Cuts, Bruises, Bleeding and Swelling: The Chaos of Wound Care for the Acute Injury
In our wound center, we see at least one to five patients per week with lower extremity injuries that they sustained in a variety of ways. These are mostly frail, elderly individuals who seem to find objects to bang into or surfaces to slip on. As the recently published article states (http://www.marketwatch.com/story/the-number-one-reason-people-go-to-the-er-2016-02-15), the number one reason that patients visit emergency rooms are injuries; and the most common injuries are related to steps or stairs. This is followed by injuries related to floors and flooring materials; in third place are those injuries related to beds or bedframes. The doors from a dishwasher, washing machine, oven, or automobiles are frequent offenders in our wound center.
The entire wound care team needs to review with all patients in the wound center risk factors for falls. This should be considered a standard of care for wound centers. A wound in the elderly person can take months to heal; with underlying pathology such as venous or arterial disease, a small injury can easily turn into a serious wound that involves a high level of engagement by the patient and intelligent wound care by a professional team. We must not forget that many of our patients also are on some form of anticoagulation that only complicates matters, as bleeding in a lower extremity wound persists well beyond the time of the injury.
By the time that the patient has made it to the wound center, they have often made contact with multiple healthcare facilities. We find that after the emergency room, the patient will often seek repeated help from urgent care centers as they attempt to deal with the persistent injury. Often, the primary care clinician gets involved along the path of recovery (I suspect after emergency rooms and urgent care centers due to the inability to see ‘urgent’ cases). By the time the patient sees us in the wound center, the patient commonly comes in with a bag of wound care supplies; and evidence of being placed on antibiotics (sometimes, two or three courses). If cultures were completed, it was — as if we did not already know the answer — a swab of the surface of the wound done without any debridement or even cleansing of the surface prior to the culture. I have enough issues with the variability of care of our current wound care centers including my own, let alone the complete chaos of care that describes the above events.
Despite all of this, there must be a small percentage of patients that eventually make it to the wound center for the care of their now unhealed wound. Many of these patients have sustained actually three types of injuries that prevent healing of their wounds:
1. The first is the wound itself. There is the abrasion, tear, puncture, laceration that got them into the healthcare system. If severe enough, the ER physician will often attempt to suture the wound together; other methods include the adhesive strips to keep everything together. For the patients that we usually see in the wound center, the ‘error’ here is the lack of understanding of the impact of the injury on the tissue.
2. The second is the physical impact of the actual injury. When the patient makes it to the emergency room or urgent care it is usually under duress (and panic) with an acutely bleeding wound that requires attention. As the wound is sutured together, the full impact of the subcutaneous tissue swelling that will occur over the next day or two is not realized. So over the next few days, the subcutaneous tissues swell from the impact. I explain this is this way: if you punched someone really hard in the arm and did not break the skin, you would have swelling in the arm from the impact. The same thing happens when you bang your lower leg against a bedframe, whether you have a wound or not.
3. The third issue with many patients is the fact that at the time of the injury they were on some form of anticoagulation. In this way, the effects of the original injury persist as the blood clots and forms a hematoma in the subcutaneous tissues. As the hematoma begins to liquefy, it will drain out of the wound opening, maintaining the existence of that wound and increasing the chances that some clinician will place the patient on an antibiotic, as this abnormally hued liquefaction drains from the wound.
When a patient with this type of injury presents to our wound center, we explain these three principles to them clearly so that they can understand why it has taken so long for the wound to heal. Of course, we examine the wound and evacuate the hematoma and the non-viable tissue from the wound as the first step in their recovery. We begin the process of lower extremity compression (most of these injuries are in the lower extremities) to expedite healing and counter some of the forces of impaction and hematoma. Those patients with vascular problems (either arterial, venous or lymphatic) receive additional attention.
The next step in leadership is for us is to share our findings with our colleagues in the emergency rooms and urgent care facilities. Early initiation of compression may lessen the morbidity of these injuries considerably. Suturing a wound in which a hematoma is developing in the subcutaneous tissues requires careful observation, not a simple instruction sheet and ‘go see your doctor in two weeks to have the sutures removed’ directive. Fast tracking into a wound center may be a great option in a well-organized healthcare system. This is clearly an example of how the impact of a clinical decision made by first contact clinicians (suturing a wound that is on top of swollen and bleeding subcutaneous tissue) never has an opportunity for evaluation of its efficacy.
A worst case scenario is a patient that sustained an injury to the their lower leg; had it sutured; multiple visits to the emergency room, urgent care, and primary care clinician; several courses of antibiotics; now presenting to the wound center two months later with necrotic tissue and a purple ooze (liquefied hematoma) coming from wound. One of the first questions the patient asks is: “Why did it take so long for someone to get me to the wound center?”
© Scott Matthew Bolhack, MD, MBA, CWS, CMD, FACP, FAAP