Ernie Bisset, Wound Care

A New Leg Up On Life

Ernie Bisset climbs up onto the exam tables, coaxing his new limb into a more comfortable position. The prosthetic leg is only five days old and Bisset, 80, is still getting used to wearing the new device. Today, he is meeting with Dr. Terence Quigley, chief of surgery at Northwest Hospital & Medical Center and attending physician at the hospital's Wound Care & Hyperbaric Center. They greet one another like old friends, sharing a brief catch-up before getting down to business. Dr. Quigley is inspecting a healing wound on the big toe of Bisset's remaining foot when he notices him absently rubbing the top of his left leg where the prosthetic device fits into his hip.

"How is it feeling today?" Dr. Quigley asks of the new limb.

"It's a little sore and it moves around a lot inside," Bisset answers.

"You're doing extremely well," Dr. Quigley says. "Give yourself six months and you'll probably be getting around on a Par 3 course."

Bisset is an avid golfer and walker, but a year ago a sore developed on the side of his right foot. He didn't feel much pain, so thought little of the growing wound and treated it with daily applications of bacitracin ointment and clean bandages. In the late 1970s, when he was 50 years old and approaching the end of a 30-year career as a detective in the Seattle Police Department's homicide unit, Bisset was diagnosed with diabetes. At the time, doctors advised him on the importance of monitoring his disease and nurses gave him materials to read. Today, he says he paid little attention to their warnings and, at times, even disregarded his own body's response to the disease.

Diabetes is a metabolic disorder characterized by abnormally high glucose levels in the blood, a result of either the body's inability to produce sufficient insulin or because the body's cells do not react properly to the insulin that is produced.

As of 2007, 23.6 million people, or 7.8 percent of the U.S. population, had diabetes. The disease is commonly found in older adults, but lately, healthcare providers are also finding more young adults with Type 2 diabetes. Diabetes is a complex illness that compromises the immune system and puts individuals at greater risk of serious health problems. One of the leading complications of diabetes is diabetic neuropathy, or nerve damage, that lessens an individual's ability to feel pain, heat and cold.

"Diabetic neuropathy prevents patients from having normal feeling in their legs and feet," Dr. Quigley says. "People with diabetes get blisters and sores on their feet that they sometimes can't feel or see and because they can't feel, see or treat them appropriately, the wounds often get infected."

In addition to neuropathy, people with diabetes routinely struggle with circulatory problems. Poor circulation limits the flow of blood to the lower extremities and sores, infections and cuts have trouble healing without the benefits of oxygenated blood. If a wound persists for more than one month, it is considered chronic. Belinda Martinez, a hyperbaric technologist and safety director for Northwest Hospital's hyperbaric therapy program, knows the clinical definition of a wound inside and out, but her description is different. She calls it a sore on a life and not just a limb.

"Think about a wound. It hurts. It aches. It limits your mobility. You can't even shower. Think about wearing shoes and not being able to take a long walk without pain. A wound that does not heal will change your whole life," Martinez says.

Bisset's wound didn't heal, and by the end of summer 2009, his life had changed. He no longer golfed, he walked with pain, and three months after the sore appeared on this foot, he finally went to the doctor. Dr. Quigley treated it locally first, with antibiotics and wound debridement a process in which dead skin is separated from live, healthy tissue. The combination of debridement, antibiotics and keeping the wound elevated typically promotes the healing process. However, Bisset's wound didn't respond to these therapies.

"An amputation is rarely the first option for our patients," Dr. Quigley says. "We try everything we can to avoid an amputation, but in Mr. Bisset's case it was necessary."

The majority of amputations are performed because arteries in the legs have become blocked due to hardening, a common effect of diabetes that results in insufficient blood supply to the limbs. Over time, this caused Bisset's foot ulcers and, subsequently, advanced gangrene.

Dr. Quigley performed two operations on Bisset's leg. The first was a below-the-knee amputation, but the amputation site did not heal. Dr. Quigley then performed a second, above-the-knee amputation. Following the final surgery, Dr. Quigley noticed the wound was still struggling to heal and he turned to the Wound Care Center's newest technology hyperbaric oxygen therapy. Hyperbaric oxygen chambers were first developed to help divers recover from "the bends," or decompression sickness, caused by surfacing too quickly. In recent years, this same technology has also been found to accelerate the healing of many types of wounds and soft tissue injuries.

"When a patient breathes pure oxygen at an increased pressure, the blood becomes saturated and carries up to 20 times the normal amount of oxygen to the body's tissues," Dr. Quigley says. "Wounds require oxygenated blood to heal properly." Bisset was already familiar with the technology. "I was a diver during my time with the police department," Bisset says. "I never got the bends so the idea of going into the chamber was a new experience I looked forward to. They call it diving, going down, going under pressure. They have to teach you how to clear your ears and equalize. That was always easy for me when I was diving so I didn't have much trouble with it."

In the hyperbaric therapy treatment room, Martinez closely monitors two patients lying inside the chambers. Both are watching movies on the flat screen TV monitors mounted above the chambers. Like Bisset, both have Type 2 diabetes. Here, for two hours a day for two months, Bisset lay in the pressurized chamber. After 40 treatments, the wound on his leg improved and so did the others on the toes of his right leg. Bisset can't help but attribute the improvement to the therapy.

"Over the course of the hyperbaric treatment for my amputated leg, the toes on the remaining foot started to get better. They cleaned up and started showing signs of life again," he says.

The Wound Care Center added hyperbaric therapy in 2009, which Dr. Quigley says has greatly enhanced the center's ability to heal stubborn wounds.

"It is yet another tool for us to help heal chronic wounds," Dr. Quigley says. "It is an adjunct to wound care but it is not a cure-all in and of itself. It must be used in the context of a comprehensive wound care program."

Bisset's treatment continues at the Wound Care Center. Dr. Quigley monitors his other wounds and encourages him in getting around on his new prosthetic leg. Meanwhile, Bisset has developed a new approach to managing his diabetes. He is more observant and keeps an eye on scrapes, cuts or wounds that don't appear to heal on their own.

"It has been a long road trying to get my wound healed and it surprised me that it didn't heal on its own the first time," he says. "This entire process hit me pretty seriously and now I know that I have to be really watchful of my diabetes." Dr. Quigley agrees with Bisset's new approach. Like most medicine, he says the best treatment option is prevention in the first place.

"People with diabetes need honest doctors and providers early in the process who will communicate with them about what will happen later on in the course of disease," he explains. "If you manage your weight, manage your cholesterol and manage your blood sugar levels, you can expect to live a long, healthy life."