Managing pressures ulcers in a resource constrained situation: A holistic approach
Managing pressure ulcers remain a challenge and call for a multidisciplinary team approach to care. Even more daunting is the management of such patients in remote locations and in resource constrained situations. The management of pressure sores in a patient with progressive muscular atrophy has been discussed using resources that were locally available, accessible, and affordable. Community participation was encouraged. A holistic approach to care was adopted.
Keywords: Constrained resources, Pressure ulcers, Progressive muscular atrophy
A pressure ulcer is an area of localized damage to the skin and underlying tissue caused by pressure, shear, or friction or by a combination of these (European Pressure Ulcer Advisory Panel). The reported incidence varies from 1.5-25% in long-term care facilities and can be as high as 70% in bed-ridden elderly population. It remains a major cause of morbidity in the terminally ill and -bedridden patients and a major cause of physical, psychosocial, and financial distress for the caregivers.
Here, we describe the innovative and holistic model of management of pressure sores in a patient with motor neuron disease in a resource-constrained setting.
Mr. PS is a 52-year male with a diagnosis of motor neuron disease (MND) and has been bedridden since last 7 months [Figure 1]. He was brought to our notice during one of our routine rural health camps. He resides in a remote village and was the only breadwinner for his family. His symptoms started 2 years back with a sudden onset of tingling in his arms followed by weakness that was irreversible. The weakness progressed and involved all limbs. He was diagnosed as a case of progressive muscular atrophy (PMA) at a neurosciences centre.
He is currently bedridden and cannot sit-up without support and totally dependent on his wife, who is the primary care provider. He has Grade-II muscle power in his upper and lower limbs. He however had no difficulty in breathing, chewing, or swallowing. He had evidence of fasiculations of muscles on his shoulders and neck. He was fully conscious, oriented, and co-operative and was distressed by pain in his lower back. He also appeared to be depressed and was saddened that he was a burden to his family.
He was not on any drug therapy currently, although he had been advised therapy with Riluzole, which he could not afford. He had an insight into the nature of his illness.
We gently probed for evidence of other concerns and assured him that we could provide symptomatic relief to him and accepted that we could not cure his disease. We asked for his co-operation in the care process and outlined our management strategy to him, to which he accepted. He was pleased that his opinion was being sought.
An examination revealed a Grade-III pressure sore 4 cm × 5.5 cm, overlying the sacrum with malodour, local inflammation, significant serous exudation, and edema of the surrounding skin [Figure 2]. It was tender, with a base of unhealthy granulation. The wound was documented photographically. Focused questioning did not reveal incontinence of bowel or bladder. He however was constipated and could not turn side-to-side without support. His wife reported that the sore was there since last 2 months and had gradually increased in size and depth. Focused questioning revealed that she changed his posture twice in a day and cleaned the affected area with water from a -tube well. They could not afford medications or doctor. Our hospice not having any access to funding could not provide him with dressing material; however, we could provide him with some medications that we had received as "samples" from pharmaceutical firms. This was a resource constrained setting situated in a remote location and posed a challenge. Also, we realized that we could not provide continuity of care.
We discussed the natural history of PMA  amongst our team (emphasizing the importance of a multidisciplinary team approach in care) and learnt that it affected 5-7% of people suffering from MND, primarily affected the lower motor neurons, was progressive with an onset age of below 50 years and had a life expectancy of 5-10 years. We learnt of the symptoms such as progressive weakness, loss of muscle bulk, fatigue, fasciculations, loss of reflexes, etc. Death usually occurs from respiratory problems or failure. The management strategy is mainly nonpharmacological and centers around physiotherapy, optimizing pulmonary function, feeding, care of bladder, bowel, and skin. We learnt about the diagnostic tests in addition to clinical diagnosis, being nerve conduction studies and electromyography. We were also made aware of the possibility of the need of future interventions for feeding like a feeding tube or a percutaneous endoscopic gastrostomy (PEG) and the possible future need for long-term ventilation at home. Such patients often experience physical pain due to muscle cramps and neuropathic pain.
