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Board Review Wound Care

War on Wounds: Psychology of Wound Care and the Need for Limb Team Six

Jeffrey Frenchman, DPM

Jeffrey Frenchman, DPM reviews the statistics on amputations of the lower limb and emphasizes the importance of taking an aggressive and timely treatment approach. Dr Frenchman relates by examples how the decisions the physician makes impacts both the patient and the entire family.

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Goals and Objectives
  1. Recognize the risk diabetics have in developing cardiovascular disease
  2. List short and long term mortality rates in the different types of lower extremity amputations
  3. Examine the benefits of a Limb Team Six approach
  4. Recognize the need to go beyond the "call of duty" in treating lower limb wounds
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  • CPME (Credits: 0.5)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.5 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Jeffrey Frenchman, DPM

    Director of Limb Preservation
    Atlanta VA Medical Center
    Decatur, GA

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  • It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems sponsored programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.

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    Jeffrey Frenchman has nothing to disclose.

  • Lecture Transcript
  • [Introducer:] And I have asked Jeff again to come and start off our meeting with a talk on the War on Wounds � the psychology of wound care. So Jeff Frenchman is a podiatrist, in podiatry, at the Atlanta VA, and I was just with him in another meeting just last week � I think I�m seeing a little bit too much of him, but let�s welcome Jeff Frenchman to the podium.

    [applause]

    [Jeff Frenchman:] Welcome. I just have one small housekeeping point. Although I appreciate being called the Chief of Podiatry, that actually honor goes to Dr Rick Oadham of our facility. So on that note, thank you for having me back again. I�d like to thank the organizers for bringing us all together over the next several days to share our personal experiences, to share the science behind why we make the decisions that we do, and novel approaches to how we treat. The true heroes are veterans.

    Last year I had the opportunity to introduce the important role in the concept behind the psychology of wound healing. Today I�d like to raise that bar to another level once again, and challenge each and every individual in this room to possibly think more critically about how the decisions that we make impact not only our veterans but their families as well. With that said, I�d like to introduce the concept of war on wounds: the psychology behind wound healing, and the need for LIMB Team 6. All of us are very familiar with SEAL Team 6. They�ve been in the news, they�ve done a lot of great things for our country. This is a modified version of that. That�s where the concept of LIMB Team 6 came in. And I�ll introduce all of you to that a little bit later on.

    Are we able to advance?

    In the words of President Harry S Truman, �Our debt to the heroic men and valiant women in the service of our country can never be repaid. They have earned our undying gratitude. America will never forget their sacrifices.� It is those sacrifices that they made for all of us to be here today � it is those sacrifices that they made for our families as well. It is my belief that all of us sitting in this room have a responsibility and an onus to sacrifice for better veterans, as they have sacrificed for us. It is our responsibility to raise that bar, to challenge ourselves and challenge those around us, to do things that we never thought we were capable of doing.

    [applause]

    Last year I spoke about several topics, looking at quality of life issues: isolation, depression, the inability for many of these individuals to go work and provide for their families, and the fact that wounds and amputations are a form of disfigurement. Today, what I would like to focus on is the family impact that these wounds have.

    I truly believed in my heart that I was doing everything that I could for our veterans. I truly believed that I was able to relate to them, that I could understand their losses, that I could understand the fact that they had decreased quality of life, the fact that they were unable to do simple things with their families, like go to the beach or go to the grocery store. I truly believed that I was doing everything that I could better than anyone else out there, to help heal those wounds, save their limbs, and ultimately save their lives.



    Today, that impact that I believed I had a clear understanding of, is far different.

    We could advance that one more time.

    It was not until approximately two months ago that the true impact of what a wound could do and the impact that it could have upon a family resonated in my own home. I�d like to introduce you all to my grandmother � as we affectionately call her, Gigi. My grandmother suffered from peripheral arterial occlusive disease. She suffered from critical emyschemia, that was not diagnosed early enough in her life to make a difference for her, to make a difference for our family.

    If we could advance that one more?

    This is my grandmother. She had what we would think as a simple wound. The bigger underlying issue is, wounds are not always what they appear to be. So for her, the fact that she had diminished inflow, the fact that that wound wasn�t able to close, the fact that there�s a high correlation and association with cerebral vascular disease and cardial vascular disease � it may not necessarily be the wound that tips the balance. But that wound leads to grave consequences, and in this case, that consequence was her no longer able to walk the face of this earth, for us not to be able to call her and pick up the phone, to share in our trials and tribulations, the birth of a new grandchild � that can�t happen anymore. I truly believe that if we understood the underlying etiology, if we more aggressively addressed those components, my grandmother would be here today and be proud of what we�re all doing in this room. Proud of the fact that we�ve chosen a profession where we can impact and change people�s lives and not only people�s lives but families� lives as well.

    We can advance that again, please?

    That�s my family.

    I need to go back one.

    That�s my family. With the true matriarch in the family centered in the front. She�s no longer with us, but I know that she looks down today, wanting each and every one of us in this room to be different, to strive for excellence, to face our darkest fears about treating people, and make a difference and an impact, not only on that individual�s lives [sic], but the life of their family members as well.

