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.    

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