This is part of the Brejcha Personal and Disability Resource Site at http://www/netreach.net/~abrejcha, and after reading this page you can Click here for a Menu .
Note May 16, 2006, after reading this, also see new relevant site added at bottom
Note: A shorter version of this article, without the operative notes (unnecessary for the intended journal readers), was originally published in the October 2001 issue of Plastic and Reconstructive Surgery (pp. 1457-1458). It grew out of an unnecessary five month hospitalization for flap surgery to close a severe sacral decubitus ulcer that developed due to my incorrect treatment at a wound care center. However, as suing a surgeon can be a lost cause, and because it was an error of ignorance and not malpractice -- and I prefer to educate rather than vindicate -- I decided to try to educate doctors and patients on treatment and prevention by writing articles about the experience. This article is for doctors, but hopefully understandable to all. I am working on a simpler "Care and Prevention" article for spinal injured and other para/quad consumers. I want to thank the PRS journal editor, Robert M. Goldwyn, M.D., for his permission to post this expanded version with restored operative notes (feel free to skim past them). Otherwise, this article is basically as published.
© F. Alexander Brejcha
Abstract:
As a frequently published writer and active disability advocate who is paraplegic due to multiple sclerosis, I also lecture and write on disability topics. This is intended as a brief cautionary commentary drawing on personal experience as a paraplegic man whose small decubitus ulcer progressed into a deep, infected one that required surgery. It is being written as paraplegic and quadriplegic patients with sensory deficits – in particular those with spinal injury – often present with advanced decubitus development requiring immediate assessment, aggressive treatment, and prescribed changes in sitting and sleeping surfaces. This was my situation after several prolonged hospital stays combined with an inappropriate wheelchair cushion.
However, the wound care center where I went -- and its supervising surgeon who will not be named as I still respect him personally and professionally -- badly mismanaged my care, and a small stage II sacral decubitus ulcer was inadequately diagnosed and treated and progressed to a large stage IV ulcer requiring bilateral V toY musculocutaneous flap surgery after operative debridement to excise extensive necrotic skin and tissue.
Commentary:
Recently I found myself the recipient of mismanaged wound care which resulted in a small and manageable decubitus ulcer approximately 2 cm by ½ cm progressing into a large stage IV ulcer of the sacrum approximately 4cm by 3 cm and extending down to the bone – and this increased to nearly double that after final pre-operative debridement. It put me out of work from February 23 till July 31, 2000 (March 9 till June 10 in hospitals, nursing homes and finally a rehab), and after an operative debridement of extensive necrotic tissue, required a bilateral V toY musculocutaneous flap. Needless to say, this experience also provided me with material for several articles.
I do not intend to name the wound care center or plastic surgeon 'caring' for me, though during the course of my extended hospitalizations and home recovery I was sorely tempted (pun intended) to call a contingency lawyer since the experience cost me over $12,000 between deductibles and lost income, plus over $30,000 for a specially converted new van I can drive from my wheelchair (I am weaker now and also need to reduce the stresses of frequent transfers and driving from a driver's seat).
But, as there was no intentional neglect or malice involved, and I still highly respect the surgeon both professionally and personally, I prefer to deal with the situation by attempting to educate both health care providers and consumers by writing this commentary for surgeons; a "care and prevention" piece for a prominent publication with a large spinal cord injured readership; and an appreciative local newspaper article giving credit to Dr. David Kim – the superb plastic surgeon at Paoli Hospital who performed the surgery – and the many other positive people and experiences I also encountered.
I'll begin with the genesis of my problem – which can very easily be a common scenario for any patient with a spinal cord injury or reduced sensation due to a neurological condition. The initial decubitus was the result of several two-week-plus hospital stays – on inappropriate hospital beds without position shifting. Note to hospital care providers: paralyzed patients have a critical need of position shifting and/or specialized variable pressure sleeping surfaces because normal nocturnal position shifting is often absent.
The first hospitalization was due to a staph-infection in my arm, contracted at the hospital where I work from the infection of a cut on my arm.. I was discharged prematurely, and a month later the infection recurred along with a perirectal abscess in a high stress (due to transfers) body area, and that hospitalization was then followed by a third one due to a bladder infection. The abscess closed gradually with home care after discharge, but a supine decubitus then became noticeable which was aggravated by wound care mismanagement and further compounded by my inappropriate wheelchair cushion and sleeping surface, and my impaired healing (complicated by my diabetis) following the repeated systemic assaults of infection and strong antibiotics..
