Baromedical Nurses Association (BNA)

  • Laura Josefsen, RN, ACHRN
  • Volume 10 - Issue 3

Baromedical Nurses Association (BNA)

The BNA annual membership meeting was held at the Gulf Coast Chapter meeting this year and what an exciting meeting it was! There were familiar faces as well as many new members. 

The membership meeting PowerPoint will be available for you on the BNA website at to catch up on past accomplishments and future plans. 

Be watching for information on the 3rd annual Hyperbaric Nurses Day on the first Tuesday in April 2020. Updates will be provided on the BNA website for this very special day. 

We are happy to announce two new board members this year: Karen (Kari) Fowler - Director at Large and Heather Wheaton - Secretary. The positions to be filled for 2020 include Vice President, Director-at-Large, a position on the BNACB (Baromedical Nurses Association Certification Board), and UHMS Liaison. Please be thinking about nominating a person—or yourself—for these positions. The board is a very dynamic and productive group of people working together to further hyperbaric nursing. Your ideas and participation will enhance this process.

Thanks to all nurses who have volunteered to assist on committees. We are still looking for more people willing to give a few hours of time to help on committees such as publication, research, education and membership. Remember that being on the board as an officer or serving on committees will help toward receiving your ACHRN. Check the BNA website at for the duties for these positions. 

BNA Awards: There are 5 recipients for awards this year. Congratulations to all!

  1. Diane Norkool Award for Excellence in Hyperbaric Nursing: Awarded to Terry Beard — This award is for dedication and commitment to the field of hyperbaric medicine as a nurse. The recipient is currently serving in the hyperbaric field or making significant contribution to the field of hyperbaric medicine. He/she must have been a member of the BNA for a minimum of two years.
  2. Rising Star Award: Awarded to Samantha Wooldridge and Mindy Skjordal — This award is presented to nurse that has five years or less and proves to be leaders, innovators, member of the BNA and making significant contributions to our field. 
  3. Circle of Excellence Award: The recipient of this award will be announced at a chapter meeting later this year. This award honors a nominee who is not a member of the BNA. The recipient is an individual who exemplifies extraordinary mentoring and/or professional support to promote the mission and vision of hyperbaric nursing, including but not limited to research, education or safety.
  4. BNA Honorary Lifetime Achievement Award: Awarded to Laura Josefsen — This award is presented to a member of the BNA for outstanding contributions, time and support for our organization. He/she must have been a member of the BNA for a minimum of five years. 

Special Note from the president of the BNA: The Baromedical Nurses Association would like to give special recognition this year to Laura Josefsen. The BNA Honorary Lifetime Achievement Award has not been presented since 1991. This award honors a nurse that has given many years of service to hyperbaric nursing. This was an easy award to present this year. The Baromedical Nurses Association is pleased to honor Laura with the “Lifetime Achievement Award.” She has worked in HBO2 for most of her nursing career. She was one of the founding members of the BNA in 1985! She has been involved in patient care, education, publishing and is a surveyor for the Hyperbaric Facility Accreditation program. We honor her for the example she is to us. She is always willing to answer questions and share her expertise in the field of hyperbaric nursing! Thanks, Laura, for all you have done for our unique field of nursing.

We are looking forward to a great year for the BNA!

Tina Ziemba, Awards Chair, Connie Hutson accepting the award for Terry Beard, Laura Josefsen, Samantha Woodridge and Annette Gwilliam, BNA President

Hyperbaric Medicine

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Critical Thinking Put to the Test and “Take Five to Stay Alive”

  • Darren Mazza, EMT, CHT
  • Volume 10 - Issue 3

Critical Thinking Put to the Test and “Take Five to Stay Alive”

This article was originally published in the inaugural year of WCHM 10 years ago. Darren Mazza has reviewed the content to ensure its applicability to today’s environment.

As a CHT/Safety Director I often use phrases such as “stand by-1” or “A-firm” around staff that reflect my days spent on an ambulance as an EMT. But for me, the phrase “take five stay alive’’ has been the most influential and a phrase that truly means just that. Take five seconds to survey the scene before entering the scene. This will keep you alive, and will potentially save the lives of others.

Every hyperbaric center designates a Safety Director that is responsible for keeping the hyperbaric patient and the entire staff safe. The Hyperbaric Safety Director conducts monthly emergency procedure drills. These emergency drills pertain to hyperbaric patient safety during an emergency.

Recently, I found myself with two emergency situations that were never rehearsed or practiced. The first incident is one that most CHTs will never encounter in their career — at least, I hope not!

