Thursday, December 20, 2007

Decubes















I was in the ER yesterday seeing a consult when I noticed a goddawful odor in the slot next to me. Nurses were actively spraying the hall with deodorizer as I asked what the hell was going on. Oh, it's actually a guy you know, I was told. The nursing home sent him over. I read the chart and realize it's an old guy I had operated on about 6 months prior for fulminant c diff colitis. I did a total colectomy and end ileostomy. He was a demented old guy, but in relatively good overall health. Somehow he survived the c diff episode and recovered and was transferred to a long term care facility. Apparently he had developed sudden hypotension and tachycardia and the nursing home sent him right over. No mention was made of the sickening odor the poor guy was emitting on any of the transfer forms. I say hello to his wife, who was sitting ever vigilantly by his bedside, and examined him. The belly looked fine. Stoma functioning well. The nurse helped me roll him over and the sight was something out of Night of the Living Dead. I've seen some nasty decubitus ulcers in my time, but this was absolutely horrifying. The skin and subcutaneous tissue had almost liquefied and a black dead escar extended almost to his lumbar spine like a glaze. His WBC 24k. Lactate 2.8. Pressors already started. We carted him to ICU and I got three nurses to help roll him over again. In these situations you don't need anything fancy. A clamp to grasp tissues and something sharp to cut it with. I found a hemostat and a scalpel in the supply room and went to work. And by "work" I mean literally filleting chunks of dead flesh from his sacral area. Two nurses had to leave secondary to near fainting or extreme nausea. I could feel the odor seeping into my pores. You cut and cut until you get tissue that bleeds. Must have been a pound or two of gunk on the bed by the time I was done. He didn't feel a thing. I hadn't done something like this since early residency; senior level surgical staff always tries to pawn off the crapola decubitus cases on juniors. But the guy needed it. He was septic and dying from an ulcer. He's doing much better today.

Decubitus ulcers are a problem in institutionalized patients. Studies suggest that all it takes is 32 mmHg of pressure applied to an area for two consecutive hours to overcome capillary pressure and thereby impede perfusion of cells. The typical mattress applies 150mmHg of pressure. Pressure sores are an epidemic in certain patient populations: para/quadraplegics, the demented, institutionalized patients, and patients on vents in the ICU. Precautions such as off loading and frequent rolling of the patient and some of the newer air mattresses can help, but the work that goes into prevention can be taxing to nursing personnel. Especially in nursing homes. It's troubling though, nonetheless, that an institution in the United States of America would allow an ulcer to progress to this level of rancidness. I'm certain that odor didn't acutely present itself.

7 comments:

rlbates said...

Buckeye, tough case. There are some nice new dressings to manage the wound these days. I reviewed them (http://rlbatesmd.blogspot.com/2007/10/dressings-for-acute-and-chronic-wounds.html). Good luck to you.

totsu said...

This picture makes me want to kill someone. But-- who? The nurse who has 35 patients? The CNA working his 18th hour of turning and feeding? Or the nursing home owner who doesn't give a rat's ass about appropriate staffing? Grrr, shameful.

Anonymous said...

Have you guys ever seen this in long-haul truckers who need to sit for long hours?

Or is it isolated to patients who are incapacitated or homebound to chairs or beds for the most part?

Bongi said...

i find this is one procedure where nurses hate me afterwards. i get accused of brutality etc. but i'm sure your 'brutality' saved the guy's life. well done.
anonymous, truck drivers are conscious and will shift position as they become uncomfortable. so not seen. the other small matter of a pilonidal sinus? we'll yes. that they can get.

Buckeye Surgeon said...

Ramona- Great link... there's so many products with similar sounding names, it's hard to keep it all straight.

Anonymous said...

read your article and i see this A LOT. i'm just an emt out in southern california doin 911 coverage. anyways i saw this story and couldn't help but read it. the sad part is that i've seen a decube ulcer far worse then that but in the same region. we picked up a full arrest from a place called shae convo in whittier ca. when we found him he was incontinent x2 and we just scooped and ran. we got to the hospital they called him there. well as they where cleaning up his body the rolled him and saw a decube. this was really bad. it was down to the pelvis bone to where it was easily visible. it had also gone to his colon and he had been incontinent through this open wound. and it was about the whole size of his left buttocks. i assume what happened to the poor man was that he had gone into septic shock from this wound that wasn't even bandaged. it was just left open unattended by some cna's and rn's that should have their licenses revoked. it truly enrages me when i see people do these things to another human being.

sorry if i ranted
vince r.

Anonymous said...

I worked at a nursing home as an Activites Asst and saw this kind of stuff all the time they laft patients there and would make fun of them when they cried out in pain and for help. When my grandmother was admitted to the nursing home, I saw her a lot until the end and on our last visit the nurse rolled her over and she was covered from head to toe on her backside with bed sores. I can't work for those kinds of homes they don't care, they steal from the elderly, and they leave them alone in the rooms to die or in their chairs in their own urine and feces for hours before they feel like changing them, I think it's a great post to put out for the world to see. Thank You Doc.