    Can advance again please?

    Could we advance that slide?

    And one more time.

    Dr Robbins wrote a paper that I addressed last year. And in last year�s talk I spoke about the psychology and the important role that that plays in what we do. But the reality of this is that five year mortality rates should be addressed more aggressively by patients and providers. It�s the cardiovascular disease, it�s the major causal pathway in early intervention to improve life expectancy in this most vulnerable patient population, is the most important thing that each and every one of us in this room can do on a daily basis.



    The global impact of wounds is far-reaching. It is projected in 2025 that there will be approximately 366 million individuals afflicted with diabetes; there�s a two to four time increased risk of heart disease and stroke in these individuals; and when you look at those five-year mortality rates of 45 and 55%, we should be ashamed of ourselves that we�re not doing a better job to address this earlier and more aggressively. These results are unacceptable in today�s environment where we can do better for every human being that we touch. We know that diabetic foot ulcers precede 85% of all lower extremity amputations, and as I�m standing here talking to all of you, one limb is being lost every six minutes within the United States itself, and globally that�s one every 30 seconds. So when you look at amputation statistics, what I like to focus on are the toe, and trans-tibial or below-knee amputation. There a study that was done that actually looked at this within the VA population. 1.7% of individuals that have what we would consider a benign procedure were no longer living at the 30-day mark. 7% that had a below-knee amputation no longer living at the 30-day mark, with 20% of those individuals being deceased prior to even walking out the same doors that they came through.

    More alarmingly, when you look at five-year mortality rates, is the 46 and 56% respectively for a toe and a below-knee amputation. Again, for me, these numbers are unacceptable. For my grandmother, these numbers are unacceptable. So what can we do better? How can we look at this more critically? Each and every one of us every day asks our patients to take their socks and shoes off, and a lot of times we see those thickened toenails. A lot of times we see that dry, thin, shiny skin, or a lot of times we will hear them complain of pain, numbness and burning. I�ll be the first one to raise my hand and say, a lot of times I attribute it to diabetic neuropathy, I attribute it to onychomycosis. It�s an easy, quick diagnosis for us to make. But the reality of this is that underlying this, there may be anoxia to the tissues, the peripheral arterial occlusive disease. The critical emyschemia. The things that we need to working up at a greater level. How many of us in this room check for popliteal or femoral pulses on a routine basis in our patients?

    These are the things that we need to do a better job at. We are at the tip of the spear. We are the ones that are doing this. We have the responsibility and the onus, not only to our patients but to our colleagues as well, to be able to give them direction as to where they need to go to help get that intervention early. Again, I believe that if my grandmother had that intervention early on, she would be here today with us.

    So how does this play into what we do? And that importance of the angiosome, and using skin perfusion pressures in order to address this. In my perspective, to rule out lower extremity or arterial disease, any patient with a wound, anyone over the age of 50 that has a history of smoking or diabetes should be looked at more critically. Anyone over the age of seven. Because the thing with this is that it�s not impacted by callus tissue, edema calcified arteries. We're able to get a clear understanding of actually what angiosome is involved, what vessel is involved, and we can target that to improve that inflow into that lower extremity and into the wound.

    I�d like to share a few stories with you about what I consider to be the true heroes. Those are the veterans that we have the opportunity to treat each and every day. This individual is an army ranger. This individual is a homeless veteran as well. This individual came from out of state to come and get his children back. He had the unfortunate event of being bit by a spider and being in the military he�s trained to treat these wounds by himself, and he


    decided to try to do that for approximately two years until he presented to all of us. These are the types of wounds that we as providers need to go to war on. These are the types of wounds that we as providers need to battle each and every day. These are the types of wounds that we need to confuse. We can�t keep doing the same thing day in and day out, if we�re not getting a positive response. It is these individuals that have borne that battle, that have borne the burden for all of us, that we should never give up on, that we should never turn our back on, that we should never walk away on, that we should raise the bar on each and every day, to help improve their quality of life, to help improve their families� quality of life, and get them back to the things that they deserve to do. And that�s live life to its fullest, which is what each and every one of us in this room hopefully do on a daily basis.

    Success is not final. Failure is not fatal. It is the courage to continue that counts. Winston Churchill. These are the important things. It�s never to give up in the face of adversity. It�s never to think that we can�t do something. As long as you can dream it, it can become a reality. That�s what I believe all of us in this room need to do. We need to dream for our patients. We need to be able to give them hope. We will need to give them the respect that they deserve, and bring them back from the brink to life once again.

    This is another one of our heroes. This individual�s wife has end stage renal disease. She has to go to dialysis three days a week. She depends on him to get her back and forth. He was with his family; he stepped on a nail; because of the comorbidities as we�re all aware of in this room, he didn�t realize that he had done that until he went to take his shoe off and was unable to remove it from his foot. At that point he realized that he had a very big problem. Once he was able to remove that shoe, he still chose to stay home for several days until he presented to us with a very bad infection in his foot. So options that are presented for an individual like this might be trans-metatarsal amputation, ray amputation, whatever all of you would choose to do in your hands.

