High-Tech Advances in Wound Care Yield New Promise
by Tina Cauller
M.D. News - Dallas
For patients who have chronic wounds that are difficult to heal, basic medical and surgical care is essential, but not always enough. The primary cause of non-traumatic amputation is diabetes. There are nearly 16 million diabetics in the U.S., and about one million of those reside in Texas. One quarter of those Texans affected live in the Metroplex area. More than 67,000 patients with diabetes require surgical amputation each year, necessitating long and costly rehabilitation. For many, mobility and independence are severely affected, permanently altering their quality of life. HealthSouth Medical Center of Dallas has established a Wound Care Program devoted exclusively to preventing and healing wounds.
Difficult-to-heal wounds can result from traumatic injury, diabetes, peripheral vascular disease, complications following surgery, rheumatoid arthritis, congestive heart failure, arterial or venous ulcers, lymphedema and many other conditions which compromise circulation. Dr. Jeffrey A. Stone, medical director of the Wound Care Program at HealthSouth Medical Center of Dallas explains, "Wound care is complex by nature. Our program is designed to provide care on a highly individualized basis, so we constantly evaluate and readjust our approach as necessary to achieve results." The Wound Care Program also recognizes the importance of prevention. Susan Rainwater, R.N. of the Wound Care Program explains, "We assess patients at risk for early signs of tissue breakdown so they can be closely monitored and followed to assure that wounds do not develop. Since implementing this aspect of our program, the incidence of hospital-acquired ulcers has dropped to zero." Ms. Rainwater adds, "We have also recently established an outpatient clinic for our wound care patients so that followup care can be provided by the same physicians and staff who provided their inpatient care. This allows for excellent continuity of care and helps patients to feel comfortable and confident."
Dr. Stone and his staff are well known by patients and family members, not only for their great abilities to treat serious and difficult wounds, but also for their attentiveness and compassion. Photo by Gittings Photography According to Dr. Stone, "We need to first establish a foundation of good basic wound care and we can aggressively encourage healing by using the most advanced technologies available." The implementation of therapies like Regranex, a platelet-derived growth factor which stimulates healing, has proven to be tremendously beneficial for wound care in appropriate patients. Other advanced wound care technologies include WoundVAC (a vacuum-assisted device which applies negative pressure to the wound to facilitate closure) and hyperbaric medicine, which is helpful in some cases.K
Dr. Stone earned a master's degree in public health from Harvard after graduating from medical school, followed by a residency in aerospace medicine and a fellowship in hyperbaric medicine and wound care at the U.S. Air Force School of Aerospace Medicine at Brooks Air Force Base in San Antonio. He served as Chief of the Department of Aviation and Hyperbaric Medicine at the U.S. Army Aeromedical Center in Fort Rucker, Alabama, where he is credited with developing the Army's hyperbaric medicine program.
After initiating and developing the Army's hyperbaric medicine program, an appealing opportunity to do research and have a clinical practice led Dr. Stone to join the Institute for Exercise and Environmental Medicine at Presbyterian Hospital of Dallas where he is medical director of the Hyperbaric Medicine Unit. He believes that hyperbaric oxygen therapy deserves to be included among those treatment modalities which can benefit a new patient population. After many years of practical experience with hyperbaric oxygen therapy, he is convinced of its usefulness and has set out to prove it with good, solid research.
Dr. Stone has been active in wound care in Dallas since 1992. In 1994, Dr. Stone reviewed the records of diabetic patients with non-healing ischemic wounds and found that those individuals who received HBOT as an adjunct to standard care had a higher limb salvage rate (72% vs. 53%, p<0.002), despite the fact that the 119 patients who were selected to receive HBOT had larger, more serious wounds and were at increased risk for amputation. His data was presented as an abstract in 1995 at the annual scientific meeting of the American Diabetes Association.
Doctors have used hyperbaric oxygen therapy for over 60 years to treat patients with decompression sickness, a condition that results when divers retain too much nitrogen in their bodies. Hyperbaric oxygen therapy (HBOT) is also the primary therapeutic modality for patients with carbon monoxide poisoning and those with air or gas embolism. It has proven to be an important adjunctive therapy for many other conditions, including gas gangrene, radiation tissue damage, compromised skin grafts, crush injury, acute traumatic ischemias, necrotizing soft tissue infection, and chronic refractory osteomyelitis. Dr. Stone believes that HBOT will also prove to be helpful as an adjunctive therapy for the treatment of some non-healing hypoxic wounds. "I see patients, many of them diabetic, who have chronic foot wounds. On average, their wounds have been present for 11.8 months. Some have wounds which have not healed in years. These wounds can eventually lead to amputation."
