Differences Between Pressure, Diabetic, Vascular, and Kennedy Ulcers
Do you know the difference between a bedsore and a diabetic ulcer? Misidentifying these wounds can lead to improper care. In this week’s episode, nursing home abuse attorney Rob Schenk welcomes guest Martha Kelso to talk about the differences between pressure, diabetic, vascular, and Kennedy ulcers and why it matters for patient care.
Schenk: The differences between pressure injuries, diabetic ulcers, vascular ulcers, and Kennedy ulcers. Stick around.
Hey out there. Welcome back to the nursing home abuse podcast. My name is Rob. I will be your host. I almost said I’ll be taking care of you tonight. That was a weird muscle memory thing from when I waited tables forever. Hey, my name is Rob. I’m going to be taking care of you tonight. Can I start you guys off with something to drink?
That’s almost what I said. I can’t tell you how many millions of times I’ve said that in my life. Anyway, in this episode, we are going to be talking about different wound types and the differences between them and why obviously that is important, but we don’t do that alone. We have a fantastic guest who’s been on the show several times, Martha Kelso. She always brings the knowledge and is always fun to have on.
I’m so happy to have Martha Kelso back on the show. Martha Kelso is the CEO of Wound Care Plus, a leading mobile wound care group.
She’s renowned for her visionary leadership and post acute care with the dedication to wound care to advancing wound healing. She excels as a published author, clinical editor, and expert witness for wound litigation. Martha’s contributions extend to national advisory boards where her award winning expertise shapes the future of healthcare.
And we are so happy to have Martha on once again, Martha, welcome to the show.
Kelso:
Hey, good to see you again, Rob. Thank you.
What is a pressure injury?
Schenk:
We were just talking right before you came on about how I think that the last time that you were on the show, I’m looking at my notes, I want to say it was in January of 2021. We were still doing phone calls, like we hadn’t even, and because we film these, or we do these a lot very far in advance, and Just the technology of you and me talking has changed so much in those three or four years.
It’s pretty funny. But very happy that you’re back on talking with us today. And this is actually a topic that I get a lot of conf my clients have a lot of confusion with because sometimes they’ll call and say, Hey, there’s an ulcer here. Let’s sue. Or there’s an ulcer here and it’s pressure.
And perhaps it’s not. So I wanted to have you on to just let’s go through each one of these injuries because ulcer might not be the right name for some of these, but let’s go through these and just give a basic understanding to our audience about what it means to have a pressure injury, what it means to have a diabetic ulcer, these type of things.
So we’ll start at the top. Can you just give us a 40,000 foot view of what a pressure injury is?
Kelso:
Sure. A pressure injury is a spot on the human body where a form of pressure has compressed the tissue enough where the blood flow has been pushed out of the tissue and then necrosis or tissue death can set in.
So that’s a 10,000 foot view. Typically with pressure ulcers, you’re going to find an area that mimics or looks like whatever was causing the pressure. So for example, if somebody laid on a bedpan for four hours, you would see an imprint or an outline of that bedpan or maybe the heel sat on the footboard of the bed.
There’s going to be a line where you can clearly see pressure occur. There’s also two types of forces, friction and shearing, that can also create pressure wounds. Shearing is usually when we’ve drugged somebody across a bed, maybe with a turn sheet or a pad, and that shearing rips the tissue off the bone essentially and interrupts the blood flow supply.
That injury is going to occur at the muscle bone interface and so then it takes time for that injury to work its way out enough for us to see it with the naked eye. And then friction is where something has been drug across the skin and created a friction type injury that results in a pressure wound as well.
And I’m giving the glossy version, but those are basically the definitions as defined by CMS.
Schenk:
So tell me, sorry. So tell me then why would it be the case? Some people would say that the term pressure injury is more appropriate than pressure ulcer. Can you tell us why someone would think that, or if that’s actually legitimate, or if that’s where we’re headed in terms of terminology?
