Why This Doctor Chose Wound Care: Part 2

Today’s Wound Clinicshares the journey of one wound care physician as she works her way through a fellowship program. This is the second in a series of articles. 

I have spent a great deal of time reflecting on what I love most about my job over the last few weeks. Sometimes, I think it is the procedures. Other times, I’m convinced it is the patient interaction. One thing that is certain, however, is that while my days are filled with similar-looking diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs), what I really enjoy is listening to the “stories” behind each one. The treatment for these ulcers may also be similar, but each and every one has its own identity because of the individual patient. With this article, I will share a recent week’s worth of stories. Call it “A Week in the Life of a Wound Care Physician,” if you will. As I write these stories, I realize that they each have taught me something. Being in this profession, the learning will never cease. I cherish every lesson that I have to learn from my patients, and I hope that I am helping them learn about their healthcare as well.

MONDAY

Every physician has those few patients who they are really excited to see. Today is one of those days. This particular patient is a returning “new” patient, and he is one of the sweetest people anyone could hope to meet. We last saw him in the office several months ago for a DFU with underlying chronic residual osteomyelitis. We had broached the topic of hyperbaric oxygen therapy, but he has an extreme fear of enclosed spaces. We had referred him to podiatry for surgical management and learned that he was readmitted to the hospital with a supratherapeutic international normalized ratio (12.9 to be exact) and had experienced a major heart attack
followed by ischemic cardiomyopathy. When he arrives to our office, he is wearing a defibrillator in preparation for a transcatheter aortic valve replacement. During his hospitalization, his legs had swelled severely and he developed typical venous ulcers. His cardiothoracic surgeon wanted clearance prior to proceeding with surgery. Despite this traumatizing ordeal, the patient has remained pleasant, optimistic, and grateful. “Thank you so much, Dr. Jill, I just want to get better,” he is fond of saying. Patients like him really warm my heart. His treatment plan is going to be extremely difficult due to his cardiac issues, but he will try to smile all the way through. His optimism is a great way to begin the week. 

TUESDAY

A solemn day here today. From time to time, you have those days where situations are difficult. The day starts normally enough, until a sweet, 80-year-old female who’s living with Alzheimer’s disease visits as a new patient, presenting with a Stage IV pressure injury to the sacrum. Recently hospitalized, the patient underwent extensive surgical debridement of osteomyelitis and is accompanied by her healthcare proxy, who is clearly overwhelmed. These cases are difficult because the patient is not able to reliably communicate how the ulcer impacts her life. I’ve spent a great deal of time explaining all options and, after a thorough discussion, the proxy decides on wound palliation. It is frustrating as a physician to admit that nothing much else can be offered to a patient. In this case, keeping the patient comfortable and eliminating as much pain as possible becomes the priority. We collectively formulate a plan to do just that. Soon after, I’m informed that one of the clinic’s long-time patients has passed away unexpectedly. I hadn’t known this particular patient long, but in the short time I knew her, she had really made an impression on me. The shock of this news stays with our staff the rest of the day. On the way home, I reflect strongly on how our patients affect our lives. I take the difficult situations of today and try to learn from them in anticipation of another day.

Wednesday

The final Wednesday of each month means one thing: vascular clinic! We are really lucky to have a great working relationship with the vascular surgeons in our health system. We attempt to make vascular consults easy for our patients by having them see a surgeon in tandem with us in our clinic. Today, we see a relatively young patient living with VLUs. I had been working with him for many weeks, trying to close a right lateral lower leg wound that just will not budge. We set him up to undergo comprehensive venous testing. As I am reading the report, my jaw drops.  The sheer size of his greater saphenous vein is astonishing — the size of some people’s abdominal aorta! It also has seven seconds of reflux and is shooting like a garden hose directly at the area of the ulcer. He is set to undergo endovenous ablation for the following week. Now, during all of this patient’s visits he talks about his kids and the activities he misses with them because of his ulcers. I’m going to hope that the next chapter to his story behind his ulcers will start after the ablation.  

THURSDAY

Today is a day for those atypical ulcers. We tend to go months without seeing any, but then we are inundated with them. One patient in particular sticks with me today because of the irony. A 40-something-year-old female who has spent the last four years trying to lose more than 300 pounds with diet and exercise alone, she began her weight-loss journey at more than 500 pounds. She has been taken off all her cardiac and diabetes medications, and as her weight has decreased she is left with a large abdominal skin pannus that hangs almost to the floor. Beneath that, she has a second pendulous pubic pannus. The large pannus has developed a foul-smelling necrotic ulceration. Unfortunately, due to the poor vascularity of the tissue, this wound will likely not heal. She is waiting for insurance authorization to undergo a massive surgery to have all the excess skin removed. In the meantime, she constantly worries about this wound and the odor.  What makes this so ironic is that when she weighed more than 500 pounds, she never expressed fear of being in public. She had become used to the staring and wasn’t anxious about using a wheelchair or motorized cart. Now that she has put in all the work of diet and exercise, she hates leaving her house due to her wound’s circumstances. Her fix is going to be surgery, and I believe this will change her life completely. Her story will hopefully end ulcer-free.

FRIDAY

Today I see a follow-up patient who I have been thinking about recently. He is a hard-working, active male who underwent surgery on his fractured left ankle four months ago. The bones and hardware healed well enough, but in his effort to “get back out there,” he dehisced his surgical incision. The wound deteriorated to the point that his extensor tendon was exposed, prompting his referral to our clinic. We have not been able to make much progress. I do not think this patient has been following the instructions for self-care that we have provided. He confesses to working on small projects (he works as a contractor) when he should be keeping his ankle immobilized. We had an extensive discussion at his last visit about what needs to happen for this wound to close, but I am not sure he is accepting the severity of his condition. I decided to try a new product that is indicated for placement over tendon and bone to see if we can make progress.  As we sit here one week later, I am glad to report his wound is one centimeter smaller in each dimension! Is the progress due to the new product? Or are his promises to me to wear his removable cast walker and behave himself finally being realized? Perhaps it is a combination of both. Honestly, all that matters to me is the progress. I have reapplied the product and will anticipate that we will see similar success next week. 

Jill Eysaman-Walker is an attending physician at Catholic Health working out of St. Joseph Hospital, Cheektowaga, NY, and Mount St. Mary’s Hospital, Lewiston, NY.  She lives in the region with her husband and two young children.