Getting Mary Back to Goa
It is great when patients show their appreciation and they often do, but sometimes the difference that we have made is tangible. It took about 4 months to heal Mary’s leg wound and when it healed I was as pleased as she was. She gave me a hug and some tomatoes and courgettes from her garden. She is 80 years old and a widow, full of life and adventure. She had injured her leg in Goa while on holiday, a traumatic wound from an accident as she stepped onto a boat, an L shaped skin flap laceration that stretched from below her knee to just above the ankle. She presented about 10 days after the accident with black sutures, like liquorice bootlaces holding the wound together.
My colleague called me in to have a look, with her back to the patient she pulled a face that suggested ‘OMG!’ The sutures were holding the vertical part of the wound but the horizontal was covered with black eschar and beginning to gape, a number of the sutures were flapping about doing nothing. The wound didn’t look infected but the leg was swollen. I told Mary that I wasn’t sure we could heal this in primary care and that plastics might be an option. I explained to Mary that I thought we should try to treat this with compression, it didn’t look like a venous leg ulcer but I was hopeful that the mechanism that allowed compression to heal venous leg ulcers might work here. Mary, bless her, had faith in us!
The doppler result gave us an ABPI of 0.9 so, with the sutures out, we started short stretch compression, over a simple non adhesive dressing with some padding to absorb the exudate. We were seeing her twice a week. After four weeks we had some improvement but the lower part of the wound was sloughy and the black eschar, although reduced ,in size was still there. Actiform Cool® (marmalade to Mary) helped hydrate the eschar and de slough the wound. It took weeks but there was a little improvement each time. We got to a point when the exudate was minimal and we changed to the Activa® hosiery kit which give the same amount of compression as a two layer bandage but meant Mary could share the management of the wound but more importantly enabled her to shower without an ungainly cover to protect her leg. We moved to weekly appointments with Mary replacing the primary dressing and stockings in between. The Venus IV study (2014) found that this hosiery kit healed ulcers at the same rate as 4 layer compression and that recurrence rates were lower.
Progress was painfully slow and although Mary didn’t say that she was discouraged her face let us know. Then finally the day came, my colleague who had shared the management of this wound with me called me in for Mary to declare that her wound was healed. This is when we got the garden produce and the hug. “By the way’ said Mary ‘ I have booked to go back to Goa next year!”
Nurse Practitioner and Educator on the NB Medical Primary Care Nurses Course