Wrinkly people, ERs, and pressure ulcers

The title of a press release regarding a recent study published in the Annals of Emergency Medicine elicited a wry smile. The clever wording, “Seniors Are Not Just Wrinkly Adults” took a little jab at those who need to be reminded not to merely lump our elders into anyone over 30 (or now is it 40? Or 20?!), just as we know not to treat children simply as littler people. The reality is that each decade presents its own healthcare challenges (that may then be subdivided according to individual health situations), and cookie cutter approaches don’t cut it. Especially with regard to persons in their golden years.

The study, Profiles of Older Patients in the Emergency Department: Findings from the InterRAI Multinational Emergency Department Study, available at http://tinyurl.com/npenmba, found that elders require specialized care to avoid missed diagnoses, pressure ulcers, and a range of other potential problems associated with this age group. I was particularly pleased to see that pressure ulcers made the list of issues of which ER departments need to be aware. OWM has published studies demonstrating the need for awareness that a busy emergency department can keep you sitting or lying for hours before and during treatment, positions and time frames that facilitate formation of ulcers that will exacerbate the original condition for which the person presented. Couple that with already age-compromised skin and existing comorbidities and you have a recipe for stageable disaster.

Practitioners, caregivers, and patients should remain mindful that the wrinkly among us should be afforded a few extra precautions when requiring emergent care.

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Obesity. Really?

With the declaration by the American Medical Association (AMA) that obesity is a disease, more than 35% percent of U.S. adults and 17% percent of children and teens now have an official medical label. While this may provide clinicians and patients the validation and wherewithal needed to address the underlying causes of obesity — ie, nutritional deficiencies, disease/conditions, toxicity, stress, and emotional trauma, as well as the consequences (such as diabetes) that reining in obesity will avoid — I am feeling disgruntled a condition that for many people is a self-control issue now will be subject to the vagaries of the existing (and soon-to-be-inaugurated) healthcare system, and potentially further stress an already VERY stressed economy.

New York Times’ writer Andrew Pollack believes “medicalizing” obesity would define one third of Americans as being ill (is that what you want? I’m not overweight, I’m sick?) and could lead to more reliance on costly drugs and surgery rather than lifestyle changes. Documentarian and author James Colquhoun says education, not medical intervention, is critical to providing a lasting solution. My thought exactly.

But someone, please tell us, what is the definition of obesity? Melissa Francis on her news show last night beseeched medical weight loss specialist Dr. Sue DeCotiis to provide parameters for who is too-many-Oreos overweight and who is medically obese, and the guest sidestepped the question (perhaps because she seemed to qualify as the Big O. That might be mean. Sorry).

Part of me wonders whether this new “declaration” will allow overeaters to flaunt Obamacare as I-don’t-care — I’ll eat, I’ll get fat, the government will take care of me. I’m pondering the possibility that if the system should ever short-circuit itself regarding pre-existing conditions and you have been deemed to be obese whether you could be denied coverage. Will treatment (and reimbursement) be structured as it is in wound care — ie, you try the least invasive/expensive interventions before bringing out the big guns of advanced technology, which means you have to demonstrate proof of diet and exercise before you get your belly band surgery? Did anyone think any of this through?

I feel sorry for people who have conditions that render them obese, such as children with Prader-Willi syndrome, people for whom obesity has nothing to do with ignoring doctor’s orders. Pun intended: I invite readers to weigh in on the motivation for and execution of this latest, for now, for me, insanity.

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Incontinence when the bladder is underactive

OWM often addresses overactive bladder (OAB). After a few moments on Twitter updating whom we follow, I came across an organization that deals with just the opposite — ie, underactive bladder — where patients lose bladder control because they cannot pass urine. We have touched on this in the past, but I felt it was worth revisiting.

Underactive bladder (like some forms of overactive bladder) may be due to a condition called neurogenic bladder, where the nerves that control the holding or release of urine do not function properly. The messages that make the brain aware of a full bladder and that it is time to urinate are disrupted, so the bladder continues to fill but the person is unable to pass urine. Urine pressure in the bladder overcomes the sphincter muscle’s ability to hold it, and urine leaks out.

This condition may occur in men and women and may be attributed to injury, diseases that affect the nervous system (eg, polio, syphilis, multiple sclerosis), diabetes, acute infections, genetic nerve problems, or heavy metal poisoning. Persons with neurogenic bladder can experience urine leakage or retention, damage to the tiny blood vessels in the kidney, and bladder or ureter infection.

Patients with the condition may need to use catheterization in order to drain the bladder — ie, a thin tube is inserted through the urethra and into the bladder. Clean intermittent catheterization (CIC) is an on-demand approach. An alternative is an indwelling Foley catheter placed in the bladder for extended periods. When the patient’s bladder and sphincter muscle do not work in tandem, the problem can be addressed surgically. Urinary diversion and bladder augmentation can divert the urine or enlarge the bladder to help protect the kidneys and keep patients continent.