I had not been aware of the problem at first until increasing weakness problems and some discomfort led me to get checked out (unlike spinal cord injured, I do have some sensation, though it is somewhat reduced). When the decubitus was discovered, I naturally went to a convenient wound care center, and as I knew the supervising surgeon, I made the mistake of not questioning his minimal care or researching alternatives. This treatment consisted mostly of repeated debridements (increasing the size of the decube) and minimal maintenance using Hydrogel-soaked Nugauze strips to keep the wound open and gauze dressing -- supposedly so the wound would heal from inside out). No assessments (such as pressure mapping) of my seating or sleeping arrangements were performed.
Months of this led nowhere except repeated visits to the wound care center – each involving more debridement. I had questioned the care at one point and asked about the use of Mesalt or other treatment paradigms I had read about, but I was told that they were not needed. Dissatisfied, I made an appointment at the Paoli Hospital wound care center in Paoli, Pennsylvania where Mesalt treatment was immediately started, though doubt was expressed as to whether the wound would heal due to its size. I had already been too weak to work after February 23, and on March 9, I had to be taken to Paoli Hospital by ambulance because the wound had become infected and I was too weak to drive. I was immediately admitted and placed on a Clinitron bed (1) and it was determined that flap surgery would be the only solution once the infection had cleared. But due to the amount of necrotic tissue present, further debridement would be needed first.( Note: The Clinitron bed with its powered, air-filled sand massage surface was used continuously until just before discharge when I was sent home on a variable pressure air-mattress.)
On March 22 I underwent the first procedure after intravenous antibiotics and general anesthesia were administered. A #15 blade was used to excise necrotic skin and a Bovie cauterizer was used to excise necrotic tissue down to bleeding and viable tissue. The necrotic tissue extended down to and included the bone, but the procedure went well, and after hemostasis was achieved, the wound was irrigated with 3,000 cc plain lactated Ringer's under Pulsavac lavage and packed with Kling soaked in saline and Betadyne.
I was returned to my room for observation until March 29 when I was transferred to Manor Care Nursing center in King of Prussia for recovery. Then on April 5 I was readmitted to Paoli for the second round of surgery.
Again, prior to surgery, intravenous antibiotics and general anesthesia were administered and this operation was performed in two stages. First, another operative debridement of the wound was performed using a Betadyne scrub brush and a #10 blade scalpel. All necrotic tissue was debrided to bleeding tissue and then pulse lavage was used to irrigate the wound.
With hemostasis achieved, the musculocutaneous VY flaps were performed. The flaps were insized using a 10 blade scalpel down to and including the fascia of the gluteus maximus muscle. The gluteus maximus muscle was then elevated with the cutaneous portion of the flaps from its origin. Once the flaps were mobilized and hemostasis achieved, the closure was begun.
This procedure was performed in multiple layers. #2-0 PDS sutures were used to approximate the gluteus maximus muscles in the midline covering the sacrum. The fascia and subcutaneous tissue were reapproximated also using #2-0 PDS sutures. The subcutaneous tissue was then closed using #2-0 PDS sutures, the midline incision closed using a series of 28 #3-0 nylon sutures in a horizontal mattress stitch, and the Y portion of the wounds were closed in two layers using #2-0 PDS sutures and 90 staples. The final operative area after closure measured approximately 24x15 cm. Prior to closure, two round drains were placed laterally and secured using #3-0 nylon sutures. The flaps were then dressed with Xeroform and a bulky dressing.
I was kept at Paoli for observation until April 12 when I was sent back to Manor Care for recovery and partial reconditioning. At first I was given bedside physical therapy with upper body resistance and Theraband exercises combined with tendon stretching of the lower extremities – with care being taken not to impact the surgical site. The staples and sutures were gradually removed during separate visits to Dr. Kim's office, and after the removal of the last staples on April 27, I was moved by padded stretcher to the physical therapy department for short stretches on a tilt table up to 80 degree elevation, and then I was transferred to a ROHO (2)air cushion-equipped wheelchair for short periods of arm exercises and leg muscle stretching. Note: The use of the tilt table was at my request as over fifteen years of paraplegic life, I have been regularly using a standing frame in order to prevent tendon contraction and bone density loss, and to gain other benefits of standing such as circulation and G.I. tract care. As I had been flat on my back for months without standing, I wanted to gradually do some weight bearing again.
