DIABETIC ULCERS

by
 Lorrie D. Gray, PMAC
3823 Smoke Tree Dr.
Colorado Springs, Colo.
80920
Phone: 719-548-8003
Important to check the patient's allergies.  If your office has 
the soaking instructions printed out, it is still a good idea to 
go over them verbally with the patient.  Many people will not 
even read what you hand them.  If you go over it with the patient 
and the person who might be helping the patient, they will have a 
tendency to ask more questions.  Therefore, the patient will have 
a better understanding of what he or she is expe


*- daughter of a diabetic patient.  She is very upset and is 
going on and on about her mother's foot.  She says that her 
mother has an open sore on the bottom of her foot.  You schedule 
her immediately for that day.  As you hang up the phone your mind 
goes into action.  You are asking yourself  what grade ulcer 
could this be, how long has it been there and will she need to 
have a vascular consult.  Other questions that are going through 
your mind are how will the doctor treat her.  Here are a few time 
saving steps that an assistant can follow to help things run 
smoother.

	In cases such as this,  it would be helpful for an assistant 
to be familiar with the Wagner ulcer grading scale.  The Wagner 
classification of ulcers grades ulcers on a scale of  I-V, with V 
being the worst.  First, Grade I is strictly superficial in 
nature.  It only affects the outer layer of skin.  Next Grade II 
is considered deep.  It goes through the outer layer of skin and 
down into the muscles, ligaments, capsules, and or fascia.  With 
a Wagner grade I-II you will not find  evidence of any 
osteomyelitis, which is an infection in the bone.  Osteomyelitis 
will not be present because the soft tissue breakdown and 
infection have not reached the bone and penetrated.  Following 
Grade II,  III ulcers will commonly show evidence of 
osteomyelitis.  If you have an ulcer of this grade there is a 
good chance that the patient will be admitted to hospital for 
intravenous antibiotics and possible surgery.  If a Wagner grade 
III goes untreated, you will find localized gangrene. When this 
happens, it is considered a Wagner grade IV.  This can lead to a 
loss of one or more toes.  Finally a Wagner Grade V  is extensive 
and could affect the whole foot.

	Other helpful information that an assistant would need to 
know about the patient would be the patient's family doctor's 
name and phone number, the patient's current medications, and the 
patient's drug allergies.   By knowing these things ahead of time 
you can save office time and the doctor's time.  If you have  to 
admit the patient you will already know what hospitals they can 
and cannot go to.  This is important, because some insurances 
have stipulations on where patients can be treated.

	When an assistant knows that a diabetic patient is coming in 
to the office, there are some other time saving steps to be 
considered.  First, always update the patient's current 
medications.  This will be helpful later if the doctor needs to 
put the patient on antibiotics.  The doctor needs this 
information to make sure that there will not be the risk of  a 
possible side effect due to a current medication.    Also, the 
patient's drug allergies should be checked.  The patient's chart 
may say no known allergies, but you should still ask.  It is 
possible that the patient has seen another doctor who could have 
prescribed medications to which the patient had an allergic 
reaction.

	Along with the patient's current medications and allergies, 
the assistant will need to know the results of the patient's last 
fasting blood sugar and when it was taken.  Some patients may 
check their sugar two to three times per day while others may 
only check it once a  week.  A normal fasting blood sugar is 
somewhere between 70-120 milligrams per deciliter.  If a 
diabetics sugar is elevated, it will take them longer to heal.  
If their sugar is elevated during their visit, ask them what it 
normally is.  If their sugar is always high, the doctor may refer 
them to their family doctor to help them get their sugar under 
control.

	Making sure the patient's blood sugar is within the normal 
range helps because diabetes affects the feet in several ways.  
One way is in the form of diabetic neuropathy.  Diabetic 
neuropathy can be a very serious problem for a patient with an 
ulcer.  Neuropathy is the loss of sensation.   Therefore,  the 
patient could have had the ulcer for several weeks.  Because he 
or she could not feel it, the patient may not realize it was 
there.  Diabetics with neuropathy in their feet should be 
cautioned and educated to avoid possible problems that will be 
mentioned later.

	Another important factor that can slow down the healing 
process is smoking.  If the patients are smokers, ask them how 
much they smoke per day. Because smoking causes vasoconstriction 
of the blood vessels, it creates a decrease in the circulation to 
the area.   For this reason, the doctor may ask them to quit or 
at least cut back until the ulcer is healed.  Due to the loss of  
circulation to the area, the ulcer will take longer to heal. 

	Also, when questioning the patient, the assistant should try 
to find out how long the ulcer has been present.  If it has been 
present for more that one week, the doctor may want to get a set 
of radiographs.  When an ulcer has been present for a period of 
time  osteomyelitis could show up on the radiographs.  

