03/10/2014    Wm. Barry Turner, BSN, DPM

Using Nitropaste to Increase Blood Flow

In this time of studies and verifiable proof of
effectiveness, I can only offer what I have seen.

I once used nitropaste on a patient, and tested perfusion with a laser Doppler. The digital perfusion increased 300% in five minutes. When I applied nitroglycerin paste
as an RN (treating acute MI), we would apply the
paste to a piece of paper and tape the paper to
the person's chest. The PDR distinctly states "do
not rub in".

I once heard that Dr. Harkless had participated in
a study, but I have never seen it. I contacted the
company making nitropaste. They were not
interested in doing any studies.

All I can tell you is I use nitropaste on about
90% of my patients. I use it with Raynaud's, DM
ulcers, ischemic digits, ASO, venous ulcers, and
pretty much any wound that is responding slowly.

When I treat Raynaud's, I tell the patient to rub
the nitropaste in their calf or arches 1/2 inch
tid, alternating legs or 1/4 inch into both
arches.

When I treat DM, ASO, or any ischemic ulcer, I
tell the patient to rub in 1/2 inch tid, as near
as they can to the wound, without disturbing the
dressing.

For venous stasis, I instruct the patient to rub
in 1/2 inch tid behind the knee, while keeping the
leg and foot in an Unna boot.

I tell my students do not be neglectful of the
edema that Nitroglycerin paste causes. If the
edema becomes problematic, use an Unna boot or
some form of limb edema restriction. Using an Unna
boot on a patient with an ABI less than 0.6, I was
taught to be a no-no. Using the Unna boot with
nitropaste, I have never had an issue.

I am a firm believer that majority of venous
stasis wounds are of mixed etiology and I have
seen some amazing results with nitropaste.

Before I prescribe the patient nitropaste, I do a
trial in my office. I get a BP, the systolic must
be over 100 mmhq. I rub in the nitropaste, and
repeat the BP in five minutes. I am "hoping" for a
20 mmhq drop in BP, but I seldom see that much.

In my 20+ years of practice, I have had one
patient become problematic, one. In that case, I
rubbed the nitropaste off, raised the patient's
feet, until they felt better. The patient was well
into her 90s and did not weigh 100 pounds. A half
inch is not a very strong dose. The paste does
effect the entire body, but if works strongest
where it is applied. I have had headache
complaints with nitropaste, maybe three times in
all my years.

My rationale for rubbing in the nitropaste is that
I am trying to break up calcified and hardened
arteries-I want a surge effect.

Now I use multiple modalities to heal my patients,
so I can not say for sure whether I can point to
the nitropaste as being the causative agent, but I
do see radiographic improvement of calcified
arteries in my patients.

Rx NItropaste 2%, Disp 60 gm, 1/2 inch to be
rubbed in xxxxx, tid (xxx=arch, calf, behind the
knee...) I do avoid rubbing it in over boney
prominences.

When I write an order for nitropaste for an
inpatient, Nitropaste, rub in 1/2 inch to xxxx,
tid, hold for SBP under 100mmhq.

Also, like narcotics, the body does develop a
tolerance to nitroglycerin topical and you may
need to increase the dosage. I do not recommend
long-term use of nitropaste because of the
tolerance issue. I will recommend oral calcium
blockers to the patient's primary care doctor.

I hope this response is some help to you. Of
further note, I now have the Emory cardiologist,
to whom I refer many of my circulatory impaired
patients, following my use of nitropaste. I
lecture and direct a five tier, wound care course
for the GPMA's, and I teach my students to use
nitropaste as well as other medications to
improved arterial and venous blood flow.

I always start my nitropaste lecture with these
questions, "Have you ever cut yourself shaving?"
How often does it not heal? How often does the cut
get infected?" You shave, how often have you cut
yourself and have the wounds not heal or get
infected? Have you ever thought of why that is?
My thoughts are it is directly related to the
abundance of blood flow to the face. I want blood
to all my wounds! And plenty of it!

Spread the word and let me know if I can be of any
more assistance.

Wm. Barry Turner, BSN, DPM, Royston, GA,
claret32853@ymail.com

Other messages in this thread:

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03/14/2014    Wm. Barry Turner, BSN, DPM

Using Nitropaste to Increase Blood Flow (Robert Bijak, DPM)

In response to Dr Bijak's "slam" on my
nitroglycerin paste protocol, I am familiar with
his rude responses and judgmental behavior that is
so typical for him. I will try not to take it
personal.

I am fairly certain in my description of my
protocol using nitroglycerin paste, that I
presented both sides of the discussion using this
particular modality. I mentioned that the
medication had a dangerous potential and cited my
experience of using it on a 90-year old patient,
with low body weight.

I had a similar event of hypovolemia while
treating a patient when I was a cardiac nurse.
That incidence dosing was a full inch, applied
directly over the heart. That time was under the
direction of a cardiologist while I was working in
a Cardiac Cath Lab. The time I used it on that
"little old lady" in my office was in an attempt
to save her foot. She died shortly after the
amputation. That was over twenty years ago and yes
I learned from the incident. I have saved
literally hundreds of limbs using that technique
since then. Not one person has died.