Critical thinking put to the test

The patient is a 65-year-old male with s/p L fem arterial graft placement along with a hematoma adjacent to the graft that was evacuated leaving the arterial graft exposed. The sartorius muscle was rotated to cover the graft, and the patient then underwent a split thickness graft to cover the wound. The split thickness graft began to fail, and NPWT was ordered over the L groin wound site as well as hyperbaric therapy for a compromised graft.

One morning this patient arrived with his wife, had no complaints, and was in relatively good spirits. The patient disconnected his wound V.A.C. line in preparation for his hyperbaric treatment and ambulated to the gurney. Meanwhile, I was imputing patient’s profile into the computer-driven chamber. As I turned to face the patient, I noticed he was sitting on the gurney with his wound V.A.C. line hanging towards the blood-covered floor. The patient was hemorrhaging from his left groin through the V.A.C. line. I estimate there was around 1000 cc on the floor and still pouring through the V.A.C. line. I immediately reached down, clamped off the line, and placed the patient in trendelenburg. I had another tech get help and call 911. I placed the patient on high-flow O2 with a non rebreather that is used for oxygen challenges during a TCOM.

I held direct pressure while staff took vitals and prepared a face sheet and other necessary paperwork. The EMS arrived within three minutes and I gave a report to the paramedic. I continued to hold pressure to the ambulance, through the ER, and all the way to the OR. It was exhausting, physically and emotionally. This patient went from being outpatient to critical in short order. The good news is that this patient’s life was saved and he made a full recovery. It turned out that the fem graft had torn, and the femoral artery ruptured.

Conclusion: Although we conduct monthly emergency training drills specific to emergencies in the chamber, I urge outpatient hyperbaric safety directors to do a risk assessment specific to your location and think beyond hyperbaric emergencies. Thinking critically to prepare yourself and your team above and beyond the chamber is crucial.

“Take Five Stay Alive”

Approximately two weeks after the arterial bleed incident, another life-threatening event took place.

I work in a facility that is located off-site from the hospital a block away. Our hyperbaric center is on the second floor of a professional plaza building shared by multiple dental and outpatient surgical businesses. The building sits in the center portion of a parking lot with two busy roads on the south and west side of the building.

At 1:30 pm, I had one patient in the hyperbaric chamber. The patient and I heard a loud bang and felt the floor shake. Initially, I thought one of the clinics next to ours was changing out one of their oxygen cylinders and the banging sound was the cylinder striking the ground. This was a sound I have heard several times before. I told the patient not to worry and that I would investigate it further. As I was preparing to have someone sit with the patient so I could check it out, I could hear a faint humming sound coming from outside the building, possibly in the south parking lot area that is directly below my hyperbaric room. I looked outside of the window and I could see a truck with the front end of the vehicle through the wall. The humming sound was coming from the trucks rear tires that were spinning on the ground and billowing out blue smoke.

The phrase “take five stay alive” became a reality after all. Who would have thought this would ever happen? Most CHT’s go through their whole career without ever having anything happen but the potential is always there. My first thought was to call 911, end the patient treatment, and bring them to surface. I had two concerns:

  • The tires were spinning and could potentially ignite the vehicle and catch fire to the building. This could be particularly problematic considering the vehicle has impacted the wall just below an outpatient surgery center as well as other patient-populated areas.
  • The driver might be unconscious from the impact or from something else, needing immediate medical aid.

I immediately ran to the chamber room door and got the attention of one of the hyperbaric providers. I told her what was going on and had her watch the hyperbaric patient. I had the front office call 911 as I grabbed a fire extinguisher.

Before running down, I told the provider to keep an eye on me through the window. I would signal her with a thumbs up if she needed to abort the hyperbaric treatment and evacuate the clinic due to a potential fire. When I arrived at the vehicle, there were two other people in scrubs assessing the patient. Someone from one of the clinics arrived with an AED, O2, and a BVM.

I then assisted the gentleman with assessing the driver, who was a physician from the outpatient surgery center. We began CPR on the driver, and we then placed the AED on him. A “shock” was advised and delivered. The EMS arrived shortly afterwards and took over care of the patient. We found out later that the patient did not survive.

The driver of the truck had drifted off of the main road approximately 25 yards down through the flower beds, and into our building. It was suggested that he may have had a syncopal episode that caused him to veer off and crash. I conducted a risk assessment of the incident and found several scenarios that could have changed the overall outcome.

  1. The truck impacted the wall exactly 23 feet from the oxygen lines that feed the chambers. if the truck hit the lines, the scenario and outcome could have been different.
    WCHM Fall 2019 Critical 01
  2. It was raining that day; had it been dry outside, the tires from the truck could have caught fire.
    WCHM Fall 2019 Critical 02

Conclusion: When an outpatient hyperbaric facility designates a Safety Director, their role is often perceived just as a title or an NFPA 99 chapter 20 ( requirement. It has been by my own experience and observation that the entire wound care and hyperbaric team may depend on you as the Safety Director for more than simply providing monthly emergency drills. The entire team may look to you for leadership in a crisis situation, whether it is within or outside of the hyperbaric environment.