We discussed the management plan with our team members keeping the prognosis, financial, and resource availability factors in mind.
Our management plan began with educating and empowering the care-provider in the care process. We stressed upon the importance of physiotherapy for PS and taught his wife how to perform passive range of movements of his joints. We also highlighted the importance of skin care and advised her to give him a daily massage with groundnut oil, which was locally available. We encouraged community participation by requesting the neighbors to help in the care process. We assured the care-providers that this was not a communicable disease and thus removed the stigma associated with the disease and encouraged visitors. We taught his wife to use cut pieces of linen and boil them in a covered utensil prior to using them for wound dressings (they did not have a pressure cooker). We suggested her to use raw papaya paste for wound debridement till healthy slough was visible. Raw papaya has papain that has exfoliating properties, and can remove dead cells effectively.  This advice was given as we did not have access to facilities for surgical debridement at that point of time. She was advised to use preboiled and cooled water (1 L) to which one pinch of salt was to be added, thus preparing normal saline. This is a level-III evidence for wound cleansing. She was also advised to use turmeric paste to dress the wounds after applying it on a clean piece of linen. Turmeric accelerates the healing process and has antiinflammatory and antibiotic properties.  Recommended cleaning solutions are sterile water or normal saline (level-III evidence) as disinfectants are toxic to tissues and can impair healing (level-II evidence).
We taught his wife the importance of frequent change of posture, preferably 2 hourly, to reduce interface pressure.  They could not afford mattresses and hence stress was given on frequent change of posture. In addition, advice was given to avoid shear and friction forces as far as practicable while changing sheets or clothes of the patient. We also taught them to pad bony prominences such as sacrum, elbows, greater trochanter, heels, which were particularly prone to pressure sore.
Thankfully, PS was continent. We taught them about the importance of maintaining a clean and dry local environment. We also taught them about the importance of preventing secondary infection as that would prevent healing, aggravate the wound and could lead to septicaemia and death. We also advised that they use a mosquito net to ward off flies.
We also highlighted the importance of nutrition and supplementation with vitamins and minerals in prevention and healing of the sores.  We stressed on intake of zinc-enriched food such as peanuts, pumpkin, and watermelon seeds, etc. because of their positive effects on wound healing (www.healthaliciousness.com/articles/zinc.php). PS could swallow but was anorexic, probably resulting from his constipation, which was compounded by his immobility. We advised that he should take plenty of water and fluids along with isabol husk that was available locally. We understand that a stimulant laxative like bisacodyl would have been appropriate combined with a stool softener. However, we only had access to isabol at that point of time and we suggested its use with adequate potassium supplementation. We also suggested that he should consume bananas and coconut water (which is rich in potassium and good for gut motility), both of which were available in plenty locally. We also highlighted the importance of positioning and privacy for tackling the issue.
PS also had significant pain and of a burning nature in his lower back and appeared distressed. We used the S-LANSS (self-report version of leeds assessment of neuropathic symptoms and signs) questionnaire in the interview format, which revealed that he had neuropathic pain as well.  He also had difficulty in sleeping at night and was saddened that his wife no longer slept with him. We gently brought up the issue with his wife and suggested that they talk about it. We did not consider it appropriate to dive into the issue in detail in our first visit and also to respect the social and cultural issues.
We had Lignocaine gel (2%), paracetamol tablets. (500 mg), Metronidazole (400 mg), Ciprofloxacin (500 mg), and Amitrytiline tablets (25 mg), which we gave him with instructions for.