	While taking the radiographs, it is important to take at 
least three different views.  If you only have one to two views 
you run the risk of missing something that could appear from a 
different angle.  For example, if you are looking at the 
patient's right hallux, and you only take an AP (anterior 
posterior) view and a medial oblique view, you could possibly 
miss something that would show up on a raised hallux lateral.  
Also radiographs should be taken to have a record for comparison 
at a later date.

	While reviewing the radiographs, the doctor may find them 
inconclusive.  He may want to order a triphasic bone scan, which 
means that it is done in three phases, or he may want to order a  
magnetic resonance imaging, MRI.  During a bone scan, the patient 
will be injected  with a radioactive isotope  that will collect 
in any irritated areas of bone.  After the injection, the area 
will be scanned immediately, scanned after five minutes, and 
scanned after three hours, hence the name triphasic bone scan.  
Since bone scans show only bone and not necessarily soft tissue, 
they are considered sensitive but not specific in nature.  A MRI, 
on the other hand, will show a clearer picture since it shows 
bone and soft tissue.  However MRI's do have their drawbacks.  
They can be very costly and are not always readily available.  
MRIs work magnetically.  Therefore, if you have a patient with 
any type of metal in their body this may not be an option for 
them.

	After  finishing  talking to the patient, an assistant 
should get an oral temperature reading.  An elevated body 
temperature could mean nothing more than the onset of a cold, but 
it could also alert the doctor to the possibility of an 
infection.  Although you are already aware that the patient has 
an ulcer with infection locally,  a fever could mean an infection 
in the blood stream.  At this time, it would be helpful to have a 
check-off sheet to record information on.   You will have a 
permanent record for the patient's chart as well as a central 
place for current information.  This way the doctor will always 
know where to look.

	Other things an assistant can have prepared would be the 
culturettes for a gram stain, culture, and sensitivity.  These 
should be done for every patient.  First, you would receive the 
gram stain that shows the doctor the general type of organism 
that is present.  If organisms are present their shape will be 
apparent.  This is important, because it will determine the 
initial antibiotic coverage.  Most of the organisms present in 
the foot are Staphylococcus and Streptococcus.  Next, the culture 
will determine the specific type of organism present.  At that 
time the antibiotics may need to be changed.  The final step 
would be the sensitivity.  This will tell you the antibiotic of 
choice for the treatment.

	After you have your cultures ready take a look at the ulcer.   
One good idea is to  have a camera so that you can take a picture 
of the ulcer.  Make sure that the pictures are clear and have no 
obstructions in the area.  A good picture is important for 
several reasons.  First, the doctor will have a general idea of 
what is waiting for him in the treatment room.  Second, the 
doctor will be able to compare how the ulcer looks from visit to 
visit.  Lastly, the picture should become part of the patient's 
permanent record.  Photos should be labeled correctly listing the 
ulcer site, right or left foot, dorsal or plantar aspect.  Also, 
you should list the patient's last name, first name, the date, 
the doctor's name, and the assistants' initials.

	Once an assistant has most of the paper work and pictures 
done, one should check the patient's pedal pulses in each foot.  
The assistant would check the dorsalis pedis, which is located on 
the top or dorsal part of the foot, and the posterior tibial 
pulse, which is located on the medial side of the ankle.  If you 
get in the habit of doing this on all patients you will have a 
good idea of what is normal.  In a diabetic it is not uncommon to 
find a decreased pulse or no palpable pulses at all.  If there 
are no palpable pulses, and your office has a Doppler, you can 
put it in the room for the doctor.  A Doppler simply lets the 
doctor listen to the patient's pulses  rather than feel them.  
After checking the pulses, an assistant should be able to get a 
good idea whether the doctor may need to order vascular testing.  
If so,  it would be helpful to have the orders written up so all 
the doctor would need to do is check them over and sign them.  It 
also helps for you to be familiar with the different test and 
what they do.  On the test orders it is common to see PVR, pulse 
volume recording, and PPG, photoplethysmography.  These two tests 
will tell you the amount of circulation that is getting down to 
the foot.  The other common term is transmetatarsal pressures.  
This is how much blood flows at the transmetatarsal level.  A 
N.I.V.E. stands for a non invasive vascular exam.  A N.I.V.E. 
will be done bilaterally.  Both legs will be tested and compared 
to one another.  This will show if there are any discrepancies 
between the two.  The test is usually read by a vascular 
specialist.  The report should be given verbally over the phone 
with a written copy to follow.  After the test has been read, the 
specialist will be able to advise the doctor whether the patient 
has adequate circulation to the area to allow healing.  In some 
cases they could suggest bypass graft surgery or possible 
amputations that, in turn, could save the patient from a future 
limb threatening infection.

	By now the doctor is ready to enter the treatment room.  If 
the assistant can stay with the doctor while treating the 
patient, it is very helpful.  The culturettes should already be 
in the room and ready to go.  At any time during the debridement 
of the ulcer the doctor may need them.  Having these already 
prepared the doctor will not have to wait for you.  The doctor 
may also want another picture after debriding the area.  After 
debriding the ulcer, the doctor will measure the area.  If you 
are right there, the doctor can just tell you to write it down 
instead of having to remove his or her gloves to do it or trying 
to remember until later.

