04/01/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)
Medical Perspective:
Decubitus or pressure ulcers occurring in the acute spinal cord injured population is a regrettable and preventible complication in the acute spinal cord population and can rarely be explained by another cause other than poor nursing care. Decubitus ulcers will delay or interfere with acute rehabilitation efforts, causes significant morbidity and mortality, prolongs hospitalization, and leads to dependence rather than independence. It can also lead to significant depression.
Pressure ulcers are simply caused by pressure. Higher the pressure applied, the shorter the period of time the tissue of the body can be exposed to pressure prior to the onset of tissue death. Studies have shown that the tissue that will breakdown first is muscle and the skin is much more resistant to pressure. The effect of this is normal or intact skin with death of the muscle underneath the area of pressure which will subsequently cause the skin to break down. There are other factors that will make tissues more susceptible to the effects of pressure which would include moisture, malnutrition, anemia, and shear.
Decubitus ulcers are staged by severity under the National Pressure Ulcer Advisory Panel according to the depth of the ulcer. Stage I ulcers will be redness which persist in intact skin. Stage II ulcers involves loss of the outer layer of skin (epidermis) into but not thru the inner layer of skin (dermis). Grade III ulcers extend thru the skin into the subcutaneous tissue but not into the muscle. Grade IV involves ulcers that extend into muscle and bone. It is this author’s opinion that this grading system clinically helps but may not accurately describe the true extent of an ulcer. For example, in the African American population, Grade I ulcers are difficult to identify because redness will be difficult to observe. Grade II wounds can intact be a Grade III or Grade IV decubitus because the skin is much more resistant to pressure than the underlying muscle.
Intact skin often harbors a deep tissue injury because the underlying muscle dies prior to the break down of the more resistant skin. I had a patient young African American spinal cord injured patient who I saw for the first time in my clinic with complaints of increased spasticity. Close inspection of his skin showed a 0.5 cm circular area of depigmentation on his butt (skin became white) under a pressure point where he sits. I told him to go to bed with no sitting, and turn side to side for absolute pressure relief. One week later on follow up there was some scant drainage from the area of depigmentation. I admitted this patient, placed him on a 100% pressure relieving bed (cliniton bed) and over 5 days with absolute pressure relief the skin then died. This patient on surgical debridement had a wound the size of a grapefruit and we ended out performing a muscle flap and he was later discharged to home. The cause of his sore was not related to sitting in his wheel chair but caused by his desire to take long baths without carryout his pressure reliefs. This is an example of how the skin is often the last tissue to breakdown and that Stage IV ulcers may in fact precede Stage I changes.
Stage III and IV decubitus ulcers are catastrophic complications in the acute spinal cord patient and in my medical opinion are most often caused by poor nursing care. It is well established in the medical community that these patients are at high risk for skin ulcers and must be turned side, back, side every two hours and that their skin must be meticulously inspected by nursing personal on every turn to check the pressure points for signs of tissue damage. In patients with multiple associated injuries it is sometime very difficult to obtain pressure relief by way of turning. These patients must be place early on a clinitron bed which will absolutely provide pressure relief without the need for turns. It is this author’s opinion the clinitron beds should be used in situations where pressure relief is impossible to prevent a decubitus ulcer instead of merely utilizing one to treat a deep tissue injury.
‘The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during one admission, and $124,327 for community-acquired ulcers over an average of 4 admissions.’ This is a tremendous hard cost. In the acute rehabilitation patient a deep Grade III or Grade IV decubitus ulcer will interfere with rehabilitation efforts, cause prolonged hospitalizations, lead to depression, dependence rather than independence, and increase the morbidity and mortality of the acutely injured spinal cord patient.
Life Care Planner Perspective:
A properly constructed life care plan will serve as a guide to future medical, rehabilitation, and day to day needs of a catastrophically injured patient. A life care planner is a medical professional with experience in the case management of catastrophically injured patients. The role of a life care planner is to provide an objective in the evaluation of the needs of the patient and provide a guide of future medical treatments and care into the future that is medically necessary and appropriate for the patient to prevent complications, improve functional outcome, and improve the overall psychosocial welfare of the patient. The earlier that a life care planner is involved in a spinal cord patient the better. A life care planner can evaluate the available scope of services, medical expertise, and outcomes available at community based acute rehabilitation program and compare those services to what is offered at a Model Spinal Cord Injury Systems Program and give their recommendations to the patient and the families. A life care planner will need to inform the patient that a study showed that the incidence of decubitus ulcers at a Model Spinal Cord Injury Systems Hospital with their well trained professionals in the care of spinal cord patients substantially decrease the risk of this complication compared to community based rehabilitation facilities. Further, a life care planner, as a expert in case management, should be able to research the facilities that offer the state of the art wound care to optimize wound healing in an unfortunate patient with this preventable complication. Further, life care planning involves evaluating and recommending all care necessary to prevent this type of complication going forward as a patient ages which would include equipment evaluations, physical therapy, aid and attendant care, and wheel chair and wheel chair accessories needs.
Lawyer’s Perspective:
A competent lawyer must provide a foundation (evidence) for the court for all future medical cost that are a direct related to the spinal cord injury. Future management of medical complications more likely to occur than not that are related to a spinal cord injury would be one of the included cost for future damages and over the projected lifetime may be a substantial amount. Up to 79% of patients with prior decubitus ulcers will have a reoccurrence. A serious injury lawyer must provide evidence in the form of medical testimony that reoccurrence of a significant decubitus ulcer in the future is more likely than not to occur for this cost to be included in damages. Also, pain and suffering would be a large component of an award which are not typicaly capped at an arbitrary amount in any jurisdiction and testimony for the patient, family, and care givers regarding the misery that occurs with bed confinement, prolonged IV antibiotics, and surgical procedures will be compelling evidence to base damages.
Media Information:
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