Kelso:
Yeah, it goes back to terminology. So in the old days, we used to call them bed sores, then the terminology got updated to pressure ulcer, and now the more universally accepted terminology is pressure injury, because it’s an actual injury to the underlying skin and or tissue from pressure as a result.
It’s interesting because my dad always had this generic, like, all people die from heart failure. The heart has to quit working for people to die. But it’s almost like you can also think of it in terms of all wounds. are injuries to the skin, even surgical wounds. It’s somebody taking a scalpel and creating an injury to the skin.
And injury is now the more universally accepted term, even though it’s still the same or similar causation all the way back from when pressure ulcers were first defined or developed.
Schenk:
I guess at the end of the day, what we’re talking about really is tissue and skin death related to some type of force, whether it’s pressure or pressure in terms of friction or shear, as opposed to anything else like trauma, surgery, that type of thing.
Is that a kind of a fair statement?
Kelso:
Correct. And we know that the sicker somebody is, the greater their chance of developing a pressure ulcer or pressure injury because their tissue is less resistant to the external forces of pressure. So there’s certain things, immobility, urinary incontinence, fecal incontinence.
There’s certain things that we know are predictive of pressure injury or pressure ulcer development.
Schenk:
I see that at least a few times a day with my toddler, who is in diapers, and although I’m careful I sometimes push that diaper back to put it on him. And I know that he’s a baby. So his skin is strong and he’s extremely healthy.
But if that was a 95 year old person, that’s going to potentially be a massive problem for him, that amount of friction while changing a brief essentially. So yeah, so the characteristics or the clinical condition of the person has a tremendous impact on whether someone develops a pressure injury.
Kelso:
That’s correct.
What is a diabetic ulcer?
Schenk:
Okay. Okay. So we have that one. We’ve talked about that one a lot. So we got that one out of the way. What about diabetic ulcers? What are, what is that? And how do we tell the difference from an observational standpoint between a pressure injury? It’s open and a diabetic ulcer.
Kelso:
Great question. So CMS in the federal guidelines for post acute care or long term care talks about that we have to rule out other causes before we can diagnose a wound as pressure ulcer or pressure injury. What they’re saying is there can be other etiologies or underlying conditions that may not be related to pressure, diabetes being one of them.
Diabetes is a big deal because it affects the microvascular circulation. So the capillary blood flow, for example, is directly affected by diabetes. And there’s some really big statistics out there. I’m going to paraphrase them, not quote them. I don’t have the actual numbers in my head. But anybody with diabetes, about 60% of them will form a wound at some point in their lifetime.
Of those 60%, there’s a huge number that will end up with sepsis, gangrene, and possible amputation. So we know that once somebody has an amputation as a diabetic, their average lifespan is no more than five years. So preventing amputations and diabetic wounds becomes very important. How do we do that?
Managing hemoglobin A1c, but more importantly trying to catch them before they develop into bigger wounds. So when our microvascular circulatory system is impaired, there is no way to repair it. We can’t do stints on these little tiny capillaries. Additionally, diabetics develop neuropathy, where they cannot feel if their shoe is rubbing incorrectly.
So most people from the time we’re born, quite frankly, were trained for pain. With diabetics ending up with neuropathy, that protective sensation of pain is missing. And so it’s why it becomes so important to do foot inspections at least daily, typically twice a day on a neuropathic person. On your arterial wounds, the reason why arterial wounds are such a big deal is the arteries are the largest, It’s the blood flow that flows away from the heart with the big vessels.
Venous wounds are, is the blood flow returned back to the heart. Typically what we see in elderly or long term care population is these patients, residents, clients have all three blood flows impaired. And that means they can be ticking time bombs for amputation. If the arterial blood flow is impaired, the venous blood flow, and then the microvascular blood flow from diabetes are all impaired, these people are at an extraordinary risk of developing a wound.
So differential diagnostics becomes important so we can look at the underlying condition and get interventions in place, like maybe a vascular surgeon to restore blood flow early on if they’re a surgical candidate.
