The Ulcer in the Room

One physician’s experience with incorporating wound healing into her vein practice

GOLIATH. THAT’S WHAT I think of wounds. The big, scary beast when it walks into my office or when the word is scribbled across a consultation request. I am just poor little David - barely having ALL the dressings and patches and goop that are out there to tackle Goliath.

But then Goliath starts telling me the story of how long he has been present and how many procedures he has been through. Nothing kills him. For three years he’s been ravaging the medial ankle. Just living below a varicose vein. Twenty-one procedures later, all truncal veins present, and still he finds a way to just be present and alive.

However, I (David), find that I have the correct support behind me. I have our ultrasound technologists. I have our lymph- edema therapists. I have venous procedures (foam!) and tools and skills. I have what Dr. Mark Melinso eloquently said to me in an interview for this magazine— intellectual curiosity. Why is the leg not healing? Why 21 procedures? What compression? Why do you care?

So my team and I decide to tackle Goliath — and guess what — the underdogs are making a difference. We added lymphedema therapists to our toolbox about five years ago. As we saw more wounds grow in our office from lymphedema — we also saw an increase in wounds after the pandemic. Venous leg ulcers. Diabetic leg ulcers. Phlebolymphedema with skin breakdown. We started using more pneumatic compression pumps. We were seeing healing.

We were doing venous mapping and saw reflux disappear in patients after MLD and CDT with mild CVI and no varices. Local hospitals grew their lymphedema therapists and they also closed their wound centers.

We are now seeing more Goliaths in our office. Give all the tools we have, we are starting to realize how can actually help these patients. We can coordinate their long term compression afterwards once their venous pathology is corrected and give them a boost with lymphedema therapy. We have also begun using cellular tissue products (CTPs). Yes, we are getting reimbursed, while patients are healing and it feels great! Who doesn’t love to win and kill the beast? What still doesn’t make sense is how reimbursement is higher for CTP use versus endovenous laser ablation and ambulatory phlebectomy — procedures that are more risky, more labor intense and take a specialized skill set to accomplish successfully. I guess David doesn’t get to make the rules and just has to play Goliath’s game.

The problem in our game ear- ly on — the qualifiers — was that we did not appreciate our skill set enough to recognize that we can help our patients. We can still work with wound centers, but assuring patients are getting adequate long term compression without seeing us weekly for months, and some cases years.

We have found ways to use local lymphedema therapists as well ad industry leaders with pneumatic compression pumps to better coordinate the care our patients deserve.

We are slowly running down the hill to Goliath and cre- ating protocols to include all the players to beat him. It can be done, but it’s going to take everyone from phlebotomists to therapists to wound centers. V

The Vein Care Center was established in 2004. It was started by an in- terventional radiologist, Dr. Praveen K. Malhotra. Dr. Aggarwal joined the practice in 2010. Dr. Malhotra trained her for 3 1⁄2 years prior to retiring. Dr. Aggarwal took over the practice in 2013 and immediately expanded services to include more comprehensive venous care as well as adding on cash-based aesthetic services to meet the roller coaster demands

of reimbursement. Constantly getting squeezed financially and seeing more patients suffering unnecessarily, Dr. Aggarwal added wound care in the last year. She watched as two wound centers closed around her and realized a gap to fill was right in front of her.