Patients Have Expectations As Well

Anthony Ferraro, DPM & John Liantonio, MD

  A fascinating yet troubling case recently presented itself to a hospital wound clinic. A 44-year-old female presented with a one-month history of a full-thickness heel wound she sustained as a result of services rendered at her local podiatrist’s medical spa. The patient stated that the wound was caused by the application of an unknown chemical to her left heel for the treatment of thickened skin. She denied pain, difficulty walking, fever, nausea, vomiting, or diarrhea at the time of presentation. Her medical history is significant for fibrosarcoma (left leg), foot drop, lymphedema, and peripheral neuropathy as sequelae of the radiation she received for her sarcoma treatment. She currently manages the lymphedema using compression stockings and wears an ankle-foot orthoses (AFO) for her foot drop. Her surgical history is significant for surgical resection of the left leg sarcoma.

Left Lower Extremity Physical Examination

  • Pedal pulses biphasic on Doppler
  • Capillary refill time - less than three seconds
  • Temperature gradient - within normal limits
  • Vibratory sensation - absent distal to tibial tuberosity
  • Protective sensation - absent
  • Proprioception - absent
  • Muscle strength - 0/5 dorsiflexors, plantarflexors, invertors, and evertors of the foot
  • + full thickness ulceration to subcutaneous tissue with granular base
  • No undermining of periwound tissue
  • No exposed bone/tendon
  • No active drainage/purulent discharge
  • No periwound erythema
  • No malodor
  • No tenderness on palpation

  The patient presented to our clinic following the recommendation of her podiatrist. The wound itself did not present the average wound care specialist with a difficult situation, as the extremity is clinically non-infected, lacks exposed bone, and has a granular base with good vascularity. The patient’s existing comorbidities of left lower extremity lymphedema and drop foot, however, require two concomitant treatment modalities (compression stocking and AFO) be used in conjunction with a proper wound dressing. The significance of this was emphasized by the patient, who feared not using the above regimen would keep her out of work. This would require compromise between the providers and the patient to come up with the best plan.

  The wound care team presented a plan that would provide optimal healing while allowing the patient to continue activities of daily living. The immediate concerns were maintaining a clean wound while reducing edema to the extremity and pressure to the wound. These concerns were addressed with a silver impregnated wound dressing and an outer multilayer compression to be changed once every three days. The plan was introduced over three weeks and wound size decreased by approximately 80%. During week four, the patient requested that she return to work, so the treatment plan transitioned to an overlying silicone wound contact-layer dressing, a compression stocking, an AFO during the day, and a silver dressing and dry sterile gauze at night. The patient went on to wound closure within eight weeks of initial presentation and was discharged from the wound clinic on her ninth weekly visit.

  The case presented may not be so atypical from other wound care patients, but two crucial lessons merit discussion: First, listen to your patients and work with them. This will ultimately lead to a jointly agreed upon treatment regime. In this case, we discussed the importance of a wound dressing with multilayer compression. As a result, the patient decided to take a leave of absence from work. As physicians, we occasionally instead focus exclusively on our recommendations and forget that our patients are parents, spouses, grandparents, and employees who have lives outside our clinics. Though we are trained to use this kind of “long view,” ignoring even perceived needs might impede patient compliance and, as a result, outcomes. Second, the creation of this kind of wound can be avoided by refraining from the egregious act of placing a chemical on the skin of a neuropathic patient.

Anthony Ferraro is on staff at Good Samaritan Hospital, West Islip, NY. John Liantonio is on staff at Mount Sinai Beth Israel, New York.