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Medical Intel

Aug 30, 2018

Serious diabetic foot sores used to require major surgery, including amputation. Dr. Tammer Elmarsafi discusses how vacuum-assisted wound closure devices can help diabetes patients heal faster and avoid amputation.



Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re talking to Dr. Tammer Elmarsafi, a podiatric surgeon at MedStar Washington Hospital Center. Welcome, Dr. Elmarsafi.  

Dr. Elmarsafi: Thank you so much for having me.

Host: Tell us a little bit about yourself. Why did you go into medicine and how did you come to practice at MedStar Washington Hospital Center?

Dr. Elmarsafi: As far back as I can remember, I’m the quintessential geek. I always loved biology and chemistry, and then one day, when I was in high school, I joined my local first aid and rescue squad, and when I became an emergency medical technician I realized it wasn’t the sciences that I loved so much; it was the patient interaction, and that really sparked the whole trend for my future career. I knew that I was going to be a doctor and I did everything I can to get to where I am today.

Host: Today, we’re talking about how negative pressure wound therapy can help heal diabetic foot ulcers. Dr. Elmarsafi, negative pressure wound therapy often is referred to as vacuum therapy. How does this treatment work and is it really like a vacuum?

Dr. Elmarsafi: That’s a wonderful question, and it’s probably the most famous question that I get from patients. When I explain that, we’re going to put a dressing on that’s connected to a tube connected to a machine that acts like a vacuum, the first thing that they say is, “You’re putting a vacuum on me?”  And, ultimately, when you break it down it truly is a simple vacuum, but it’s much more complicated than that. It’s very sophisticated. The technology is not all that new. It’s been around for quite some time and it’s been robustly researched.  A negative pressure wound therapy is a medical device that is designed to clean wounds and at the same time provide some wounds that are very deep, allow the patient the opportunity to fill in their wounds with this vacuum. The vacuum allows the tissue to be stimulated in such a way that the patient can begin to, what we call, granulate in, and it works. It works very well.  

Host: What do you mean by granulate in?

Dr. Elmarsafi: That’s a term that we often use to describe new tissue growth. So, the patient has a big wound, and let’s say that it’s very deep, when we attempt to heal these wounds, the one thing that is very difficult to get is the depth to decrease. We want the wound to become more and more shallow so that the skin can grow over it, and then it becomes like a normal-looking site. Granulating in essentially means that the wound is filling in and is becoming more shallow, and negative pressure wound therapy is a device that essentially does that.     

Host: What would be a reason that an individual would have a deep wound, or what are some of the most common causes of those wounds that you treat?

Dr. Elmarsafi: For the lower extremity, by far, the number one thing that we see are diabetic foot infections. The complications of diabetes and peripheral arterial disease culminate in a long downstream effect of risk that results in ulcerations to the foot. Additionally, there are lots of other things that also lead to ulceration, like venous stasis ulcers, and then there are surgical wounds as well, patients that have had cancers removed from their extremities, and ultimately, they are left with these large deficits, these large wounds that now need to heal.

Host: So, when you say ulcer, you’re not talking about the same type of ulcer that people probably have heard about in the intestines. You’re talking about a superficial, a wound on the skin.

Dr. Elmarsafi: That’s right. An ulcer in the lower extremity is basically a break in the skin, but it goes much deeper than that, and it’s basically a crater in which can be very small. It can be on the tip of a toe, for example, but can be as large as a deficit that takes up the entire heel, and then we see much larger wounds as well.   

Host: What is it about the nature of diabetes that causes individuals to develop these wounds on their feet? You wouldn’t necessarily associate the foot with the pancreas or other body parts associated with diabetes.

Dr. Elmarsafi: It’s a very interesting disease. Diabetes, we don’t use the words epidemic and pandemic for chronic diseases, but it’s a disease process that’s very prevalent and is, despite a lot of emphasis on disease screening and prevention, and lots of research dollars being put into designing new therapies and genomics to understand our patient population better. Despite this, diabetes has a natural course. Patients that have diabetes, whether it’s type 1 or type 2, over the years, do develop lots of consequences. The most common that we identify are cardiovascular risks--increased risk for heart attack, increased risk for stroke, increased risk for kidney disease and blindness, but the reality is that it affects everything in the human body, and that also includes the vessels in the lower extremity and also includes the nerves. And, so a patient that does not have good sensation in their feet, if they were to step on a nail, for example, they would not know, they wouldn’t feel it, and therefore there would be a delay in care.  We call this neuropathy. Diabetic peripheral neuropathy is a big problem, and it’s the first downstream effect of diabetes that puts patients at risk.          