Lesson: incontinence can just as likely be caused by not being able to go as it is by going too much.

Adapted from a Columbia University Medical Center posting

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Visual validation

I’m going to make this personal. I just returned from my annual check-up with one of my (increasing) stable of physicians. I have been a patient of Dr. B’s for 39 years — through three “successful” pregnancies, several breast scares, and a hysterectomy. Obviously, not all fun times, but overall positive outcomes. As many doctors as I’ve had to see through the years, he remains my favorite. Why? Because he validates my concerns and celebrates my health.

Today’s visit started by his smiling at me and saying with genuine admiration, You REALLY look good. Do you know how nice that is? To look eye-to-eye at a health professional who isn’t buried in drop-down files on the EMR or going through the motions with a foot out the exam room door? Who I’m sure is assessing my health status, not just tossing compliments because by meeting my gaze, this doctor also has been known to see through my upbeat (or not so much) demeanor and ask what’s up.

I know as a journal OWM repeatedly beseeches clinicians to treat the whole person, not just the hole in the person, and to avoid minimizing patient concerns. Just know that this is a mental as well as a physical health issue. Please, notice us patients. We are far greater than the sum of our imperfect parts.

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Show me some skin… with care

Despite the recent cold snap on the East coast, it really is Spring, Memorial Day is but a week away, and summer is close on its heels. The season for fun in the sun. The season we all need to be reminded to soak up vitamin D and those warm rays with care.

May is Melanoma Awareness Month, aptly timed to coincide with the days of increased exposure to the harmful effects of too much sun. A few tips to reduce your risk for this deadly form of skin cancer:

1. Protect your skin daily. Routinely apply and reapply a broad-spectrum sunscreen with an SPF of at least 15. Stay out of the sun from 10 am to 2 pm when its rays are the strongest. Wear protective clothing, especially brimmed hats.

2. Avoid indoor tanning beds. Let Nature do its thing naturally; don’t try to speed up the process.

3. Know your personal risk for skin cancer. If you had a blistered sunburn as a child or have fair skin, freckles, light hair color, an unusual or large number of moles, or a family history of skin cancer, up your protective actions.

4. Always avoid getting a sunburn.

5. Make skin exams part of your hygiene/beauty routine. If you see a lesion with any of the following, consult a dermatologist ASAP:
• Assymetry—irregular, unevenly shaped
• Jagged or blurry-edged border
• Multicolored (tan, dark brown, black, pink/red, blue, or white)
• 6 mm or larger diameter (size of the head of a pencil eraser)
• Any lesion that has changed since the last time you checked it.

Always err on the side of caution. Have anything suspicious examined. Healthy skin is a thing of beauty. Tanned cancerous growths, not so much.

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Leave (eschar) alone

Remember how as a child your mother told you “not to pick”? As a mom myself, I think it had more to do with the fingernails-on-a-chalkboard reaction to that repetitive action and the subsequent blood than the notion that the scar was protecting the boo-boo from further damage and infection and it best be left alone.

Wound care specialists, however, know (and subsequently, related guidelines have been developed) that eschar/necrotic tissue keeps a wound covered and helps facilitate healing. Concern that eschar prohibits accurate assessment for the most part is assuaged by the realization that if no other signs of trouble are present (such as warmth, redness, and the like) that herald infection or suggest debridement is warranted, the “dead” tissue is best left undisturbed. Obviously, there are exceptions, but the rule of thumb (more accurately, the rule of foot) with regard to heel wound eschar should be: Leave it alone.

Care to debate?

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When wound care sucks

It is no surprise that I — the Hoover/Oreck queen of my family — have more than an abiding interest in anything with the word vacuum in its name. Plus, the concept vacuum-assisted therapy was just beginning to really take off when I took the reins of Ostomy Wound Management.

 

Through the years, OWM has provided numerous articles and supplements on negative pressure wound therapy (NPWT). Morykwas and Argenta published their groundbreaking article on the use of subatmospheric pressure in wound care in 1997, but according to Miller’s¹ aggressive search, their concept is predated in Russian medical literature by 11 years. However, despite NPWT’s 20-plus year history and although the visual makes sense, no one is completely sure why sucking backwards on a tightly adhered dressing helps heal a wound. Current thinking is that NPWT promotes wound healing by 1) removing exudate from wounds to help establish fluid balance, 2) providing a moist wound environment, and 3) removing slough — this to potentially decrease wound bacterial burden, edema, and third-space fluids; increase blood flow and growth factors; and promote white cells and fibroblasts.^1,2 But NPWT research mostly involves one specific company’s product, and randomized, controlled trials are somewhat lacking. Plus, the 411 from patients isn’t always positive: NPWT treatment, as well as the post-treatment process of extracting the foam dressing of the manufacturer most associated with the wound vac,³ is painful.⁴

