For more photos from our visit to Desert Springs Hospital Medical Center, visit http://www.todayswoundclinic.com/slideshow/facility-focus-wound-healing-las-vegas-safe-bet-desert-springs Las Vegas — Delvin Lee has lived with HIV nearly 25 years. Not coincidentally, he was diagnosed with toxoplasmosis more than 12 years ago, his vision progressively worsening and seizures occurring throughout his life as a result. A cancer survivor as well, Lee, 51, has learned to live and survive on his own since the age of 16, even with a healthcare history that reads like a novel. But a nonhealing wound nearly killed him last summer.
Had he not met Minh H. Nguyen, MD, WCC, medical director at the Advanced Wound Care Center at Desert Springs Hospital Medical Center, soon after enduring his most recent grand mal seizure, Lee is certain that he would not be alive today to share his story — a story of how true inner strength can help one on the road to healing — a story that really begins off the Caribbean coast on the island of Antigua and has spanned many parts of the globe. It’s also a tale of rescue — a rescue by a collaborative wound care and allied healthcare team that dramatically changed its long-suffering patient’s life in a matter of weeks.
Early Introduction to Adversity
Lee was born in New York in 1962. His parents met in the Big Apple and most likely had plans to raise their family there as best as Lee can remember, but when his younger sister was born 1 year later with Down syndrome, the family uprooted to be with his mother’s family in the West Indies, where Lee grew up as a boy very close to nature who learned “every nook and cranny” that the island had to offer.
“The way nature heals itself has always been fascinating to me,” Lee said. “So, as part of nature I feel I can do the same if I have the right mindset.”
One who was always a productive student, Lee graduated high school from St. Joseph’s Academy on the island as the school’s Student of the Year and from there traveled to St. Mary’s University in Halifax, Nova Scotia. Although he’d leave school early prior to earning a degree, Lee would “continue” his education by traveling the world, ending up back in the US full time by the mid 1980s.
With no specific reason to consider himself unhealthy, he mutually volunteered to undergo HIV testing at age 30 when he entered into a new relationship and both he and his partner wanted to be tested as a precaution. To his surprise, his test came back positive. To his dismay, he learned from a social worker that he’d actually been living with the disease for at least 3 years. Records showed that an employer who screened him in 1989 as part of a job application had led to a positive result. However, laws at the time did not require third parties to notify anyone beyond local health officials regarding HIV status. With the amount of traveling Lee had already done by that point, he believes he would have been tough to trace anyway. However, one certainty remained: He showed no signs of the disease.
“I had no symptoms, nothing that would lead me to believe that I was carrying HIV,” said Lee, who recently spoke with Today’s Wound Clinic during a visit to Desert Springs, a 293-bed acute care facility located in the city’s southeast section that’s become a staple in the community for its longstanding Diabetes Treatment Center (see sidebar at right) and, more recently, its wound care and hyperbarics center. At the time of the visit, Lee was nearing his 30th oxygen therapy treatment of an anticipated 60 indicated for a radiation burn that formed more than 10 years ago after extensive treatment for anal squamous cell carcinoma, a condition that developed following a case of human papillomavirus (HPV), both of which his HIV-weakened immune system may have been susceptible too. What’s not debatable is that Lee tried unsuccessfully to self-treat the open wound for more than a decade, using a range of over-the-counter pharmaceutical products from petroleum jelly and Vagisil (for its numbing agent) to toilet paper, diapers, and even Maxi pads for bandaging. His vision poor enough to the point that he could not see for himself that the wound was not properly healing, he relied on total sensation to care for it, as pain would fluctuate based on his body temperature (the pads allowed more venting than the diapers), and how often he would have bowel movements during a given day.
“I was worried about losing my sight some day, so I wanted to teach myself to see with my fingertips,” he said. “I did my best to take care of it by making sure that it was always clean and dry.”
As the years passed, the attention that he found himself dedicating to the wound began consuming his time and his life to immeasurable and even dangerous levels.
“I ‘became’ the wound — I was so worried about getting an infection that it’s all I thought about, all day every day,” Lee related. “The burn just became this big hole in my body that I tried to keep clean and had no time for anything else.”