HBOT for wound care is based upon sound physiological principles. Without adequate oxygenation, the normal healing process cannot take place. According to Dr. Stone, "Revascularization is key in the diabetic with an ischemic foot, but even after this, there are some individuals who remain refractory to healing. In the diabetic, we know that there microangiopathic changes in the eye and kidney. These changes also occur in the foot." Dr. Stone feels certain that HBOT may play a role in improving the outcome of some individuals who fail to improve even after revascularization.
The physicians and clinical staff of Wound Care Consultants keep communications open to ensure quality care by meeting with the appropriate members at HealthSouth Medical Center to discuss patients' progress and treatment plans. Photo by Gittings Photography The Institute for Exercise and Environmental Medicine's hyper/hypobaric environmental chamber is capable of reproducing the atmospheric pressure from 165 feet below sea level to 100,000 feet above sea level. This large three-lock complex is 40 feet long and 9 feet in diameter. In addition to its hyperbaric applications, the chamber is also used for studying the effects of high altitude and low temperature on mountain climbers or skiers. The unit is also used in the care of critically ill patients, such as those with crush injury or carbon monoxide poisoning, who are intubated and require respiratory support. Chamber operations are monitored at all times by advanced computer systems and medical monitoring systems.
The study Dr. Stone is presently conducting is a double blind prospective study designed to examine the effectiveness of HBOT for the treatment of non-healing diabetic foot wounds. Despite his conviction about the effectiveness of HBOT, Stone is conservative in his selection of candidates. "Less than three percent of my patients receive HBOT," he notes. "There are many aspects of wound care. It is essential that a wound be kept clean, properly dressed and surgically debrided, that patients receive good nutritional care, that any wounds are off-loaded, and that antibiotics are used as needed." Dr. Stone is quick to add that good wound care requires a multidisciplinary approach. "I work as part of a team that includes multiple physicians in many specialities, nutritionists, physical therapists, certified diabetic nurse educators, and other health care providers. Wound care is not provided by any one individual." Dr. Stone's practice includes Kenneth Sherman, Jr., M.D.,M.S., Julia Dillard, R.N., M.S., CS-ANP, Mechiell Hunt-Tucker, P.A.-C and Amy Conkey, P.A.-C.
Dr. Stone's clinical staff consists of (clockwise) Julia Dilliard, R.N., M.S.,C.S.-A.N.P.; Mechiell Tucker, P.A.-C; Jeffrey Stone, D.O., M.P.H.; Amy Conkey, P.A.-C; and Ken Sherman Jr., M.D, M.S. Photo by Gittings Photography Dr. Stone has chosen the HealthCare Vision, Inc. (of Fort Worth) Telemedicine System to conduct remote wound care at the nursing homes where he sees patients. Dr. Stone believes he is the first such provider to offer this very important value-added service. Dr. Stone says, "The telemedicine technology that HealthCare Vision incorporates on their laptop and desktop systems will enable me to remotely monitor my wound patients. I plan to have my physician assistant and nurse practitioner carry the laptop telemedicine system into the nursing homes. The portability of the laptop will enable my mid-level providers to present residents of the nursing home who have certain types of wounds and disease states that require immediate consult. The HCV system transmits over most modalities including telephone lines and incorporates videoconferencing, image capture and a medical record system. I strongly believe that we will provide improved patient care and reduce the cost of delivering care." Dr. Stone will be conducting a formal outcomes-based wound study. His goal is to provide critical data for the State of Texas to encourage payors to expand reimbursement for telemedicine consults.
Consistent with the character of this remarkable man, he remains humble, summarizing the growth and success of his practice with the words, "I have been so fortunate. I have a wonderful staff who are caring and dedicated to giving the best possible care." Indeed, his patients have shared the good fortune of receiving state-of-the-art wound care from a compassionate, experienced physician who is dedicated to investigating and promoting the best possible level of patient care.
Dr. Stone has a website at www.wound.com and can be contacted via e-mail at stone@wound.com. For referrals or more information about the HBOT research study, call 214-345-4679.
Jeffrey Stone, D.O., MPH is board certified in both Hyperbaric Medicine and Aerospace Medicine. He serves as senior medical examiner for the Federal Aviation Administration and as a consultant to many insurance companies, Veteran's Hospital of Dallas, Dallas Poison Control Center, and Divers' Alert Network (DAN). Dr. Stone is past president of the Texas Affiliate of the American Diabetes Association and serves on two ADA committees at the national level. He has published articles on hyperbaric oxygenation and decompression sickness in publications including Undersea Biomedical Research and Aviation Space and Environmental Medicine. He is both an avid pilot and scuba diver.
For more information on Telemedicine, contact Dr. Stone.
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Last Updated: September 18, 1997
