Millions of patients each year in the United States suffer from chronic wounds — those that haven't healed long after they should have — and caring for them accounts for billions of dollars in annual spending.
And with obesity and diabetes rates skyrocketing in recent decades, the need for such services has only grown, while the field of caring for chronic wounds has become its own specialization, with centers and departments popping up across the country, including in Montana.
"Ten years ago we didn't have wound care specialists, and a lot of these patients just fell through the cracks," said Dr. Tim Dernbach, a cardiovascular surgeon and medical director of St. Vincent Healthcare's Wound Healing Center.
Chronic wounds are characterized by hypoxia, or a lack of oxygen reaching the surrounding tissue, which in turn leads to bacteria thriving in the affected area and keeping the wound from healing, even over a period of months.
Common chronic wounds include ulcers — including diabetic, pressure, arterial, atypical and a number of other types — as well as radiation injuries, problematic skin grafts or flaps, osteomyelitis and other wounds that haven't healed after 30 days or so.
Dernbach said that people who just go to an emergency department or get a short inpatient hospital stay for chronic wounds usually won't get the continued care and treatment they need and that 90 percent will return to the hospital if they're only admitted to the ED.
"There are people who've had these wounds for two, three, four years and they wouldn't heal," he said. "It markedly devalues the quality of life. These wounds, without appropriate care, will never heal."
At centers like St. Vincent's Wound Center, there are a number of treatment options. They include: extended time in hyperbaric oxygen therapy, which forces oxygen into the areas not getting enough to promote healing and the growth of new blood vessels; advanced dressings; removal of dead tissue; vascular work; reconstruction; or skin substitutes or grafts in the affected area.
Mark White, director of wound care and hyperbarics, said that the center employs a team of experts — including two plastic surgeons, a general surgeon, an interventional radiologist, an infectious disease doctor, three vascular surgeons, a primary care doctor, a podiatrist and numerous support staff — to treat a growing number of patients.
"It has just exploded," he said of the chronic wound care industry.
Annually, chronic wounds affect as many as 6.5 million patients in the U.S., with more than $25 billion spent on treatment.
With drastic increases in both obesity and diabetes — a recent World Health Organization said that diabetes rates nearly quadrupled worldwide between 1980 and 2014, from 108 million adults living with the disease to 422 million — the number of patients with chronic wounds is expected to increase in the coming years as well.
One of the most common wounds seen at the St. Vincent Center is diabetic ulcers. The American Podiatric Medical Assocation says they form in an estimated 15 percent of diabetes patients, most often on the bottom of the foot.
Due to what Dernbach called "diabetic foot neuropathy," some patients might lose feeling in their feet, making it tough to know if there's a wound right away.
But, interest in the field is increasing to meet the demand. Both Billings hospitals have wound care centers, and a number of other health care facilities across the state offer at least some related services as well.
When the Wound Healing Center first opened in 2012, it had 2,500 patient visits in its first year.
In 2015, it saw 8,100 visits.
Gathering to learn
Last year, St. Vincent presented its first wound care conference, drawing more than 100 medical professionals and students from the region to spend two days learning about the issue.
This year's conference on April 14 and 15 drew even more people, and Dernbach said that more than 100 people have visited the center during the past year to observe.
"It's really exciting for us to see this many people here," he said.
Among the attendees — both at the conference and visits to the center — are students in Rocky Mountain's Master of Physician Assistant Studies program.
For the last two years, staff from the center has been providing guest lectures to the students, who in turn spend a day shadowing staff during day-to-day operations.
"It is a wonderful opportunity for them to get out in the community, to see what our Billings medical community has to offer," said Heather Heggem, the PA program's director. "Each student gets a very individualized approach."
It's also a field that brings together a number of the program's modules — including infectious diseases, endocrinology and vascular disease — while allowing the PA students to get out and interact with patients.
"It really does combine a lot of great medicine," Heggem said.
White said that it's important for those learning medicine to get some experience with chronic wound care, but that many newly graduated doctors, nurses and PAs might not have done so.
Students like those in Rocky's PA program, as well as physicians on rotation as part of residency programs, who do spend time there are important throughout Montana because of that growing need.
"They're the tip of the spear for Eastern Montana," he said. "If a PA or a doctor didn't have an understanding of what they're looking at, what they're diagnosing, it can make care more difficult."
Wound care can be complicated and can take a while, but Dernbach said that early treatment with advanced techniques can save time and money in the long run.
If left untreated, he said, it can have lasting effects on a person's life, from keeping them from going out and socializing to affecting their personal relationships, not to mention constantly dealing with an often painful wound.
"We're all just doing the best we can to make the patient better," he said. "If you've got a wound that's still there three or four weeks later, come in and get it evaluated. Don't wait six or eight months."