    I chose to go a different road. I chose to say this: �Once you amputate, you cannot put it back on.� There is no harm in trying, in fighting, because that�s what they come to us for each and every day. They come to us for hope. They come to us with the expectation that we�re going to be able to heal that wound, save their life, and improve their quality of life.

    With a lot of hard work and very aggressive management of this individual, he started to respond. The sad part of this is, that many of us have seen this when we go up to round on our patients, in the morning and the afternoon and the evening. They�re slumped down with their feet pressed up against the end of a footboard. These are the results of � we were making progress, he developed two secondary wounds. And again, he becomes at a higher risk, not only for a trans-metatarsal amputation, but for a below-knee amputation. The only thing that this individual said to me was, �Please save my life. Please save my life. My wife depends on this. My children depend on this. My grandchildren depend on this.� And I made a commitment to him that I would fight harder than anyone else to try to accomplish that for him. So in my world, failure is not an option. If success is just a matter of trying harder, each and every one of us in this room have that responsibility to try harder, even in the face of adversity, when we believe we�re not going to be able to accomplish that goal.

    [applause]



    �He told me it would be better to cut my leg off.� That�s what this 37 year old individual, married, with three children, came in and stated to us. This individual lives off of a two-income family. He provides roughly 50%; his spouse provides roughly 50%. They were coming back and forth twice a week, a two hour drive each way, to receive therapy. His wife was having problems going to work. It was cutting into their quality of life, and it was cutting into their ability ultimately to provide for their family, to keep the lights on, to go to the grocery store. The only way of finding the limits of the possible is by going beyond them into the impossible.

    Many of us in this room may have felt that the only option was a below-knee amputation, as this individual was told. I say differently. I understand that we cannot save every limb. I get it very clearly. These individuals deserve at least a shot at saving that limb, so that they can get back with their families, and he can go work and provide that income that�s necessary and be there with his wife. Again, these are the challenges that I hope each and every one of you walk away with today, to raise that bar, to do a better job and to be more aggressive in the management and care of our veterans.

    So what�s next? Where do we go from here? So we can all talk a good game, and we can all say that we do these things, but the reality of it all is that it doesn�t really matter �till the rubber hits the road. I�d like to introduce something to you called the limb preservation service line, and VALSAT, also known as LIMB Team 6, and why this is so important.

    Many of us work in a federal institution. We either belong to the surgical service line, or we belong to a medicine service line and there�s geriatric service lines, and every service line that the government can think of to create more red tape. My concept would be this to all of us. Why not have a dedicated service line to limb preservation? Why not have a dedicated service line that will help provide continuity of care, streamline the efficiency and the speed in which these patients get therapy? How many of us, we see a patient, we write a console, and then it takes two, three, four weeks for that individual to get to the next gatekeeper, whether it be vascular surgery or endocrinology or plastic surgery � wherever they may be funneled?

    My perspective is that it all needs to be funneled into one location. This location needs to house the PAVE clinic, to restratify our patients. It needs to have a wound clinic, both an acute and a chronic wound clinic, to help us guide our therapeutic approaches, and ultimately improve outcomes in quality of life. An amputee clinic � we know that there are amputee support groups, but what about a wound support group? How wonderful would it be for our heroes, for our veterans, to be able to go with a group of their peers and share their experiences, and what it took for them to close their wound, and have that psychological support, and be able to speak with someone dedicated to them? That�s where we need to go. That�s where the future is. And that future, in my perspective, starts today � right here with all of us. It doesn�t start tomorrow; it doesn�t start a week from now or a year from now. These are actions � a call to action, if I may say, to get us to raise that bar to another level, to do better, and to be better human beings in the long term for doing that.

    LIMB Team 6, also known as the Veterans Affair Limb SAlvage Team. These are just a few of the many players in that arena. And why is this so important? Because our patients need this level of care. They�re critical. They�re high risk. All of us that work in a federal institution understand that they don�t come in with one medical comorbidity. It�s a whole


    litany of them. They need a true team approach. They need that crack elite unit to come in, rapidly assess that wound, get the angiograms or the CTAs or the MRAs, get them treated, re-establish that inflow, not wait and say, �Well, the wound�s progressing. It�ll get a little bit better,� and wait a month or two months or six months. Too many times it�s too late. In the cas of my grandmother, it was too little, too late.

    I went down there ten days before she passed. I thought that I would be able to go and change her life and change our family�s life. I realized when I got there that I would not be able to do that. I watched her decompensate over ten days, and then I left to come home, and I got a phone call the next morning, that she was not here anymore. And I couldn�t do anything. I was not only helpless, but I felt hopeless. So it is our responsibility, it is our onus, it is our job, by choosing to work in a federal institution, or for that matter, anywhere becoming a physician, to aggressively manage these patients, because wars end; the battles don�t. They never end for our patients. They are at high risk to have a recurrence. They are always at high risk to lose that limb. So I challenge each and every one of you today to be better than you were when you came in this morning, to fight hard for the true heroes, and to make a true difference in the life of another human being.

    That is the greatest thing that anyone in this room can do. Thank you all very much.