Regardless of the situation, remember to take five seconds to survey the scene before responding. This will not only keep you safe and alive, but will possibly save the lives of others and will definitely determine the overall outcome. 

Hyperbaric Safety

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Hyperbaric Facility Safety: A Practical Guide, Second Edition Will Be Available 2020

  • W.T. “Tom” Workman and J. Steven “Steve” Wood, Editors
  • Volume 10 - Issue 3

Hyperbaric Facility Safety: A Practical Guide, Second Edition Will Be Available 2020

The first edition of Hyperbaric Facility Safety: A Practical Guide is an integral part of virtually every hyperbaric facility’s reference library, serving as the go-to standard for a hyperbaric safety program. 

After 20 years, the second edition will be available in early 2020! The editors W.T. “Tom” Workman and J. Steven “Steve” Wood have endeavored to establish a comprehensive balance between those hyperbaric providers who have a keen interest in the underlying design standards and regulatory framework and those who need to “get it done.” 

The second edition is structured into two parts. Part 1 explains the various regulatory agencies that may influence the field of hyperbaric medicine (including international perspectives), while Part 2 emphasizes a nuts-and-bolts approach to hyperbaric safety program development and how the safety program integrates all aspects of a hyperbaric facility. 

The editors, along with the 80 chapter authors and contributors bring experiences from clinical hyperbaric medicine, the U.S. Air Force and Navy, the UHMS Hyperbaric Facility Accreditation program, hyperbaric chamber engineering, manufacturing, and regulatory/standards development. 

Preface to Hyperbaric Facility Safety: A Practical Guide, Second Edition

The fundamental premise of medicine embodied in the Hippocratic Oath, Primum non nocere (“First, to do no harm”) is, at its core, an admonition to provide medical care that is safe. 

The field of hyperbaric medicine has undergone a sea change since the publication of the first edition of this text. The number of facilities worldwide has increased substantially, yet the field faces monumental challenges. Economic pressures from health care funding agencies have placed a glaring spotlight on the accepted clinical conditions as the gimlet eye of evidence-based medicine has further challenged years of case experience that formed the foundation of the clinical condition lists. In the United States, the growth of wound treatment, using hyperbaric oxygen as an adjunctive therapy, has further constricted the number of conditions treated, as most wound clinics are not structured to provide hyperbaric therapy for patients with serious or unstable conditions. But despite changes in the practice and application of hyperbaric oxygen therapy, the guiding tenant for providers of HBO2 must be to deliver therapy safely.

There are two distinct aspects to the field of hyperbaric medicine that influence safety: technology (hardware) and the operators of that technology (software). HBO is a technology-based therapy, supported by a long history of engineering and manufacturing refinement. The military and commercial diving roots of hyperbarics resulted in an initial pool of technologists who were trained to rigorous standards. Many of the pioneers in the field transitioned to the clinical and research sides of hyperbarics and brought a strong culture of operational safety.

Codes and standards related to the design, manufacturing, and installation of hyperbaric chambers are well-established and have broad distribution worldwide. Even in countries that don’t have a mandatory regulatory scheme, end users can easily access and reference construction standards that will provide a chamber that is constructed in accordance with a proven safety record. One challenge posed by the existing standards is that due to the inherent inertia of the code/standard-writing process, the introduction of new materials and technologies often outstrips the code/standard process, resulting in the potential for stifling of innovation or the introduction of new technologies that might not be fully proven. Even in countries with a strong regulatory climate, it is not uncommon to see chamber designs that pose substantial risks due to their design or construction in widespread use. The bottom line is a chamber built, installed, operated, and maintained in accordance to accepted standards is rarely a factor in accidents.

Human factors—acts of omission or commission—play a role in the majority of hyperbaric safety-related incidents. The demographic change in the background of the people who operate chambers poses a great risk to the field. The growth of the field since the early 1990s resulted in a thinning of the experienced talent pool and the rise of a new generation of hyperbaric technologists. The risk- and cost-averse nature of modern health care has further restricted the use of HBO2 predominately to medically-stable patients treated in an outpatient setting. The number of clinical facilities with the staff and equipment capability to manage seriously ill patients has dropped precipitously (at least in the United States), resulting in the need to transfer patients hundreds of miles to receive lifesaving treatment. Without a mandate to treat acute indications, facilities reduce technical staff, support equipment, and the specialized training necessary to provide high-level care is leading the hyperbaric field into a crisis of experience. The “old hands” (technologist and physician pioneers) in the field who set the bar for HBO2 and were the fearless innovators who pushed the envelope of HBO2 applications, are leaving the field due to retirement (or death). The challenge to the new generation of hyperbaric professionals is to preserve the institutional memory of the first generation and transmit it to the successors.

