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Thread: Will this sacral wound EVER go away?! (Graphic Pic Warning)

  1. #1

    Will this sacral wound EVER go away?! (Graphic Pic Warning)

    Hello forum! I have been reading a lot of the posts on wounds and just wanted to reach out for some hope. I am not a spinal cord injury but I do have a form of muscular dystrophy. For my age and type I am doing very well... no tubes or breathing assistance on a daily basis or anything like that. I work full time also and have been wheelchair bound since 8yrs old. I weigh 52lbs... no, not anorexic or anything ... I am just super tiny and my disease has wasted me too.

    So I have a roho quattro cushion, always have actually. I have a tempurpedic mattress. Let me explain how I got into this mess. I had a bony prominence (trust me at 52lbs there are lots!) on my sacrum and ishium. Never in all 34yrs have they come even CLOSE to breaking skin. Well, I was getting physical therapy and it was recommended to do "preventative" bandaging on those spots. We didn't know any better and thought yeah, prevention is good right?

    Well they began dressing them with duoderm. After a few weeks my ischium (which I of course sit on every day) began hurting... so I stopped that. I am ONLY touching my sacrum if in bed. But my mom rolls me sometimes HOURLY at night... no more than 3hrs in one spot for sure! Well they (they meaning home health care) were changing the bandages 2x a week. They told us to go ahead and shower in them... (I am sure you can see where this is going)... Well the one on my sacrum... it because kinda hurting some on day 2... I told my mom to take it off... well... the skin had totally masserated. We discontinued all services and my mom was PISSED!! We decided just to take care of it ourselves. Well it amounted to a scabby spot for almost a year. But, it finally began oozing a tad. I realized only by my sheets on my bed. So we called home health care back--BUT only because I knew someone that worked there and they said they had a new WOC RN. Great!!

    So he comes... tried to treat it with alginate, silvermed, collagenase, medhoney... just about everything. He couldn't get it debrided any and even when he took a curette to it it wouldn't bleed. **Might I add the thing doesn't hurt me one bit!** So he was suspecting osteo.

    Started going to a wound clinic... Debrided it SOME and wanted me to get an MRI... long story short... they doc that read my MRI was wrong, sent me to the hospital on the weekend in panic that basically I could drop dead any minute from meningititis. No joke. Spent 3 days in the hospital basically for a plastic surgeon to come in ... cut the whole wound out, do a bone biopsy and put a vac on. The surgeon said there were no visible signs of infected tissue, nor bone; in fact the bone was quite dense and healthy. Finally sent me home and 2wks later official that there was no osteo. So that was ruled out why the wound wouldn't heal. They also ruled out my nutrition as all my levels including protein intake were good.

    So once a week for the last 4 weeks I go to the wound clinic, and in between (3x a week) I got vac changes from my WOC RN. But, every time I go there is a lot of slough buildup. For the first 2 weeks they had me on continuous 125 pressure. Each week the general surgeon has to sharp debride it. The last two weeks they changed it to 175 pressure and intermittent 5/2 because sometimes that stimulates circulation. For the first time 2 weeks ago we actually had some granulation. Now there is a layer covering the bone and I have been having blood tinged fluid coming into my vac.

    Skin flap has been discussed and at one point they wanted me to do a consult (before there was any granulation) and to be frank... I am NOT a candidate. I can tell you that for sure. I get pneumonia in the blink of an eye if immobile and in bed for any length of time, I have a history of DVT clots in my leg that I take warfarin for, with my severe scoliosis and poor respiratory system; anesthesia is very dangerous as well as intubation on me would be difficult and dangerous. The 30 days in bed... umm yeah... I would lose any muscle strength I still have and end up bedridden.

    I have told them that if this requires any kind of surgery they better get DARN creative because the risks FAR outweigh any benefits. I told them I'd leave the van on as long as possible to get as much out of it as possible. The wound, of course is a stage IV. To me the wound still looks the same size give or take after 4 weeks. Of course it has to be reamed out each week. But the bed doesn't seem to be sloughing as much anymore and I feel more positive that I am seeing blood now and then also (which I wasn't before they turned up the pressure and intermittent).

    So I guess what I am wondering is... will this ever heal???? Am I a freak because it keeps sloughing? Might I add on top of me not laying on it very long, ever, that it never has ever gotten scraped from rolling or being picked up or anything. Im so light my mom and dad lift me straight up and I never get "dragged" on the wound.

    This has been a total nightmare!!! I feel like if we can get it to heal I would be a better candidate than some for reoccurrence because this didn't happen on my mom's watch, nor is there a prerequisite for things to happen that typically cause one to open anyway other than being bony. People assume when I tell them I have a "bed sore" that that just comes with my condition. Which of course it can, but I know for a FACT it wouldn't have if we hadn't let them do those bandages and get masserated. It measures about 3cm x 1.7 is all I know regarding size. My hopes are, even if it takes a long time... the bed keeps rising with granulation. How long do some people stay on wound vacs with obstinent wounds? At this rate it could be MONTHS I am thinking.

