Maggots, leeches and healthcare aren't supposed to mix. The first is a product of filth, the second a medical treatment used in the Middle Ages. And one would think that virtually every member of the public doesn't expect to encounter the first two while accessing the third.
Maggots and leeches are quietly worming their way back into the practice of medicine. Yes, 21st-century medicine. According to experts, the necrotic flesh that green blowfly maggots feast on and the antiseptic liquid they secrete as a self-defense mechanism can cleanse chronic wounds as well or even better than conventional therapies for debridement, or wound care. The bloodsucking properties of medicinal leeches and hirudin--the powerful anticoagulant they manufacture while at work--can ensure the venous flow of blood crucial to the successful reattachment of a severed limb or for delicate reconstructive surgery.
Though there isn't any specific data, leeches--considered the less dubious of the two creatures in terms of medical value--have made their way into the pharmacies of various major hospitals. Still, physicians only turn to maggots or leeches as a last resort, when the only other option is for the patient to lose a limb.
The nation's handful of maggot and leech suppliers report a gradual upswing in orders. And while there isn't an official maggot or leech billing code, HCFA officials say providers and insurers have the option of seeking reimbursement for their use.
"Leeches are great. I've used them on fingers, faces, even on nipples after breast-reduction surgery," says David Janssen, M.D., a plastic surgeon in Oshkosh, Wis. Janssen has used maggots for treatment as well. He likes them so much that he's formed a company called Biomaggot.com to ensure fresh supplies to physicians around the country.
"They're aerobic organisms and are very delicate," says Janssen, who has encountered problems getting maggots shipped to him in a usable state from other suppliers. He and a partner raise about 200,000 maggots per week, shipping them out to about 30 providers throughout the country.
Because leeches don't morph into other life forms and can go six months without a meal, they're much easier to handle than maggots. One of the major leech distributors, Leeches U.S.A., based in Westbury, N.Y., imports medicinal leeches from European swamps. It then ships them in a cold saline solution, often accompanied by leech "mobile homes" for long-term storage. The company charges $6.90 per leech for orders of up to 99; $5.25 for orders of more than 100.
Leeches U.S.A. reports that sales are growing 15% to 20% per year. "There's a wider acceptance of them in the surgical community," says Rudy Rosenberg, one of the company's owners. That's a far cry from less than two decades ago, when Rosenberg recalls a local hospital vehemently refusing his offer of leeches to treat the victim of an automobile accident whose leg had been severed. Today, that hospital--Rosenberg declined to disclose its name--is a regular customer. Although Rosenberg wouldn't disclose specific figures, recently published reports say his firm ships as many as 20,000 leeches annually.
"We keep leeches all the time in the hospital pharmacy," says Prosper Benhaim, a Los Angeles microsurgeon and an assistant professor at the University of California Los Angeles School of Medicine. (UCLA Medical Center is a Leeches U.S.A. customer.) Benhaim adds that leeches have been a standard instrument of microsurgeons for the past decade. "Questions about their use are pretty standard on board exams," he says.
Major urban hospitals aren't the only ones returning to the use of leeches and maggots. A smaller, rural facility, 90-bed Taylor County Hospital in Campbellsville, Ky., used leeches last year to increase blood flow to a patient's surgically reattached ear. In 1995, caregivers there also used maggots to clean the wound of a terminally ill cancer patient too weak to undergo the anesthesia required for more conventional forms of wound care.
"The maggots cleaned him out in two days flat," recalls Jay Eastridge, Taylor County Hospital's pharmacy director. The leeches also did their job when used on an accident victim, ensuring the successful reattachment of the patient's ear.
That's not to say leeches and maggots are found in every hospital or being regularly prescribed. Eastridge notes that the opportunities to use them are few, and traditional therapies still get the nod first. Most other practitioners share a similar view, having used maggots or leeches only once or twice. Microsurgeon Benhaim only uses leeches an average of once or twice per year and resorts to them only after other traditional ways of restoring blood flow have failed.
"They get you out of trouble," he says. He also concedes that patients aren't particularly fond of them clinging to their bodies. However, they usually prefer them to the alternative of going back for another 12-hour surgery.
And while Benhaim acknowledges the wound-cleaning abilities of maggots, he's never used them, preferring some of the more traditional methods of treating chronic wounds, such as whirlpool therapy and the snipping of necrotic flesh.