 

Which makes me wonder if this is why the brouhaha surrounding NPWT 5 to 10 years ago is diminished. Or maybe wound vac-ing has become an established part of wound care, lessening the din. After all, KCI was touted for providing its negative pressure prowess in the post-earthquake relief efforts in Haiti. Various studies show different products and dressings (for example, medicinal honey⁵) are used concomitantly to enhance treatment and counter negative side effects. Clinicians are rethinking the amount of pressure needed.⁶ What do Morykwas and Argenta think about the product size, mobility, and dressing options now available? What do you think?  

 

 

Great articles from OWM on NPWT include:

 

1.     http://www.o-wm.com/content/negative-pressure-wound-therapy-%E2%80%9Ca-rose-any-other-name%E2%80%9D?page=0,0

 

2. http://www.o-wm.com/content/negative-pressure-wound-therapy-achieved-vacuum-assisted-closure-evaluating-assumptions

 

3. http://www.o-wm.com/content/can-you-help-17

 

4. http://www.o-wm.com/content/managing-wound-pain-patients-with-vacuum-assisted-closure-devices

 

5. http://www.o-wm.com/content/active-leptospermum-honey-and-negative-pressure-wound-therapy-nonhealing-postsurgical-wounds

 

6. http://www.o-wm.com/content/the-effect-intermittent-and-variable-negative-pressure-wound-therapy-wound-edge-microvascula

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Intertrigo: obesity and the skin

Say what you will about recent concern that obesity is a disease and not a lifestyle choice, the number of overweight and morbidly overweight persons in the world is increasing. This pandemic affects healthcare providers challenged to manage the comorbid conditions resulting from obesity, payors seeking responsible ways to finance care, and society in general. Airlines (Samoa, the most prominent example) want to charge by weight; some companies require the purchase of an extra seat for the bigger among us. A popular reality show follows the struggles of a select few to embrace healthy eating and exercise habits.

But food, activity, and public opinion are but a few of the issues. Persons with excessive areas of adjacent skin folds are susceptible to intertrigo, a bacterial, fungal, or viral infection that develops as a result of inflammation when skin rubs against skin. Common areas are the inner thighs, genitalia, armpits, under the breasts, the underside of the belly, behind the ears, and the web spaces between the toes and fingers. Usually appearing as red and raw, intertrigo may itch, ooze, and feel sore. You can read more about intertrigo at:

http://www.o-wm.com/content/continence-coach-intertrigo-obese-patient-finding-silver-lining

http://www.o-wm.com/content/an-overview-dermatological-conditions-commonly-associated-with-obese-patient

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The Braden Scale: A Dynamic Tool?

The Braden Scale is a fixture in wound care circles that helps clinicians predict pressure ulcer risk. It is also the source of growing controversy. The problem seems to be that with continually increasing use, practitioners are discovering its limitations. A February 2012 article provides a meta-analysis of its use in surgical patients and upcoming articles in OWM will reflect on its ability to accurately assess risk among ICU patients. Some studies are finding that the overall Braden Scale score is not as informative as particular subscores.

The Braden Scale has been tweaked for use in children (the Braden-Q). As we discover more about pressure ulcer risk factors (eg, serum albumin levels may not provide dependable implication for risk), it is not unreasonable to anticipate clinicians making further modifications to this tried-and-true tool in wound care.

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A niche within a niche

I recently attended the 2013 National Pressure Ulcer Advisory Panel (NPUAP) conference in Houston. My kudos to the Planning Committee for the lovely venue and accoutrements and some deliciously intriguing sessions.

The focus of the conference was “Deep Tissue Injury: State of the Science.” I was most fascinated by presentations by Dr. Amit Gefen, and his Deep Tissue Injury from a Bioengineering Point of View Dr. Gefen an engineer who, among his other accomplishments (for one thing, he has published several times in OWM), creates skin tissue to test the effects of pressure and shear. Obviously, some may say that equating the results of testing laboratory-manufactured skin to human buttocks is akin to flying by the seat of your pants (pun intended) — that it is too abstract and too exclusive of other factors involved in deep tissue injury.

But as an observer of wound care literature for the past dozen years, I appreciate the effort to identify and isolate factors in a niche where everything seems connected to something. A wound is not necessarily just a wound per its etiology. And patient comorbidities. And location. And so on. This “niche” encompasses almost every aspect of healthcare. So drilling down — for study, for education, to provide care — ie, to create a niche within a niche— holds great promise and expands, as opposed to narrows — care possibilities.

You go, Dr. Gefen!

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