    Any advice would help.

    This pic is the most recent... on Monday of this week. I go back to the wound clinic tomorrow... again... I assume he will debride that slough again. The slough ain't NEAR what it was in the beginning... but still... sigh...
    Last edited by SCI-Nurse; 09-22-2011 at 01:40 AM.

  2. #2
    The photo is not very sharp, but it does appear that you have a serious stage III or IV pressure ulcer. It is very unlikely to heal without surgery from the tale you told above. Of course you should not be sitting at all, ever, no matter what wound treatment is being used. You should be on a low air loss bed. A memory foam mattress does not provide enough pressure reduction to help a wound heal.

    I agree with the plastic surgeon that you probably need a flap. With proper care, you would not get pneumonia just from being on bed rest. People with high spinal cord injuries are also at risk for pneumonia and DVT on bedrest, and are often difficult to intubate for surgery, but they have these surgeries all the time.

    How is your nutrition? What is your pre-albumin level? Your CRP level? Are you taking protein supplements? A multivitamin?

    (KLD)

  3. #3
    Quote Originally Posted by SCI-Nurse View Post
    The photo is not very sharp, but it does appear that you have a serious stage III or IV pressure ulcer. It is very unlikely to heal without surgery from the tale you told above. Of course you should not be sitting at all, ever, no matter what wound treatment is being used. You should be on a low air loss bed. A memory foam mattress does not provide enough pressure reduction to help a wound heal.

    I agree with the plastic surgeon that you probably need a flap. With proper care, you would not get pneumonia just from being on bed rest. People with high spinal cord injuries are also at risk for pneumonia and DVT on bedrest, and are often difficult to intubate for surgery, but they have these surgeries all the time.

    How is your nutrition? What is your pre-albumin level? Your CRP level? Are you taking protein supplements? A multivitamin?

    (KLD)
    I am not sure what you mean by "I should not be sitting at all, ever, no matter what wound treatment is being used." Please elaborate.

    I understand people do it all the time, but I have actually had 2 DVTs and I have a neuromuscular disease spinal muscular atrophy. If I lose muscle, its gone. No getting it back. I get pneumonia 1-2 a year as is, and back in February we had to sign an AMA because I was getting so bad in the hospital because they wouldn't get me out of bed and my lungs were getting worse, skin was sore, and we knew if I got home... up and moving I would be able to clear out more junk, get some appetite and strength back. When I was in the hospital it had been 4 days straight in bed and I barely had the strength to sit in my chair.

    My prealbumin levels are great, my protein levels were on the mark... (I am a meatatarian) but I am gonna go ahead and get some protein pills. I have my whole life taken multivitamins as is. I cannot drink the protein stuff though, so I need to find pills. I get full in a hot minute. Any other supplements suggested to boost me up before I go to the vitamin shoppe?

    Yesterday was my weekly with my general surgeon. He wants to do a RADICAL debride in 2 weeks. He needs to get a Bovie cautery in the wound clinic. He thinks we have nothing else to lose, yes, it will make it bigger, but he wants to get the sides totally clean and down to soft fatty tissue in hopes the Vac will work then.

  4. #4
    Personally, I would NEVER have a general surgeon cut on a pressure ulcer. Sort of like having a GI surgeon do a heart transplant.

    You should not be sitting at all with a pressure ulcer on a seating location.
    Can't say it more simply than that. This applies now, after debridement, and whether or not you use the KCI VAC.

    (KLD)

  5. #5
    I had one like that and got osteomyelitis on my tailbone. Had to have surgery and a flap. It healed and shows no evidence of a flap ever being done. A low air loss mattress would be a great help if you get one like mine. It turns you side to side automatically. Was well worth it. Not sure of the name of it off hand.

  6. #6
    Senior Member Leila's Avatar
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    Microcyn (Dermacyn) can work wonders with these stage IV decubiti, as per the following link:

    http://www.oculusis.com/mexico/mp/ca...bitusUlcer.pdf
    I'm back on Facebook again--up and running!

    http://www.facebook.com/profile.php?...00000532232573

  7. #7
    I have one like that only it was twice that size. I ended up having to have a skin graft done on it. The scar is kind of funny looking. If I find a picture, I'll post it
    C-5/6, 7-9-2000
    Scottsdale, AZ

    Make the best out of today because yesterday is gone and tomorrow may never come. Nobody knows that better than those of us that have almost died from spinal cord injury.