In developing the second edition of Hyperbaric Facility Safety: A Practical Guide, the editors have taken a more pragmatic approach to the organization of this edition, based on a conversation we had several years ago. We were discussing, with some vigor, an esoteric point within a subsection of NFPA code, when Tom commented on the small number of people in the industry who really cared about the minutia of regulatory code. That’s the reality. Though chamber operators might find it useful to know the background of why they do what they do, they are more interested in how to do the job—the nuts and bolts of safety. With that concept in mind, this edition is divided into two major focus areas.

First, we look at the codes and standards that influence our field. Depending upon your location in the world, as many as 15 or more agencies’ codes, standards, regulations, or laws may need to be conformed with in order for a facility to operate. Chapters cover the regulatory environment and take an in-depth look at the various systems that make up the modern hyperbaric chamber. We have also revamped information on the international aspects of the regulatory environment. Contributors from around the world completed a questionnaire that surveyed the practice of hyperbaric medicine in their respective countries. This data has been summarized in a table, with explanatory notes as required.

The second focus area takes a nuts-and-bolts approach to hyperbaric safety. Utilizing the expertise of key figures in the hyperbaric field, the reader will find a comprehensive compendium of resources that can be useful towards the development of a state-of-the-art hyperbaric safety program.

The editors express their sincere thanks to all of the contributors for their hard work and dedication to the production of this text. We hope that this edition will become a well-worn addition to your safety library. 

Hyperbaric Safety

Read more: Hyperbaric Facility Safety: A Practical Guide, Second Edition Will Be Available 2020

Diabetic Ulcer Diagnosis and Management

  • Javier La Fontaine, DPM, MS and Kathren McCarty, DPM, MS, FACFAS
  • Volume 10 - Issue 3

Diabetic Ulcer Diagnosis and Management

The Wound Care Certification Study Guide 2nd edition, editors Jayesh B. Shah, MD, Paul J. Sheffield, PhD, and Caroline E. Fife, MD is the perfect tool for anyone studying to take a wound certification exam. It is fully updated with the latest clinical practices and regulatory and reimbursement information. This all-inclusive study guide includes the following: 

  • Thirty-three informative chapters that review the core principles candidates need to know to obtain wound care certification 
  • A full-length post-course exam complete with answers and explanations 
  • Comprehension questions at the end of each chapter 
  • Over 200 color photos, tables, and diagrams 
  • Guidance on how to choose the certification exam that best meets your needs 
  • Test-taking strategies for success 

The following chapter, Diabetic Ulcer: Diagnosis and Management by Javier La Fontaine, DPM, MS, and Kathren McCarty, DPM, MS, FACFAS printed with permission from Best Publishing Company from the Wound Care Certification Study Guide 2nd edition


This chapter addresses the pathophysiology of diabetic ulcerations, the types of diabetic ulcers (neuropathic, neuroischemic, and ischemic), how to evaluate diabetic wound patients, and the management options for diabetic foot ulcers. Surgical management options include elective foot surgery, prophylactic foot surgery, curative foot surgery, and emergent foot surgery. 


Participants should be able to discuss the risk factors for ulceration, contrast the types of amputations (digital, ray, transmetatarsal, Lisfranc, Chopart, Syme, and transtibial), and discuss the wound care protocol recommended after four weeks of insufficient healing. 

