haywanchiudpm

haywanchiudpm Husband. Father of 2. Podiatric foot and ankle surgeon specializing in wounds and limb salvage. Same-day appointments are available for urgent needs.

Dr. Chiu specializes in diabetic wound care, bone infections, and advanced techniques to prevent amputation. He also provides general foot care and accepts all major insurance plans. If you become an established patient, Dr. Chiu will do everything possible to keep you ulcer-free. If wounds do occur, he provides hands-on care himself—often weekly—and manages all aspects of treatment including the antibiotics. If hospitalization is ever needed, Dr. Chiu or one of his trusted colleagues will care for you directly, with seamless coordination. He is one of the foot doctors at Albuquerque Associated Podiatrists who lead the wound care clinic.

This male in his mid 50s presented to the ER with WBC 21, vital signs stable, had a chronic wound for several months tha...
04/28/2025

This male in his mid 50s presented to the ER with WBC 21, vital signs stable, had a chronic wound for several months that became infected. The infected nidus showed necrosis, and with the dorsal blistering and ecchymoses, this is a classic type 1 necrotizing fasciitis case. We did a 4th ray amputation with I&D to get initial source control. The closure was a bit complex due to the widespread damage.

There were 2 major issues. The large size of the wound wasn’t a problem, the large dorsal wound will heal fine and its a NWB surface. Could also do a hallux fillet flap to cover dorsal. Mostly worried about the large 4th ray defect and 5th metatarsal bone exposed. I didn’t have an exact plan of what I was going to do, but once I was in surgery, I found that the abductor digiti minimi muscle was viable and had some bulk. So I separated the muscle from the overlying skin, flipped it backwards to cover the 5th metatarsal bone. The plantar 5th metatarsal skin was then mobilized medial to cover the remaining defect. The rest was closed in layered fashion, 3-0 monocryl and 2-0 and 3-0 nylon.

The path results confirmed nec fasc with negative bone margins, he was discharged on oral Augmenting. I saw him in office once a week for debridement. Dressing changes consist of betadine gauze. The hallux filet flap struggled a bit at the edges (not unexpected) but it eventually healed by the 16th post-op week.

I trained ChatGPT to write my SOAP notes. Here’s what happened.Most AI scribes do a decent job transcribing and summariz...
04/19/2025

I trained ChatGPT to write my SOAP notes. Here’s what happened.

Most AI scribes do a decent job transcribing and summarizing a visit—but they rarely capture real clinical decision-making. And almost none are formatted to meet audit-proof documentation standards.

So I tried to train it myself.

I fed ChatGPT examples of my notes. I uploaded the Novitas LCDs (I’m in New Mexico). I gave it strict instructions to mimic how I document healing trajectory, imaging interpretations, and a few other stylistic nuances. I even asked it to ask clarifying questions before generating the final note.

At first, the output was pretty good.

But then I noticed it was fabricating things—little details I never said or did. After digging, I learned these are called hallucinations—when AI prioritizes sounding smart over being accurate. Just like overconfident humans.

I tried to fix it. I gave it more rules. More structure. More definitions.

That’s when things got worse.

The bot started confusing low vs moderate complexity. Mistook erythema as a systemic symptom and upgraded risk severity. Forgot prior guidelines I fed it. Turns out it was relying on cognitive shortcuts—trained habits to reduce mental strain. When I blocked those, it collapsed.

So I’m pausing the full automation for now. Maybe I need to figure out a different way to instruct it, or maybe it needs more computing power.

But right now, I’m using it for very selectively in clinic: generating smart phrases, documenting medical necessity, and tightening high-risk notes—especially the ones insurers actually request: level 4 or 5 visits with a 25 modifier (like for doing debridements).

Most level 3s don’t get audited. It’s the notes with 25-modifier that need to be airtight. Maybe I’ll try the full bot again later. For now, it’s back to Dragon…with AI-augmented phrasing in my back pocket.

Pro tip: If you’re using skin subs, try uploading the skin sub LCD, pasting a note, and ask ChatGPT to “Review this note for a strict Medicare audit. Make sure I have all documentation requirements and medical necessity explicitly stated”

As a podiatric surgeon in New Mexico specializing in diabetic limb salvage, I’ve seen complications that never showed up...
04/02/2025

As a podiatric surgeon in New Mexico specializing in diabetic limb salvage, I’ve seen complications that never showed up in training—things you won’t find in textbooks.