I believe that I mentioned that I had tried to do
a study, but could not find any sponsors, so I
recorded my experience and presented it just as
that, "my experiences","my protocol".

I believe that I commented on hearing about a
study, but was unable to verify it.

This medication in your hands might very well
cause an MI or hypovolemic shock, but not by
anyone that uses the protocol I described. I used
a cardiologist to help me develop that protocol. I
doubt your cardiac vascular knowledge and
experience are in any way equal to mine. That is
why I put together a protocol.

As far as scope of practice, I practice in
Georgia. Dr. Bijak is correct what is legal in
Georgia may not necessarily be legal where you
practice. Regarding my practicing outside my
scope of practice, I am not. Did I mention I
served a decade on the Georgia State Podiatric
Board? How long did Dr. Bijak serve on his state
board? His statement regarding that the
prescription of nitroglycerin possibly being
outside the scope of practice of a podiatric
physician supports my doubts regarding his
knowledge of his own state's scope of practice
act. I am very aware of my state's practice act.
Did I mention I was the first podiatrist in
Georgia to be allowed to supervise and bill for
full body hyperbaric oxygen therapy when treating
lower limb pathology.

My critical care experience as a RN and my over
all medical background are extensive, starting
with my combat medic training during the Vietnam
War. I spent over five years working as a "hot
shot" agency nurse in South Florida. While I was
attending podiatry school, I worked in almost
every ICU/MICU/SICU/CCU in the Miami/Ft.
Lauderdale area. Using my knowledge to enhance my
podiatric training, is just that, enhancing my
ability to treat my patients within my scope of
training and my state delegated restrictions.

I do not remember telling anyone to practice
outside their scope of practice. Did your
residency teach you how to do ankle surgery, or
fix tibial-fibula fractures? Are you allowed to
perform those procedures in your state? Did having
the knowledge hurt you, even if you can not
perform these procedures in your practice?

I understand the need for verifiable studies. I am
a firm believer that testimonies are refutable and
need to be verified by studies.

How many lawsuits have you had? Hmm. I have never
been sued and I have practiced for over 24 years.
I have people come from all over for my wound
care, as I get some pretty impress results.

Do I sometimes push the envelope? Never without
doing due diligence; contacting various
specialist, review of literature and incorporating
knowledge with common sense.

I am unsure why your ego made you feel that you
needed to attack me in a less than professional
manner, but I have followed your writings in the
past and I am neither surprised or impressed.

Sir, when you are ready to give all to your
patients, you may some day become a physician for
your patients. I am willing to look outside the
"box" in my attempts to heal my patients. No
subterfuge. I am up front and tell them their
options. I encourage second opinions.

One final word, if I might provide Dr. Bijak with
a lesson in professionalism. When you disagree
with other professionals, it would be more proper
to contact them at their provided email address,
instead of being pompous and acting like you are
the moral authority of our profession. Dr. Bijak's
behavior is embarrassing for our profession, or
any profession for that matter.

Wm. Barry Turner, BSN, DPM, Royston, GA,
claret32853@ymail.com

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03/11/2014    Robert Bijak, DPM

Using Nitropaste to Increase Blood Flow (Wm. Barry Turner, BSN, DPM)

The PDR distinctly says "don't rub in", so Dr.
Turner instructs patients to rub it in! Game over!
Also, what defense is there for the unfounded
theory he is "breaking up calcium with a surge
effect." How unscientific and unproven. It makes
podiatrists look bad to talk this way. In my
opinion, this is dangerous, unproven advice. The
fact he tried it on a 90 year old 100 pound woman
speaks volumes. I don't care who he lectures to.

Here's what you need to know. Podiatrists need to
honestly determine if they are capable of
evaluating the cerebral and cardiovascular status
of a patient and concomitantly understand the
pharmacology of drugs these patients may already
be on, like calcium channel blockers, ACE
inhibitors, etc.

The danger is, you can cause a hypovolemic stroke
or MI by dilating the vessels and reducing the
blood pressure. Without prior sophisticated
vascular testing, like carotid or vertebral artery
Dopplers, you're just guessing how much the
pressure can be dropped before you kill or stroke
someone. Nitroglycerin is not an innocuous drug
with the co-morbidities these patients present. I
also do not believe a half inch strip is a low
dose for some patients. Rubbing into the calf or
behind the knee may even be illegal in some states
for a podiatrist to do!

I think Barry Turner's "RN credential", backed by
MDs in the hospital, has mistakenly led him think
he has a scope beyond that allowed a DPM. His
advice is anecdotal and should be followed at the
DPM readers own risk. Once again podiatry's
limited training and license places the
practitioner in a legally dangerous gray zone, and
their patients at risk.

Robert Bijak, DPM, Clarence Center, NY
rbijak@aol.com