Diabetic Wound Case Report – Mr. L.T.
Mr. L.T. is a 56-year-old self-employed male plumbing contractor who was diagnosed with diabetes in 1995. As a result of nerve damage associated with his condition, he began experiencing diabetic neuropathy to both of his feet in the form of reduced sensation. Consequently, due to prolonged periods of standing at his work wearing construction boots combined with the loss of sensation to his feet, Mr. L.T. began to develop ulcers over the toes of the right and left foot. As a result of the impaired circulation or blood flow to the lower limbs, the ulcers failed to heal with rest. Mr. L.T. elected to further limit the time he spent standing at work and changed to softer footwear. However, the ulcers on his toes continued to progress.
Mr. L.T. visited his treating physician and was instructed on a wound care protocol which included keeping the wounds cleaned and properly dressed with saline along with increased control and diligence over his blood glucose levels. Despite these interventions, the wounds at the 1st and 5th toes on the right foot and the 1st and 2nd toes on the left foot continued to increase in their size and depth.
Mr. L.T. noticed inflammation and a purulent discharge from the right first toe in 2006. Mr. L.T. underwent debridement and a sample was obtained for culture testing. As expected, it was determined that he developed a staphylococci infection in the wound. After undergoing an aggressive course of antibiotic therapy, his wound unfortunately spread to the subcutaneous tissues of the right foot. In order to control the spread of the infection, Mr. L.T. was required to have the great toe of his right foot amputated.
After a prolonged period of time off work, Mr. L.T. resumed attending to plumbing projects. The remaining wounds appeared to have stabilized, however, limited healing was demonstrated over that time. Due to increasing demands in his work during the summer months of 2007 in conjunction with poorer control over his blood sugar levels, Mr. L.T. experienced a progressive worsening in the condition of his existing wounds. Furthermore, additional wounds were developing at new sites along the right foot. His treating physician advised that additional amputations were imminent in his current condition.
Mr. L.T. was in a precarious position as a self-employed plumber with no opportunities for modified or reduced work duties. He began inquiring into alternative solutions to manage and heal his wounds. He became aware of Pneumatic Compression Devices or PCDs. These devices are externally powered sleeves or cuffs that are wrapped around the distal lower extremity and essentially mimic the vascular system for those with impaired circulation. In essence, PCDs have been shown to effectively deliver oxygen-rich blood to the lower extremities and accelerate the healing of chronic diabetic wounds. However, for Mr. L.T., the prolonged periods of immobility during treatment periods with PCDs was not a viable solution.
Subsequently, in 2008 Mr. L.T. was informed of Mobile Compression Devices or MCDs. MCDs serve the same function as PCDs but exist in a more compact and portable system. After evaluating different MCDs, the Venowave device was particularly appealing for Mr. L.T. The Venowave was powered by two AA batteries allowing for up to 16 hours of continuous operation and was enclosed in a very simple and compact design. In comparison to other MCDs, the Venowave would not intrude with his ability to resume working.
Due to the condition of his right foot, Mr. L.T. was forced to stay off work for a second time. During that period, he utilized two Venowave devices for both his right and left leg. He found the devices very comfortable and did not interfere with his mobility. More importantly, Mr. L.T.’s treating physician observed that the wounds demonstrated significantly accelerated healing compared to the traditional wound protocol.
Mr. L.T. gradually resumed working but continued to wear the Venowave devices throughout the course of his work day. As expected, Mr. L.T. found that the devices did not impact his productivity during working hours. Additionally, his wounds continued to demonstrate increased healing with no further evidence of new wounds.
Currently, Mr. L.T. remains committed to the Venowave device. His diabetic wounds remain under control and he is able to work while incorporating standard wound care precautions. His treating physician acknowledged that without the Venowave device, Mr. L.T. would have undergone further amputations resulting in significant impairment and disability.
Chronic non-healing leg wounds and subsequent leg amputations represent some of the most prevalent and debilitating complications of vascular and metabolic pathologies. The consequential strain imparted by the treatment and management of chronic leg wounds on healthcare systems within Ontario and throughout the world is well-documented. At an estimated rate of 2.0 per 1,000 people over the age of 25, there are approximately 15,000 individuals in Ontario suffering from venous ulcers. Provided that 10 to 15% of diabetic patients will develop a foot wound in their lifetime, an estimated 70,000 to 105,000 Ontario residents will become a victim of this condition and its associated functional limitations. Amputations are reported to occur at rates of 1.5% for diabetic ulcers and 0.4% for venous leg ulcers (Shannon, 2003). More specifically, according to the Canadian Association of Wound Care, 85% of all amputations are a result of a non-healing foot ulcer. The estimated direct cost of a non-traumatic lower extremity amputation in Canada was $24,582 in 2000 (O’Brien et al, 2003). More recent estimates are more prohibitive. As reported by the Ontario Health Technology Advisory Committee in their 2005 economic analysis of diabetes mellitus, the estimated hospital cost for a diabetic wound without amputation is $58,500. The additional cost for limb amputation was reported at $63,000. In sum, the total cost for lower limb wound care in Ontario is within the magnitude of several hundred million dollars annually.
As suggested by this case report, the cost of a portable compression device such as the Venowave relative to the long-term hospital expenses for in-patient therapy, surgery, and amputation allows for a more efficient allocation of provincial healthcare spending. Moreover, the improved quality of life and expedited return to pre-ulcerative functional states experienced by this patient population will lead to greater and sustained benefits for the province at-large.