I was recently involved in the care of a patient who developed a pressure ulcer.
Behind this seemingly innocuous sentence lurks a whole raft of issues, concerns and aspects of modern healthcare.
More surprisingly perhaps, I have spoken with several doctors who believe that pressure ulcers, their care, treatment and avoidance are not a medical thing, assuming that this aspect of patient support is just for nurses, with perhaps the intervention of a surgeon if things get particularly awful.
At its core is the divide between organ-specific, super-specialised medicine and the more holistic model of care, treatment and support that I teach and to which I aspire.
If you are a doctor who spends all their time focusing on the minutiae of, let’s say, eye surgery or a sub-division of a sub-division of lung or heart disease, it is easy to become misled into seeing your area of expertise as being a world entire unto itself; it is easy to miss the person.
There are however many non-specialists who, whether because of the pressure to address a raft of competing demands or a natural tendency to an over-specific focus on short-term fixes fail to see the bigger picture.
(When I think this, I am always taken-back to the scene at the beginning of Enter the Dragon where Bruce Lee, Shaolin Master slaps his student on the head for gazing at his finger and missing ‘all the heavenly glory’.)
Back to the problem.
What is a pressure ulcer?
It is when an area of skin, most commonly one sitting over what is called a ‘bony prominence’ – the sticky-out or bony parts of our skeletons are in contact with a surface for too long, the result being a critical interruption to blood supply that causes damage to the skin and consequent potential death of cells.
The bonier the prominence, the less pressure or time required for the damage.
In susceptible people an ulcer can begin in 20 minutes.
Why my readers don’t tend to get pressure ulcers, even when spending too long watching repeats of The Office is because we are a) able to move around and reposition ourselves if uncomfortable, b) have in the most, healthy skin that is less susceptible to injury and c) have a reasonable blood supply that keeps oxygenated blood flowing to our skin and all over our body.
This is probably all you need to know about pressure ulcers.
There is a whole science attached to the assessment of ulcers, their grading and treatment.
Here I will just look at the causes which are the same as the ways to prevent.
It is easy, in a minimalist sense to revert to my earlier notion that it is the nurse’s job to stop pressure ulcers – indeed, when such ulcers develop and there is a culprit to be found, it is often poor nursing care that is held responsible (or far more often, poor documentation of nursing care).
I don’t want to labour the point and prefer to focus on what nurses, doctors, therapists and everyone else can do to avoid pressure ulcers, which are, for the most, painful, uncomfortable and far easier to avoid than treat.
What can a doctor do?
Returning to the physics, pressure ulcers develop when the pressure on the part of a body is greater than the pressure of blood flowing to the skin.
We all know from standing on drawing-pins, that pressure is the result of an equation:
Pressure = Force/Area
This means, if the area is smaller, you need less force to create a bigger pressure.
This is where the bony-prominences come-in.
Many of you, me included, might not have too many bony prominences, this being because we are, well, fat.
Fat is a great defence against pressure ulcers.
Unfortunately, many of our patients, and particularly those who are most vulnerable or susceptible are not fat.
Many of the patients I care for, especially those in their late 80’s or 90’s weigh less than 50Kg, some are less than 40. This is between 8 or 6 Stone for those of you who use those measures.
If you weigh 40Kg and you are anything more than a very small person you will be very thin. Bits will stick out.
A picture of the body parts that most commonly stick-out is below.
Once a person reaches these extremes of body weight, there is little you can do to build them up. If you are young and very malnourished, with years of eating ahead this is doable, if you are in the last year or two of life, the best that can be achieved is maintenance, although often, the cause of your low body-weight – dementia or other systemic diseases such as Parkinson’s, diabetes, cancer or heart disease do not get better as time passes.
This is the area part of the equation.
Bony prominences provide a very small area, requiring little force to interrupt blood supply that leads to all the changes that happen when cells of an individual’s body are starved of oxygen, glucose and other nutrients – they die.
If we can’t make our patients fat, or at least maintian a healthy body weight (despite the valiant efforts of dieticians, nurses, carers and family to encourage people to eat) how do we prevent ulcers?
Well, this has to do with force.
We can reduce the force applied by providing padding or special mattresses or helping the person to move (in healthcare we call this ‘reposition’) – you can encourage those who can, to stand every so often.
