“Highland Care Center has been privileged to have Dr. Bret Boyle consulting with
our facility for over two years. During this time Dr. Boyle has given specialized
training to our nurses in wound care, and one-on-one education with nurses
during individual patient wound treatments. We have seen significant results in
progression of wound healing through Dr. Boyle's treatments and monitoring of
our patients with extensive and non-progressing wounds. Dr. Boyle has been
fantastic to assist in patient education and compliance. Our patient's families
have appreciated the time and attention he takes to address patient and family
concerns and questions. Compliance and follow through have been improved
with this ongoing education from Dr. Boyle.
Dr. Boyle has been available to our nurses for wound care questions and
consultations 24 hours a day. He is always willing to give us new orders and
recommendations for treatment on any of our new patients with wound care
concerns. Dr. Boyle has also offered ongoing education to our direct care staff on
preventative measures, proper positioning, and proper use of cushions and
mattresses. His care and concern for the patients whole being, not only the
wound or area of concern, has made a significant difference in our facilities
approach and success in wound care of our residents.”
– Heidi, RN, Highland Care Center
Venous Leg Ulcers -
A Little Known, Big Problem
By Dr. Bret Boyle
Skin ulcers on the lower legs and ankles associated with venous disease are the most common type of problem wound affecting the lower extremity. Recent reports estimate that these challenging ulcers plague approximately 1% of the population, or roughly three million Americans.
A multitude of causative or contributing factors can result in these troublesome sores more commonly referred to as venous stasis ulcers. For example, congestive heart failure and chronic renal failure contribute to excessive fluid accumulation in the circulatory system. The effects of gravity on this fluid often results in near constant swelling or edema in the legs. The persistent blood pressure elevation and engorgement of the leg veins can result in permanent damage to the system of one-way valves that help facilitate normal movement of blood from the feet to the heart. Once these delicate valves are destroyed, a chronic condition develops which has several names such as “venous stasis,” “venous incompetence,” “varicose veins” and “venous insufficiency.” There are other conditions and factors that can lead to the problem of venous insufficiency. For example, certain types of employment involving standing or sitting for many hours per day with little associated leg muscle activity can gradually lead to congestion and dilation of the veins, resulting in valve damage. Another potentially serious occurrence called deep vein thrombosis (DVT), otherwise known as “blood clots” in the deep leg veins, frequently results in damage to the venous system. At the outset it can be life threatening because the larger clot in the leg can break off sending clot fragments to the lungs which can disrupt blood flow and breathing and lead to death. Sudden and unexplainable swelling of a single leg, with or without pain, should never be taken lightly, especially if occurring shortly after an extended period of sitting or lying. Other potential contributors are pregnancy, obesity, certain blood pressure drugs, some diabetes drugs, aspirin-like products and estrogen. These along with surgical and/or radiation treatments for specific cancers of the pelvic region can cause problems with swelling and subsequent vein damage in the legs. And, of course, there is the category of the unexplainable or “genetic” predisposition to venous disease.
Uncontrolled or poorly controlled leg edema will eventually result in further problems at the superficial and deep skin level of the lower leg and ankle. The two main processes responsible for this: 1) chronic tissue inflammation caused by various bio-chemicals leaking out from the engorged veins, and 2) edema and back-pressure in the veins restricting blood flow within the small, fragile capillary vessels where oxygen and nutrients are released to the skin. The chronic inflammation and reduced oxygen leads to scarring and sclerosis in the skin of the lower legs and non-healing ulcers/wounds can occur either spontaneously, or from minor trauma. One visible clue that this process has begun is a red rash known as stasis dermatitis that develops on one or both legs in the area around and above the ankle. In addition, this area can become permanently stained a “rusty” brown color, called hemosiderin staining.
As one might imagine, a complex problem like this with often multiple contributing factors would likely require a multi-pronged approach to management. The principle goal is to reduce and control the leg edema and the most important non-invasive modality available for this is compression therapy. However, it is very important to identify then treat or modify any underlying or contributing factors like uncontrolled hypertension, congestive heart failure, and chronic renal failure, the degree of sodium and fluid intake and obesity. Medications that maximize heart or kidney function must be taken exactly as prescribed to reduce the potentially serious side effects of some of these drugs. The effects of gravity on the “pooling” of blood in the legs cannot be reversed, but it can be reduced and controlled. Most people with leg edema problems will notice that the swelling is usually at its worst toward the latter part of a day when legs have been below the heart or in the “dependent” position all day. Edema is often reduced first thing in the morning when legs have been more level with the heart for several hours and gravity is allowed to “pull” edema out of the leg. Therefore, whenever possible each day, elevating legs above the heart for 30 minutes, three to four times per day, is extremely helpful to minimize edema and improve circulation to the skin.
Muscle activity in the legs is the primary means for venous blood to move to the heart against gravity; however when the valves are incompetent, muscle action alone is much less effective. As blood is “pushed” or “pumped” toward the heart by muscle activity, the blood will simply fall or reflux back toward the feet through the open and ineffective valves. External compression on the entire foot, ankle and leg will help to reduce the venous reflux and makes the pumping action of the leg muscles much more effective. Compression therapy initially takes the form of layered wraps that extend from the “ball” of the foot to just below the bend of the knee and are changed every three to seven days depending on individual factors. When an ulcer is present, the wraps will serve two important functions. Most of the time drainage from one or more ulcers is too excessive to contain with a single dressing. Therefore the initial cotton layer of the wrap will serve both as a large dressing to contain drainage from the ulcer and as padding beneath the elastic layers needed to reduce the edema. This treatment modality is the single most important step toward healing of these problematic ulcers. Once all ulcers are healed, special compression stockings are prescribed and worn daily to maintain healthier skin by controlling edema. Stockings are an important and necessary part of life for those with venous insufficiency and should help to avoid invasive surgical procedures. For those who may choose this, there are specialists available to remove the problem veins.
Dr. Bret Boyle is a local physician with specialty training and board certification in management of non-healing, problem wounds. He is the medical director of Physician Wound Care Specialists of Utah, located at St. Mark’s Hospital, on the 3rd floor, above the Emergency Department. His background includes 13 years of active duty military service where he began as a board certified family medicine physician. In 2001 the Army sent him to Duke University Medical Center for a one-year fellowship in wound care and undersea and hyperbaric medicine. He then ran the Army’s only specialized wound and hyperbaric clinic for four years and has continued to provide his expertise here in Utah for the past four years.
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