I. Diabetic ulcer diagnosis 

  1. Epidemiology of diabetes 
    1. 120,000 amputations a year in the United States 
    2. Two-thirds of those amputations are attributed to diabetic complications 
    3. 85% of all diabetic amputations are preceded by ulceration (Figure 1)
  2. Pathophysiology of diabetic foot ulceration (Figure 2)
    1. Diabetes plays a significant role in the development of plantar pedal ulceration.
    2. Neuropathy, vasculopathy, and deformity are essential for the development of a neuropathic ulceration.
    3. Neuropathy is the most important single independent risk factor.
    4. Neuropathy leads to loss of protective sensation.
    5. Neuropathy leads to deformities via motor neuropathy of intrinsic muscle of the foot. Therefore, deformities, such as hammertoes, will predispose the foot to areas of increased pressure, which in this case would be the dorsum of the toe and the metatarsal head of the respective toe via retrograde force. In the presence of neuropathy the area of pressure will develop callus and subsequently become an ulcer.
    6. Neuropathy, especially autonomic, promotes anhidrosis, which causes dryness of skin and fissures. Both ulcers and fissures, along with vascular disease, place the patient at risk for infection and gangrene.
  3. Evaluating a diabetic wound patient
    1. Poorly controlled diabetes is associated with the development of end organ disease such as arteriovascular disease and peripheral neuropathy. However, the data linking hemoglobin A1c to healing are not strong. Current guidelines suggest that attempting to lower A1c below 7 may be associated with death in older patients. Therefore, while glucose control is always an important component of diabetes management, the possible benefit of very tight glucose control on healing should be weighed against the proven risk of adverse events.
    2. Pertinent medical history should be gathered in relation to cardiovascular disease. Patients with a history of coronary artery disease, stroke, and smoking may have significant peripheral vascular disease, and further vascular evaluation is warranted.
    3. A complete evaluation of the wound is essential to formulate a treatment plan.
    4. Assessment of the contralateral limb should be done as well to screen and compare pathology with the affected limb.
    5. The first assessment of vascular status should be done by palpation of the dorsalis pedis and posterior tibial pulse.
    6. Non-invasive arterial evaluation should be performed in all patients with non-healing wounds or on patients over age 50 with a history of diabetes. This can be done using the ankle-brachial index or other noninvasive methods such as transcutaneous oximetry or skin perfusion pressure.
    7. Palpable pulses may be unreliable in diabetic patients because of Monckeberg’s sclerosis (calcification of the tunica media of vessel wall).
    8. Neuropathy should be assessed as well. Monofilament, vibration, and deep tendon reflexes should be tested to assess the severity of neuropathy.
      1. Peripheral neuropathy screening for loss of protective sensation can be accomplished using the Semmes-Weinstein 5.07 monofilament and deep tendon reflex testing vibration with 128 Hz tuning fork.
    9. There is evidence that neuropathy may have an effect on autoregulation of capillaries and, therefore, poor oxygenation at the wound base.
    10. Infection should be ruled out in diabetic wounds (Figure 3). Although erythema, swelling, heat, and pain are classic signs of infection, it is not always the case in the diabetic wound.
    11. Inflammation is commonly seen in neuropathic ulcers because of repetitive stress, which occurs in the development of the ulcer, as well as an excessive inflammatory response observed in neuropathic limbs (Figure 4).
      1. For example, Charcot neuroarthropathy may simulate an underlying bone infection when in reality there is no infection.
    12. If infection is suspected, deep cultures are preferred.
    13. The deformity that is causing the ulcer should be evaluated.
    14. Identification of the deformity is not only important for wound healing, but also to prevent recurrence.
    15. Structural deformities, such as bunions, hammertoes, and limited joint mobility, need to be recognized for the management of these wounds.
    16. The increased pressure observed is directly proportional to the severity of the deformity. 
  4. Types of diabetic ulcers 
    1. There are three types of ulceration the healthcare professional will encounter. 
      1. Neuropathic ulcer (Figure 5)—the neuropathic ulcer is painless with a hyperkeratotic rim and red granular base. Maceration is usually present underneath the hyperkeratosis. It occurs in locations where there is increased pressure, commonly the plantar aspect of the foot.
      2. Neuroischemic ulcer (Figure 6)—the neuroischemic ulcer is the most difficult ulcer to treat in the foot. It has characteristics of the neuropathic ulcer, but microvascular disease makes this ulcer a challenge to heal. Often noninvasive arterial studies demonstrate mild macrovascular disease. The appearance of the foot is consistent with signs of vascular disease as well as severe neuropathy. The wound base is pink in color mixed with a fibrinous type tissue that recurs even with sharp debridement.
      3. Ischemic ulcer (Figure 7)—the ischemic ulcer has a yellowish or grayish base with a margin that bleeds for a short period of time. This sign is deceptive as the clinician may believe that the wound is well perfused. It is usually painful since the patient may present with rest pain as well. Vascular consultation is imperative for the treatment of this type of wound. 
  5. Prevention of diabetic foot ulceration 
    1. Universal standards of clinical prevention and treatment of ulcerations must be established to ultimately decrease the rate of infection, amputation, and mortality of patients with diabetes. Foot biomechanics, structure, and skin integrity should be evaluated. 
    2. Diabetic patients are more prone to onychomycosis, cutaneous infections, and deformity. 
    3. It has been shown that prescriptive shoe wear, shoe inserts and cushions, and debridement of calluses are crucial for decreasing plantar pressures and redistributing pressure loads. 
    4. It has been shown that prophylactic foot surgeries can be effective in preventing foot ulcers in diabetic patients when indicated. 

