Q. I’m 63 and in my 26th year as a T11 complete para. I’m healthy, I eat right, I stay active and I still do a “mirror-check” of my skin every morning. My skin has always looked fine and I never had a pressure sore until last year when out of nowhere my right buttock became discolored and swelled up. I thought it was a blood clot, so I immediately went to my doc’s office. It turned out I had a bad pressure sore that had started at the ischium and worked its way out. I ended up needing skin flap surgery, and it cost me three months flat on my stomach.
I had been using the same brand of foam cushion since I got out of rehab. Thinking back, I hadn’t replaced my cushion in seven years. After I healed, I got pressure-mapped and found the type of cushion I was using no longer provided the support my skin now needs. I switched to an air flotation cushion for my chair and bought another one — low profile — for my car seat. But none of this explains why I suddenly got this pressure sore.
Nobody has been able to tell me what might have caused this. The idea of another one appearing out of nowhere really scares me.
A. Dan, since you were diligent about doing daily skin checks, and a major pressure sore still appeared with no warning, your story gave me a scare as well. So I ran it by a few experts. Based on your description, you may want to ask your doctor or wound care specialist if you had a “suspected deep tissue injury.”
Darren Hammond, MPT, certified wound specialist and senior director of the ROHO Institute for Continuing Education and Research, offers insight on this type of pressure sore. Hammond explains that while skin is very resilient — partly because it is one of the most vascular organs in the body — underlying tissue is less vascular and more susceptible to damage.
To understand the ramifications of Hammond’s explanation, it is important to know that the National Pressure Ulcer Advisory Panel has a scale for classifying pressure ulcers — stage I being red skin that doesn’t blanch (does not show a temporary white spot when you push on it with a finger); and stage IV being full-thickness tissue loss with exposed bone, tendon or muscle.
Hammond says unlike a pressure ulcer that first appears as a stage I, and if not addressed, progresses to stage II and so on, a SDTI pressure ulcer is thought to be caused by some type of force — shear, friction, or blunt trauma — that causes an ischemic response (lack of blood flow). This can cause destruction in deep tissue and eventually work its way out to the skin. In 2007 the NPUAP recognized this and added “suspected deep tissue injury” to its staging scale.
“Rarely does pressure happen alone,” Hammond says. “Shear (pulling back and forth on tissue) is probably worse than pressure alone.” He explains if you have pressure on capillaries, when the pressure is removed in a timely manner — as in a weight shift — usually the blood flow will resume. But shear can rip capillaries (tiny blood vessels). Blunt trauma — like hitting the floor from a missed transfer — can also damage capillaries.
Cherisse Tebben, family nurse practitioner and certified wound care nurse at Craig Hospital, says they see quite a few SDTIs in their clinic. “The typical suspected deep tissue injury looks purplish, or maroon or discolored, and sometimes is accompanied with a blood blister,” she says.
Tebben advises people with this type of discolored area to keep all pressure off the area for 24-48 hours. Watch it and see what happens. After 48 hours there should be some sign of the discoloring going away. If not, or if it starts to look worse, it is time to have it evaluated by a wound care specialist.
Tebben cautions if the area is very warm to the touch, red and spreading, or if you are also running a fever, or don’t feel well, it is time to see a doctor right away. It may be cellulitis or another type of soft tissue infection. If you can’t get in to see your physician right away, it is important to go to urgent care or the ER.
“A lot of these SDTIs can be from shear or a simple bad transfer,” says Tebben. “You hit the wheelchair tire or something and don’t even remember the incident.” To avoid this, Tebben advises wheelers to be hypervigilant about transfers. She likes the “climbing analogy” of treating every transfer like a rock climbing move, making sure of your handholds and the entire move before you make the transfer. This is especially important as people age and shoulders start to tire. “It may be that a person can’t transfer like they used to, so they should think about making changes, like using a sliding board for more difficult transfers.
“We see quite a few people with long-term SCIs who have never had a pressure ulcer, and suddenly they come in with a major one,” Tebben says. “Sometimes they have gone so many years without any kind of skin problem that they get complacent and don’t do a skin check with a mirror every morning and evening. Also, as we age, our skin thins and becomes less resilient, so you have to pay even closer attention.”
Craig Hospital recommends that outpatients have their cushions checked during their annual re-eval. Tebben says the wound clinic gets people who have pressure ulcers that were caused by cushions that were worn out — and they didn’t know it.
When it comes to replacing your cushion in a timely manner, funding can be an issue. There may be no definitive answer to how often you can be reimbursed for a new cushion, but according to industry sources, Medicare and most other reimbursement sources will pay for a new cushion every three years. One source recommends being proactive and staying involved in the process, getting an evaluation and a doctor’s prescription and even setting up a conference call between you, your supplier and your funding source. That way you can get a direct answer.
Dan, it sounds like you’ll be on the right track with new cushions, keeping up with mirror checks and taking Tebben’s advice to treat every transfer like a rock climbing move. Hopefully, this will be your only pressure sore.
Advice in this column is supported by Craig Hospital’s SCI Nurse Advice Line, a toll-free hotline for people living with SCI, a community service partially funded by grants from the PVA Education Foundation, Craig H. Nielsen Foundation, and Caring for Colorado Foundation. For non-emergency nursing information about SCI health, call 800/247-0257 between 9 a.m. and 4 p.m. Mountain time.