Host: So, wound VAC therapy, or the negative pressure wound therapy, why is this such an effective treatment for diabetic foot ulcers?

Dr. Elmarsafi:  The simple negative pressure wound therapy device that we described earlier has evolved, and the technology has grown over the years. And now, it’s not just able to provide suction to allow the tissue to granulate in as we described. Now, we’re also able to instill or put fluid into the wound, and so we’re able to essentially lavage or clean the wound, and we can use different solutions, so we can put different solutions that would clean the wound depending on the type of bacteria that’s growing, et cetera, and that’s really increased our ability to custom tailor our treatments specifically to each patient.            

Host: So, an individual for whom you would recommend this device or this therapy, what should they expect during the implantation process, or how do they go about receiving this therapy?  

Dr. Elmarsafi: Most of the patients that we see do require some surgical intervention. We really do need to clean out these wounds very well and get surgical biopsies, particularly if we also suspect that there’s bone infection. Once we apply, we usually apply it in the operating room, but then while they’re an inpatient, if they’re an inpatient, then dressing changes. They’re just changed at bedside and usually there isn’t any problem with that. There’s no pain and it’s a very simple process. But, if they require multiple surgeries, we’ll just divert that to be done in the OR and then the patient doesn’t feel anything. But, many times our patients only get one done in the operating room and then they require long-term therapy, at which point they get a small device, it’s a portable device, and it gets changed every several days and we follow up in clinic, and it’s not cumbersome in any way.   

Host: Is this a device that people can go home with or is it always inpatient care?

Dr. Elmarsafi:  There are many different versions of these devices. And some devices are designed specifically for in-hospital use, but there are devices that are designed to be very portable. Some devices are battery operated. Some devices are spring loaded and have no noise and no alarms, it’s very simple device.  And, some devices are designed specifically for wounds that have been closed, surgical incisions, to help promote quick healing for wounds that are at high risk for complications afterwards.    

Host: What can patients do on their own, either before or after receiving this negative pressure therapy, to promote healing of those diabetic ulcers or to prevent them from the beginning?

Dr. Elmarsafi: I love this question, and it’s something that a lot of people tend to not think about. It’s easy to control infection after surgical cleanout and giving antibiotics, and it’s easy to ask the vascular surgeon to improve circulation. Doing all those things is very important, but if you exclude nutrition and exclude really tight glycemic control and getting their sugars under control and exclude the idea of really good personal hygiene to the extremity, then we lose sight of long-term successes. All surgical patients in general require a little bit more in terms of their protein intake, but with the diabetic patient, in particular, you have to really balance this. You have to be careful, of course, with their calories, and you have to be careful if these patients also have cardiac disease and renal disease, and many of our patients have all three of these, and so a nutritional consult is something that we rely on very heavily, and almost all of our patients have an endocrinologist as well, and so we work as a team. Our methodology for treating our complex patients with complex wounds is a multidisciplinary approach. It’s about ensuring that all of the appropriate doctors are involved and integrated in the patient’s care to make sure that everything is addressed to provide them with the best care. The most important people that we have integrated into our team are the vascular surgeons, infectious disease, and, of course, physical therapy and occupational therapy. Rehabilitating our patients is very important for long-term outcomes, making sure that the patient has the right balance and the right coordination, and to prevent fall risk in our lower extremity patients is very vital, and they are very strong proponents of being part of our team, even before we take them to surgery.        

Host: What would you say is a good estimate for an anticipated recovery time for an individual who undergoes the negative pressure wound therapy, and then for their wound to ultimately heal?  

Dr. Elmarsafi: You know, that’s a very hard question, and I get this question all the time from family and patients, but everyone heals differently and every wound is very different. A wound on the bottom of the foot heals differently from a wound on the top of the foot. A wound on the ankle heals differently from a wound above the ankle. A wound in a patient who’s 90 years old is different from a wound in a patient who’s 20 years old. And, we assess risk and rates of healing at different intervals for different patients, and so we are constantly at every time I see a patient, I’m reevaluating what things need to be tweaked, what things need to be changed in order to change the rate of healing.  With negative pressure wound therapy, it offers the opportunity not just to readjust our management. Sometimes, negative pressure wound therapy, in the beginning, is a great modality, but later on you realize that the wound is now amenable to a different therapy, and that’s exactly what we’re looking for. It’s not a permanent therapy. It’s a different stage in the patient’s management, at which point you can switch from negative pressure wound therapy and move on to something more definitive.     