I had to revise how I think.
I slowly developed a different approach to infection, source control, and surgical decision-making.
It started as stuff I had to constantly remind myself, and then eventually it became instinct. I developed a framework that I could pass onto my colleagues. One of my limb salvage partners I work with told me that it just feels as natural as breathing now.

And together, we started getting better results.

But the truth is—this framework I’ve been building is still too abstract and disorganized to publish.
It lives in mental notes, case photos, and intra-op problem-solving.
Between spending time with my wife and 3 daughters and working my beyond-full time job, I never had the time to turn it into a book, course, or formal teaching tool.

Then I came across something online:
People were building custom versions of ChatGPT and training them to act as teaching assistants.

And I thought—what if I could teach it to what I know now?

So I gave it a shot.
For two weeks, I casually fed it what I knew—voice notes during commutes, uploaded a few cases I’ve already posted on Instagram, random thoughts between surgeries or downtime in the clinic.

When I ask ChatGPT, “What is the current diabetic limb salvage approach?”
It’ll show me all the usual stuff I see in textbooks.

Then I asked it again:
“Show me my limb salvage framework.”

And honestly, it surprised me.

“Limb salvage does not equal wound care”
“You emphasize knowledge acquisition, not just protocols”
“Look for vascular thrombosis at the edge”
“Bacteria move passively via human motion...”

It showed me things I’ve either thought of but never verbalized quite this way, or stuff I say all the time.

Not bad for two weeks.

There’s still a lot to refine—but this might be the start of something bigger.
A chatbot to teach limb salvage?
A real-time reflection tool?
Maybe even the beginning of a textbook I could never sit down to write?

Let’s see what happens if I keep this up for a year.

These are all TMAs.But none of them were the same.Each one required a staged approach: • First, source control—every inf...
03/24/2025

These are all TMAs.
But none of them were the same.

Each one required a staged approach:
• First, source control—every infection created a unique defect.
• Then, a different closure strategy based on what was left behind.

This kind of decision-making isn’t usually taught in school.
And if your residency doesn’t have a dedicated limb salvage specialist, you may never see it.

Over the years, I’ve learned how to problem-solve in the OR with techniques I’ve refined, learned, and developed over time.

Scroll through the slides to see a few examples:
• Fillet toe flap
• Intrinsic muscle flaps
• SALSA spike
• Split-thickness skin grafts
• Secondary intention when it makes sense

That’s the difference with diabetic limb salvage.

You can plan your approach…
But the infection doesn’t always follow your plan.

And when things shift mid-case, you need both strategy and flexibility.
• Sometimes the tissue is more infected than you thought.
• Sometimes perfusion isn’t what you hoped.
• And sometimes the closure you mapped out… just isn’t going to work.

In those moments, you can’t force it.
You pivot.
You adapt.

These aren’t things you memorize.
They come from doing the work—and from letting go of the idea that there’s a perfect playbook.

When you stop trying to make the case fit your technique…
and instead adjust your technique to fit the case.

That’s where the creativity starts.

And honestly,
that’s where I have the most fun.

Hi all, I’m working on a collaboration with Amanda Killeen to publish more retrospective data on the medial band planta...
09/14/2024

Hi all, I’m working on a collaboration with Amanda Killeen to publish more retrospective data on the medial band plantar fascia release for hallux IPJ ulcers. If you do this procedure and would like to contribute data, please DM me your email and I’ll send out more details. Don’t worry if you see a lot of complications/failures with the procedure, or do it with a different technique than what I’ve published, I’m looking for honest data on the good, the bad, and the ugly.

We have 20+ collaborators already which is amazing! Still working out the details of IRB approval so we are still recruiting collaborators. We want to have as much data as possible. Please share this post with attendings and colleagues whom you know that does this procedure as well. Thank you.

At my old job 7 years ago, I had a few patients with hallux stump ulcers that did not heal, but they did not want it amp...
08/27/2024

At my old job 7 years ago, I had a few patients with hallux stump ulcers that did not heal, but they did not want it amputated. We don’t have much options at this point, so it’s a low risk situation to try new procedures. It was for this specific type of ulcer that I started doing plantar fasciotomy for hallux ulcers. When done in isolation, the hallux ulcer improved but didn’t heal. I decided to experiment with a flexor hallucis brevis tendon release. I tried doing it with #11 blades, #15 blades, and beaver blades. I used to do it under ultrasound guidance so that I can hug the bone. After doing a few and going into private practice where I don’t have ultrasound anymore, I’ve done the FHB release based on palpation only. Here’s one recent case where I did a needle plantar fasciotomy and FHB release with #15 blade, closed with a single stitch in office, patient healed in 6 weeks.

