By Dr. Bret R. Boyle, DO
Superman was not taken down by Kryptonite – it was a bedsore. Actor, Christopher Reeve was well known for his portrayal of “The Man of Steel.” He was paralyzed in 1995 and died in 2004, at age 52, from complications of an infected bedsore. These potentially devastating soft tissue “wounds” are caused by pressure and/or friction and since they do not always occur from a mattress, the better term is “pressure ulcer” rather than bedsore or decubitus ulcer. They occur in individuals who are either temporarily or permanently confined to a wheelchair and/or bed as a result of surgery, illness or paralysis. Over 60,000 Americans die every year from complications of a pressure ulcer.
As a certified wound care specialist with 10 years of experience managing these types of problems, I have been privileged to help a significant number of individuals throughout three counties as a traveling consultant to a number of skilled nursing and assisted living facilities. Before starting this unique service in 2009, I thought I knew a fair amount about the problem of pressure ulcers. I can tell you now, after hundreds of bedside encounters, it is a much more complicated and challenging issue than I had imagined. Following are two hypothetical, yet very real examples to illustrate a few components of this problem.
Jill is in her late 60s with progressive paralysis due to multiple sclerosis over the past 20 years. As Jill became more and more weak and unable to walk or stand, her family obtained a hospital-type bed for use in her home. During the day she began to spend more time sitting up in bed watching television and listening to books on tape and this position placed significant pressure on the tailbone area. She was not able to recognize this due to the lack of normal sensation caused by the multiple sclerosis; therefore, within a few weeks the lack of blood flow, caused by pressure to the tissues over the tailbone area, caused a large, deep wound. This new problem resulted in placement in a skilled nursing facility for special 24-hour care. A large amount of necrotic (dead) tissue was present and was debrided (cut away) there in her room. Although she was placed onto a special, high-quality air mattress, proper adjustment of air-pressure levels and proper positioning off of the injured area were necessary for healing to begin. Eventually with good wound care, improved nutrition and avoidance of pressure to the tailbone area, the large ulcer closed in about six months and remained healed.
Jack is an active male in his 70s with adult onset diabetes, who tripped and fractured his right hip. He was hospitalized for surgical repair of the fracture and four days later transferred to a rehabilitation facility where they discovered a silver-dollar-sized area of painless, dark, black skin on the back of his right heel. Likely due to the combined effects of diabetic neuropathy and post-operative levels of pain medications, he was unaware that his heel had been resting on the firm hospital mattress day and night as he lay still in bed over four days. Treatment for this pressure injury involved a plan of care slightly different to the one Jill experienced. Because Jack has had diabetes for 20 years and is in his seventh decade of life, his risk for reduced circulation to the feet is higher and therefore removal of the dead skin potentially exposes bone to infection and increased risk for loss of a limb. When the dead skin over this type of ulcer is fully adherent and intact around the edges, it is often best to encourage it to stay dry and intact as long as possible as a sort of “biological dressing.” Of course, the most important portion of treatment will always be avoidance of any significant or prolonged pressure to the area. This was a challenge as Jack was in the rehabilitation facility to get back on his feet. Normally this therapy involves use of shoes; however, in his case shoes were kept off to avoid the pressure to the injured heel while walking and he wore a padded heel protector when in bed. His wound healed in about eight weeks.
With these two examples as a sort of “stick-figure” outline of the topic, I will add some detail and “flesh-out” the picture a little. Following are some conditions that increase the risk for development of a pressure ulcer:
1) Increasing age – over the age of 60 the skin becomes more susceptible to injury. Skin vulnerability is often exacerbated by current or past smoking, malnourishment and increased moisture from incontinence or increased perspiration; 2) Sensation – diseases, injuries and/or medications that can reduce or eliminate sensation of certain body parts set the stage for pressure injury because pain, the normal feedback mechanism, is disrupted; 3) Excessive or persistent pressure – injury usually occurs to skin overlying a boney prominence where less “padding” is present between skin and bone. The “tail” bone (coccyx), the “sitting” bones (ischium), and heels are the most commonly affected. The sleeping and sitting surfaces must consistently and adequately distribute pressure more evenly across the greatest body surface area to minimize pressure on the boney points; 4) Cognitive deficits – brain injury, stroke or dementias associated with immobility and/or sensory deficits add to the challenges of preventing or healing pressure ulcers. Even when aware of pain from excess pressure, many cannot communicate this specifically. Therefore they are completely reliant on the skill, knowledge and persistence of their caregivers to protect the vulnerable or already injured areas of tissue, 24 hours per day, seven days per week, for extended periods of time.
This article is an attempt to create a very basic awareness of this frustrating and complex problem. For those who have not encountered the subject I trust that you have gained some potentially helpful information. For those of you who may have a loved one or know of one battling this problem, help is available.
Dr. Boyle is board certified in family medicine, and fellowship trained/board certified in hyperbaric oxygen therapy/wound care from Duke University. His career includes 13 years military medical service. He has nearly 10 years of experience as a wound specialist and is medical director of Physician Wound Care Specialists of Utah, located on the 3rd floor of St. Mark’s Hospital, above the Emergency Room, 1220 E. 3900 S, Suite 3A, Salt Lake City, 84124. Dr. Boyle also provides consultation outreach services in 15 nursing facilities in Utah where he delivers at the bedside wound care. For information call 801-590-9064.
Even a Superhero is Susceptible
(Pressure Ulcers, Bedsores, Decubitus Ulcers)
“Dr. Boyle has taken the initiative to significantly change our facilities’ prospective in the area of wound care. His method of treating wounds is to treat the patient as a whole, not just the wound. This has allowed our staff to take a more comprehensive and holistic approach in wound care. Dr. Boyle’s keen sense of observation of the patient and their daily activities allow him and our wound nurse to find the initial cause of the wound. This is where successful treatment can begin. By encouraging us to utilize simple and fundamental treatment techniques while caring for wounds, we have found a more rapid and positive response in healing.
His commitment to education, teaching and his consistent commitment to showing up regularly has provided value and stability to our staff as well as our clients and their families. Our partnership with Dr. Boyle has given our staff the tools and confidence needed on a day-to-day basis to benefit our residents and staff.”
– Amber, Paramount Health and Rehab
“Dr. Boyle has been a marvelous support to our clinical team in avoiding and managing pressure areas, assisting our team since 2009. He also takes the time to provide education about wound care at our Lunch and Learn to our team and invited guests. We have also found that he has excellent interactions with our residents who suffer from Alzheimer’s and related dementia. We are thrilled to have his support with our clinical team.”
– Kimberly, Silverado Senior Living
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