Recognizing And Addressing The Impact Of The COVID-19 Tidal Wave On Lower Extremity Wound Care

Lower extremity wound care has changed dramatically. A few months ago, we provided regimented care to our patients with ulcers. We identified and treated infections seamlessly. We referred patients with vasculopathy to vascular surgeon colleagues for endovascular or open bypass procedures to restore blood flow. We would perform elective surgery procedures to relieve ulcer-causing deformities.

Then the COVID-19 pandemic turned health care upside down, shattering the wound care supply chain in the process.

We have recently heard about a broken supply chain in the meat industry. I believe we are seeing a similar issue with the wound care “supply chain” falling apart.  

Undertreatment. I have noticed patients forgoing care in fear of catching the virus. Some patients are trying take care of their wounds themselves with varying degrees of success while others neglect their wounds completely. Patients may not always get the appropriate dressing deliveries due to shipping delays or they did not always apply the dressings correctly. Patients have often had to evaluate the condition of their wound with limited mobility, impairments of vision and/or without the proper knowledge of what to look for. Debridements could not take place.  This made it hard to evaluate wound depth, especially for those with tunneling wounds. 

Telehealth. My practice was quick to adopt this opportunity. Telehealth is a saving grace for some patients. I am able to talk to patients and look at their wounds, but this did not go off without a hitch. Some patients do not have computers or smartphones. Additionally, limitations on the quality of the camera makes visualization difficult at times. I cannot palpate areas to feel warmth or fluctuance. I feel helpless on telehealth visits when I cannot adjust offloading for a worsening wound.

Home health care. Home nurses became sick and could not come to houses. Other nurses were not let in homes due to patient fear about contracting the virus.  Some nurses stopped doing these types of calls. The decrease in overall home health visits led to the closure of two home health agencies in my region. These patients were abruptly left without care and had to scramble to find alternative arrangements. Other agencies were too busy and unable to take on new patients due to lack of staff.  I found myself on a telehealth visit trying to explain how to change a dressing via Facetime to a patient or patient’s family member who had visual impairment. This certainly isn’t the level of care that I usually provide but the best I could do under the circumstances.

Facilities. Facilities became a difficult to contain breeding ground for COVID-19. Patients at rehabilitation centers, nursing homes and short-term care facilities went on lockdown. Limited doctors remained on-site and some facilities did not allow people into the facilities. Most would not even allow for telehealth due to staffing issues. It was a complete blackout. Many of these facilities had much bigger issues to worry about than a foot wound.   

Social factors. The underestimation of all of this was the social effect. Social isolation also played a big role. Depression and isolation caused some patients to overeat. Being stuck at home also led to less activity and blood sugars skyrocketed in a number of my patients. Many at home did not wear shoes at home and therefore did not have offloading a majority of the day.

Tidal wave. Now here comes the tidal wave. There is a large influx of patients coming in with infections. Some have exposed bone exposed while others have the start of gangrene. Cellulitis is common. Patients need antibiotics reinstated. New radiographs and advanced imaging are necessary.  I have scheduled infection-related surgeries every day for the last two weeks.  

Denouement. Why are the patients coming in now? Some are coming in because they realize that their condition is worse. Relaxing shelter in place restrictions reported in some areas on the news and “quarantine fatigue” are other reasons. Whatever the reason, I am grateful to see these patients again and reestablish care. 

What do we do about this situation? I am instituting recall campaigns for these missing patients. We will e-mail them, send them a postcard or just call them. If your patients are not engaging in telehealth visits, please encourage them to do so. It is hard to control all of these factors. Fear is hard to mitigate. Prepare for this tidal wave. It will likely come to a town near you.

Dr. McEneaney is a Diplomate of the American Board of Foot and Ankle Surgery, President of the Illinois Podiatric Medical Association and Co-Director of the Northwest Illinois Foot and Ankle Foundation Fellowship. He is the owner and CEO of Northern Illinois Foot and Ankle Specialists.