II. Management of diabetic foot ulcers 

  1. Treatment of diabetic foot ulceration
    1. Consistent wound measurement
    2. Glucose control
    3. Surgical debridement
    4. Antibiotics
    5. Off-loading
    6. Moist wound environment
    7. Advanced wound care therapies
    8. Vascular and surgical reconstruction
    9. Bed rest or limited activity; cutout felt pads and total contact casting should be used to off-load these wounds.
    10. If after approximately four weeks the wound care protocol is producing insufficient healing, the treatment must be reassessed; determine if edema, blood supply, and/or nutrition are preventing the healing process.
      1. Alternative therapies such as cellular tissue products should be employed.
      2. Hyperbaric oxygen therapy may help in ulcer healing and provide a significant reduction in the risk of major amputation.
    11. After appropriate wound care and debridement, an off-loading modality should be chosen to transfer or decrease the plantar pressure from one specific location to the rest of the plantar aspect of the foot in balanced redistribution. Bony prominences, edema, previous amputation, wound location, and wound care all play important parts in the decision-making process for off-loading.
  2. Surgical management in diabetic wound patients
    1. Sometimes surgical intervention may be necessary. The role of surgical management is a viable option when it comes to successfully treating recurrent diabetic ulcerations, infections, and other related complications that exist in the foot and ankle. In regard to surgical intervention for the diabetic foot, Armstrong and Frykberg have offered the following classifications.
      1. Class I: elective foot surgery, performed to treat a painful deformity in a patient without loss of protective sensation
      2. Class II: prophylactic foot surgery, performed to reduce the risk of ulceration or reulceration in patients with a loss of protective sensation, but without an open wound
      3. Class III: curative foot surgery, performed to assist in healing an open wound
      4. Class IV: emergent foot surgery, performed to arrest or limit the progression of acute infection
    2. Whether surgical intervention is curative, prophylactic, or elective, the patient with diabetes should be fully assessed preoperatively for the degree of deformity, history of ulcerations, general physical condition, vascular status, and impairment of glucose control.
    3. When surgery is emergent, the primary surgical intervention should be done immediately with staged additional procedures to follow after the above considerations have been addressed.
    4. Prophylactic and elective surgery can successfully prevent future ulcerations. Withholding surgical management of deformities in the well-controlled diabetic patient may place the foot at future risk for ulceration and amputation.
    5. Failure to remove the deformity can prove more dangerous than the judicious use of surgery to relieve bony pressure.
  3. Elective surgery
    1. There are several goals for elective surgery candidates:
      1. Prevention of recurrent ulceration
      2. Reduction of pressure, primarily over bony prominences
      3. Establishment of a functional foot
  4. Amputation is usually reserved for emergent cases to treat severe infection.
    1. Amputation and plastic surgery techniques may actually be used to cure persistent problem wounds and improve quality of life (QOL).
    2. Several recent studies have shown that patients may prefer and enjoy a better QOL with amputation and a closed surgical site versus continual, wearisome treatments for a chronic or recurrent open wound.
    3. Surgeons must weigh many considerations in order to successfully plan the appropriate level of amputation. These factors include tissue viability (e.g., presence of ulcerations, tissue deficits), micro- and macrovascular circulation, anatomy and biomechanical function, cardiac demand and energy expenditure, and rehabilitation potential.
    4. Also, the reality that one amputation can lead to another in the future due to the creation of biomechanical abnormalities or a worsening of disease must be considered.
    5. Maintaining toe-off and propulsion in the gait cycle to reduce transfer pressures to adjacent metatarsals and digits should be achieved, if possible.
    6. The levels of amputation in the lower extremity include: digital (Figure 8), ray (Figure 9), transmetatarsal (Figures 10a and 10b), Lisfranc (Figure 11), Chopart (Figure 12), Syme (Figure 13), and transtibial (Figure 14).
  5. Some other possible surgeries include:
    1. First ray surgery (e.g., Keller arthroplasty, bunionectomy, sesamoidectomy, first metatarsal osteotomy)
    2. First metatarsal-medial cuneiform fusion
    3. Digital surgery (e.g., hammertoe repair, lesser metatarsal osteotomy, resection of a lesser metatarsal head, nail avulsion for ingrown nails), exostectomy
    4. Midfoot and rear foot arthrodesis
    5. Achilles tendon lengthening
  6. Following surgery, appropriate accommodative or off-loading shoe gear must be fabricated and used daily to prevent future ulceration (refer to Chapter 20). 


  • Figure 1

    Figure 1: Diabetic preulcer at the hallux.

  • Figure 2

    Figure 2: Neuropathic diabetic foot ulceration.

  • Figure 3

    Figure 3: Diabetic foot infection

  • Figure 4

    Figure 4: Inflammation secondary to repetitive stress.

  • Figure 5

    Figure 5: Neuropathic ulcer.

  • Figure 6

    Figure 6: Neuroischemic ulceration.

  • Figure 7

    Figure 7: Ischemic ulcer.

  • Figure 8

    Figure 8: Digital amputation.

  • Figure 9

    Figure 9: Partial ray amputation.