	After having collected the information from the assistant 
and the patient, the doctor may decide whether he or she would 
like to have blood work for a baseline reading.  Blood work is 
usually done when cellulitis is present.  Cellulitis is the 
inflammation around the area will appear red and blotchy.  It is 
important to draw a line with an indelible marker at the edge 
where the cellulitis is present.  The doctor may also want 
another picture of the area with the line drawn on it.  In these 
cases, the doctor usually will not admit the patient to the 
hospital at this point.  However, the patient will be ask to 
follow up in forty-eight hours.  At the follow up, if the 
cellulitis has progressed past your initial line the doctor will 
probably admit the patient to the hospital. 

	If the doctor does do the blood work it could consist of 
many different tests.  For example, a CBC is a complete blood 
count that will show an increase of white blood cells due to an 
infection.  On the other hand a sedimentation rate will show if 
there is any inflammation in the body.  A glucose will check the 
patient's sugar level.  A BUN, blood urea nitrogen, and 
creatinine will show how well the patient's kidneys are 
functioning.  This test is important because antibiotics are 
filtered out of the body by way of the kidneys.  A hemoglobin A1-
C will show the doctor how well the patient's sugar level has 
been controlled over the last one hundred twenty days.  The 
doctors' preference will determine exactly which test they would 
like to see.

	As the patient is being treated, an assistant will have a 
good idea of how the doctor can relieve the pressure from the 
ulcerated area.  This would most commonly be done  with a post-
operative style shoe.  The shoe would have an accommodation or 
cut-out around the ulcer.  If the doctor has told the patient to 
stay off  his or her feet as much as possible and if at follow up 
visit the post-operative shoe is very worn, it would be important 
to let the doctor know this.  For example, if the patient is no 
better, and says he or she is staying off  his or her feet the 
post-operative shoe will tell the real story.  Soles on a shoe do 
not get worn off by being propped up on a pillow all day.  In 
these cases, the doctor will need to stress to the patient how 
important it is to be as inactive as possible.  The doctor may 
also build up the accommodation on the shoe to compensate for the 
non-compliance in the patient.

	If the patient has a Wagner grade I or II ulcer and is not 
being admitted to the hospital, the doctor may send him or her 
home  with instructions for local care.  Again, if you know the 
patient has a betadine allergy you could have white vinegar 
soaking instruction ready.  This is one reason why it is 
important to check the patient's allergies.  If your office has 
the soaking instructions printed out, it is still a good idea to 
go over them verbally with the patient.  Many people will not 
even read what you hand them.  If you go over it with the patient 
and the person who might be helping the patient, they will have a 
tendency to ask more questions.  Therefore, the patient will have 
a better understanding of what he or she is expected to do.  
Always stress to the patient that if he or she has any questions 
or concerns to please contact the office.  You would be surprised 
at how reassured this makes the patient feel.

	Essentially, there are three components for healing a 
diabetic ulcer.  The first component is the patient's ability to 
heal which depends on their circulation.  Next, the infection 
needs to be properly diagnosed and treated through the use of  
gram stains, cultures, sensitivities, x-ray, bone scan or MRI, 
and various lab work.  The final component would be to relieve 
the pressure from the ulcerated area with a post-operative shoe 
or other means.  If any one of these components is missing the 
ulcer will not heal.  For example, if you have a patient who is 
following the doctor's orders, wearing the post-op shoe, taking 
antibiotics as prescribed, and there is still no improvement, 
then it is possible that the patient's circulation is so poor 
they can not heal the ulcer.   You need to understand how crucial 
adequate circulation, proper diagnosis and treatment, and 
relieving the pressure from the ulcer is to the healing of a 
diabetic ulcer.  They all work as a team, the same way you and 
your doctor do.  By knowing and understanding the different steps 
in treatment you will be able to better assist the doctor and the 
patient.

	In many cases these patients are going to be very upset.  As 
far as the patient is concerned, the doctor may seem to be 
talking in a foreign language.  The patient will not always 
understand the doctor and can become even more frustrated.  If 
the assistant knows and understands what the different tests are, 
you will be able to explain the information to the patient in a 
way they can comprehend.  This will help the patient to feel 
confident in the doctor's skills as well as your own.  The 
patient may feel more comfortable talking to you and may tell you 
things that he or she will not tell the doctor.  The patient may 
also feel more comfortable asking you questions.  With all of 
these things in mind, you can begin to understand how it will 
benefit the whole procedure.  This routine can run very 
successfully from the time the patient calls to the time they are 
discharged from the doctor's care.  As a Podiatric Medical 
Assistant there are many ways in which you can contribute to this 
daily occurrence.   Dealing with a diabetic ulcer is just one 
example of how you, as an assistant, can use your knowledge and 
skills to help the day run smoother.