Notes on Practice: Living with a Necrotic Wound: A Clinician’s Personal Journey

    Wound care professionals deal with necrotic wounds daily. We instruct patients in self-care as a routine task in our management plan.

The expectation is the patient will do as instructed and the wound will likely progress to healing. We are aware that the necrotic wound needs to be debrided or “cleaned up” — what we often do not acknowledge is how distressing necrotic tissue can be to the patient. As a wound care specialist, I decided to share my experience with a necrotic wound for two reasons. First, despite my education and training, when my body was involved I did not want to look at let alone care for the necrotic wound. Second, I want to encourage other specialists to be more aware that the patient’s feelings about caring for the wound can affect compliance and motivation.

Background

    In August 2003, I elected to have abdominoplasty to address what exercise and diet could not. To prepare for the surgery, I worked with a personal trainer — I followed an abdominal program for 6 months and lost 10 pounds. Although these are accomplishments, people asked me if I was pregnant, something I had heard for 10 years and continued to find rude and upsetting. I went forward with the surgery to put an end to these comments; I cannot express how distressing the question is, especially because I have never been pregnant.

     I had been on Nadolol for 7 years for supraventricular tachycardia. Before surgery, I had an exercise stress test for a piece of mind before having anesthesia — my brother had recently had a heart attack at age 54. Imagine my surprise that I could go off my medication. At the very least, the exercise and weight loss at least paid off for my physical health.

    Anticipating liposuction, I did a good deal of research before choosing my physician. I asked other nurses about their surgeries and outcomes, assessing patient satisfaction uncensored and literally seeing the results. Once I made my decision, I went for a preoperative visit, asking the usual questions regarding infection rate, surgery failure rate, complications associated with the surgery, anesthesia personnel, and whether office staff were advanced cardiac life support-certified. The physician disclosed that occasional infection was a rare complication. Knowing that not every surgery goes perfectly, I was relieved he was forthcoming about possible postoperative complications. Plus, as I wanted, the surgery would be performed in his office. I believed this decreased the chances of my acquiring an infection compared to having the surgery in the hospital.

    Although I had mentally prepared for liposuction, the physician explained that I would be left with the skin causing the distressing pregnancy comment, even if I continued the abdominal program and lost more weight. The problem could be resolved, however, by abdominoplasty. I was agreeable to a different procedure — anything to end the comments.

Clinical Problem/Treatment

    The surgery was uneventful. I woke, as anticipated from my training, with two pubic drains. I took ciprofloxacin daily until the drains were removed. Three days post op my drains started leaking. I secured gauze split around the tube but the wound continued to leak through my clothes. I split a semi-occlusive foam dressing to fit the drain site and changed it twice daily, eliminating the strikethrough. The drains were removed at day 7 and I used the foam dressing a few more days until the sites sealed.

    Complications arose. My umbilicus, transplanted as part of the surgery, became necrotic. I found out about it the day after surgery when my husband helped me change my compression garment. Because circulation had been impaired from the edema, my bellybutton was black. I released compression and watched the area. When I called the surgeon 4 days later, he agreed with my assessment and management of the situation and asked that I continue to watch the wound.

    Peroxide and polysporin had been ordered for my bellybutton. Although this didn’t seem appropriate, I didn’t want to undermine the surgeon’s responsibility for my problem, so I followed his instructions. Over time, the peroxide lifted the lower edge, dropping my stitches. I could not identify the base of the wound — with my bellybutton transplanted, I couldn’t identify the actual “stalk.” The surgeon didn’t cut it out; instead, he sewed it back down. I have never heard of sewing dead tissue down to allow a “live” segment to continue to heal, as he explained it to me.

    Sharp debridement was performed by the surgeon 1 week later with more stitches and Accuzyme (Healthpoint, Fort Worth, Tex.) applied to provide additional debridement. After the second debridement 1 week later, my umbilicus was 70% clean. I continued to use the debridement ointment until the wound was completely clean. The wound healed 9 weeks after surgery.

    That was the practical, clinical approach.

Personal Perspective

    Drains. I was shocked to realize how disgusted I felt when my husband had to empty my drains when we went home. He emptied only one — I took over the task 3 hours post surgery. That, too, was unsettling, knowing it was my body draining. I hated the site of the nasty Jackson Pratt drain cups in the bathroom. This was my bathroom, not a hospital! Yet I teach spouses to do the same thing every day without a second thought. My husband admitted, well after my recovery, that emptying the drains was not an experience he cared to repeat.

