Saturday, August 4, 2007

What do you do when you know you can't prevent a horrible mistake?
Mr. P has a sore on his heel. Sores often develop on bony prominences like over the calcaneus bone of the heel, the lateral malleolus of the ankle, the sacral and coccygeal prominences on the lower back...because of pressure. Capillaries are tiny blood vessels that supply nutrients and oxygen to muscles and nerves. These vessels can be occluded by a pressure greater that 32 mmHg and if that pressure is constant, muscles and nerves necrose (die) from lack of oxygen and nutrients. In healthy people, this is prevented by weight shifting, mobility and our intact sensation that tells us when we need to stand (like over a long car ride). In the sick and elderly, all this is impaired, resulting in cell death in parts of the body where circulation is cut off.
Pressure can be relieved in other ways, like with frequent repositioning done by the nurses and pressure relief surfaces such as air mattresses, gel cushions and medical grade sheepskin.
Mr. P is also a diabetic, which indicates poor circulation at baseline.
Mr. P is not allowing us to treat the necrosing flesh on his heel. If not treated and if the sore opens up further and is infected, he could require a below-knee amputation.
As health care professionals, we are bound by the hippocratic oath to always do good and never do harm. We are also bound by a stipulation of practice that the patient must agree to all treatment and we must practice with a client-centred approach. We cannot force him to accept treatment, can we? Is the decision really his? It's hard to convince this man, fifty years my senior, that I can treat his rotting foot.