers and our activities in our units so safety is first hyperbaric oxygen at two atmospheres of pressure or two and a half atmospheres of pressure is what we do for infected diabetic wounds, chronic infected bone for late effects of radiation therapy and there's a total of sixteen indications in our clinics the way we're set up and where the hyperbaric is the the acute use of hyperbaric oxygen is not very common most of the time it's for chronic wounds, diabetic radiation and other kinds of infected bone.

And so that's what we do.

And what it does is because of what I call the Belichick law the ideal gas law remember Belichick trying to explain why the football was so soft in the cold air the the partial pressure of oxygen being 100 percent then the the oxygen dissolved in the blood not in the cells not carried by the red blood cells goes up 10 to 12 times and that oxygen getting to those tissues that has limited blood supply from either the diabetes making problems with the small blood vessels or radiation making problems with the small blood vessels will help that wound to heal.

>> It will only help the wound heal.

We have to do all the other parts of wound care or it doesn't really work very well said the hyperbaric chamber.

>> Is that a unit where the whole body goes in or the entire body?

We we are using monoplanes units and I think everybody around the other wound care centers are using monoplanes units.

There used to be a multiplex unit down at St. Joe but they tore down right.

So there was a new house unit there and a good friend of mine opened that unit many years ago and you could put more than one person there didn't like it very much because they had to go in at the same pressure and there's you know, if you do it for your treatment that's one thing.

>> If you do it three or four times a day you can get some ear problems.

>> Well, and that was mainly for burn victims, is that correct?

What really burns only some burns, you know, only some burns need hyperbaric burns is not a big part of hyperbaric.

It is for example, if they're in a closed space they have carbon monoxide poisoning, you know, carbon monoxide toxicity is one of the indication for hyperbaric oxygen in the burn victim.

But most of the time they are so sick that, you know, putting them outside the ability to care for a patient in a critical care way makes hyperbaric oxygen impractical.

>> Okay, so it's done but it's an exception rather than the rule.

I say most of the people we treat for with hyperbaric oxygen have radiation damage wound infection, crush injury, reperfusion injury and like I say three or four thirteen or fourteen other indications including sudden sensory hearing loss, central retinal artery thrombosis you know these are some you know, some specialized kinds of things that we don't very often see but we have the capability of doing all right.

>> Well, it looks like we have a call on line three and is it Coie?

>> Hello.

Yes.

Yes, go ahead.

Yeah.

So I just had a question when it came to the diabetics something that you're talking about.

>> So when it comes to if somebody didn't know they were diabetic and for four years persay and when they finally find out the diabetic is the damage that is done, stay at the person's feet were hurting for years they didn't realize that it was from diabetes or there the tips of their fingers or anything like that was numb for years they didn't know it.

Is that damage permanent or is that something that you guys look look at when you guys are looking at patients to try to get that back to normal or is it just it's done and over with?

>> That's an excellent question really is I don't know the answer as to reversible.

>> We can stop it.

We can stop it progressing and here's what I mean by that.

>> There are nerves to the muscles.

There are nerves to the sweat glands in the secrete in the sebum glands and nerves to the sensory and the getting the diabetes under control, lowering what we call the agency which is the amount of glucose that's stuck your red blood cells.

That's the thing that seems to do the damage we can stop the damage to the tendons by getting it under control and keep it from progressing.

I don't think tendons will go back and I don't think nerves will grow back.

But it's important to stop it in its tracks as soon as you can.

So that's really the reason we're on here is to, you know, help people do prevention of wound care and that's exactly right.

And we have about what, three, four minutes left in the program and I would love for you to explain and go in to the fact that prevention is the key.

How can we stay out of wound care units?

>> You know, what's the main key or a key is I should say yeah.

So the we've talked about too but there's another type of injury that we commonly see too and that's a pressure injury.

So for pressure injuries we want to make sure that you're moving around.

You're never sitting in the same place for too long changing your body position for diabetic wounds like we've discussed really inspecting your feet, getting a mirror, keeping your blood sugars under control and then for the venous leg ulcers like we talked about you see a lot of times with swollen legs we say some compression is better than no compression.

So if you can purchase over the counter socks to help keep that swelling down, elevate your legs, a lot of times this is recurrent and it's a symptom of other things that are going on like congestive heart failure.

So monitoring your weight and if you notice that you're starting to retain or gain or your pants are tight getting a hold of your primary care doctor before they get so swollen that they the skin stretches so far that it blisters.

Oh and then you end up getting a venous leg ulcer and having to come and see us and once you've had one your rate of recurrence is much higher.

So compression for swollen legs inspecting your feet if you're diabetic and ensuring you're moving around to prevent pressure injuries.

>> OK, very good.

We have about 30 seconds left.

Wesley is wanting to ask a question if we can answer this quickly, can the wound can the wound clinic treat burns when there is no burn center nearby ?

>> OK, so this has been a big problem for us because the burn center suddenly closed here in town.

It's been here since I got here.

OK, and so what we have done there's an American Burnison guidelines for the treatment of burns.

So we look at the we'll see somebody and we'll triage them and get them.

Usually we send them down to Ashkenazy.

Some people can't get there and Eskenazi will help us and Brooker's along with a couple of our nurse practitioners who used to work in the burn center help us with that.

>> So you're not the reason advertising for burn care but we provide it because we have to OK and so we get them to where they need to go following strict American Burn Association.

>> Good.

All right.

Sorry we ran out of time.

We can talk about this for another hour or so, but Dr. James Adlen, wound care specialist and Brooke Randall, clinical nurse specialist, thank you so much for being here tonight.

Very informative.

Thank you for watching.

Thank you for your calls.

Good night and good