Emphasizing The Fundamentals And Patient Education In Diabetic Foot Care

Perry Mayer, MB, BCh, CCFP

Treating the diabetic foot is relatively straightforward. We need to ensure that blood flow is adequate, eradicate infection, eliminate pressure from the wound site and regularly remove the dead and devitalized tissue from the affected area. If we do all those things, the wound heals. It really is that simple.    

However, the pathway to get to that point is often quite convoluted and requires considerable foresight. Looking into the future is critical in the successful treatment of the diabetic foot. Knowing what is coming is probably more important than treating what we see in front of us. Experience gives us this soothsayer ability.    

All too often, patients and clinicians alike mistake the use of fancy dressings, complicated procedures or expensive tests with success in wound care. Some success certainly comes from our work on the wound itself but probably a more durable form of success comes from our ability to engage our patients in actively participating in the treatment process. To be successful in that endeavor, we need to be able to deliver a truly understandable message.

Explaining To Patients Why It Is Crucial To Remove Pressure From Wounds

We know the majority of diabetic wounds are simply pressure sores gone awry. Research shows us that removing pressure by cutting or scraping away the dead and devitalized tissue from the wound site is critical if one wishes to heal the wound successfully. Repetitive trauma to the non-feeling foot simply perpetuates the tissue insult, destroys viable tissue and changes horizontally moving edge cells into vertically growing calluses. The horizontally moving cells at the edge of the wound are the ones that travel onto the wound bed and cause the wound to close. Vertically growing calluses will never end up on the wound bed as they are growing in the wrong direction.    

This ongoing trauma also alters the signaling mechanisms in the wound bed. The cells in the wound bed malfunction or stop functioning depending on the duration and the amount of tissue damage that has occurred. Without the combination of mobile cells to move onto the wound bed and signaling cells to tell them where to go, we cannot possibly expect wounds to heal.    

This small explanation is one that we give 30 to 40 times a day to our patients with diabetic wounds. Our job becomes incredibly more difficult when the patient does not understand what we are doing and why. Explaining to patients that dramatically reducing the amount of pressure they put on the wound will stop the process of wound bed trauma and callus formation now makes considerable sense to almost everyone. When we repeat the message over and over again, it sinks in. Then the patients gain a better appreciation of their role in the wound healing process and ultimately become more adherent with the things (offloading in particular) that really matter in diabetic wound care.

Recognizing And Communicating The Value Of Frequent Surgical Debridement

The other fundamental that is critical in successful wound healing is frequent surgical debridement. Again, this is a process that wound specialists often do but give little explanation to patients. Additionally, there is a notion that expensive gadgets are necessary to do the best debridement work. In reality, there really is no compelling evidence to suggest that an expensive ultrasonic or water powered debrider is really any better at producing the end result than the relatively inexpensive scalpel and curette.    

Obviously, there is a role for these highly specialized and very cleverly designed instruments, but the reliance on high-tech products and the assumption that use of these gadgets equates to excellent outcomes lacks compelling, supporting evidence in the literature.    

One can achieve excellent outcomes by paying rigid attention to the fundamental principles of wound healing. These fundamentals involve meticulous debridement of all dead and devitalized tissue, and the removal of hyperkeratotic tissue at the wound margins. This is a message that I heard first from my debridement mentor, Chris Attinger, MD. His philosophy was simple. As long as one removed all devitalized tissue from the wound bed and the wound had adequate perfusion and was not infected, the wound would heal. His simple mantra was that any tissue that was not red, white or yellow was tissue that was not healthy, and therefore needed debridement.    

We use his philosophy with every single wound that we treat. Patients comment quite rightly that “How in the world will my wound heal if you cut it open every week?” It was for this very reason that we adopted the philosophy of explaining the mechanisms of wound healing with every patient. Again, it is the cell migration sales pitch repeated ad nauseam.

Reinforcing Patient Education With Visuals

Pictures are extraordinarily helpful when trying to illustrate a particular effect in the wound healing continuum. One picture that is helpful in motivating a patient is an illustration of when a wound is on a healing trajectory. We tell our patients that migrating skin cells in the healing wound move onto the wound bed like water flowing over the edge of a waterfall. We then show them pictures of this in action, demonstrating the straightening of the craggy wound edge, followed by rolling of the margins and finally by the flowing of skin cells onto the wound bed.    

The important message is that healthy, properly functioning cells do not exist in wound beds that are slimy, smelly or the wrong color. We like it when the wound bed is beefy, red and slightly bleeding. When the wound bed looks like that, it is relatively healthy and will accept the skin cells that flow onto it. When patients understand the mechanisms involved in a healing wound, they also have a better understanding of why their wound may not be healing.

In Conclusion

I have been practicing diabetic foot and wound care for the past 20 years but only relatively recently have realized that simplifying the wound process by going back to the basics with every patient encounter produces far better results than I ever had when I was younger and thought I knew everything.    

Developing a strong relationship with our patients is also key to success in the treatment of the diabetic foot. Interestingly, the diabetic wound is the least of our patients’ problems but it is one that brings them to us for care. It is critical that we capture their attention and find ways to deliver an understandable message. By doing so, our patients may suffer less in the short-term and also live a more healthy and uncomplicated life in the long-term.    

In this regard, we liken ourselves to salespeople. We need to convince our patients with diabetes about the gravity of their situation and empower them to do something that they would not inherently do of their own volition, like changing their lifestyle, reducing their weight or increasing their exercise.    

Patients often will comment on the miracle of saving their limb after we have successfully healed a disastrous diabetic wound. The miracle, however, is not the healing of the wound. It is the leveraging of the strong relationship that we have formed with these special patients and using that to sell them on an idea about changing their life for the better.    

Trust, understanding, compassion, enthusiasm and knowledge are a few of the elements that are necessary to produce success in the diabetic wound world. We can learn some of this in books and lectures, but learn most of it through experience. In order for diabetic wound care to evolve at a faster pace, those of us with experience need to be able to think in a non-linear fashion of ways to share this with the up-and-coming stars of diabetic wound care so their learning curve is less steep than ours. In doing so, we can help them achieve success with their patients sooner than we did.    

Dr. Mayer is the Medical Director of the Mayer Institute for Advanced Diabetic Foot and Wound Care in Hamilton, Ontario.    

Editor’s note: For a related article, see “How To Facilitate Better Patient Compliance” in the June 2003 issue of Podiatry Today or visit the archives at www.podiatrytoday.com .

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