  8. #8
    Your story is sadly familiar. Our experience with the abyss called wound care is about as haphazard. We are 5 months in now and I finally feel like we are on the homestretch. I predict her wound will close by December without flap surgery. This is from an original wound about 3 - 4 cm at the skin and 5 - 6 cm undermined. In a nutshell, my advice would be to quit the vac and try something else. It seems a little funky down at the base for is post-surgical debridement. I suspect the vac may be doing more harm than good. More on that later.

    Like you, I also attribute my wife's sacral wound not to excessive sitting, but to bad advice from healthcare professionals. Primarily it was the OTs (transfer boards are not appropriate for people with little strength and balance) and inattention/inexperience of her primary care physician. I believe it was a combination of several small falls (chair to floor) over the years leading to broken a coccyx which was not evident due to lack of feeling and skin breakdown from frequent incontinence. I take her to every medical appointment so I know that no one had looked at her skin in years. The doc even wrote the Rx for wheelchair and cushion without looking at it.

    After seeing blood on the toilet seat and some previous scars from falls opening up, I finally decided it was time to make some noise. I took pictures and brought them to the doctor to get some action. She ordered home nursing to come out and evaluate and treat her. Over the next 3 weeks the wound got bigger and bigger but the odor and slough problems were dissipating. Then one night the home care nurse manger called me at 9:30 PM yelling at me for not taking my wife to the hospital. But, she had no clinical reason why other than it "isn't healing." We had already been to a general surgeon a few days earlier. He looked at it for all of 10 seconds and said there was nothing he could do. And, that it would not heal without plastic surgery. He did not advise immediate hospitalization. Instead, I she got another referral (gotta love the funnel everything thing the primary lunacy) but the appointment was several weeks away. Apparently everything in health care can either wait weeks or months or it's an emergency.

    About a week after my "friendly" call I was changing the dressing and found a good size chunk of bloody tissue had been ejected from the wound. It looked like healthy tissue to me. I agonized about it, but decided to risk financial devastation and put her into the hospital system. The very same surgeon we had an appointment with performed the surgical debridement. Her coccyx was entirely removed (there were loose bone fragments) and she was prescribed IV Ertapenem (bone infection) for 6 weeks. She was put on a wound vac in the hospital and sent home a week after being admitted.

    Thus began about 5 weeks of total frustration with home nursing's lack of skill with wound vacs. It took about 2 weeks of me basically arguing with them to get them to understand that they weren't holding an adequate seal. As an engineer it was obvious to me. Once I deliberately stalled an obstinate nurse who insisted the dressing was good because the alarm wasn't going off. I could tell by the sound of the pump that it was a particularly bad job and it was on the edge of alarming. With a few minutes it did. Still she had a hard time accepting that there was a basic problem with how she was doing it and just added more tape until the alarm would stay off. On top of that was total disregard for the clinical guidelines. They frequently put granufoam and vacuum directly on skin and they put on too many layers of tegaderm. The net result was it would generally loose seal within 8 hours. Using the bridge approach (to move the tracpad off the wound site) renders the pump alarm system nearly useless from what I've seen. I finally got frustrated and started doing the dressings myself instead of calling after the hours number when it failed. They would never come until the next day anyway. My very first one held for 24 hours and I could get as much as 36. I'll admit the sacrum is a tough location. Plus my wife sweats at night to the point the sheets are visibly wet (even on LAL mattress) and I don't know that 3 changes a week is a realistic goal for her let alone 2. After almost 5 weeks of excuses why they couldn't hold a seal and it must be the pressure, they requested the doctor to authorize upping the pressure to 150 psi. Then they promptly stopped it altogether days later. In the end I just don't think they had enough attention to detail and analytical skill to refine the dressing technique enough make it work.

    At that point she was still not ready for plastic surgery. There was very little progress covering the bone. And her blood numbers never came down despite very healthy looking wound with no evidence of infection. Fortunately, stopping the vac was the best thing that could have happened. They switched back to purocol plus and within a week there was noticeable growth over the bone. It was still a struggle with home nursing's inconsistent skills with wound dressings, but at least there was progress. Over the next 6 weeks I got to the point I could look at the dressing after I get home from work and determine if I would need to redo it before the next visit. I do about 2/3 of them now. It's just easier than waiting or risking wound contamination.

