Schaper is one of millions of Americans who are treated each year for chronic wounds — typically ulcers that have not healed significantly in four weeks and not healed completely in eight weeks. Some experts estimate as many as 6 million people, 2 percent of the population, suffer from such wounds each year.
According to the National Center for Health Statistics, more than 600,000 patients were hospitalized in 2001 with chronic wounds. They included about 382,000 with pressure ulcers, typically in patients who are immobile; 154,000 with ulcers resulting from circulatory problems and 70,000 with wounds stemming from diabetes. The numbers do not include patients such as Schaper who received only outpatient treatment.
Chronic-wound cases are on the upswing, experts say, largely because of the steady increase in diabetes nationwide. Of the 17 million diabetics in the United States, about one-third already have foot or leg ulcers or will develop them, a recent University of Pennsylvania study reported.
The variety of specialists treating chronic wounds reflects the complexity of inducing healing. They include infectious-disease experts, vascular surgeons, plastic surgeons, endocrinologists, hyperbaric oxygen specialists and podiatrists, or foot doctors.
Some of these same specialists may also treat wounds infected with fast-moving, flesh-eating bacteria that can disfigure patients. But that condition, necrotizing fasciitis, is relatively rare and requires much more urgent treatment to prevent death — usually quick surgical removal of significant amounts of infected tissue.
In recent years, specialized chronic-wound treatment centers, typically hospital based, have sprung up to accommodate the growing number of patients, most of them elderly and needing extensive care. Patients come to the centers for treatment instead of having to travel from specialist to specialist.
"We, the physicians, go to one place. It's easier to monitor progress with a wound," said Dr. Prema Raghu, medical director of Northwest Hospital's Wound Care Center, which treats about 300 patients a year. Swedish Medical Center-Providence Campus, Stevens Hospital and Providence-Everett Medical Center also have wound-treatment centers, and most hospitals have nurses who specialize in treating stubborn wounds.
Insurance usually covers wound care, and under some plans patients can self refer to clinics. Treatment time may range from a few weeks to a year or more.
Diabetics vulnerable
Schaper is fairly typical of diabetics who suffer from chronic wounds, though his treatment was longer than most. Diabetes damaged nerves in his feet, so he doesn't feel sores very well when they occur. Arteries supplying blood to his feet also are damaged by diabetes, so the tissue is very slow to heal.
When Schaper finally got treatment for the infected callus, it already had developed into an ulcer — a small-pea-sized hole in the tough tissue on the bottom of foot. Weekly treatments and daily precautions soon became his routine.
Most treatments involved removal — "debridement" — of dead tissue that could promote infection in the wound. Dressings to promote healing were applied and a new, hard-plaster cast was fitted each week to protect the wound from any contact.
For months, Schaper, an office-based social worker, hobbled along on the cast, wrapping it in a rubber booty when showering. But the wound wouldn't heal and Schaper was referred by his diabetes-care physician to Northwest.
At Northwest, nurses weekly debrided the wound, measured its depth, tried new dressings and applied a new plaster cast. Finally, the wound began healing, and Schaper was switched from the hard cast to a "diabetic boot" — a removable, knee-high, air-cushioned device that continues to keep pressure off the wound. He also wears special stockings to help circulation in his legs.
Now new tissue has mostly replaced the ulcer and Schaper is being fitted for orthotics — special shoe-sole inserts — to continue to keep pressure off his tender foot. Northwest doctors used electronic shoe inserts to transmit computerized pictures of the pressure points on his feet.
"I can't wait to wear shoes on both feet again, not just when I sneak the boot off to fly," said Schaper, an avid small-plane pilot.
Wounds caused by diabetes can lead to major consequences. If not treated soon enough, the infection can spread through the body resulting in death. Many such infections require amputations. In the U.S., from 1997 to 1999, about 82,000 amputations of legs or feet were performed a year in diabetics, according to the American Diabetes Association.
