This two-week wound care elective starts at 8:00 am. Most hospitals have a wound care service that is run by certified wound care nurses who change dressings, order offloading devices, and apply negative pressure wound vacuums to complex wounds. Unusually, our hospital has a wound care physician who joins the nurses in their morning rounds.
Patients fall into three categories: (1) frail elderly with pressure wounds on their heels, sacrum, and buttocks (decubital ulcers), (2) obese patients with necrotizing soft tissue infections, and (3) IV drug users with abscesses. There are the occasional complex surgical patients with non healing incisions and fistulas (abnormal connects between two hollow organs, e.g., colocutaneous – colon to skin. The head nurse calls out: “We’re going to need all hands on deck for the next one.” A 450 lb. 38-year-old white male underwent debridement for a necrotizing soft tissue infection of the scrotum (perineal infections are common in the morbidly obese diabetic.) General surgery performed a debridement of the “dishwasher” fluid necrotic tissue and applied a wound vacuum to the 10″ x 6″ wound with three incisions merging in the middle. The ICU nurse, PA student on our team, the two wound nurses, and I hold up folds of skin, revealing his testicles, as we remove and reapply the wound vacuum. A first-year nursing student is observing. “Did you see her face?” asks the head nurse. “She was petrified, but I’ll bet she enjoys telling this story to her friends.” We finish rounds at 10:30 am.
[Editor: Let’s hope that nobody quoted Dr. Evil in his group therapy session: “There really is nothing like a shorn scrotum… it’s breathtaking- I suggest you try it.”]
After lunch, Daniel Boone, the 45-year-old attending, takes me to the outpatient wound care clinic and I learn about the Christian mission trips that he runs to Third World countries. “If the patient needs a tooth pulled,” he explained, “I pull it. Nobody else is going to.” After completing a residency in family medicine, he worked as a hospitalist for ten years. He overcame a short bout of alcoholism by switching to a new specialty: wound care. “I loved procedures and I loved guts and blood. I would never want to be a sissy family medicine doc who refers everything out. I realized I had a knack for taking care of complex wounds and that there was a huge need for these providers.” He exhibits old-school tendencies by making house calls and slaughtering pigs, sheep, and goats in his backyard.
The most severe complications of obesity and diabetes get a lot of press. People are warned about heart attacks, strokes, and blindness. After a day at the clinic, however, I appreciate that these patients spend years suffering from chronic issues, such as venous insufficiency and lymphedema that lead to leg ulcers that seldom heal. “People can say fear is not a motivating factor,” said Daniel Boone, “but I can tell you that fear of losing a leg is usually an impetus for change.” He’s living proof, doing a “20:4” intermittent fast in which he is restricted to one meal per day. “This all started because I checked my blood sugar and was technically prediabetic,” he said. “The nurses think I’m crazy, but I’ve lost 15 pounds and my sugars look great.”
(Leg ulcers don’t motivate everyone; many of the nurses on the service are more than 60 lbs. overweight. One of them is trying to bring her BMI down below 40 so that she can qualify for knee replacement.)
During a typical visit, the nurse will remove the patient’s dressings. After a bit of instruction from the attending, the PA student or I take a scalpel and debride non-viable tissue. We might apply a stem cell product (e.g., foreskin or placental-derived tissue) or collagen matrix. If the wound is deep, we’ll apply a wound vacuum. The nurse will then apply compression with a wrap or stocking. The patient will come back 1-2 weeks later and usually end up loving our attending, who has healed wounds that they’ve had for years.
Wednesday we meet at 6:45 am in the Starbucks parking lot. Against LCME regulations that forbid students and attendings from sharing a vehicle, we hop in his 15-year-old pickup for the one-hour drive to a rural hospital where he runs another wound clinic. Unlike in our academic hospital, everyone here is relaxed and informal. The docs and staff are integral parts of the community.