The hallux stump has a short lever arm and a lot of pressure that goes to the tip during push off, so I think being more aggressive with the release is necessary. When I do the FHB release this way, I believe some of the plantar fascia fibers at that level is released, but the plantar fascia has attachments to skin at all aspects of the plantar foot so an additional level of release makes sense. This approach should be safe from cutting arterial supply if you cut from superficial to deep.

Here’s how i do it now:
Sterile prep in office
Palpate the proximal portion of the tibial sesamoid
Make a vertical incision with a 15 blade through skin
Cut a few fibers at a time from the inferior margin of the sesamoid to until I feel bone (inferior cortex of 1st metatarsal neck)
Start advancing and cutting until blade is buried completely

(2/2) I think the dogmatic practice of treating forefoot osteomyelitis with aggressive surgery comes from the fact that ...
08/16/2024

(2/2) I think the dogmatic practice of treating forefoot osteomyelitis with aggressive surgery comes from the fact that a lot of patients with diabetic foot infections get complications, recurrent infections, deformities, repeated hospitalization. I get it, it can be frustrating to try to treat something with conservative surgery only to get it infected again. It sucks for the patient too. So I sometimes do amputate when I can give my patient a better long-term biomechanical foot. But I’m also flexible in being ultra conservative and giving the host and antibiotics a chance to fight off infection without removing bone in order to optimize long-term biomechanics as well. Over the years I feel I’ve gotten better at figuring out when to be ultra conservative and when to be ultra aggressive. Sometimes its patient driven, sometimes its mechanics driven, sometimes infection severity require it. It all depends, but the more you do this the easier it becomes. One day i’ll try to come up with a way to publish something on whats salvageable, but its as simple as this:

If it’s not gangrene or not necrotic, it is salvageable.

The next question is: Is it worth saving for biomechanical reasons?

To me, these are the 2 simple rules I follow with approaching diabetic limb salvage source control.

(1/2) This is a great case that challenges dogma of how we treat osteomyelitis of the foot, especially in the setting of...
08/16/2024

(1/2) This is a great case that challenges dogma of how we treat osteomyelitis of the foot, especially in the setting of diabetes. It’s so easy to remove bone. Think about how osteomyelitis of the spine is treated, is it amputate first? Even infected obliterated bone can be treated with antibiotics. Check out case reports from India. Yes it’s low level evidence but it’s also eye opening. I think all of these slides are self explanatory so this caption is just for the big picture thinking. I’ll share my final thoughts in the next set slides in the next post.

Facebook reminded me of this 7 years ago, .chiu was 8 months pregnant with our first daughter, I was still working at th...
05/20/2024

Facebook reminded me of this 7 years ago, .chiu was 8 months pregnant with our first daughter, I was still working at the UNM School of Medicine as an associate professor and podiatrist for the diabetic limb salvage program called CHILE. Allyssa, the chief of vascular surgery at the time (Dr Wei Zhou) and I presented our work at the Desert Foot Conference in 2017 on evaluating 5 year outcomes of veterans at VA Palo Alto who underwent minor amputations, separated into cohorts of patients with or without calcified arteries in their toes. We found that in 5 years, patients with calcified toes had a 3 fold increased risk of major amputation. But all-cause mortality was 30% regardless of calcified toes. Our poster won first place and we had submitted our manuscript to JFAS. The editors wanted some revisions that we never had the chance to complete because we then had our first child. I switched jobs, and 3 children later, we put this manuscript in the bottom of our to-do pile. However next year our youngest will start school, which frees up some time for Allyssa to jump start her medical writing career. As far as we know, she was the first podiatrist to complete the TICR program at UCSF, and used her knowledge to perform all the statistics for our research paper that we never published. I mention this because I owe my knowledge of research to her. So any and all papers you might see me publish will have some influence by my smart beautiful wife whom I’m grateful to have in my life.

This patient was in her early 50s, had diabetes, recent renal transplant requiring immunosuppresion therapy to prevent o...
05/14/2024

This patient was in her early 50s, had diabetes, recent renal transplant requiring immunosuppresion therapy to prevent organ rejection, had a recent infection treated by another surgeon, was on a PICC line getting Ceftriaxone, but her weekly labs were uptrending WBC, now up to 16, which brought her to the ER. This history alone gives me high index of suspicion for infection. Erythema is expectedly absent. When I look at the foot here, I notice dessication of the tendon with extension into the inflamed 4th toe, and some blistering going transversely across the plantar fat pad. This is classic type 1 necrotizing fasciitis, and it is really hard to convince patients about how serious this infection truely is due to the immunosuppression, she doesn’t have enough functioning leukocytes to even for pus. Cellulitis is difficult to detect on the plantar foot due to the thickness of the skin, but with immunosuppression meds? It’s nearly impossible, can only rely on other things like blistering, petechiae, and necrosis.

