When Your Toe’s On The Line

Synthetic skin graft sparks speedy closing of diabetic foot ulcer

The seeds of the mobile detailing business that Harold Smith has been running since he was a teenager were planted during his youth, when he would happily tag along with his father to help wash and wax the family car.
In business for more than 30 years, Harold does more than detail cars. He coaches youth and semi-pro football and runs a youth development program. The latter venture is where Harold does his most important work.
“Not long ago, a judge ordered four troubled teens into my program,” Harold says. “Now, two of those kids are managers at a McDonald’s and another is working for a major industrial company here in St. Augustine. They’re doing well.”
Harold, 52, is doing rather well himself these days. That wasn’t the case last fall, though, after he discovered that his ongoing battle with diabetic neuropathy had left him with a badly infected open wound on his right big toe.
“The neuropathy causes my legs and feet to swell up and go numb, so I never felt any kind of pain in that toe,” Harold explains. “The only I way I found out I had the wound was from the awful odor I smelled one day after I took off my compression socks.
“It was actually my nephew who noticed the wound. He was helping me take off the compression socks, smelled the odor and said my toe was cut and bleeding. I went straight to the emergency room after that.”
The infection was so deep that Harold was admitted to the hospital, where he was told he might be facing amputation. Before taking that step, though, his doctor set him up for home health that was provided in part by Advanced Wound, Ostomy and Continence Care.
50 Years of Experience
The four advanced practice nurses at Advanced Wound, Ostomy and Continence Care boast more than 50 combined years of experience in providing wound care, ostomy care, dermatological care, continence care and patient education.
“We are a patient-centered practice that uses evidence-based modalities in the treatment of our patients,” says team member Kristi Lord, DNP, MSN, APRN, FNP-C, CWS. “We treat venous leg ulcers, diabetic foot ulcers, pressure ulcers and all other kinds of wounds.
“There is absolutely nothing on your body that we won’t try to fix if it has something to do with the skin or excretion. I say that because wounds and excretion are correlated. If you don’t properly rid your body of waste, your wounds are not going to heal or you are going to wind up getting wounds you didn’t have before.
“Our goal is to help people live comfortably and, in terms of our continence care, we mainly instruct our patients how to improve that issue through pelvic floor exercises, therapy and education.”
When Kristi first visited Harold in October, she knew immediately that she was dealing with a deeply infected diabetic foot ulcer. The wound measured an inch in circumference and covered almost the entire tip of the toe.
“The location of the wound on the very tip of Harold’s toe was very common for diabetic foot ulcers because that’s where the end of the blood supply system is,” Kristi points out. “That’s where the capillaries are the smallest and most fragile.”
In caring for Harold, Kristi began by performing an aggressive debridement, which is the removal of dead, damaged and infected tissue to promote healing. Almost immediately, she found evidence of a deeper problem.
“During the very first debridement, I hit bone,” Kristi says. “When you hit bone in a wound like that it usually means there’s osteomyelitis, which is an inflammation or swelling of the bone. The first thing I did after that was send Harold for an MRI.”
The MRI came back negative for osteomyelitis but, taking no chances, Kristi prescribed an oral antibiotic to ensure any swelling stayed at bay. She then began debriding the wound with what she refers to as her “secret weapon” in the fight against infection.
“I switched to Iodosorb, or cadexomer iodine, which is a time-release iodine,” Kristi says. “It’s a gel that is applied to the wound that acts as a debrider and helps keep the wound bed clean between debridements.
“And keeping the wound clean is hard to do with foot ulcers because foot ulcers are dirty. They get infected so fast that you must use an antimicrobial (wound dressing) on them or you’re just asking for more trouble.”
Overdrive Shift
It took two months of weekly cleanings, but the cadexomer iodine eventually erased the infection. Kristi then began treating Harold’s wound with a synthetic skin substitute, or graft, that was applied during each debridement. That sparked a significant change.
“Once we started putting the grafts on, it was like the healing process went into overdrive,” Kristi recounts. “And that’s what we expected because the grafts are a great product. They really accelerate the healing.”
Kristi continued to place a new graft during each weekly debridement for eight weeks. During that time, Harold’s wound healed and closed so rapidly that Kristi was “blown away” by the results. But Kristi refuses to take all the credit for the positive outcome.
“Patient compliance goes a long way,” she notes. “If the patient makes me work uphill, the wound will still heal, but it’s going to take a lot longer. The bottom line is, don’t mess with my work.”
Harold was diligent in following Kristi’s directions.
“He left the dressings intact and didn’t get them wet or rub them off,” she praises. “He also did a great job with his diet, eating good food that was high in protein and low in fat and sugar, which is critical in healing diabetic foot ulcers.”
Harold had good reason to remain compliant. In addition to fearing the possible loss of a toe, he has “a lot of people that depend” on him, including the youngsters participating in his development program.
“I needed to get myself right for lots of reasons, and Ms. Kristi helped me with that,” says Harold, who also started a weight-loss program. “For six months, I couldn’t wear shoes because of that wound, but Ms. Kristi took care of that.
“I’m wearing shoes again now, and my toe looks good. It’s all healed up, so I can’t thank Ms. Kristi enough for all that she’s done for me. She’s did a great job.
“She’s a good-natured person who has a great personality. If she’s having a bad day, she’ll never let you know it. And she does great work. I can’t thank her enough for all she did for me, and if I ever get another wound like that, I’m going straight to her.” ■
© FHCN article by Roy Cummings

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