  • Figure 10a

    Figures 10a: Low transmetatarsal amputation.

  • Figure 10b

    Figures 10b: Low transmetatarsal amputation.

  • Figure 11

    Figure 11: Lisfranc amputation.

  • Figure 12

    Figure 12: Chopart amputation.

  • Figure 13

    Figure 13: Syme amputation.

  • Figure 14

    Figure 14: Transtibial amputation (BKA).


  1. Frykberg RG, Armstrong DG, Giurini J, et al. Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons. J Foot Ankle Surg. 2000; 39(5 Suppl):S1-60.
  2. Armstrong DG, Lavery LA, Harkless LB. University of Texas classification system for diabetic foot wounds. Diabetes Care. 1998; 21:855-9.
  3. Kahn KH, Derksen TA, Steinberg JS. Diabetic foot wounds. In: Sheffield PJ, Fife CE, editors. Wound Care Practice. 2nd ed. North Palm Beach: Best Publishing Company; 2007: 405-30.
  4. Bosker GW, LaFontine J. Orthotics and prosthetics in wound care. In: Sheffield PJ, Fife CE, editors. Wound Care Practice. 2nd ed. North Palm Beach: Best Publishing Company; 2007: 901-20.
  5. Malone M, Bowling FL, Gannass A, Jude EB, Boulton AJ. Deep wound cultures correlate well with bone biopsy culture in diabetic foot osteomyelitis. Diabetes Metab Res Rev. 2013 Oct; 29(7):546-50.
  6. La Fontaine J, Harkless LB, Davis CE, Allen MA, Shireman PK. Current concepts in diabetic microvascular dysfunction. J Am Podiatr Med Assoc. 2006 May-Jun; 96(3):245-52.
  7. Infectious Diseases Society of America. IDSA Infections by Organ System: Diabetic Foot Infections [Internet]. 2012. Accessed at: http://

Sample Questions

  1. What percentage of diabetic foot amputations is preceded by ulcers? 
    1. 35% 
    2. 50% 
    3. 75% 
    4. 85% 
  2. The most important single independent risk factor for ulceration is: 
    1. Peripheral vascular disease 
    2. Neuropathy 
    3. Foot deformity 
    4. History of prior amputations 
  3. Advanced wound modalities might be considered if a diabetic wound is not progressing after _____ of standard wound care. 
    1. Two weeks 
    2. Four weeks 
    3. Six weeks 
    4. Eight weeks 
  4. The Semmes-Weinstein test is used to assess: 
    1. Blood flow to the feet 
    2. Protective sensation of the feet 
    3. Pressure on the feet 
    4. Temperature of the feet
  5. All of the following are treatments are considered standards of care for foot ulcers with adequate blood flow except:
    1. Debridement
    2. Off-loading
    3. Antibiotics
    4. Glucose control
  6. Which of the following can lead to an ulcer in the presence of neuropathy and vascular disease?
    1. Hammertoe
    2. Anhidrosis
    3. Callus
    4. All of the above
  7. The most important method of treatment to heal a plantar foot ulcer is:
    1. Moisturizer
    2. Off-loading
    3. Collagenase
    4. A swab culture
  8. When foot ulcers continue to recur and obvious deformity exists, the best option is:
    1. Casting
    2. Diabetic shoes
    3. Surgical correction
    4. Dressing changes and hope it does not get infected
  9. Sometimes palpable pulses are unreliable in the diabetic patient because of:
    1. Loss of protective sensation
    2. The diabetes
    3. Monckeberg’s sclerosis
    4. Lack of pedal hair
  10. A patient presents to the emergency room and upon evaluation is diagnosed with gas gangrene. The podiatrist determined he has to perform surgery immediately. What is the class of surgery?
    1. Elective
    2. Emergent
    3. Curative
    4. Prophylactic

