Dr. William Herbert (Guest): Well, that’s a great question. As a vascular surgeon for over 30 years, much of what we do is centered around what we call limb salvage. If somebody has a wound in their lower extremity usually and has lack of oxygen from obstruction of arteries, we can repair these. Even when we do that, sometimes the wounds are very defined. If you add diabetes to the picture, which is many, many of our patients, sometimes even under those circumstances, after you’ve re-vascularized them, the wounds fail to heal for a variety of reasons. These are all very challenging wounds. The bottom line for most of these folks is limb salvage—that is, to save the limbs and avoid amputation. That’s something which we want to do very, very frequently.
Melanie: How long do you look at a wound if you’re the patient and say, “Okay, this thing ain’t healing”? How long do you let that go before you decide that this is something that really needs to be dealt with?
Dr. Herbert: Well, interestingly, most of the patients that we see are referred by their family physician or what have you, and there’s a certain period of time where primary care doctor will deal with the wound and whatever sores and sometimes, in retrospect, a little bit longer. But if somebody has a wound that’s been there for a month, that’s too long, depending on what the cause, especially if diabetic. Some of these are urgent problems. They sometimes find themselves in the ER. And once wounds are being treated by physicians, even ourselves, if you get out beyond three or four, five to six weeks, and things aren’t working, you need to try something else, and I think that’s probably that the area where hyperbaric treatment really comes into play. When you’ve done everything, you’ve tried everything else, oftentimes that’s the way to go.
Melanie: Before we get into hyperbarics, tell us about the wound itself. What are the complications? Can it become infected? Does it spread to other areas? What really will happen?
Dr. Herbert: Well, the major complication is if the wound is left to its own devices and enlarges. Let’s say, in the lower extremity, in many locations, the bone is not very far away. If an ulceration, let’s say, on the foot or ankle area progresses to a certain depth and it involves the bone, it could be very, very challenging to heal this by any means. So I would say the major complication, especially with respect to the lower extremity, is increase in extent, size, and depth of the wound, ultimately involving the bone and other tissues, which in some cases makes complete tissue salvage impossible, such as loss of toes or loss of extremity, let’s say involvement of the bone and extension in size leading to unsalvageable extremity. That’s the biggest complication.
Melanie: You mentioned hyperbarics. And after trying other methods to heal that wound, what is hyperbarics? How does it help?
Dr. Herbert: Well, here’s what hyperbarics is, basically. A patient goes in a Plexiglas chamber that had been pressurized to atmosphere, so it kind of feels like you’re diving to the bottom of the swimming pool with 100 percent oxygen. This is the main technique. And what it does is that it super-concentrates oxygen in the patient’s body so that wound is seeing 50 times more oxygen than it was otherwise. These treatments, there’s different recipes, but for a lower extremity wound, let’s say on a diabetic, this treatment might involve essentially a one-hour treatment in the chamber, five days a week for four weeks. It’s fairly involved. But in well-selected patients, this has been wonderful and has been sometimes the only way we can get these things to heal. There are some risks and complications, but the hyperbarics itself, it’s relatively safe. The major problem that is seen is claustrophobia, and because of the pressurization in the chamber, folks have to do the ear equalization techniques, like when you’re flying in an airplane and those such things. It’s very closely monitored, very carefully supervised, and again, it’s sometimes the only thing that will work.
Melanie: You mentioned it feels like going to the bottom of a swimming pool and your ear pressure and that. So is it very uncomfortable? Is it something you have to work with deep breathing to relax during it? Do you feel that pressure on the rest of your body?
Dr. Herbert: We don’t feel it in the rest of your body. I’d say the major place to feel it is in your ears. Again, patients are very carefully prepared for it. They’re aware of it. They’re instructed, too. You can talk with folks when they’re in there. They can talk with you. You have them relax, swallow, sometimes they can do that maneuver where you pinch your nostrils and kind of blow out a little bit. Again, it’s not too much different than air travel when you have to do the same kind of thing. And once people equilibrate, it’s quite safe. I’d say the treatment’s an hour, but it takes about 15 or 20 minutes to pressurize and then to de-pressurize. So the block of the treatment time may be close to two hours. Very, very rarely; very rarely, if someone has a difficult time clearing their ear, they can get a ruptured eardrum. That’s extremely uncommon.
Melanie: How soon do you start to see results? Is this something that takes awhile after you finish your treatments? Or does it start to work pretty quickly?
Dr. Herbert: It starts to work pretty quickly. I’m glad you asked that because one of the many benefits of the wound center is that the recordkeeping is meticulous, including photography. These wounds are measured, documented, and we keep very close track of the size of the wound and its response. With the many wounds within the hyperbaric scope, you start to see tangible results within a week or two. The wounds become more shallow. They become smaller, and the progress is very carefully documented for a multitude of reasons, not the least of which is if you don’t see a certain amount of progress within X amount of weeks, then you need to consider changing your treatment or adding something else. You can see fairly dramatic results in a fairly short period of time, within a week or two, yes.
Melanie: What’s going on? This is a relatively new form of study, isn’t it? This wound care is such a burgeoning field right now. What’s going on in this field?
Dr. Herbert: Well, I think what’s going on is -- what I see is a lot more science. I think now there’s a lot more interest in evidence-based medicine, benchmarks, and results. I think as we’ve seen in the last decade, for sure, many wound centers are opening up. And this data is being coalesced, and there’s a lot more, I think, good science going on with regard to various wound products. There’s a lot in the industry now. There are so many biological and non-biological skin substitutes that are wonderful adjuncts. The other thing that is happening is—not the least of all—is the people. The people now that I find, the physicians, the caregivers, the nurses that are involved in this area, they’re passionate about it. I think one of the things that I’m very excited -- one thing that will make this wound center very special, in my opinion, is that we’ve got a very wonderful and diverse group of dedicated clinicians for vascular surgery, myself; podiatry, my associate, Dr. David Micca, who is my co-medical director. We got plastic surgery on board, trauma and burns, [physiatry], infectious disease, ENT, and the nursing staff with wound credentials. I think what we’re seeing is there are a lot of very qualified people now very interested in wounds across the board.
Melanie: In just the last minutes, give your best advice for someone suffering from a wound and why they might come and seek care from you.
Dr. Herbert: Okay, I would say if someone has a wound and they’ve had it for more than a week or two and they’re not sure how it’s doing, just go to the doctor, just anybody, anywhere. Just go to the doctor. I think as we move forward, we will do our best to make sure that primary care physicians, family docs all over, will call us sooner rather than later and not be trying to frustratingly be battling with the wound. For the patients, I say go to your doctor and we’ll do our best to make sure the doctors in our region have our number.
Melanie: That’s great advice and such fascinating information. You’re listening to MMC Radio. For more information, you can go to mainemedicalcenter.org. That’s mainemedicalcenter.org, mmc.org. This is Melanie Cole. Thanks so much for listening.