I couldn’t get consent for a TMA, so we started with a 4th ray with I&D and pathology demonstrated necrosis. Then convinced her to do a guillotine TMA with vac. Few days later, was good enough to graft. I prefer Integra for gTMAs, I think it’s a bit easier to incorporate than Dermacell, and I haven’t been impressed with Kerecis or Stravix to be honest (disclaimer, I am consultant for Dermacell). 1 month later, did a STSG for definitive coverage. Things that went in her favor was she had excellent flow, was relatively young, didn’t smoke, and was compliant. Cultures were initially polymicrobial but after the gTMA, residual cultures were MRSE (methicillin resistant staph epidermidis), a commensal bacteria that is rarely pathogenic with exception in cases like this in a very compromised host, which was why her infection was so slow to progress. On discharge she was treated with oral doxy and augmentin.

3 years ago, I treated this man in his 60s who had history of preDM, hypothyroidism, PAD s/p pop stent, scleroderma, for...
05/07/2024

3 years ago, I treated this man in his 60s who had history of preDM, hypothyroidism, PAD s/p pop stent, scleroderma, for osteomyelitis of the 5th MTPJ that a 5th ray amputation with staged closure. He had a hard time healing, got a recurrent infection that needed staged surgeries again, finally healed 8 months later. He went on to do fine until his hammertoes started bothering him a year later, pain was at the PIPJ with walking and in shoes, and he wanted them surgically corrected. I was not excited to offer surgery, but he did have ADL-limiting pain. I had great concerns about healing from a traditional open hammertoe procedure, and I didn’t want any pins sticking out for fear of infection risk. I also didn’t want any retained implant

So I decided on a MIS approach. I did MIS joint prep with insertion of a bone pin. I wanted an absorbable implant so if there are wound issues in the future, he won’t have to worry about seeding infection to metal.

I prepped the joint through a lateral approach using an MIS burr. I left the DIPJ alone cus it was asymptomatic and to reduce my surgical footprint. Fusing that isn’t critical to the success of this patient IMO. I then retrograded a k-wire. I don’t do hammertoes often, but retrograding these isn’t too hard. I use the dorsal quarter to third of the toe as my entry point, and I try to palpate the bone with the k-wire before I start advancing the wire. I go through one bone at a time carefully feeling and then positioning each bone I pass so I don’t swisscheese. I then used a cannulated drill to “ream” for the implant, took out the wire, and tamped a 3.0mm Ossiofiber implant while holding the toe in place. Before I tamped it in all the way, I made sure to leave some room, I then used a saw to trim off the excess implant near the skin at the tip of the toe, and tamped the rest of the implant into place.

He healed his incision sites in 2 weeks with no complications, postop photos are 2 months where you can barely see the scar.

(3/3) 1 week after closure and graft, I remove the bolster dressing and go to once or twice weekly betadine gauze dressi...
05/02/2024

(3/3) 1 week after closure and graft, I remove the bolster dressing and go to once or twice weekly betadine gauze dressing. If they have a home health nurse and want to do more frequent dressing changes for whatever reason (drainage, peace of mind, etc) then I’ll write orders for medihoney + gauze, but honestly doesn’t matter at this point what the wound care regimen is, the bulk of the work has already been done at the hospital set up the wound for success. 3 weeks postop is when I remove sutures. After 4 weeks I debride anything from that graft that isn’t adhered or granulating. I started letting her walk at around 2 months post-op when the wound was for sure 100% granular, and flat edges. Flat edges tell me at a glance that there’s no undermining/tunneling, and that they’re healing. See my posts on August 11, 2020 and June 27, 2020 to learn more about flat edges and July 25, 2020 on measuring rates of secondary wound healing to decide on skin grafting vs healing naturally.

Total healing time took 6 months. I get a lot of questions about choice of graft, bolster options, and wound care, but none of that matters much, I’ll even throw in that choice of irrigation and suture to close doesn’t matter much either. Because we can’t even get to have these debates unless the first step of limb salvage (which is source control) is accomplished. Usually once good source control is done, the rest is pretty easy and the nuances become irrelevant.

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