Don’t be the “Loose Cannon” of the Wound Care Team! Boone Hospital Wound Healing Center Kimberly Jamison, MD, FACP, FAPWCa Kim Mitchell, RN, BSN Clinical Nurse Manager Why aren’t these wounds healing???  A chronic wound is a window to underlying disease. Each wound is a symptom of underlying infirmities that undermine the potential for healing.”  – Dean Kane, MD Acute vs. Chronic Ulcers Any break in the skin is considered a wound Regardless of what causes the wound, the healing process is much the same The rate of recovery is influenced by:  Extent of damage  Type of damage  Underlying intrinsic factors 1 Startling Statistics  One million Americans develop a chronic ulcer each year  Elderly population is at risk and numbers(65+) are growing:  2002: 35 million  2010: 40 million  2020: 55 million  18.2% of all elderly persons (85+) reside in a Nursing Home -22% suffer with pressure ulcers  There are approximately 11 million venous ulcers in the world  12.2 million people (60+) have diabetes -15% will develop a diabetic foot ulcer  Peripheral Arterial Disease affects about 8 million Americans - most commonly associated with non-healing ulcers (US. Census Bureau, 2002) $tartling Co$t$  Annual cost of venous stasis ulcers -$2.5 to $3.5 billion  Total annual economic cost of diabetes in 2007 - $174 billion  Cost of diabetes –related limb amputations - $3 billion annually  Specialty dressings, devices, treatments - 1.7 billion  Additional cost:  Lost workdays / productivity All Hands on Deck………  An overview of some of the most interesting cases we have seen over the years…..  Can you guess the outcome?  What could we do differently? Wh t ld d diff tl ?  What would you do? 2 Castaway I…..  73 year old male  Presents with gangrenous right great toe  Wagner Grade IV  Home Treatment: Epson Salt Soaks  WC Treatment: Iodosorb/Vasc Consult/Arterial Studies BHWHC, 2013 Shiver Me Timbers! Meds: Lantus, Miralax, ASA, Lipitor, Prilosec, 70/30 Insulin, NTG PRN, CoReg, Citalopram, Colace, Lisinopril, Torsemide, Effient Past Med Hx: DM II, ASCVD s/p CABG, Hx CVA, Obesity, Hyperlipidemia, CRI, Anemia, Sleep Apnea, ASPVD s/p CEA, Ischemic Cardiomyopathy with EF of 25% 20 pack history smoker Get Underway……  Podiatry start….referred to interventional cardiologist as no vascular surgeon involved  2/5- Abdominal aortogram revealed SFA 80- 90% diseased.  Silverhawk arthrectomy and balloon angioplasty performed with success  2/11- HBO Consult with agreement to proceed / y the start of a new  2/14Valentines Day- beginning- HBO DIAGNOSIS: DM, PAD, Failed Flap 3 Close Quarters.…..  One dive, pt developed “flu” like symptoms, ended up admitted for unknown loss of blood over weekend..  Pt developed s/sx of cellulitis and infection Pt d l d / f ll liti d i f ti the following week….  Toe amputated on 2/21  Resumed HBO on 2/28 The Cat’s outta the bag…. Post Debridement Silver Alginate Dressing Pre-debridement Coast is clear… Almost 30 days of HBO and traditional wound care….. 4 Clear the Deck……. Weekly debridements and good wound care! Completion of 39 HBO Treatments Even Keel!  6/3‐ Healed within 18 weeks of treatment‐ including vascular interventions HBO interventions, HBO, debridement and Wound care!  Has not returned! Castaway II  79 year old male with iodine seed brachytherapy 3 years previous  2/13‐ / Develops hematuria with clot retention. Undergoes cystoscopy, clot evacuation and fulguation of bleeding sites.  3/13‐ Admitted AGAIN with same symptoms. Same treatment treatment. Consult made to Wound Clinic for HBO therapy 5 Rough sailing…  Medical History: Leukopenia/thromboc‐ ytopenia, PAD, HTN  Surgical History:  Social: Retired Teacher, moved to MO to be closer to family, very active volunteer l Prostate, Appy, Carpal Tunnel, Basal Cell  Medications: Baby ASA, Multivitamin, Lisinopril, Rapaflo, Norco, Vitamin C, Vitamin D Fits the Bill….  3/7- Inpatient requiring IV narcotic, PRBC’s, Continuous bladder irrigation. Quality of life d decreased. d U Unable bl to t participate ti i t in i volunteer l t projects, unable to leave house for any length of time Choppy Waters…. Patient tired, ready to try necessary treatments  3/15- First HBO treatment 2.5 ATA for 90 minutes  4/14- Relapse of bleeding, clot retention  5/11-One more ER visit…..  6/6-That dang ER……..  6/14- Completed 60 HBO treatments….  7/12- 4 week F/U with no bleeding!   