Journal of Dermatology and Therapies (JDT)

A Holistic Approach to Patients with Chronic Wounds €“An Example: A Patient with Non-Insulin Dependent Diabetes Mellitus with A Diabetic Foot Ulcer for The Past 15months



Jassin Hamed1*


1 Consultant Physician, Medical Institute - Medical Affairs, Sheikh Khalifa Medical City, 51900, Abu Dhabi, UAE.


*Corresponding Author: Jassin Hamed, Consultant Physician, Medical Institute - Medical Affairs, Sheikh Khalifa Medical City, 51900, Abu Dhabi, UAE, TEL: +971 2 819 0000 ; FAX: +971 2 819 4795; E-mail:jashamed@seha.ae


Citation: Jassin Hamed (2018) A Holistic Approach to Patients with Chronic Wounds €“An Example: A Patient with Non-Insulin Dependent Diabetes Mellitus with A Diabetic Foot Ulcer for The Past 15months. J Dermatol & Ther 2:109.


Copyright:© 2018 Jassin Hamed, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited


Received date: December 02,2018; Accepted date: December 10, 2018; Published date: December 13, 2018.


Objectives

• To introduce and highlight the backgrounds of holistic medicine.


• To describe and discuss the benefits of a group care model –inter-professional and multidisciplinary patient management.


• To emphasize the importance of empowering the patient.


• Finally to demonstrate the above with a practical example of a patient with diabetes and a chronic foot ulcer.


What is holistic medicine?

In short holistic medicine is the recognition of a patient as a person with a certain medical, psychological, social and private status, who needs to be assessed, analyzed and investigated. Meanwhile a circle of care should be formed according to the needs identified to provide the best of care, support and ultimately the optimal environment for a patient to manage his health and life while healing his chronic wound.


Who belongs to the inter-professional and multidisciplinary team?

The members making up this team are nurses, wound care specialists, podiatrists, orthotic and prosthetic specialists, as well as internists, neurologists and endocrinologists, surgeons – of the plastic, vascular, orthopedic and general surgical divisions. In addition the interventional radiologists, psychologists, dieticians and social workers are to be included.


Why has a chronic wound become chronic?

All wounds start as an acute incident of tissue break down, whether due to external causes – cuts, sheer and tear, pressure or moisture or direct hits, or they are caused by internal causes as septic emboli to the skin, lack of blood or oxygen supply, venous stasis, lack of central nervous control either due to peripheral nerve injury or due to central stroke, as well as organ failure. When this wound cannot be healed within a definite frame of time, it is defined as chronic. It’s very important to investigate the cause of the wound initially, and as important to analyze why this wound became chronic. A wound may be considered a non-healable maintenance wound when the general condition of a patient including his social and psychological status do not allow favorable circumstances to change the wound status into a healable one. Once these indirect factors have been considered, healing is possible.


So why does a similar wound heal in one patient, but not the other?

Because the whole patient requires attention to all his problems, which need to be addressed, changed, improved - if possible, now the basis for healing is made.


Who is in charge?

Contrary to the common believe, it is not the care giver, but the patient. The patient himself must be empowered to be able to give an informed consent, to accept treatment including possible invasive interventions, to ask for specific requirements and to work with the team for hidden obstacles to be identified and cleared out of the way.


This is called the circle of care. With the patient in the center and the care givers joining in to attend to each specific item of the agenda of the whole case, patient centered care becomes visible and practical.


This circle of care is able to identify all the individual parameters of this patient and allow for an individualized plan of care with a patient empowered and in charge of his life, including his therapy. This is the ideal of holistic medicine!


• Meet Mr. Ahmed - a patient


• Mr. Ahmed is a 43 yrs old male, married, 4 healthy kids


• He works as oil engineer – often standing in one position outside in hot surroundings for long hours


• FH: mother obese, IHD, HTN, T2 NIDDM, father HTN, uncle colon carcinoma – died


• Smoker – shisha and cigarettes, no alcohol


• No known allergies


• Mr. Ahmed is a patient with longstanding – recently insulin dependent diabetes mellitus – type 2 with diabetic nephro-, neuro-, angio and retinopathy, overweight, arterial hypertension, ischemic heart disease and a diabetic foot ulcer for the past 5 months


• He has been seen in multiple medical centers


• These commitments were always temporary until short-lasting improvements deteriorated again


These are the questions the circle of care has to address:


• What is the cause of the left foot ulcers?


• Which underlying problems can be identified?


• Are there any additional factors to look for?


• Why did it appear at that time?


• Why does it not heal in 5 months?


Systemic factors to be considered are: IHD, PVD, co-morbidities of diabetes, obesity, HTN, HLP, individual lack of knowledge, awareness of personal hygiene, management of his medical issues, anxieties, wearing the wrong shoes. Other factors include the work requirements, possible social issues currently more important to him and his general psychological status.


Just the diagnosis of diabetes mellitus with all its comorbidities and increased risks for impaired organ and body functions requires the team to assess the patient in a multidisciplinary approach, added to this the legs will require assessment of its vascular status, its neurological status – before any decision can be made in regards of interventions or even open surgery. While the patient is included in our assessments and discussions, he may learn to decide, what is bearable for him at present and what is not – this way some interventions can be timed according to the setting in life the patient presents with.


Summary

Start treating the patient as a whole, rather than the hole in the patient.