A Sore Subject: Anatomy of a Killer

by Lori A. Wood

At first glance, pressure ulcers can seem rather insignificant, compared to the other physical challenges that people with spinal cord impairment (SCI) face. In light of actor/activist Christopher Reeve’s recent death, this perception has been exposed as a fallacy. Pressure ulcers can be dangerous, even deadly, but the sad truth remains that many people don’t fully understand the magnitude of the threat.

Sores Can Happen to Anybody

Pressure sores are known within the medical community as decubitus ulcers. “They can happen to any bed-bound patient, regardless of what’s causing it,” says Dr. Harold Brem, director of the Wound Healing Program at Columbia University Medical Center. People can have them in multiple places on the body at one time, including: the heels, sacrum (the area just above the buttocks), the buttocks themselves, and the hips. “There’s a mythology that says that they can be prevented, but it’s really never been established. That’s based on a 1961 paper, which said that you could just turn every two hours, but that was never really proven. That belief took on a life of its own, and therefore, the whole field was focused on prevention, rather than diagnosis and treatment. That’s a problem. The solution is to turn the patient and provide treatment.”

Patients with SCI may encounter many health problems, such as pneumonia, urinary tract infections, and spasms. While no one argues that these conditions should not be treated with medication, pressure ulcers are not necessarily viewed the same way. At least 28% of patients with SCI are known to have this problem in their lifetime.

“Anybody who is bed-bound can get a pressure ulcer,” Dr. Brem explains. “You should never feel guilty or bad that you didn’t take care of yourself. You should consider it an emergency and get treatment right away. Every week, have a measurement taken to make sure that the wound is getting better.”

Pressure Relief

Unfortunately, there is no FDA-approved drug for the condition.

If not with medication, how can pressure ulcers be treated? “Make sure you’re in the best possible chair or bed that relieves pressure,” Dr. Brem advises. “There are superb pressure-relieving beds out there now, and, in the last two to three years, there have been several different technologies that really have advanced the field very dramatically.”

An example of such technologies would be the newer model of the Clinitron bed, which provides good pressure relief and is easy to get into and out of. Additionally, there are companies that make pressure-relief beds that turn a patient. “There are also tremendous technologies in alternating air beds,” Dr. Brem says.

How Sores Progress

Should these methods of removing pressure from the wound fail to heal the ulcer, it may start to worsen. “Once there is an opening in the skin, there are bacteria that are living there, so you could become infected at any time,” Brem states.

Though they often start out as tiny ulcers, a pressure ulcer is considered to be worsening if it gets bigger, deeper, and starts to drain fluid. This is a sign of trouble. “If there’s drainage, that probably means infection, and you need to make sure that the wound is cleaned,” Brem said. “You should make sure that you’re getting some form of medication for the drainage. The wound should be properly cleaned, before the infection gets into your bloodstream. That’s the most important thing.”

The symptoms of wound infections are often mistaken for pneumonia or urinary tract infections. According to Brem, it’s important to understand that surgeons, medical students and doctors are not taught about medical care for pressure ulcers in medical school. It’s not a formal part of training, and therefore, unlike other diseases, there are no courses or training offered on the topic. Therefore, they may not have this knowledge available to them.

Another myth about pressure ulcers is that bacteria, which are present in all wounds, are not necessarily harmful to the wound and patient. “It’s just not true,” declares Dr. Brem. “That’s by far the most important myth to break. Bacteria do contaminate certain sites in the body where they do not cause harm, but when a wound is infected, certain types of bacteria can spread into your blood. Patients should be advocates for themselves, to make sure that their wounds are cleaned and, most importantly, healing without cellulitis or significant drainage. Dead or nonviable tissue should never be present.”

To determine whether or not a wound is healing, you have to have an objective measurement. “In today’s day of digital technology, you should have someone take a picture, with a ruler, to see if it’s objectively healing and closing,” suggests the doctor. The absence of drainage and evidence that the wound is filling in with healthy, red tissue are more signs that a pressure ulcer is on the mend. “After treating thousands, I’ve never seen a wound that doesn’t heal.”

According to a study done by the United Spinal Association, on average, most pressure ulcers are 47% healed over four weeks. “United Spinal spent two and a half million dollars funding this work and showing this data that pressure ulcers do get better.” Though these statements may give cause for optimism, Dr. Brem cautions that the process can be slower for some patients. “The more severe ones are slower to heal,” he explains. “Some can take many months, or up to a year.”

No Magic Bullets

Dr. Brem stresses that there isn’t one cure-all solution to the problem of pressure ulcers. “The idea is that pressure ulcers are easy to treat- they’re not,” he says. “Often, you’ll have to do many things, like every other medical disease. Some people might benefit from nutritional supplements, or a type of anabolic steroid that has been suggested to help build up healing for pressure ulcers. Some people might benefit from oral or intravenous antibiotics. Some might benefit from surgical debridement [the process of removing affected tissue], some people might benefit from topical antibacterial drugs. There are no magic bullets here.”

Nutrition can affect a person’s ability to heal. One way to measure overall nutrition is with a lab test for albumin, a protein that reflects a person’s nutritional state. “Anybody should take regular nutritional supplements if their nutritional markers are down,” recommends Dr. Brem.

The staff of the Wound Care Program also checks to make sure that their patients have suitable beds and wheelchairs to help alleviate pressure ulcers. “The less movement you have, the more you’re bedbound. The more you’re bed-bound, the more likely you are to get a pressure ulcer.”

Aggressive Treatment

A third myth says that, just because you’re ill, pressure ulcers are inevitable. “You may develop them because you’re sick,” Dr. Brem acknowledges, “but you should be able to heal, even if you are sick.”

This false perception of inevitability may have been a contributing factor in Christopher Reeve’s death. “Reeve spoke out about bedsores many times,” Dr. Brem says. “There’s no doubt that he didn’t get care. Had I not worked for the VA in the Spinal Cord Unit for several years, I myself never would have treated ulcers as aggressively. I myself was taught not to treat them, so I’m sure that that’s what happened to him.

“One of the biggest myths is that if the wound doesn’t look bad, and drainage is normal, it’s not a threat. These are myths that patients should never accept. Your wound may look good, but it may kill you. The risks of not treating it are much higher than the risks of treating it. People should seek medical attention immediately. They should never wait. You wouldn’t wait for an appendix, and, similarly, you shouldn’t wait for a pressure ulcer.”

When the bacteria from an infected ulcer enters your bloodstream and spreads the infection to multiple sites throughout the body, a condition called sepsis occurs, which can be fatal. According to Dr. Brem, death need not be a foregone conclusion for patients with SCI with pressure ulcers. “This became my life-long work,” he says. “Every single patient should be getting better. There’s no reason people have to die.”

Lori A. Wood is a frequent contributor to Orbit.