Thursday, December 20, 2007
I was in the ER yesterday seeing a consult when I noticed a goddawful odor in the slot next to me. Nurses were actively spraying the hall with deodorizer as I asked what the hell was going on. Oh, it's actually a guy you know, I was told. The nursing home sent him over. I read the chart and realize it's an old guy I had operated on about 6 months prior for fulminant c diff colitis. I did a total colectomy and end ileostomy. He was a demented old guy, but in relatively good overall health. Somehow he survived the c diff episode and recovered and was transferred to a long term care facility. Apparently he had developed sudden hypotension and tachycardia and the nursing home sent him right over. No mention was made of the sickening odor the poor guy was emitting on any of the transfer forms. I say hello to his wife, who was sitting ever vigilantly by his bedside, and examined him. The belly looked fine. Stoma functioning well. The nurse helped me roll him over and the sight was something out of Night of the Living Dead. I've seen some nasty decubitus ulcers in my time, but this was absolutely horrifying. The skin and subcutaneous tissue had almost liquefied and a black dead escar extended almost to his lumbar spine like a glaze. His WBC 24k. Lactate 2.8. Pressors already started. We carted him to ICU and I got three nurses to help roll him over again. In these situations you don't need anything fancy. A clamp to grasp tissues and something sharp to cut it with. I found a hemostat and a scalpel in the supply room and went to work. And by "work" I mean literally filleting chunks of dead flesh from his sacral area. Two nurses had to leave secondary to near fainting or extreme nausea. I could feel the odor seeping into my pores. You cut and cut until you get tissue that bleeds. Must have been a pound or two of gunk on the bed by the time I was done. He didn't feel a thing. I hadn't done something like this since early residency; senior level surgical staff always tries to pawn off the crapola decubitus cases on juniors. But the guy needed it. He was septic and dying from an ulcer. He's doing much better today.
Decubitus ulcers are a problem in institutionalized patients. Studies suggest that all it takes is 32 mmHg of pressure applied to an area for two consecutive hours to overcome capillary pressure and thereby impede perfusion of cells. The typical mattress applies 150mmHg of pressure. Pressure sores are an epidemic in certain patient populations: para/quadraplegics, the demented, institutionalized patients, and patients on vents in the ICU. Precautions such as off loading and frequent rolling of the patient and some of the newer air mattresses can help, but the work that goes into prevention can be taxing to nursing personnel. Especially in nursing homes. It's troubling though, nonetheless, that an institution in the United States of America would allow an ulcer to progress to this level of rancidness. I'm certain that odor didn't acutely present itself.