Even to the point that he felt too overwhelmed to seek medical treatment for it and, even worse, began to seriously neglect his HIV and toxoplasmosis medication regimen. He estimates that after about 7 years he was no longer taking any of his meds.
“I just became so obsessed with the wound because I could feel it getting larger and larger that I didn’t realize how much I wasn’t paying attention to other things,” said Lee, who at the time of his cancer diagnosis was living in Cleveland, but specifically targeted Vegas as his new home due to it’s close proximity to the Mojave Desert and the “spiritual energy” believed to be present within. Though cancer-free, the side effects of the radiation (48 sessions plus concurrent chemotherapy) had left him visibly and physically deteriorated. And, for the first time in his life, questioning his will.
“I had started to feel the effects of the chemo — the pain was all over my body and I dropped from 150 to 118 pounds,” Lee said. “I basically needed to learn to walk again because of where the condyloma was, and my body was reacting to the ‘poison’ that healed the cancer.”
A lifelong artist who has made a part-time career out of selling original artwork, paintings, jewelry, and greeting cards, Lee would also see the sagging economy deplete his ability to earn a comfortable living. Today, he qualifies for Medicare coverage.
“But I was in good spirits,” he said. “I’ve always tried not to go the negative route when it comes to health and most things, because that does nothing for me.”
And then, last June, his hiatus from the toxoplasmosis meds caught up to him. While lying around at home, painting in one of the only comfortable positions he could muster with the wound, he experienced another grand mal seizure that culminated in a stroke. Had it not been for a visitor who soon afterwards came to the door and called 911 for him, he would have likely died in his own living room. Instead, he ended up in the emergency department at Desert Springs. A few weeks later he was on an acute rehab floor in the care of Nguyen, who promptly inquired about the wound.
“Dr. Nguyen told me he thought he could do something for me, so I said, ‘Have at it.’”
A Wound Worth Healing
Despite the location of the burn, extensive comorbidities, and time elapsed, Nguyen remained confident that he and his staff could heal Lee’s wound — measured at 6 cm long, 3 cm wide, and 4.5 cm deep — in accordance with their wound care benchmarks, which call for at least a 50 percent reduction at 4 weeks. Beyond that, length of stay is based on wound severity, which is determined by evaluations made during initial assessment and ongoing by Nguyen and respective members of Desert Springs’ multidisciplinary physician staff, an eight-member panel that includes specialists in restorative medicine (Dr. Nguyen), emergency medicine (Anthony V. Carrozza, MD), and infectious disease (Ronald Shockley, MD), among others.
“Our initial evaluations are very comprehensive,” Nguyen said. “Everything starts with a thorough history so that we can answer the main questions: Why is the wound chronic and nonhealing? Is it a nutritional factor? Is it an infectious disease issue? Is it an offloading issue? Is it a circulation issue? Is there a red flag that nobody has raised yet? We maximize wound healing potential by considering all possibilities.”
As a preemptive measure to closure, all patients are also given a host of clinical workups on first visit that includes hemoglobin A1C, blood sugar, ankle-brachial index, and bone scans, if necessary.
“We can’t trust anyone else’s data,” Nguyen said. “We need to piece everything together ourselves so that we can be sure that we’re not missing any pathology.”
Neurological evaluations are also conducted upon referral in an attempt to gauge one’s ability to help care for his or her wound while away from the clinic as well as cultures for MRSA.
“And not a lot of physicians will check for that from the get-go, but we do,” Nguyen said. “That’s a lot of ground to cover on a first visit, but we like to be as comprehensive as we can. We then slot the patient for the appropriate specialist and protocol that best fits their wound care needs from the start.”
A Challenging Population
As unique as Lee’s case appears to be, at Desert Springs it’s not uncommon for wound care staff to encounter patients who’ve gone longer with self-treating their chronic wounds.
“When I meet a patient, I actually expect them to tell me it’s been many years that they’ve had their wound,” said Kim McMickens, BSN, RN, clinical coordinator, who recently left home care full time to be in a setting equipped to produce better long-term outcomes for wound care patients, a population she’s cared for more than 10 years. “People just seem to learn to live with their wounds until the pain becomes so severe or until they’re infected. Unless they’re referred by a primary physician, the wound just becomes a way of life for many of them.”