Answer Key

  1. (d) 85% of diabetic foot amputations are preceded by ulcers.
  2. (b) The most important single independent risk factor for ulceration is neuropathy. Patients with neuropathy do not feel sensation, and ulceration occurs when patients do not wear any protective footwear.
  3. (b) Advanced wound modalities may be considered if a diabetic wound is not progressing after standard wound management for four weeks.
  4. (b) The Semmes-Weinstein test is used to assess the protective sensation of feet.
  5. (c) Among the treatments listed, debridement, off-loading, and glucose control are considered standards of care for foot ulcers with adequate blood flow. Antibiotics are required only when infection is present. (7)
  6. (d) Hammer toe, anhidrosis, and callus can lead to an ulcer in the presence of neuropathy and vascular disease. Any area at risk to develop an open wound will be complicated with vascular disease.
  7. (b) The most important treatment to heal a plantar foot ulcer is off-loading. Plantar foot ulcers will not heal with persistent trauma at the wound base. Moisturizer is needed for dry, cracked skin common to diabetics, but it is not a treatment to heal plantar foot ulcers. Collagenase is used for enzymatic debridement, which may be necessary in the treatment of diabetic plantar foot ulcers, but it is not the most important treatment. Swab culture is necessary if a diabetic foot ulcer is infected.
  8. (c) When foot ulcers continue to recur and obvious deformity exists, the best option is surgical correction. Rigid foot deformities often cannot be off-loaded properly. Casting is good for healing diabetic foot ulcers but will not prevent reoccurrence. Diabetic shoes are good for prevention; however, when foot ulcers continue to reoccur secondary to foot deformity they are not the best choice for prevention. Dressing changes are necessary for healing diabetic foot ulcers, not to prevent ulceration in the presence of foot deformities.
  9. (c) Palpable pulses may be unreliable in the diabetic patient because of Monckeberg’s sclerosis; the calcification of the media makes the arterial wall easily palpable even with diminished blood flow.
  10. (b) As gas gangrene is a limb threatening infection, it is considered an emergent procedure. 

Wound Care

Read more: Diabetic Ulcer Diagnosis and Management

Notes From the Editor & Staff of WCHM

  • WCHM Staff
  • Volume 10 - Issue 3

Notes From the Editor & Staff of WCHM

WCHM continues to celebrate its 10-year anniversary in 2019 and spotlight an archived article from the magazine’s prolific authors. This issue spotlights Darren Mazza, who has been a contributor to WCHM since its inception. Thank you, Darren, for sharing your expertise regarding hyperbaric safety over the years. 

In hyperbaric medicine news, the UHMS has published a special UHM Journal edition summarizing the results of recent studies in traumatic brain injury (TBI). Caroline Fife discusses how qualified clinical data registries can help MIPS, MOCs, and more. And once again, the Baromedical Nurses Association (BNA) shares their quarterly news.

The wound care section provides a chapter on diabetic ulcers from the Wound Care Certification Study Guide, 2nd edition, which is an updated 350-page study guide on wound care.

In the safety section, Tom Workman and Steve Wood share the preface to the much-anticipated 2nd edition of Hyperbaric Facility Safety: A Practical Guide. A preview chapter is also provided, sharing the innovative and important work of HBOT in animal hyperbaric oxygen systems. Darren Mazza’s article from 2011 describes the importance of critical thinking and taking an additional five seconds for safety checks.

This issue includes an abstract in the diving medicine section. Diving and Hyperbaric Medicine magazine has published an article on the effectiveness of risk mitigation interventions in divers with persistent (patent) foramen ovale.

Please help us end our 10-year anniversary for 2019 by submitting an article to This email address is being protected from spambots. You need JavaScript enabled to view it. or call 561.776.6066. If you’ve ever wanted to get an article you authored published to an audience of tens of thousands of wound care and hyperbaric medicine practitioners, 2019 is the year for you to make this happen. Your article will be published and then archived for easy access into the magazine’s database.

We also invite you to join our elite group of WCHM advertisers and reach your target audience. We welcome Hyperbarxs as our newest sponsor to the magazine!

Lorraine Fico-White
Managing Editor, WCHM Magazine

Over 10 Years of Practice-Relevant Content At Your Fingertips

The staff at WCHM continues to recognize the advancements and accomplishments over the past 10 years in wound care and hyperbaric medicine. The magazine has launched its own website so past articles can be readily found/accessed by all practitioners via keywords and google searches. The articles can also be used for continuing education and reference sources. Check it out.

In this issue, WCHM continues to spotlight an archived article that had an impact in wound care, hyperbaric medicine, facility safety, quality control, billing and coding, legal issues, and/or continuing medical education (CME). Generous sponsors and prolific and knowledgeable contributing authors are recognized. 

This issue’s archived article is from Darren Mazza, EMT, CHT. Darren’s article from 2011 describes the importance of critical thinking and taking an additional five seconds for safety checks. Also, please go to the magazine website to find all of his past articles on safety.

WCHM is the only free online magazine covering all topics under pressure: wound care, hyperbaric medicine, and diving medicine with a circulation of over 13,000 wound care and hyperbaric medicine practitioners and interested parties. 

The magazine’s past and present role continues to be a fair, objective, nonpartisan, international publication dedicated to reporting and commenting on the knowledge and advances in science and technology encompassing wound care and hyperbaric oxygen therapy. It reports on currently accepted and emerging clinical applications as well as the associated economic, social, and political issues and events that influence the administration, growth, and development of the field.

Please contact us at This email address is being protected from spambots. You need JavaScript enabled to view it. to contribute an article in 2019.

Read more: Notes From the Editor & Staff of WCHM

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