Schenk:
A couple things, it seems to me that what you’re saying is that you could have somebody that has perhaps uncontrolled diabetes, they could be in space with no pressure with no friction and they could still develop a diabetic ulcer. Is that kind? Would that be a fair statement for a severe candidate?
Kelso:
Okay, that is correct. Okay. A lot of times they can develop on the heel. If you look at the pathophysiology of the body, there’s a gigantic artery that runs along the backside of the heel.
And so people see heel wounds and assume their pressure and then we’re not getting diagnostics involved and not getting them referred to appropriate specialists. to prevent further injury or issues.
Schenk:
And so then this is why I love this podcast, not just because I can see my smiling face every week, but it seems to me, at least in, in my experience, in my training and talking to nurses, that it is, even if you have a resident with diabetes. If there is a, if there is an injury to any pressure point, the automatic assumption is that it’s pressure. And I guess what I hear you say is perhaps, but we need to check and see if in fact this is a symptom of diabetes.
Kelso:
That’s correct. And to take it one step further, I’m my mother’s DPOA, and she’s 85, so it’s the responsibility of the health care providers to give me the knowledge and information that I need to make an informed decision about my mother’s care.
Differential diagnostics is what helps us do that. So if you’re assuming that a wound is a pressure wound without diagnostic studies, and then they do have an occlusion or a blood clot or something like that, if we’re not aware of it and the lower extremity continues to rot. I’ve made poor decisions for my mother based on the poor information that was given to me.
It changes the care plan, the interventions, the trajectory, maybe the goal. Is the wound healable? Is it a maintenance wound? Or is it a palliative wound? And so differential diagnostics is everything. And by the way, nurses can’t diagnose LPNs and RNs cannot diagnose. We can assess and document our assessment and our clinical findings, but we can’t in and of ourselves diagnose a diabetic wound that has to be left up to nurse practitioners, physician assistants, MDDO, DPMs, somebody that’s trained in differential diagnostics.
Schenk:
Would you say that it could be quite difficult to look, observe a wound on a heel? and or on a toe, even if the person is still wearing shoes and there could be friction there to look at a wound on a heel or a toe and understand just based on observation whether that wound is pressure or diabetic and old in origin. It’s a difficult task.
Kelso:
That’s correct. Not only is it difficult, it’s impossible. You have to be different. You can’t treat what you can’t see, and humans are not built with x-ray eyes. You have to have differential diagnostics to determine the etiology of those wounds. Unless you saw pressure happen with your own eyes, but even then CMS says we still have to do differential diagnostics to determine the extent of any other underlying condition.
So maybe I walked in and I saw the heel sitting on a footboard. That’s clearly pressure. I saw it happen. I’m not guessing. I saw it. I witnessed it. But if they still have a 90 percent occlusion from the femoral artery down, I can float that person on a cloud of air and it’s never going to heal because it’s no different than putting a rubber band around your finger and not taking it off. There’s no blood flow.
What is a vascular ulcer?
Schenk:
So tell me then, what would be the difference, other than the cause, being diabetes versus some type of peripheral artery disease, between the diabetic ulcer and the venous ulcer like is there really a difference other than the cause?
Kelso:
The difference is the treatment. So with venous ulcers, it’s blood, it’s fluid actually trapped in the lower extremities and that fluid then pushes on the tissue and then can spring a leak.
I think about it like leaky basement syndrome, where you have so much hydrostatic pressure built up around your basement walls and the fluid pushes and pushes on your basement wall until it springs a leak. That’s actually what venous wounds are, leaky basement syndrome. And so the way that we have to heal them is putting them in adequate compression to get that fluid to return back to the circulatory system for the kidneys to kick it out.
You don’t compress diabetic wounds, you compress venous wounds. You don’t compress arterial wounds and you don’t compress pressure wounds. The only wound type that we compress is venous wounds.