Located minutes from the Strip, Desert Springs also plays host to patients in the region who are on extended vacations and are likely on foot for long stretches of the day.
As such, walk-ins are to be expected, out-of-state providers are inclined to call in travelers’ referrals, and a willingness and ability to be accommodating is a must, McMickens said, especially when considering environmental factors that can frequently impact not just the patient population’s health in general but people’s willingness and physical ability to be healthcare conscientious.
“Vegas gets extremely hot in the summer and, when we do get inclement weather in the winter, there’s a lot of wind, and cold, and rain – flooding even,” Kim continued. “Some of our compromised patients are living with multiple comorbidities and socioeconomic issues. They’re sitting at the bus stop, and some buses don’t even accommodate wheelchair access. There are a lot of challenges we and they face to getting their wound care consistent.”
Lee has not been immune to that. As of TWC’s visit, his wound had been reduced to 1.5 x 1 x 4; but there’s been some struggle, including an allergy to sulfur
. “And an opening in that area is very tough to heal because there’s recurring trauma and pressure,” Nguyen said. “We’ve educated him to be diligent and to clean and sanitize the area after every bowel movement. But we’re all happy with the level of progress he’s seen thus far.”
As is Lee, who is also now fully compliant with all medications and is observant to a difference in the care at Desert Springs as compared to past experiences.
“This group here, as varied as they are individually [as providers], comes together as a unit,” he said. “They communicate with one another. I’ve been to hospitals where it’s not like that. Everyone here has one focus – to make sure you get what you need when you need it.”
Though he’s still looking at several weeks of recovery, he’s assured his mindset is where it needs to be. His caregivers agree.
“He was in need of a healthcare team to provide guidance to understand what was important for him to heal his wound,” Nguyen said. “If patients aren’t given direction and confidence, they’re not going to know what’s important. But if they are given more direct, clear guidance, they’re going to be more grateful and more compliant, and they’ll trust you — that’s the key.”
A Head Start on Being Resourceful
by Joe Darrah
Las Vegas — Despite the universal understanding that the wound care population has been and will be dominated by those living with diabetes and (more increasingly) obesity, convenient access to a dedicated diabetes center for outpatient wound clinics is not nearly as automatic. The odds are even less in favor for clinics to have an extension to bariatrics. But at Desert Springs Hospital Medical Center, the wound clinic is in reality an extension to a diabetes center that opened in 1990. Officials at the facility didn’t want to waste time in earning accreditation, offering a director’s position to Joyce Malaskovitz, PhD, RN, CDE, and asking her to seek accreditation immediately. Today, the center has long been the first in Nevada to be accredited by the American Diabetes Association and the American Association of Diabetes Educators. Malaskovitz, a nurse who chose to dedicate her career to diabetes as a youth after her grandfather died suddenly of a heart attack due to disease complications without a chance to say their goodbyes, is most proud of the specialty allied centers the hospital has built and likewise acquired accreditation in support of the patient population (ie, bariatrics, stroke, cardiovascular, sleep, and wound care, among others).
“It’s about all the service lines that we’re offering that in the long run improves the patients’ overall well-being,” said Malaskovitz, director of health and wellness at the medical center. “From a business perspective, you can keep people coming through your doors by letting them and referring physicians know that we offer all these programs to help manage their disease.”
Malaskovitz and her staff collaborate with the wound clinic by offering patients a comprehensive program of diabetes education based on their individual needs learned through comprehensive assessments conducted upon wound clinic admission.
“We also conduct our own assessments, identify their needs, educate them, and provide extra one-on-one if there are any learning disabilities,” Malaskovitz said. “We know that you can’t heal a wound if the glucose is running 300 or 400.” Group diabetes classes are held monthly. More often than not, patients are candidates for bariatric surgery, which requires specific bariatric consultation to determine the patient’s chances of successful outcomes related to diet, overall health, and compliance. The diabetes center is also known in the community for its annual heath fair, an event that has brought local patients, providers, and vendors together the last 22 years.
“We get a few thousand people each year; it’s something that we’ve been able to grow through our reputation,” Malaskovitz said. “People are offered free screenings, free blood work, eye exams, foot exams. It’s all about exposing people to options to help them be healthy.”
Joe Darrah is managing editor of Today’s Wound Clinic.