(Sometimes things can get a bit too relaxed. The attending mixed some ghost pepper red gummy bears into the office’s bowl of regular Haribo bears. Loud Lucy, a refugee from Brooklyn who tells doctors and patients exactly what she thinks, ate one of the red gummies. “I was wrapping up one of the patients when it hit me and thought that I’d fall on her. I made it to my computer and Ginnie brought a wheelchair over. I was already on the ground under the sink in the fetal position.” It turned out that Lucy was suffering from a gastric ulcer. Before Lucy could be rolled to the ER, the attending gave her Pepto-Bismol. “Fortunately, she recovered. I was imagining having to explain this to George [ER doc] and saw my medical license flash before my eyes.”)
We see several diabetic foot ulcers, surprisingly in patients who are neither old nor severely overweight. “Diabetic ulcers” actually occur from neuropathy, or loss of feeling in the foot. Thus, repeated pressure from poorly fitting shoes or a sharp puncture wound goes unnoticed. A 34-year-old mother of two has been suffering from a heel ulcer. She stepped on a nail while setting up a soccer party. This went unnoticed until another soccer mom commented on the nail in her shoe. A person without neuropathy would start to limp from the pain, thus offloading the pressure on the wound.
[Editor: Trigger warning on the next two paragraphs!]
A 53-year-old hunter has had one of these foot ulcers for two months. He is the typical patient whose care was delayed by our overloaded multi-provider medical system. Primary care referred him to podiatry, but there was a two-week wait to get seen. The podiatrist was too busy to do surgery and therefore recommended a conservative treatment with antibiotics. The patient is without feeling in his foot so he couldn’t tell that the wound was getting worse. The wife insisted that he return to the primary care doctor, who eventually referred him to the wound clinic. “No one wanted to operate on this patient for some reason,” said Daniel Boone. “Even though he is not septic, he likely has chronic infection of the bone, which is why this wound does not heal even with offloading and appropriate care.” I probe the wound with a Q-tip and then proceed to insert my pinky to feel the exposed calcaneus (heel bone) in the 3 cm deep wound at the base of his foot.
“We could send him back to podiatry to perform a bone biopsy in the OR, or I could do it today so we get the answer.” Most physicians wouldn’t do a bedside bone biopsy with only local anesthetic, but he’s not most doctors. “We would do these all the time on mission trips, but we practice in a different environment here. This is a great example of how perfection is the enemy of the good. If I did the bone biopsy under local, I won’t get as great visualization but it will cost a hell of a lot less and we get results much quicker. If it’s infected, we know he needs to get an amputation. Most people think osteomyelitis is a medical illness, but it’s really a surgical problem. Get source control [remove the source of the infection].” The patient consents: “I trust you doc.” Daniel Boone supervises as I use the rongeur to bite out a few chunks of the calcaneus and we send them to pathology.
(We see the patient next week. The pathologist found infected bone, which means our patient will lose his foot in a below-the-knee amputation. We explain the situation: “You have osteomyelitis. You’re going to need an operation to try to remove the infected bone. You also have poor blood supply to the foot, which is further preventing healing. I’m going to see if a surgeon will manage this here or if we have to send you to the tertiary care center.” It turns out that a vascular surgeon can do the procedure in this rural hospital.
“He could sue the hospital and every doctor he touches would go down,” says Daniel Boone. “It doesn’t matter that I got him where he needs to go.” What could have been different? “The podiatrist kicked him around instead of debriding. Everyone thinks that osteomyelitis is a medical illness, requiring 6 weeks of antibiotics. It’s not. Osteo needs debridement to remove the source. I would do it myself, but we are in a large hospital setting where there is an expectation of utilizing specialty services. On my mission trips I would use lidocaine and debride the bone in our makeshift tent. In our health system, I send them to a surgeon who putzes around for several weeks until the patient is septic and needs an amputation.”)
Daniel Boone summarizes his experience: “In my first year in wound care, I changed more people’s behaviors than during my 10 years as a hospitalist and family physician.”
Statistics for the week… Study: 5 hours. Sleep: 7 hours/night; Fun: 1 night. Burgers and beers with Mary and Luke. Mary just finished a one-month cardiothoracic surgery visiting elective at an outside institution. This was part of her interview process for their residency program. She is beaming when describing her first sternotomy (cut into the chest and open the sternum with a bone saw).
The rest of the book: http://fifthchance.com/MedicalSchool2020