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Time does not heal all wounds: Bedsores killed 'Superman', don’t let them fester

SINGAPORE — The man, who was in his 70s, had complained of pain. His family members realised something was wrong only when they started detecting an overpowering stench.

Time does not heal all wounds: Bedsores killed 'Superman', don’t let them fester

Ms Susie Goh (far left), executive director of St Luke's Community Wound Centre and St Luke's Academy, instructing nurses on how to place a pillow under a patient's ankle, which is prone to developing bedsores.

SINGAPORE — The man, who was in his 70s, had complained of pain. His family members realised something was wrong only when they started detecting an overpowering stench.

By the time they sought medical attention, the festering sore in the man’s buttocks was about 10cm wide.

Explaining how it happened, Ms Susie Goh, executive director of St Luke's Community Wound Centre and St Luke's Academy, said: “The patient could not walk well and was usually seated on a chair at home.

“No one realised he had developed a huge pressure injury until the patient complained of pain, and there was discharge and a strong foul smell.”

A senior principal wound clinician, Ms Goh has seen her fair share of patients with pressure injuries, commonly known as bedsores.

They occur when constant and sustained pressure reduces blood flow, damaging skin tissues.

Most commonly seen on bony areas of the body such as the heels and the sacrum (the portion of the lower spine that extends into the tailbone), pressure injuries are typically seen in patients with limited mobility.

Nurse clinician Dorothy Wong from the National University Hospital (NUH) said that those who are bedbound and remain lying in the same position for long periods of time are also at risk.

Ms Goh said that pressure injuries can occur in both the young and old, in hospitals, long-term care facilities and at home.

Professor Zee Upton, leader of the skin integrity, repair and regeneration theme at the Skin Research Institute of Singapore (SRIS), said that chronic wounds are a “hidden” health issue that warrants urgent attention. SRIS is a collaboration between the Agency for Science Technology and Research, National Healthcare Group and Nanyang Technological University.

“If you know a third of diabetes costs go towards non-healing foot ulcers, and that a major amputation (due to) a non-healing diabetic wound has a higher five-year mortality (or death) rate than that of cancer of the breast, prostate or colon, you would want to do something about it,” Prof Upton said.

She added: “Many people think that late actor Christopher Reeve, who played Superman (in the 1970s and 1980s), died due to spinal injuries. But it was actually due to complications resulting from an infected, non-healing pressure ulcer.”

A SIGNIFICANT HEALTHCARE BURDEN

Chronic wounds such as pressure ulcers are a growing epidemic globally. 

Prof Upton said that they are expected to affect at least 150,000 Singaporeans every year — a number that is set to increase with the ageing population.

The number of wound care cases seen at St Luke’s Hospital — the first community hospital with a dedicated wound ward — doubled from more than 1,000 cases in 2015 to more than 2,000 cases in 2017.

Studies show that pressure ulcers make up the majority of the chronic wounds seen in Australia. Prof Upton expects a similar trend in Singapore, given the higher levels of humidity and moisture that accelerate the breakdown of skin.

Citing data from the International Wound Journal 2016, Prof Upton said: “If we were to extrapolate (research) data from Wales and apply to Singapore, we would estimate (healthcare) costs of S$302 million for managing chronic wounds in 2019.”

In Wales, where 6 per cent of the population is affected by non-healing wounds, the cost of managing patients with chronic wounds is £328·8 million (about S$565 million).

BEDSORES CAN BE DEADLY

While most pressure injuries are preventable, low public awareness and lack of research in wound care among Asians mean that some cases go undetected until they reach the more advanced stages.

Infected sores can extend deep into muscle and bone.

Ms Wong from NUH said: “Pressure injuries may increase the risk of infection, leading to poor morbidity and prolonged hospitalisation. Ultimately, it reduces the patient’s quality of life.”

Every year, NUH sees about one to two cases of severe complications arising from pressure injuries that developed outside the hospital.

Ms Wong said that common complications include localised infection, osteomyelitis (inflammation of the bone due to infection) and fistula (an abnormal connection between two body parts).

An infected wound could become deadly, for instance, when sepsis sets in. This potentially life-threatening condition occurs when the body's response to an infection damages its own tissues and organs — as was the case with actor Christopher Reeve.

Prof Upton said that early-stage pressure injuries in Asian skin are generally more difficult to determine due to skin pigmentation.

“One of the early signs (of a pressure ulcer) is erythema (redness). In pigmented skin, this is not as obvious.

“Often, what happens is that the healthcare team starts seeing pressure ulcers too late,” she explained.

MORE RESEARCH NEEDED IN THE TROPICS

Wounds in the Asian population remain an under-researched area. For now, most wound guidelines are based on the Caucasian population, Prof Upton said.

This is set to change with the Wound Care Innovation for the Tropics programme, the first multi-disciplinary initiative focused on the healing and management of wounds in the tropics.

Launched last year, the programme — helmed by Prof Upton — looks into the research and development of novel wound healing technologies, such as one involving the use of biomarkers to better assess whether a wound is healing properly.

The programme also aims to establish the first Asian-based wound registry from data collected from NUH, Tan Tock Seng Hospital and Singapore General Hospital.

Prof Upton said: “We need to collect data to know the size of the problem, to make a case for what we can do to change this epidemic cost-effectively, as well as look into what we can do better on future wound care strategies.”

PREVENTION CARE IS KEY

Wound care is not a medical speciality, Prof Upton said.

In the hospitals, nurses are trained to prevent and treat pressure injuries. 

Ms Wong said that prevention measures include regular inspection of the patient’s skin condition, using appropriate support surfaces such as a pressure relieving mattress and turning the patient regularly.

Nurses also teach caregivers to prevent pressure injuries after the patient is discharged from the hospital, she added.

St Luke’s Hospital, which offers a wound consultancy service, has a set of protocols in place to assess and manage patients at risk of developing pressure injuries.

For example, at-risk patients are placed on support surface overlay or mattress, Ms Goh said.

Support surfaces are specialised devices that redistribute pressure. Some of them include features that can alternate pressure and regular airflow.

Such measures have helped keep pressure injury rates at St Luke’s Hospital at around 0.05 per cent.

Studies conducted in developed nations such as the United Kingdom and the United States suggest that its prevalence can be as high as around 32 per cent in hospital settings.

While early detection is important, Ms Goh said that prevention of pressure injuries is key.

“When a patient undergoes surgery, a surgical wound is unavoidable. But a pressure injury does not have to happen. If we can avoid a pressure injury, we should,” she said.

“Regardless of where the patient is recuperating, be it in an institution or at home, simple measures like rolling a towel or placing a soft pillow under the head or ear can help to offload the pressure, reducing the risk of pressure injury development.”

Related topics

bedsores wounds pressure injuries hospitals health Christopher Reeve

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