Canadian
maple
Medical Alliance for the Preservation of the Lower Extremity
About MAPLE
This is www.CanadianMAPLE.org, the website for the Canadian Medical Alliance for the Preservation of the Lower Extremity, or MAPLE. We are an organization of Canadian wound care specialists with a particular interest in foot ulcers.
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The main directive of this organization is medical and public education for providers and the public, and advocacy for wound care issues.
MAPLE was founded in 2017 by Dr. S A Schumacher, a podiatric surgeon based in Surrey, British Columbia. Dr. Schumacher is a certified specialist in wound healing, and has worked in private practice and a hospital setting treating complex wounds. He is also board certified by both major boards in his profession--the American Board of Foot and Ankle Surgery and the American Board of Podiatric Medicine. His practice is based in Surrey, a suburb of Vancouver, in British Columbia, Canada.
The name MAPLE was chosen because there are few things more identified with Canada than the Maple leaf. It's on our flag, it's on our money, and it's the name of the hockey team in our largest city. However, while the website is geared particularly for Canadians, anyone with an interest in neuropathic ulcers of the foot may find this site useful.
Symbolic of the maple, what our organization tries to provide is a strong base of knowledge, rooted in science, with a perspective from multiple branches of medicine. The maple is meant to symbolize growth. The bright colours are to symbolize positivity. We hope this site will offer you some shelter from the worst impact of foot ulcerations, and serve as a point of reference for discussions with your health care team.
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If you are a health care provider with an interest in wounds and wish to join MAPLE, write content, provide images, click the Join MAPLE link. If you need a speaker for your organization, feel free to contact us.
Why Does This Website (and MAPLE) Need To Exist?
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This website, and MAPLE more generally, exists because there is insufficient knowledge about how
to manage wounds, and insufficient access to their proper care.
A lack of information about wounds is certainly true for many Canadian patients, many of whom come into
wound care facilities with little idea of what their wounds mean and what is required to heal them.
But it's also true for medical practitioners generally. And it's true for provincial government insurance,
which tend not to cover what's most effective in treating wounds.
There may be several reasons for this lack of understanding.
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First, from the patient's perspective, foot ulcerations (wounds)
are unpleasant. They're often messy and smelly, and they
can be embarrassing for some patients to discuss or
even look at.
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And because many of these wounds are typically associated
with sensory neuropathy (loss of the sense of touch), they
often don’t hurt. So patients may not discover a wound
until it is quite progressed.
Even if the patient is aware of the ulcer, he may
feel that something that doesn't really hurt isn't
urgent to treat.
This combination may mean a delay in a patient
seeking treatment. And this is unfortunate because
foot ulcerations are serious. They can lead to infections,
amputations and premature death. The statistics are daunting.
But, truth be told, wounds are unpleasant from a physician’s
perspective as well. Besides being messy and smelly, they’re
often quite time-consuming and wound care is significantly
underpaid for the effort and skill that’s required. Additionally,
wounds are often hard to heal, especially if you don't treat them
regularly. And they have a high tendency to recur. So there are
few doctors or nurses who specialize in ulcerations, or like to deal
with them.
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The result is that wounds are often managed inappropriately, or are otherwise given insufficient attention.
As an example, if a patient with an ulceration presents to a typical family physician, a walk-in clinic, or an ER, the most common treatment is to apply a bandage and to prescribe
antibiotics. Antibiotics, however, kill bacteria; they do
not heal wounds. So, while vitally important if an
infection is present, antibiotics are not appropriate
for wounds that are not infected, and patients wounds
often do not heal. Most wound specialists have seen
patients who have been on antibiotics for a year or
more without healing.
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Other times patients are referred from one physician to the next,
to home nursing, for tests of various sorts--often with no one physician taking real ownership of the patient's wound.
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You'll see some examples of wounds on this site that have
languished for years in this way.
Sometimes doctors conclude that because the wound hasn't healed with an antibiotic, or with a change in some other medication, or after a negative finding on an x-ray or culture, or after an unsuccessful referral or two, the patient must be unable to heal. They may conclude there must not be enough blood flow to heal. Or that a diabetic's sugar must be too high to heal. Or that the patient must be too old to heal.
