Currently, there are a number of people on the health care team touting themselves as wound care specialists. For those of you who may not know, the term “wound care specialist” does not imply a physician, a physician’s assistant or even a member of the nursing staff for that matter. Scores of people who might otherwise be considered “volunteer staff” or “nursing assistants” are now being sent for an abbreviated course in wound care products and, after taking this course, are subsequently referred to as “wound care specialists.”
These specialists, often laypeople, may be working without the strict supervision of another medical specialist. In a day and age when the health care team is being expanded to include more home care provided by people under the auspices of social services, some patients may be falling between the cracks.
In order to underscore the ramifications of these developments, I would like to present the following case in the hope of increasing awareness that the field of wound care specialists is being diluted by private entities focused more at supplying wound care materials than providing medical care.
Considering The Case Of An Obese Female With Diabetes And An Infected Heel Ulcer
The potential complications of a decubitus heel ulcer in a patient with diabetes can be devastating. When this condition is compounded by poor health, even common pathology can become morbid. The stepwise approach to clinical evaluation and management for the heel decubitus ulcer cannot be understated. While the heel decubitus ulcer is often manageable with the benefit of appropriate offloading and local wound care, serious complications can occur if valuable time is wasted on ill-conceived wound care plans.
The case presented herein centers on a 73-year-old morbidly obese, hypertensive, diabetic female patient with known peripheral vascular disease and hypercholesterolemia. She was at an extended care facility and, over time, developed a heel ulcer. A wound care specialist provided care for this ulcer. The wound care specialist’s treatment plan included offloading of the heel by elevation and using various wound care agents multiple times per day. The patient was subsequently transported to the emergency room due to progressively uncontrolled diabetes and an infected heel ulceration.
Upon presentation, the patient had an enlarged eschar on the most proximal aspect of the plantar medial heel that was atop a base of spongy and very mobile subcutaneous tissue (see Figures 1 and 2). The borders of the eschar were detached from the periphery but remained anchored to the tissue beneath it. The malodor present was suspicious for Pseudomonas.
The treating physicians consulted the podiatric medicine department after the patient was on the hospital floor and under medical management. Surprisingly, there was an additional ulceration on the lateral heel that appeared chronic in nature despite the fact that all accounts from the extended care facility indicated treatment for a solitary ulcer of the plantar heel over time. It is reasonable to surmise that the offloading plan instituted by the “wound care specialist” resulted in a transfer of pressure to the lateral heel, which lead to a second site of ulceration. This second ulceration apparently went unnoticed prior to the patient’s presentation in the emergency room.
A Staged Approach To Evaluation And Management
The initial goal was to choose the optimal empiric therapy while determining the nature and extent of the pathology in the lower extremity. The patient was placed on ampicillin-sulbactam regimen based upon the patient’s renal function. The second goal was to obtain fresh tissue specimens for both pathology and microbiology in order to study the local soft tissue and bone. Before this could be done, medical clearance from vascular surgery and internal medicine teams would be required.
After the vascular surgery consult, the patient underwent non-invasive vascular testing followed by an arteriogram. The patient had significant occlusive vascular disease within the femoral artery and the trifurcation of the lower extremity in question. The vascular team was familiar with this patient and deemed her to be a non-salvageable vascular case given the failure of prior bypass grafting in the affected limb. Local debridement of bone and soft tissues was suggested in an attempt to eradicate infection as a last resort to avoid a major amputation.
We performed provisional wound debridement and followed this with VAC therapy (KCI). We considered VAC therapy the most physiologic as it allows continuous drainage while the patient begins empiric antibiotic therapy.
We obtained an indium leukocyte (WBC) scan given the longstanding presence of the calcaneal decubitus in the presence of severe peripheral vascular disease. While the indium leukocyte scan can identify the site of infection, it doesn’t provide meaningful anatomic information. Given this fact, I recommend performing the indium leukocyte study in conjunction with a routine 99mTc-MDP bone scan, which provides the anatomical mapping for a precise biopsy of the given pathology identified on the indium leukocyte scan.
With the results of this combination imaging (Figures 3-5), one can see indium-labeled leukocytes very proximal into the calf muscle group. The extent of this infectious process is much more extensive than the clinical condition would have suggested. Consequently, the clinical condition deteriorated despite local debridement and intravenous antibiotic therapy adjusted for chronic renal insufficiency. Ultimately, an above-knee amputation was required and the patient ultimately returned to the extended care environment.
Patients with diabetes and infection are often fraught with complex medical conditions that complicate the wound care plan. The heel decubitus ulcer can be a particularly difficult wound to treat even when underlying comorbidities are clinically stable (which is often not the case). It is not unusual for ancillary “wound care specialists” within extended care facilities to develop wound care plans that may not be optimal for the patient. As with this case, they may overlook the big picture and fail to take into consideration the patient’s entire medical history and the severity of the present illness.
This case clearly emphasizes that point. If surgical debridement had been provided much earlier, the infectious process may have been averted.
In some cases, ill-conceived wound care plans may very well delay more aggressive efforts such as surgical wound debridement and wound biopsy/culture. For any patient with diabetes who develops a wound, a thorough medical history and clinical evaluation are essential. Aggressive offloading and protection in addition to appropriate medical and surgical consults will ensure an optimal total care plan for the patient.
The offloading plan must be supplemented by a decubitus prophylactic care plan in which the patient’s sleeping or resting position is modified every two hours to prevent secondary sites of pressure necrosis and ulceration. This not only requires the nursing staff to adjust the patient’s position, it requires follow-up observation of the patient in order to identify early evidence of irritation or unusual skin changes.
Physicians should establish clinical benchmarks once they have identified deep dermal defects and set stringent targets for wound progress. A simple rule of thumb in gauging wound healing is to determine whether the patient has achieved 50 percent of wound closure within four weeks of treatment. If this is not the case, one has to reconsider the culprits that may be delaying wound healing. Causal factors may include infection, dysvascularity, immune compromise or other complicating factors.
Obtaining a biopsy of the wound is essential to identify both microorganisms of infection as well as other pathologic tissue changes that may impact wound healing.
It remains untold as to whether our patient would have been able to avoid the below-knee amputation. However, I suspect most patients with diabetes would have a much better chance at healing a wound if they are referred for treatment as early as possible. Just because this patient was in an extended care facility does not imply that there was a thorough care plan involving the multiple specialists required to achieve optimal management for patients with complex diabetic wounds.