Host: So, this procedure--it’s very aggressive and intensive, it sounds like. Is this kind of a last step before amputation, or what is the progression from there if it doesn’t work?  

Dr. Elmarsafi: I view my job as being able to provide the patient with the longest ability to be mobile for as long as possible, as independently as possible, and that may mean sometimes an amputation. So sometimes an amputation is the best answer, but my job is also to prevent amputations, and negative pressure wound therapy is a great modality in most patients. There are patients, however, who are not candidates for wound therapy.

Host: Who would be a good candidate and, likewise, who would not be a good candidate for negative pressure wound therapy?

Dr. Elmarsafi: Most patients are great candidates for negative pressure wound therapy. The patient who comes in with a wound that’s heavily infected is not a good patient for wound therapy right away. Once we clean the wound, they become a good patient for wound therapy. A patient who’s had a carcinoma, for example, who may have remaining risk for recurrence, is not a good patient for wound therapy, but there are other modalities that are really good for that type of patient. And so, really to provide good care for complex wounds it has to be very custom tailored, and negative pressure wound therapy has a role in many different kinds of patients. I would say most patients are good candidates, but there are a select few patients that I would say probably would not benefit from negative pressure wound therapy, and that is an assessment that needs to be done on a 1 on 1 basis. 

Host: Have you had a patient that came in with a diabetic ulcer that was just absolutely miserable, and then what was that progression story for them? What were they able to accomplish after they had this treatment?

Dr. Elmarsafi: I recall one patient in particular who went to the operating room once, and after the operating room, just did not ever want to go back to the operating room after that, and, in retrospect, I realized that, you know, not every patient is a surgical patient. It was important for that patient to go, and probably would have benefited from multiple surgeries thereafter, but I was surprised at how well the patient responded with just negative pressure wound therapy alone, and it’s changed my practice ever since. For patients that are on the borderline of “I’m not sure I really want to go to surgery”, I know that there is another modality that I can rely on and give another opportunity for healing without surgical intervention. And negative pressure wound therapy, for some patients, is a great modality as long as other risks haven’t pushed the patient into the corner where they have to have surgery.           

Host: It’s always about that patient choice.

Dr. Elmarsafi: Yes.

Host: What are some of the reasons why an individual should choose to come to MedStar Washington Hospital Center over another provider, you know, whether it’s in their neighborhood or if they’re traveling to come see you--what makes this, the experience, for them special here?

Dr. Elmarsafi: MedStar Washington Hospital Center is comprised of a group of experts. Experts that are well trained, who are fellow trained, and specifically custom tailored to the patient’s well-being. I think that’s true of many places, but what I think our team offers that, I don’t want to say other places can’t offer, but our wound care is far superior than most. We get a lot of the complications from other places, and that’s not to say that other places have caused complications, but other places can only go so far with their abilities and their resources to provide care for patients, and then they reach a threshold where they can’t do anything more, and that’s when we get patients coming to Washington Hospital Center for further care.  I just had a referral from a patient who was told he needed below-knee amputation from two separate hospitals in the DC Metro area and came for his last opinion. And we were very, very fortunate to be able to save his limb and he is now approximately two months after his operation and he’s ready to go back to work.

Host: Is there anything that caregivers should be aware of when their loved one comes home, either after this treatment or with a VAC device?

Dr. Elmarsafi: Not necessarily. I think the number one thing to remember about negative pressure wound therapy is that the device itself makes noise, and sometimes that noise, although is not very loud, the noise can change as the wound is changing, as the position of the patient changes, and sometimes when the noise changes people become afraid that something is happening, the device is doing something it shouldn’t do, or something dangerous is happening, and that’s the number one thing that people complain about. And really, the machine is actually quite sophisticated. It is not just a vacuum. The device itself has very sophisticated sensors and computers. The change that you hear is that computer adjusting for all of the things it needs to do, and it does have alarms. So, if an alarm goes off, the patient will definitely know and the caregiver will be alerted that the device should be turned off and that a call needs to be made to the provider.   

Host: Now, is this negative pressure wound therapy something that an individual can be somewhat mobile while using, or are they, you know, basically chair-ridden or bedridden, connected to an external machine?   

Dr. Elmarsafi: For the most part, most patients can get around, and it really depends on the location of the wound, but even for patients that say have a negative pressure wound therapy device placed on the bottom of their foot, as long as they are able to get around say on crutches or with a walker or a knee scooter, that’s perfectly fine and mobility is very important for these patients as long as they are doing it in a safe manner.   

Host: Thank you for joining us today, Dr. Elmarsafi.

Dr. Elmarsafi: It’s been a pleasure. Thank you so much.

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