By Aletha Tippett MD
The great medical pioneer, Dr. Paul Brand, was right when he said it's not about medicine, it's about mechanics. Think of the ulcers you are asked to see and treat. I hope the first question you ask about any wound is "how did this get here?" If the mechanics of a wound are not addressed, the medicine will not be successful.
What if your patient is a woman who has difficulty with mobility and she presents to you with shearing wounds across her right buttock? Several questions need to be answered in order to understand the mechanics of the wound:
How does the patient move across her bed?
What kind of bed does she have?
Does the patient have a trapeze to help her move in and out of bed?
With questioning you find out she slides on her right side to get out of her bed. There is no medicine you can apply to her buttocks wounds that will help her, it is all about mechanics — how can you stop or reduce the shearing forces on her buttock? With the right support surface and ways to assist her getting out of bed, the shearing is reduced and the wounds can heal. With the mechanics fixed, then medicine can be applied with benefit.
Now let's take a look at another patient, a diabetic with neuropathy. This person has an ulcer on the bottom of their foot. It does not hurt because they can't feel it due to their neuropathy. You notice the foot is misshapen and realize it is a Charcot foot, the deformities caused by the bones in the foot slipping and breaking. If you did a Harris mat or other pressure mapping assessment and looked at the pressures on the bottom of the foot, you would see that where the ulcer is has high pressure. The ulcer will always be there unless you can alter the mechanics—you have to get rid of the abnormal pressure by either inserts to offload, total contact casting, or surgery. Only then can your medicine be used on the wound to heal it; without fixing the mechanics, your medicine is wasted.
It is the same process with a pressure ulcer on the sacrum. How long did the patient lay on a hard surface? It only takes 20 minutes to create a pressure ulcer. What support surface is the patient on now? Is it one that will adequately reduce pressure on the sacrum? Again, the mechanics need to be taken care of first, then the medicine can be applied.
Always consider the mechanics — look at the shoe, boot or sock the patient is wearing to determine if these are causing a problem on a foot or toe. Consider the dressing being used; sometimes the mechanics of the dressing can cause injury. Always check any hardware being used — a foley catheter, a wheelchair, DVT boots, pressure boots, oxygen tubing. All of these involve mechanics, a part of the equation that would need to be addressed before any medicine could be used successfully.
Please, if you don't know about Dr. Paul Brand, check him out. A good resource is The Life and Work of Dr. Paul Brand: Ten Fingers for God by Dorothy Clarke Wilson
About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.