Other causes of wounds
Besides diabetes, other major underlying causes of chronic wounds are:
• Venous insufficiency: Often an inherited condition that may be aggravated by prolonged standing. Flaplike valves in the leg veins that help the blood return to the heart become weak and the blood moves slowly. The vein may become twisted, fluid may build up and ulceration may follow. Healing is difficult because of decreased blood flow.
• Arterial insufficiency: Commonly caused by atherosclerosis, or the buildup of plaque in the leg arteries, just as in coronary artery disease. The buildup narrows the artery and slows blood flow. Blood clots may also block the artery, or smoking can cause constriction.
• Pressure ulcers: Caused by prolonged pressure, typically on the skin over a bone. Many nursing-home residents or others who are immobile develop these wounds, the worst form of bed sores.
• Other, less common, difficult-to-heal wounds may develop from burns, in surgical incisions and from collagen vascular disease, an inflammation of the interior lining of blood vessels.
Goals of wound care
"When you have open wounds, you're going to have problems with pain, odor and risk of infection. ... Patients may get weaker and sicker," said Dr. Cynthia Campbell, who treats patients in the Swedish Medical Center-Providence Campus wound center. About 500 patients a year are treated at the center.
Wound treatments focus on keeping the wound bed clear of infection and encouraging tissue growth. Infection control includes debridement, antibacterial dressings and using lab cultures and biopsies to test for infection.
Good circulation is needed to encourage tissue growth. Sometimes, special stockings can improve blood flow sufficiently. If an artery is significantly narrowed, physicians may bypass the blockage with an artificial blood vessel. Or, they may use a vacuum device that both encourages circulation and fights infection.
Patients with difficult wounds may be treated in a hyperbaric oxygen chamber, which provides oxygen under high pressure. The oxygen stimulates growth of tiny blood vessels called capillaries that supply the wound site. It also stimulates production of growth factors and collagen, the framework that tissue is built upon.
"With hyperbaric oxygen, we're turning on the healing process," said Dr. Neil Hampson, medical director of Virginia Mason Medical Center's hyperbaric oxygen treatment center.
The center treats about 250 patients a year, half of them with chronic wounds. St. Joseph's Hospital in Tacoma also has a small hyperbaric chamber. Hyperbaric patients typically include diabetics and cancer patients whose surgical wounds are slow healing because they also have received radiation treatment.
Wound centers also use a variety of topical ointments that stimulate tissue regeneration, some in combination with antibacterial dressings. These include products that supply growth factors and collagen. An additional dressing of foam may be applied to absorb drainage.
Skin grafts taken from another part of the body, typically the leg or back, sometimes are laid on the wound to promote tissue growth. Manufactured dressings containing penile foreskin from infant circumcisions and mucus membrane from pig intestines also are used.
A lesson learned
Bill Warner, a retired U.S. Postal Service manager and Lake City resident, had a range of treatments before healing finally was complete in a right-ankle wound he received from bumping the sharp corner of a coffee table in 1998.
Three months after the injury, "it was just torture" every time he laid on the ankle, and he went to Northwest Hospital to become the Wound Care Center's first patient.
Warner, now 80, was hospitalized a week for treatment of his ulcer that had reached all the way to the bone. Careful, painful debridement and elevation of his leg to speed his sluggish circulation were emphasized. So were dressings that ranged from growth-factor ointments to antibacterial agents and bandages to control his swelling.
At home, Warner used a hospital bed to keep his leg elevated and had nurse visits twice a day for three months before the stubborn ulcer finally healed. A year ago, another, smaller ulcer developed in the same spot — perhaps because he bumped the ankle again. He's uncertain how it happened. But after getting treatment much sooner than before, the sore healed in a month.
Like many patients, Warner is still amazed that such a seemingly small sore could become such a problem. "It is something that I never expected to go through," he said.
He is also impressed with the amount of care needed for such a wound.
"They were very, very thorough," he said. "They left no stone unturned." |