8/20- RTC with one episode of bleeding  9/6- No further bleeding! 6 Smooth Sailing… QUALITY OF LIFE RETURNED: PRICELESS! Castaway III…  2/14- 52 year old female presented with 2month old ulcer  Referred by Mediquick  Started as a blister From Stem to Stern….  Medications: Glucophage, Augmentin,  NKA  Habits  2-3ppd 2 3ppd smoker  Medical History  DM, Hyperlipidemia, Sinusitis, Asthma, Neuropathy  Social: Working part‐time, no health insurance, husband incarcerated  Other Stats: Reluctant to testing or any procedures that will incur cost  Set up with financial aid assistance 7 The Gully….. Hair on legs and toes Cap refill above 3 seconds Positive monofilament sensation PT- Multiphasic pulses DP- Monophasic pulses Patient declined appropriate testing/offloading r/t finances….  Silver alginate applied to wound       The Gripe….  3/7- Admitted to hospital- albumin 3.5, Hgb A1C 10.4…oh lord!  ABI ABI’s s done inpatient- RT 1.05/0.78; LT 0.94/0.75….good to get up to bat! Debridement to commence!  Surgical debridement while inpatient  3/27‐ Returns to batting cage‐ current treatment of Dakin’s The Ground Swell…  4/18‐ She’s back!  Wound Treatment Changed to a collagen and ll d xeroform  Lantus initiated, amaryl discontinued 8 Hold off…..  5/14- Finally have a PCP!  Dressings remain as wound decreasing in size  BSL’s still too high…  Making progress…. 6/28- Continues to improve, attempting to lose weight, smoking decreasing….continuin g collagen…. collagen Post surgical site Hit the Deck!!!  7/26‐ dressing changed to dry gauze….Plantar healed! o HEALED!! Good wound care, no adjunctive treatments…… 6 months Heading for the Rocks…..  Diabetes….sometimes means job security in health care….   9/3- Return to clinic…. 9/10- Wound close to healing again. Shoes ordered! Yeah! 9 Castaway IV…..  79 year old male with venous disease  First seen in clinic back in 2006  Presented with non healing ulcer of the medial malleolus December 2010 From stem to stern…  Medications: ASA, Plavix, Diltiazem, Doxazocin, Metoprolol, Torsemide, Valsartan, Zocor  Medical History: HTN 2nd to renal stenosis after stinting, A-Fib, Venous Insuff, Hyperlipidemia, CAD  Previous: history of venous ulcers, veins stripped in past, utilizes compression stockings  Social: Works as a barber, on his feet all day feet all day. Well Limey!  12/20: ABI’s WNL with triphasic waveforms…Let’s Compress! Unna!  12/31: Venous Study…no dams are working, reflux everywhere! 10 … Vascular Consult 2.8 x 2.6 x 0.5  Sent to vascular surgeon 1/11- wound care taken over by surgeon at that time  Endovascular ablation done- RTC 4/11  Success noted- continue unna boot  Work up for Biologic 5.3 x 4.2 x 0.4 Calm Waters….  Biologic workup- no infection, underlying disease managed, compression in place 4.4 x 2.8 x 0.4 All Hands on Deck!  5/24‐ 2nd biologic placed  Dressing changed to profore boot  “Booger” appearance‐ “B ” cells incorporating into the wound bed 11 Follow that Dinghy!…. • Wound has bridged • Graft incorporated • Close to healing Cl t h li • Continue protection and compression Land ahead!    Tissue has bridged over Continue compression and preventitive care~ HEALED! Castaway V  5/27/10‐ MJ – 59 y/o male present to Clinic‐ History of dog bite 2 months previous  History of significant gasoline burn to affected area at age 3  Hx of Type I DM, Insulin Pump, HTN, Hyperlipidemia, Smoker 12 Checking out the cargo  Started with xeroform  Moved to Theragauze r/t maceration  Moved to Alginate r/t M d Al i / maceration  On to Iodosorb 7/22/10  8/5/10‐ Returns with macerated, motorcycle riding wound. Becomes lost in the wind….. The Pirate Returns…..  3/26/13‐ Never Healed  Significant Drainage Present  Peroxide, TAO, and P id TAO d bandaid dressing  Presents with 2 punctate holes‐ “calcium” like crystals present‐ dx as Dystrophic Calcification No longer lost at sea…..  Plastics consult for possible flap‐ no go  Medihoney started 4/1  TCOM numbers TCOM b significantly improve with oxygen‐ 23 to 212  HBO Initiated 5/13  49 HBO treatments received 13 Life saver…..  9.20  Healed! Back to shore…  Wounds become chronic at 4 weeks  You HAVE to fix/attempt to fix the underlying disease BEFORE you can appropriately treat the wound  Weekly debridement increases healing rates  Patient compliance- make it or break it!  All caregivers need to be on the same page! Thanks! 14