Atypical and Complex Wounds

For the wound healing process to be successful, it must pass through four stages: hemostasis, inflammation, proliferation, and remodeling or maturing. Wound healing requires inflammation, but it can be detrimental if it is persistent or encouraged by other factors, such as infection. It is during this phase that wound healing is most likely to stall.

By Bruce E. Ruben MD In order to heal a wound, the body needs oxygen, nutrients, energy and a fully functioning vascular system that brings those resources to the wound and takes waste products away from the wound.

The purpose of this blog is to bring special attention to common dermatologic conditions connected with drug addiction. Although drugs are well known for their significant impact on all body organs (liver, bladder, stomach, and kidneys), various physical manifestations of drug use are often unknown or underrecognized. Many clinicians and even dermatologists fail to see the many symptoms of drug misuse in the skin. Skin lesions caused by substance use may be induced by the drug itself, an allergic reaction, the drug administration method, or any contaminants or infectious agents that may have been mixed in with the drug. It is possible to identify substance users based on the shape and pattern of their skin conditions. Clinicians can learn these signs to better help patients.

Benjamin Franklin famously stated, “An ounce of prevention is worth a pound of cure.” This statement was made in reference to the importance of fire prevention in 18th century Philadelphia, but it aptly applies to modern diabetic limb salvage. The multidisciplinary model for amputation prevention has been in place now for almost two decades, but how far have we really come? Recent literature suggests that there has not been a significant decline in reamputation rates for diabetic patients despite the team approach to care. Diabetes is a complex and aggressive disease that affects multiple organ systems and robs patients of sight, sensation, limb, and quality of life. Treating such an aggressive disease is challenging, to say the least, and often the desired outcome is not achieved.

I was asked to perform a wound consult on a newly admitted resident to a post-acute unit of a nursing home. She rested quietly with a barely touched breakfast on her bedside table. Her aide had tried to feed her, but she accepted only small spoonfuls of oatmeal and a sip of orange juice. She came to our facility after a long hospitalization for COVID-19–related complications, including pneumonia, kidney failure, and septic shock that required pressor agents. While in the ICU on a ventilator, she developed a pressure injury. At 86 years old, her transfer papers revealed feeding tube refusal and a do-not-resuscitate (DNR) order.

By Aletha Tippett MD Tetanus is a multisystem disease caused by the bacterium Clostridium tetani. This bacterium is present in feces and soil. Tetanus has been mostly eradicated in the U.S. due to childhood immunization, however, there have been reported cases among immigrants, with higher risk behaviors such as body piercing and tattooing among young adults, and with failure to maintain adult booster immunization. Often, as adults, tetanus is not considered in overall health as evidenced by significant under-immunization with less than half of adults having current immunization. Other risk factors not well-recognized include diabetes, gangrene or chronic wounds, which increase the risk of tetanus to 50%. It is fatal in approximately 10-30% of cases. It may take anywhere from 3-21 days after exposure to the bacterium for the symptoms to become apparent. There is no test to diagnose tetanus, it is strictly a clinical diagnosis.

Medical misdiagnosis is common and can be caused by errors in clinical reasoning that arise from knowledge deficits, cognitive biases, and dual-process thinking.1 Dual process thinking is a generally accepted conceptualization of clinical reasoning that includes an initial intuitive assessment followed by a slower logical analysis. Misdiagnosis can arise during both of these evaluative processes.

Severe burn wounds are among the most debilitating injuries because they can significantly affect the entire body. The body’s inflammatory response to a severe burn injury can lead to fluid loss, dangerously low blood pressure, and shock.

By Holly Hovan MSN, APRN, ACNS-BC, CWON-AP In patients with end stage renal disease (ESRD), there is a decreased renal clearance that causes an increase in phosphorus, then calcium, in the body. Elevation of these two electrolytes causes the parathyroid gland to secrete additional parathyroid hormone to compensate. This, however, leads to increased movement of phosphorus and calcium throughout the body.