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And the patient is referred for amputation.
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But this has profound implications. Patients who have one amputation usually end up with more. This is because even small amputations alter biomechanics. This causes no pressure sites, new ulcers, and new health risks.
Further, amputations affect a patient's health and longevity. Amputations create depression. They affect the patient's ability to work and provide for the family. They strain our social programs. They increase the costs to our health system.
But a wound's not healing is often not a result of a patient’s inability to heal. Often wounds don't heal because they are not receiving all the care they require, whether because of a lack of knowledge in how to deal with them, or because the provincial health plans simply don't wish to invest resources in proper management that are actually proven to work.
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However, a little knowledge can pay huge dividends. So our aim is to try to provide some of that knowledge.
Wound care is a medical field unto itself. Wounds require a
specialized skill set, including an understanding of how wounds develop, and what they need to heal. They require a degree of surgical skill, to remove the dead tissue that typically develops in a wound, sometimes extending down to bone. And they require an understanding of biomechanics--understanding the movement of the foot, both normal and abnormal, and the physical forces that cause the wound and prevent it from healing.
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There are few doctors with this skill set, or with wounds as a
specialty. This is even more true in a country as vast as Canada with a population spread out over an enormous geography.
"A very little key will open a very heavy door."
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---Charles Dickens
Hunted Down
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Because most physicians do not have the time or expertise to deal with wounds, and because our health system has insufficient inclination to pay for appropriate wound care, many Canadian patients develop preventable infections and have unnecessary amputations performed, even if the wounds are able to be healed if given proper care and attention. This is immensely frustrating for those of us in wound care, as we know limbs and lives could be saved. And we'd save money in the process.
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The final reason for this website is that wound care is a
billion-dollar industry. Thus, much of the information on
wound care that does exist on the internet is put out by
companies or individuals selling a product or treatment,
and the information may be compromised by financial
self interest.
So this website, produced by specialists who work in this
field, seeks to give patients access to information on
wound healing that they may otherwise be unable to access.
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"If what I say resonates with you, it is merely because we are both branches on the same tree."
-- W. B . Yeats
Even if a patient is close enough geographically to appropriate medical care, he may not get the care he needs. For instance, podiatrists (foot doctors) have with some of the most important skills for wound healing—such as a specific specialty in the foot, extensive surgical training (appropriate in surgical debridement), and biomechanical expertise (important for effective offloading).
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Yet some provincial medical plans do not insure podiatric services. And those provinces that do pay for some podiatric services to one degree or another often exclude wound care from reimbursement. The result is the nonsensical situation seen in British Columbia where the provincial government will pay to amputate, but not for the proper wound care that would save the limb.
Many extended plans do pay for podiatric services, including for wound care. But not all patients have such plans, and reimbursement rates may not always be sufficient. So, too often a patient may have to pay out of pocket, and many patients most susceptible to wounds—the elderly, minorities and indigenous populations, and those in lower income populations—simply cannot afford the care.
Those who are most at risk for amputations are those who have already had an amputation, and many of those patients are not working because of an earlier amputation, and simply cannot afford the out-of-pocket care.
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Services for wound care nurses are often covered by provincial health plans, but nurses are often underfunded, overworked and inadequately supported. Further, wounds really require a multi-disciplinary approach to address the aspects of wound healing that no single health care provider can provide alone.
In addition, most provincial governments do not pay for offloading—specialized dressings, casts, boots, shoes, etc. that seek to get pressure off the wound and give it the opportunity to heal. And this is the single most important factor in most wound healing.
To return to the top of the page,
click on the maple leaf to the right.
This page written by Dr. S A Schumacher
Podiatric Surgeon
Surrey, British Columbia Canada
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Unless otherwise noted, the clinical photographs found on this site are the possession of Dr. Schumacher. They may be used for educational purposes with a credit to Dr. S A Schumacher, Surrey, BC www.CanadianMAPLE.org.