His wife was advised to give him a daily bath before wound dressing, followed by topical application of lignocaine gel on the sore and one tablet of Paracetamol 20 min prior to change of dressings. In addition, Amitryptiline 25 mg and Paracetamol 500 mg were to be given at bedtime. If we had been afforded the luxury, we would have started him on Extended release Tramadol (100 mg) given at bed time, thereby ensuring good and pain-free sleep and reviewing his status after a couple of days to guide further therapy. Amitriptyline would act by its sedative, antidepressant and analgesic properties (for neuropathic pain). Amitriptyline acts primarily by inhibiting the reuptake of noradrenaline and serotonin in the descending inhibitory pathways in the spinal cord, thus potentiating analgesia. We advised that Metronidazole tablets be crushed and applied topically on the ulcer to reduce malodour as we suspected anaerobic infection. 
The NICE guideline clearly states that "while implementing evidence-based guidance it is important that all health care professionals understand the local context in which they work..." Our management in this case might seem outrageous but on careful thought, one would realize that we used locally available, affordable, acceptable, and situationally appropriate management strategies. Hydrocolloid or hydrogel-based dressing materials would have been appropriate in this setting in view of the moderate amount of exudation and stage-III sore.  However, we had to use clean linen in view of the non-availability and affordability of proper dressing materials. A trial found little difference between the use of hydrocolloid dressings and traditional saline-soaked gauze in ulcer healing.  Most of the studies comparing different dressing materials did not find any statistically significant benefit over other. In fact, one study comparing a modern dressing with placebo found no evidence of significant difference in wound closure rates. 
PS had many risk factors for development of pressure ulcers such as immobility, poor nutrition, reduced physical activity, poor general physical condition, prolonged pressure, etc. We assessed his risk index for developing pressure ulcers using Waterlow, Norton and Braden's scales in conjunction with clinical judgment.
We used a combination of chemical (papain) and mechanical methods (saline irrigation) for removal of slough and debridement. There are other nonmechanical debridement agents such as hydrogels, dextranomer polysaccharide beads, adhesive zinc oxide tape, etc. Also, there is no evidence to indicate if surgery is effective in the treatment of pressure ulcers; however, it is clearly indicated as a treatment option.
We also advised his wife and the local community members to reposition and turn PS within intervals of 2 h if possible based on PS needs and preferences and also on the importance of giving pain relief medications 20-30 min prior to this.
PS was also interested in music and we encouraged the community to arrange for a radio so that he could listen to music and the news, thus highlighting the importance of a holistic model of care. We discussed the burden of the care process with him and his wife and empathized with them. We even talked to the Panchayat (leader) of the village to arrange some employment for his wife.
We were able to demonstrate the three central virtues in the praxis of palliative care, namely medical expertise, compassion, and respect for dignity. We demonstrated our moral values by an unconditional respect for the dignity of PS and the acceptance of human finitude. Our reflections centered upon individual decision making (micro-ethics) as well as keeping the socioeconomic and cultural considerations in mind (macro-ethics).  The principle of therapeutic proportionality  was well demonstrated in which our moral obligation to provide UPS with treatments that fulfilled a relation of due proportion between the employed means and the end pursued was employed.
We demonstrated the ethical principles of beneficence by our intention to provide symptom relief (physical, psychological, social, and spiritual) with appropriate use of available, acceptable, and affordable materials and techniques to promote healing of the ulcer. Also, preventive strategies were worked out to promote healing and prevent recurrence. Non-maleficence was demonstrated as we used techniques and clinical practices that were supported by evidence-based medicine. Prescriptions and suggestions were made keeping their economic background and availability issues in mind. The principle of autonomy was adhered to by taking UPS permission and co-operation in the care process that was discussed with him. Distributive justice was demonstrated as we used techniques and suggestions that were locally available, acceptable, affordable, and appropriate for his social environment.
A review 3 weeks later revealed a happy and confident PS who has minimal pain and good evidence of healing (wound size - 1.5 cm × 2 cm).
Larval therapy has been used for wound debridement. One group also reported on the topical application of insulin and its significant benefit on wound healing.  Also there is insufficient evidence to indicate whether antimicrobials are effective in the management of pressure ulcers. 
[Figure 1], [Figure 2]