Other wound-care specialists, such as Leddy Hoffman, a clinical nurse at the outpatient wound center at Cedars-Sinai Medical Center in Los Angeles, simply find the use of maggots repulsive, a common feeling among those who must apply such exotic treatments.
"There are other ways to debride wounds that don't seem as offensive. If I sent a patient home with maggots (in their wound), there's no control, and Lord knows what could happen," she says. "I could get phone calls about flies coming out of wounds."
That's not going to happen, says Ronald Sherman, M.D., a pathology professor at the University of California at Irvine. In what is probably the answer to the most commonly asked question about maggot therapy, Sherman notes that maggots go through a pupa stage before they become flies, and that can only be accomplished by burrowing into the ground.
Sherman attempts to dispel the maggot antipathy displayed by many caregivers through the work he performs at a laboratory tucked in a far corner of the UCI campus. That's where he uses an eclectic mixture of powdered bodybuilder's supplement and rotting beef liver to raise green blowfly maggots for medical use and research. Much of the bounty is shipped to providers around the country.
Sherman possesses a wryness that probably comes with being the country's leading--and perhaps the only--maggot wound therapy expert. Sherman, 43, greets phone callers by deadpanning "maggot lab" into the receiver. He regales a recent visitor with dry anecdotes of reconciling his vegetarian diet with cleaning out supermarkets of their liver inventory, and his slight build with ordering cases of weightlifting supplement at health food stores.
Sherman advocates somewhat passionately for maggots: His research indicates that they prefer strawberry-flavored bodybuilder's supplement to chocolate and vanilla, and he notes that animal rights activists seem to have no problem ignoring their plight as a lab animal. "These are warm and fuzzy (as well)," Sherman says, holding up a bottle of his charges, which resemble frenetic grains of rice.
One difference between Sherman and other physicians may be how he reacted to first seeing maggots in a patient's wound during his residency (Patients being admitted with maggot-infested wounds are very common if they've been neglected or are homeless). The maggots fascinated rather than repulsed him, and eventually set him on his course as a scientist. "I want to make maggot therapy widely available," he says.
There is nothing quirky about Sherman's medical research. According to his scholarly writings, physicians have known about the medical benefits of maggots since the 16th century. They were first used purposely to clean wounds during the Civil War. By the 1930s they were in use at more than 300 hospitals around the country. But the miracle drug of World War II--antiobiotics--pushed maggots out of the acute-care setting.
Despite the disgust generated by the sight of maggots, Sherman is convinced that they're extremely beneficial. "They clean necrotic wounds faster and less traumatically," he says.
Janssen, the plastic surgeon in Wisconsin, concurs.
"This whirlpool debridement stuff hurts, and it can cost 20 times what maggot therapy does," Janssen says. And for patients with lupus or other diseases, the healing process is even more complicated, often making maggots the best option.
Sherman's research concludes that applying maggots to spinal-area pressure ulcers--better known as bedsores--can clean them more than 50% faster than conventional dressings. The only side effect was the anxiety among the nursing staff when an occasional maggot strayed from the dressings.
Even when maggots don't work, Janssen believes there is an underlying success. "You may not be dealing with a salvageable wound, period. But (maggot debridement) cuts the period required to recognize that," he says.
But resistance will probably always remain a big problem. "They're still creepy-crawly guys, and nurses aren't trained to apply them or paid extra to do it," Janssen says. Moreover, there is still an enormous amount of fear about using them.
Sherman, for example, hasn't applied maggots to a patient's wound in about four years, mainly because UCI is worried about liability issues, he says. Janssen's firm charges $159 for 1,000 maggots--generally considered the number required for effective treatment of a small wound. That's about double what Sherman charges, partly because Biomaggot.com can't get liability insurance.
Yet as the unsettling term "antiobiotic-resistant" is found more often in today's medical literature, maggots may eventually become commonplace in hospitals once again.
Hoffman, the Cedars-Sinai wound center nurse, was surprised when she learned that maggots can cost less than a tube of topical wound salve and that they can eliminate an impressive 15 grams--or half an ounce--of necrotic flesh from a wound daily.
"I still don't want to use them, but I do want to learn more," she says.