Don’t be the  “Loose Cannon” of  the Wound Care  Team!

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
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
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)
 Annual cost of venous stasis ulcers
-$2.5 to $3.5 billion
 Total annual economic cost of diabetes in
- $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?
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,
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
Failed Flap
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
Coast is clear…
Almost 30 days of
HBO and traditional
wound care…..
Clear the Deck…….
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
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
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 U
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!
Smooth Sailing…
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,
 Habits
3ppd smoker
 Medical History
DM, Hyperlipidemia,
Sinusitis, Asthma,
 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
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!
s done
inpatient- RT
1.05/0.78; LT
0.94/0.75….good to
get up to bat!
Debridement to
 Surgical
debridement while
 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
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,
g collagen….
Post surgical
Hit the Deck!!!
 7/26‐ dressing changed to dry gauze….Plantar healed!
Good wound care, no
treatments…… 6
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!
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!
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‐
” cells incorporating into the wound bed
Follow that Dinghy!….
• Wound has bridged
• Graft incorporated
• Close to healing
Cl t h li
• Continue protection and compression
Land ahead!
Tissue has bridged
compression and
preventitive care~
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
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
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!