On May 16th I was finally transferred to Bryn Mawr Rehab for superbly executed acute rehab with increasing out-of-bed periods with standing frame conditioning and intensive arm therapy in the P.T. department, supplemented by self-exercise in the room. On June 10 I was sent home – on a variable Recovercare pressure mattress and hospital bed (3), and dependent on home care nursing and aides.
I am still weaker and in need of attendant care on a daily basis for dressing and showering and every other day for my bowel program, but on July 31 I was finally able to resume working and a more 'normal' life.
It has been a totally unnecessary, expensive, and painful ordeal some simple steps would have prevented – steps plastic surgeons and wound care centers need to be aware of in order to incorporate them into their treatment.
First of all, upon clients presenting for wound care treatment, an immediate assessment needs to be made to determine the nature of the decubitus – supine, seated, or a combination? What surface is the client sleeping and sitting on, and is pressure shifting being applied? The lack of nocturnal motion and seated lack of shifting are key issues both client and care-providers need to keep in mind. A decubitus ulcer – depending on severity – may require variable pressure or other specialized mattress and/or frequent position shifting. Similarly, for clients with a seated sore, special seating arrangements need to be made. A static air cushion such as a high profile ROHO or a variable pressure cushion like one from Aquilacorp (4) may be needed. The latter is similar to the ROHO, but has two sets of battery-operated air cells to provide pressure shifting, and through air evacuation onto the skin as cells shift inflation posture, it provides for a reduction of the sweating that can also compromise skin integrity. Both sleeping and sitting measures may also be required to maximize healing and prevent recurrence.
Clients also need to be instructed to manually and regularly position shift in addition to any automatic relief being provided. Another supplemental option which may be called for is a tilt and space wheelchair which through power or manual reclining shifts pressure from the thighs, buttocks and sacrum to the back and shoulders. Whatever system is implemented, clients – and wound care and other care-givers – need to be made aware of the critical importance of weight shifting. This is particularly important with spinal injury clients with sensory deficits. Frequent inspections of at-risk areas are also critical. A contributing factor is urinary leakage from catheters or continence pads. Sweat moisture plus irritation and wetness from urine combine to dramatically compromise skin integrity and impair healing, and continence care also needs to be stressed – not just as part of a wound care regimen but as a life-style issue after healing.
The best treatment is obviously prevention, but barring this – as clients may present with a stage I or II decubitus which can easily be treated – raising awareness and educating clients and care providers on options early on can make the difference between minor and major treatment needs. Care provider awareness needs to be heightened not just in terms of immediate assessment and treatment, but also in terms of preventing a recurrence of problems which are far more difficult to treat as healing ability is reduced substantially every time a similar procedure is performed.
Resources:
1) Hill Rom (at www.hill-rom.com) fluidized Clinitron bed: Hill Rom, 4349 Corporation Road, Charleston, SC 29405, 800-638-2546 (move cursor to "products" at the top and then click on "Beds and surfaces", then click on "CLINITRON® RITE-HITE® Air Fluidized Therapy Unit" to see bed I was on for months!)
2) ROHO, Inc (at www.rohoinc.com), PO B 658, Belleville, IL 62222-0658; 100 N. Florida Ave., Belleville, IL 62221-5429, 618-277-9150, 800-850-7646
3) Recovercare (at www.recovercare.com): 27302 Cindel Drive, Suite 8, Cinnaminson, NJ 08077-2035, 856-303-1880, FAX: 856-303-1004, toll-free: 800-575-2337
4) Aquila Corp. (at www.aquilacorp.com), P.O. Box 102, Clarks Grove, MN 56016, 888-878-1141
NOTE MAY 16, 2006: The following superb page on bed sores was just sent to me and I am adding it here:
Bedsores - at http://www.surgeryencyclopedia.com/A-Ce is a superb page on bed sores It is part of a superb site for patients and care-givers at Surgery Encyclopedia
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