THE BEDSORE THAT ATE PHOENIX

The bedsore on Renata’s coccyx was the stuff of a horror movie chronicling the hit-and-miss care of most nursing homes:

“While the starched white sterile world bustled about Renata’s hospital bed, oblivious to the fact that pure evil was growing on the warm, moist area of her backside, the decubitus was taking on an insidious life of its own. The bedsore had developed an infection-spawned brain, functioning on a rudimentary level and intent upon feeding its insatiable hunger. Several of the aides noticed that not only was the bedsore not abating with salve and dressing changes, it seemed to grow larger and more powerful each time it was cleaned and dressed.

Heavily sedated, Renata did little more than moan as the monstrosity swallowed her whole body with one gulp. After eating her night-stand and bed, it lumbered down the midnight hallway, devouring everything in its path, until it emerged into the darkened streets of Phoenix, Arizona, evil and ravenous…”

Taber’s Cyclopedic Medical Dictionary defines a decubitus, or bed sore/pressure sore thusly: “Ulceration and gangrene of a localized area, due to pressure from prolonged confinement in bed. Emaciated, weak, elderly patients and those who must remain in one position because of orthopedic or similar problems are especially likely to develop decubiti.” Taber’s does not mention the number one cause of bedsores – inappropriate staffing in residential care facilities.

Bedsores are nasty, hard-to-heal lesions. They stink like the rotting flesh that they are, easily become infected, and cause a great deal of discomfort for the patient. More care unit hours are expended in managing a bedsore than would have been spent to have completely prevented it.

Elderly people with limited mobility and a compromised nutritional status are especially at risk. To prevent these minions of suffering, those at high risk should have a dietary consultation to determine if they are receiving adequate nutrition. If a person is immobilized in either a bed or a chair, turning and repositioning at least every two hours is of paramount importance. The skin must be kept very clean, dry, and well lubricated, and assessed every time that it is exposed in bathing, changing clothes or incontinence care. Bony body prominences, such as hips, coccyx, and elbows should be especially watched for any kind of reddening which does not blanch when pressed.

There was a time, not so long ago, when bedsores were not acceptable. A bedsore, or decubitus, was indicative of bad care. These days, they are quite acceptable in the best of long-term care facilities, and are indicative, not especially of bad care, but rather, bad staffing. Aides simply do not have the time to turn, reposition and assess. Frequently, aides not only care for a 30+ patient load, they must also assist in serving meals and other chores which should be performed by staff members not involved in direct patient care.

The reason? Money. It always comes down to money. Facilities staff only enough aides to get them by, not enough to provide quality care. In the year 2000, the Tucson Daily Star reported that nursing home residents received only an average of two and one-half minutes of personal care per day. This is not even enough time to give a good bed-bath, and staff has only become sparser in the past seven years.

I telephoned the Arizona State Board of Nursing to inquire as to what the law says regarding aide-to-patient ratio. There is no law. Currently, the number of patients assigned to one aide is entirely at the discretion of the facility.

Renata was an eighty-three year-old cancer patient who had received her yearly twenty-nine days of Medicare-paid nursing home stay. Since, after the initial twenty-nine days, she and her family had to pay for her care themselves, they opted for care at home instead of continued care at the facility.

Renata was admitted to local Hospice Services, and Angel Team was called to provide around-the-clock care.

In conferring with Jane, Renata’s primary hospice nurse, I learned that Renata had developed a decub during her twenty-nine days at the nursing home. “It’s awful,” Jane told me. “Prepare yourself.”

An inservice for our aides was scheduled for 1:30 in the afternoon. When I entered the patient’s bedroom at 1:15, two of our aides were already there. Lillian, the senior aide, was gloved and holding a gauze square with hemostats. She looked sick.

Jane handed me a bottle of camphorated oil. “You might want to put a little of this under your nose,” she whispered. I grabbed the bottle just as the smell of putrefying flesh almost knocked me to my knees.

Renata was positioned on her right side with the aid of pillows, facing away from me. “I’m showing the girls how to clean and dress the wound, “ Jane explained.

I only vaguely heard Jane as she walked Lillian and Karen through the wound cleansing and dressing change. I felt as though I would pass out any second. I had never seen a decub as cruel as the one on Renata’s coccyx. The wound itself was as large as my hand, with hard, blackened gangrenous edges. The open flesh was infected, red and angry. Renata’s tailbone was quite visible; the coccyx was exposed. The elderly lady had had a bowel movement, and Lillian and Karen were diligently cleaning all visible traces of feces from the open wound with sterile gauze and normal saline solution.

When I regained my composure, I whispered to Jane, “Why hasn’t this wound been debrided?’ Serious decubs are commonly debrided, but this one, with its ragged, hard black edges, obviously had had no such surgically cleansing procedure.
“Because of Renata’s condition, Jane explained. “Her cancer has metastasized, and her doctor believes that death is only days away.”

Renata lived longer than had been predicted. Our team worked constantly on that bedsore, and we resented the wound because of the time it took away from Renata, herself. Her last days could have been spent with more loving, comforting care to her whole person, rather than cleaning and dressing the monstrosity on her backside. We could have spent more time reassuring her, comforting her family, reading to her, anything but what we had to do - work constantly on the decub.

What a cruel thing! That grand lady could have passed form this life with grace, dignity and much more comfort if only the bedsore had not been allowed to develop. In my opinion, bedsores are a crime against the elderly and infirm because they are preventable with good care.

There is a sensible, cost effective solution to the problem of low staffing vs. good skin care:

Each twenty-five patients receiving nursing home care should have one aide per shift, trained by the nursing home L.P.N. or R.N., whose only duty is skin care. This aide-of-my-wildest-dreams would be constantly on guard for reddened areas, small sores or other indications of developing wounds. She/he would assess each day, chart each day, and report each day on each patient. She would not have to be paid any more than standard scale for a floor aide, and the care centers would save money with preventative care.
It is my belief that “Prevention of Pressure Sores” should be a disease management issue with Long Term Care Providers, right along with the “big four” of disease management, Diabetes, COPD (Chronic Obstructive Pulmonary Disease), Osteoarthritis and CHF (Congestive Heart Failure). Nursing homes would also benefit by preventing the noscomyal infection of MRSA (Methacillin Resistant Staph) which has swept the nation’s long-term care facilities for the last twenty years.

Therefore, in my Almost Perfect World of elder care, Long-Term Care Providers would
address and effectively manage:

· Diabetes
· Osteoarthritis
· CHF
· COPD
· Pressure Sore Prevention