Lower Extremity Compression of the Patient with Wounds

In addition to the main treatment for two of our most common events in our wound center (venous insufficiency and lower extremity trauma wounds), it turns out that clinically, compression may assist in the healing of most lower extremity wounds.

Most primary care clinicians will tell you that their experience with the compliance of patients wearing compression stockings is poor. And that is what I would have told you as an internist before practicing wound care.

First a couple of thoughts about the concept of “patient compliance”. I am not so sure that my change in perception is due to thirty years of practice. The case here is a lecture given by a social worker [See Paige Hector, MSW at www.paigeahead.com) at a conference that reset my compass.

As clinicians, we make recommendations to patients based upon our knowledge of their clinical disease and what we think will help them. We offer suggestions to them. The patient (or family) has the option to accept or decline the option. If they accept, we should be both honored and humbled; if they decline, we should still be humbled. When a patient declines a recommendation, our obligation is to figure out something else that might work for the patient. As a palliative care physician for wounds, I try never to abandon the patient. My goal is to support a patient in whatever way that I can.

I think of all the recommendations that I made 20 years ago that are no longer proven to be true; hence humbled.

Patient complaints about compression include:

· Too tight

· Too hot

· Too difficult to put on

· Too difficult to take off

· My last doctor ordered them and I never wore them

· They don’t work

· They caused a rash

· Too expensive

Most of these complaints are due to the fact that the clinician failed to figure out the best way to decompress the lower extremities of the patient.

The first mistake is ordering compression stockings before the patient is decompressed. If the patient is fitted for stockings at this juncture, they will spend a lot of money on stockings that are not the correct ones.

The patient should be decompressed first, monitored over weeks with increasing compression dressings, and then when the patient is comfortable with level of edema (or lack thereof) and the clinician is satisfied with results (wound healing, patient comfort with the then current level of compression, patient improvement in ambulation, etc.,) then stockings can be ordered.

We have found that use of a tubular compression line of product accomplishes the goal of progressively decompressing a patient. The tubular systems, depending on the individual product line, are designed as a single or double layer of compression to reach a certain level of pressure. The clinician needs to assess the arterial status of the patient either by clinical exam (palpation of pulses, ankle-brachial indices) or by imaging (arterial duplex studies or the like) before advancing compression.

© Scott Matthew Bolhack, MD, MBA, CWS, CMD, FACP, FAAP

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