WARNING: this is not medical advice, it’s a narrative, and this may not be the best way to handle similar problems. CareGiving Old Guy is not a wound care specialist. Old Guy called for help and guidance!!!!!! [click on links below for other references]
FIRST OF ALL, a CareGiving Old Guy needs to know his limits and what can be done well at home, and when to call for help, because there is a primary goal: healing, ASAP, with safety and good outcomes. The Old Guy knows that things can get out of hand quickly, and sometimes innocent-looking areas can suddenly become a wildfire disaster. Having clinical experience helps, since Old Guy has seen worse, but let me make it clear that Old Guy called for help and guidance right away.
During a routine change, Old Guy was surprised and alarmed to see the skin change in the photo above. It was a small pressure ulcer, about 1/2″ x 1/4 ,” (~10 x 5 mm) right at the top of the gluteal cleft (butt crack), but right where the skin is thin and the tailbone /sacrum bone is underneath. The top layer of skin was already broken and had worn away.
The Old Guy mind raced a bit. It didn’t seem to hurt. It didn’t look deep, didn’t elaborate pus, didn’t seem to have a creeping cellulitis (extended red borders), wasn’t wet, and didn’t smell (although Old Guy is a little limited in sniffing and vision these days). It was in a place that was hard to see and get to for care. No others were found in other vulnerable pressure zones.
Old Guy did some simple cleansing, put on some zinc oxide ointment, and covered it with a bandaid. The bandaid was not a good idea; the adhesive was so sticky that pulling it off the next day almost pulled off a layer of skin!
“Wound care” has grown into a medical and nursing specialty, with a lot of guidelines for diagnosis and monitoring and lots of newer products for very bad situations. But this was tiny, right?
Old Guy made the call for help, having seen deep wounds lead to devastating bone infections, or even the system wide infection, sepsis; things can get worse quickly with terrible consequences.
“Dr. Google” is full of resources , care guidelines, and even horrible pictures of very bad cases, but I needed an experienced person who wouldn’t be overly dramatic, because an Old Guy can easily overthink things.
Our geriatric consultant thought it was in a typical place, and had seen them get much worse. She was worried that the visible skin “island” was an eschar, or scab, or skin remnant which could hide bacteria and make things worse. They sometimes delay healing and may require specific removal.
The ulcer was still shallow enough (Stage 2) that simple measures could work: mainly frequent soap and water cleansing and dressing changes, frequent position changes to keep pressure and wetness away, no need for specific ointments or antibiotics, but zinc oxide for protection was OK.
We blamed the rocker recliner. Just the week before, we thought the big blue overstuffed thing might be safer than a conventional living room chair, with less potential to slide out and fall. And she seemed to like to rock! She spent 4-6 hours in it a day, in various positions moving herself, many times even lying crossways to nap. Although the seat was soft, and that spot had two or three layers between the skin and chair itself, in retrospect she seemed to pivot on that point.
So the routine now included changing chairs every 2-3 hours with different seat cushions, each required a pickup. The wound was examined at least three times a day; wet wipes and soft TP were used, zinc oxide or “A&D type ointment” applied, then covered with a bit of gauze cut to size. We added another nutritional beverage to the daily intake, to add more protein and vitamins, since healing takes nutrition.
Turns out that OTC medical “paper tape” was also too sticky, but sometimes Old Guy would stick it on a clean garment first, to pick up some lint and make it less sticky. As healing improved, the tape was rolled on itself to make it sticky on both sides, to keep gauze in position on the inside of disposable underwear.
Old Guy did medical handwashing each time before and after; this was a “clean” procedure, but not “sterile;” Old Guy did not wear gloves, but if anyone else were to do wound care (no one did), Old Guy would have them wear gloves for their own protection. Couples probably shared all their bugs over forty years.
By day 4, the wound had shrunk lengthwise, there was no spread of redness, but it still wasn’t sealed off on top:
Getting a little nervous, because it was still open and in a bad spot, a little OTC triple antibiotic ointment was added, even though some say that kind of therapy can actually delay healing.
By day 10, it looked sealed, but a bit fragile. Ruler is in millimeters.
By day 14, things looked almost normal. The care routine had backed off a bit, and the recliner was moved elsewhere. The vigilance continues though!
Compared to a kid’s skinned knee, this seemed to take days longer to heal, and it took more hands-on care. Of course, this was in a darker, moist place, it still got some unavoidable pressure, and kids heal like lightning. But it was also gratifying to see that her healing processes worked well.
Luckily, the position of this ulcer was out of the way of soiling. There was moisture, but due to sweat and summer heat. This has been a good outcome so far, but if the reader has to be responsible for something similar, Old Guy has three common sense bits of advice:
1) keep it clean and get help, even over the phone (there are several bedsore / pressure ulcer websites, some tend to be technical and a little overwhelming); 2) develop a plan that can be handled, pay attention to frequent moves to relieve pressure, think about nutrition, and be diligent about handwashing before and after; and 3) if it’s not too hard, try to document progress with a diary or pictures (using a ruler helps).
The best approach, of course, is PREVENTION! I’m not saying that rocker-recliners are bad, just not good for our current situation. We moved it out. Old Guys know too well the saying “It Seemed Like A Good Idea At The Time.” I did see a license plate around here that read “ISLA GIATT”….which would be a great name for a boat, doncha think?