    Six weeks post vac (10+ weeks from debridement), the surgeon finally said she was ready for flap surgery. He felt it would be more likely to heal that way but we didn't need to decide immediately. It would take several weeks to schedule a surgery anyway. By the next six week visit we still hadn't decided. Turned out waiting was the right thing to do because now the surgeon is no longer recommending surgery. The undermining is now almost gone and the wound is down to less than the size of a quarter and only about 1/4" deep. The original wound volume (after debridement) would have held a golf ball. One thing I am convinced of is that controlling moisture (not too wet or too dry) is the key. Early on I had to literally pull dry gauze out of new growth that had gone dry and leathery. Now I monitor the bandage, wound, and skin condition every day and I feel like I have it pretty dialed in. With the right dressing process it will last up to 2 days without excessive leakage and will have some moisture at day 2. I also rotate bandage sizes to avoid stressing the surrounding skin. I'll listen to what the nurses say but I only adopt what works. And I don't hesitate to make changes when things aren't working. It takes them far too long to make adjustments. Recently she had 3 catheter failures in 2 weeks. There's no excuse for that. It cost me 2 half days of work cleaning up her, the wound and the LAL bed. If I don't do the research and get to the bottom of things, nothing gets fixed. I had to pull the catheters out of the trash and test them to find out they are plugging with mineral crystals. Now they are using an 18 and have OK'd me to irrigate it daily. So far we've gone a week without blockage. I'm trying to get them to try silicone next time since some research shows they are less susceptible to formation of the salts.

    I don't know exactly how the vac is working for you misty, but from my experience and what you describe, I doubt you have had much effective vac time. My guess is they are using a bridge to get the trackpad away from the wound area. If so, do not trust the alarms on the pump. If you can see moisture under the drape, or the drape surface is not drawn in tight, the system is NOT working. Given you are only having it changed twice a week it's probably just holding in moisture most of the time. My wife had only about 3 cm between the wound and the rectum. The best seal method was adding a small amount of stoma paste (size of a baby pea) in the crevice. Too much paste and the force of the vacuum would pull the drape toward the wound and break seal. Too little, and the mucous would release the adhesive too soon. Avoid excessive layering of the drape. It's vapor permeable and needs to release moisture from the skin. I found more than 2 layers would cause too much moisture buildup and the adhesive would fail. Poor draw on a tracpad bridge also kills the seal. The slough will accumulate near the edges of the wound and start soaking the drape off. To be honest, if they hadn't discontinued the pump I was going to ditch the bridge and KCI trackpad and try a tube routed directly into the wound with a stoma paste seal. In the end, you have to decide if you lack of progress is due to poor technique with the vac or it's not the right method for you. Unfortunately, giving up the vac may mean more mess for awhile. When the vac works it keep the clothes and bed dry. Good luck.
    Last edited by MSspouse; 09-24-2011 at 04:05 AM.

  9. #9
    Quote Originally Posted by SCI-Nurse View Post
    Personally, I would NEVER have a general surgeon cut on a pressure ulcer. Sort of like having a GI surgeon do a heart transplant.

    You should not be sitting at all with a pressure ulcer on a seating location.
    Can't say it more simply than that. This applies now, after debridement, and whether or not you use the KCI VAC.

    (KLD)
    SCI-Nurse. This may be a general surgeon, but it is a surgeon that also knows a great deal about wound care, especially considering that he is in the wound clinic. There is no need to call in plastics every week when I need some debriding.

    As stated in my original post. I do not sit on this wound and it is NOT in a seating location. It touches nothing when up in my chair, if pressure is ever put on it it is in bed for the night, which I am rolled very frequently.

    MSspouse-Wow... I do feel your pain and your story is very very similar to mine. Yes, you are correct... they are using a bridge. I have questioned myself with each change on if it's really working like it should. I judge it by how much fluid comes out in the actual tubing. I do think it is probably correct that the wound needs to be reamed out surgically--walls and all. He can scrape the sides and they are so hard it sounds like bone! So my hopes are that once that is gone there may be more success with the vac. I don't think my seal issues have been as bad as yours though. I let them know if I don't feel it seal down, I can feel it when it does. I have only had one time of fluid leakage under the dressing, and one time of leak alarm. I too also know by the way it sounds, and by how much fluid is coming out. I feel for you and your wife. This is truly a total nightmare.

    I am not gonna let them push me too quick into a major surgery. We shall see what happens. Like I said I have only been on the vac 4wks and I have no even had any infection or anything. So I am blessed in a lot of ways. Its all just so scary.

  10. #10
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    Picture=bad memories
    I had one on the tail bone after an 8 week coma and more. You do have to stay off it. I had the flap surgery, and lousey care after and it never healed. After the insurance ran out they put me out of the hospital no instructions, got worse, had home care. This starts the longer story, first nurse SUCKED, was lucky to have a relief nurse one weekend who demanded I went to a wound care center (she had one in mind) followed up on Monday to make sure I followed her instructions, no excuses!

    Went to the wound center and a few months of triple antibiotic treatments twice a day, PROPER dressing. The thing finally healed, the doctor was no specialist and did a great job. After a self inflicted one to my leg afterward later I went back and happily had that one taken care of.

    Love the Wound Center, as long as it's a good one and it can love you back.

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