And, I guess, you could interpret some of this as being the work of a nurse.
Yet, as I have mentioned on countless occasions, modern healthcare is far too complicated to be left to one person or discipline, the picture of the situation, the plans for treatment and care require everyone who works with that patient to contribute, both from their own narrow sphere of experience as well as taking the viewpoint of the other, either the patient or the other member of the team.
A doctor or a physiotherapist who sees a patient on too hard a bed or who is in too small a bed, should flag this and question.
Anyway, if it is just a matter of mattress or bed or chair what is there for the doctor to do?
If my patient who perhaps has dementia is restless or at risk of falling because they get up from their chair without realising that they can’t stand unaided, I could prescribe a sedative, a trivial dose of Lorazepam or Diazepam.
This would for the most be considered the wrong thing, at least first-off, as the correct answer, were this an exam question, would be to try to find out why the person is restless – yes, all the basics that make you and me want to move – hunger, boredom, pain, frustration, fear, anxiety, need for the toilet and so on.
If I knock my patient out, I might stop them falling in the short-term, I may also stop them moving which allows those bony bits to remain exposed. Also, sleeping or drowsy patient is less likely to eat, leading to a drop in their weight, they are less likely to drink, leading to more drowsiness and even a fall in blood pressure, which if you plug-in the above equation, leads to reduced blood flow to areas that are perhaps ‘at risk’ and all that follows.
Sometimes if a patient is very anxious, treatment for that anxiety is appropriate, this may make a person less restless; I guess what I am saying is think before you risk stopping someone moving.
Another doctor might feel they are doing a good job prescribing antihypertensives, that is medicines that lower and control blood pressure, yet, if you artificially lower blood pressure you might take the blood supply to that critical area to a level at which the skin is starved of the oxygen that keeps it healthy.
You might be another doctor who is happy they have followed every single line of NICE guidance, provided primary or secondary prevention for every disease or condition the patient has or has had.
Sometimes too many medicines can make a patient feel sick, can make them feel less like eating or drinking, can lead to constipation or exhaustion that fuels the cycle.
Another situation might be to not notice the level of exhaustion of the patient and send them for all sorts of therapy, investigations, tests and treatments, which renders them too tired to eat, get out of bed or do anything, again, it goes on.
Many of our patients are dying. Nor recognising this deterioration, which can be very slow, is common in healthcare, with patients subjected to all the above without realising that all of this is hastening not delaying death.
You see, it can get quite medical.
I am often concerned that nurses, colleagues and patients see me as ineffective as I am less likely to reach for an MRI request and more likely to fuss over how much they have had to drink.
For many patients the best we can do is get them some decent, tasty food.
I realise I have written almost two thousand words and I haven’t mentioned Covid.
Well, we are vaccinating like crazy.
The vaccine is not a panacea – we don’t even know the level of protection it offers and, we shouldn’t forget about eating and drinking that are the mainstay of keeping our patients well.
Just because I have been jabbed/jagged doesn’t mean I can forget about everything else. In a way the vaccine has put some of us at greater risk as our level of alertness or caution has waned.
If one of my patients is saved from Covid yet develops a pressure ulcer are they better-off?
Pressure ulcers may not be as deadly as Covid although the treatment, the pain, the repositioning (day and night), dressing changes and all the rest is equally bad.
Will this blog have resulted in a doctor changing their behaviour? Will someone, the next time they call the hospital to enquire about their mum or dad ask about pressure ulcer prevention or care?
I don’t know.
You see, there is really so much to know and do.
That’s why my go-to is the mantra of person-centred holistic care – you see, if that this your aspiration, even if you forget to remember every single component of the holistic-whole, you are at least moving in the right direction.
I don’t want to knock my fellow super-specialists – I might need them one day. Yet, a super-specialist who is an adherent of PCHC is likely to be a better doctor, nurse, pharmacist, teacher, or whatever.
And my patient, she died soon after she was found to have developed a pressure ulcer.
I was not sufficiently involved in her care to say whether her dying was acknowledged as the issue – with all that involves – getting the family in, stopping the bad medicines, determining and facilitating ways to provide a kind, caring natural death, or if the ulcer became the focus of attention.
There is a thin line between doing things right and doing the right thing.
Most of us want the right thing to be done right.