    Drainage. The drainage on my clothes, something that upsets me when it happens to my patients, was totally unacceptable. It made me feel dirty and depressed. I had only dreaded the drain removal and that was not as painful as I imagined. I hadn’t considered prolonged drainage. I teach patients to manage drains and to use gauze for drainage. This procedure was woefully inadequate for me and now I realize probably is for them as well. Unlike my patients, I was fortunate to have the access and knowledge to utilize a foam dressing. Presumably, patients must wait to see a professional to better address such problems.

    Complications. When healing complications occurred, I felt betrayed. I had planned this surgery for almost a year and had performed proper (I thought) preparations before surgery. As part of my recovery, I experienced several common emotional phases. I got off cardiac drugs (bargaining). I reasoned that I help so many people who don’t take care of themselves, why should this happen to me (whining, self pity). I questioned whether I was being punished for wanting a surgery based on vanity rather than crisis (faith testing). I even checked whether my emotions were hormone-based (they were not). I considered whether the anesthesia and surgery could affect my disposition when I became somewhat uncharacteristically apathetic and disturbed about concepts of self-care I deal with every day. I know that a patient is physically challenged after surgery and now I realized anesthesia can exacerbate negative emotional responses.

     I lied to my husband when he asked why my bellybutton was black (“It’s just a scab”), using my specialist status to reassure him. Inwardly I obsessed, noting the size of necrosis and checking it hourly for a few hours immediately post surgery to make sure it was not necrotizing fasciitis. Although I knew that was not a likely option, my mind was flying with thoughts of potential wound infection. Would the black tissue continue advancing? I could die. Yet I didn’t call the doctor for 4 days because I did not want to deal with the answer if I was wrong, days that could have been critical. Now I have a better understanding about why my patients wait so long to seek treatment. Perhaps, like me, they did not want to deal with the possibility of bad news.

    While using the hydrogen peroxide treatment, I called the surgeon’s office and told him, “Cut out this nasty dead thing or I will cut it out myself!” He instructed me to come to the office immediately. Great, I thought. I can get rid of the sloughy, nasty thing on my body. Then the phrase “leap of faith” took on a new meaning when he decided to suture the dead tissue to my abdomen shortly before I was to leave for a conference. How could I have allowed this? I thought cellulitis would follow for sure. I sniffed under my shirt 20 times a day that week, determined not to inflict repulsive odors on others. I felt completely unattractive, knowing I had a rotten piece of flesh on my stomach. The day after the suturing, the stitches turned pink - was I getting septic? Thankfully, the erythema resolved in 48 hours and I did not get cellulitis or become septic. This made me more aware of concerns patients may have when we ask them to take a leap of faith and agree to care options they don’t understand. Plus, I was fortunate to have the means to utilize both sharp and enzymatic debridement. Not all patients can afford the options that would improve emotional as well as physical recovery.

    “Walk a mile in my shoes”. The postoperative experience exposed me to many emotions I did not expect. Betrayal, loss of control, fear of the future outcomes, and apathy were ever present during the physical recovery. My faith was tested in my doctor, my body, and myself as the treatment plan rolled out. I did not like taking care of the wound every day. I felt all of this despite the fact that I should have felt more empowered by my wound care knowledge.

    Many colleagues have or had ostomies. I have always thought that they would be the best teachers for their ostomy patients. I hope I can take some of the insight gained from my experience and apply it to my wound care patients — I have learned support, reassurance, and explanation can never be given in excess.

Prognosis and Education

    Although some physical scarring remains, I have had a complete recovery. However, as I reflected back on my emotional responses to care, I wondered if the literature supports my reactions. The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease.”¹ The emotional quality of life related to wound care can and should be assessed periodically in the chronic wound care patient. Highly validated tools are available to provide social and psychological measurement in the wound care patient — they need to be more widely utilized. These issues also provide valuable future research opportunity for holistic wound care.

    Meanwhile, I am proof that emotional issues can have a negative impact on a patient even if the final resolution is acceptable and even if the patient is well educated on the risks and skills required for wound management. Sometimes, it is all about the journey, not the final destination.

1. Franks P, Collier, M. Quality of life: the cost to the individual. In: Morison M. The Prevention and Treatment of Pressure Ulcers. St Louis. Mo.: Mosby;2001:37-43.