Schenk:
And is that the same end of this might be off the wall, but I think I see basketball players in the past 10 years or so, they wear compression sleeves. Is that the same principle?
Kelso:
People that stand on their feet a lot are at high risk of developing venous disease or venous insufficiency later in life. Obese people, think about cashiers, butchers, also people that sit a lot, like truck drivers, because we’re cutting the circulation off from whatever you’re sitting on.
And anybody that’s on their feet a lot, any surgeon any length of time should be wearing compression stockings as a preventative. With venous insufficiency, it’s because the valves in our veins have failed. And once the valves fail, there’s no valve replacement surgery. And so then fluid pools in our lower extremities.
Eventually, you end up with discoloration of the lower extremities, what’s called hemocytorin staining. And then the fluid pools, and eventually you develop ulcerations that are extremely difficult to treat.
Schenk:
So all the cool people that got standing desks need to get compression socks. That’s the takeaway from this podcast today.
Kelso:
That’s correct.
What is a Kennedy Ulcer?
Schenk:
Okay. So in the final few minutes here, Martha, let’s talk about, um, Kennedy ulcers. And I was gonna say like notorious Kennedy ulcers, because in some circles it’s notorious. I feel like on one hand there are people that say that this is not a thing, and some people say this is very much a thing.
But for anybody. Tell us what that is and when we typically would see a quote unquote Kennedy ulcer.
Kelso:
October 1st, 2023, Medicare and the federal regulations have now stated that Kennedy Terminal Ulcers, Skin Changes at Life’s End, or End of Life Wounds are its own wound type. They are no longer considered to be pressure wounds.
Prior to October 1st, 2023, they were considered by Medicare to be pressure wounds. So now they’re not. What end of life wounds or Kennedy terminal ulcers are essentially wounds that develop because the body’s failing. And so traditionally you will see one, two or more of the major organs failing the brain, the liver, the kidneys, the heart, the lungs.
One of the major organs or more are failing and therefore we’re not able to keep the skin perfused, skin being the largest organ of the body. If the major organs are failing, the largest organ is also going to fail. And so because of that it’s because they are end of life or in some type of end of organ failure and therefore the skin fails too.
Traditionally we refer to them as hypoperfusion and injuries.
Schenk:
And this again would be one of those things where this type of wound, the Kennedy end of life wound or Kennedy terminal wound ulcer, could develop in space with no with no gravity in the literature or in, yeah, in the literature or in your experience, is this something that’s hours, days, weeks, months, a year. Can somebody have a Kennedy ulcer for five years? What’s typically, what does it mean, to be the end of life, so to speak?
Kelso:
Yeah. So that’s a great question. Medicare. I’m just going to reference Medicare because it’s easy, but Medicare refers to it, that it can occur within hours, but also for weeks or even months.
I’m not sure that I’ve ever seen an end of life wound that was there for years, but we don’t want to confuse end of life. with skin failure. You can have acute skin failure. For example, somebody that’s in the hospital actively dying and on a ventilator that’s maybe in their 50s, and then we give them LevoPHed, and we create hypoperfusion injuries, and then eventually their body turns around and they get better.
But while they were acute and sick in the hospital, they were dying, literally dying. and acutely dying. And yet we were able to save them and turn them around, but they’ve developed a wound. So there is acute skin failure. There is chronic skin failure. And then there’s end of life skin failure. There’s actually three different types.
And that was published by Diane Langamo in 2009 and some of her colleagues, where Kennedy terminal ulcers are quite literally somebody at the end of their life. Usually, we typically see it in end stage dementia, people that also have a malnutrition disorder, they’re cachectic, gaunt, emaciated, lots of ICD 10 codes, and there’s no coming back from this.
People with end stage dementia don’t suddenly turn around and get up and start walking and get better. These are end of life people that have been slowly dying for quite some time and their body is literally just at the end where it just starts to fail. And usually there’s congestive heart failure or renal failure, some other type of major organ failure that’s happening concurrently.
Schenk:
Like it’s a piece of a complex action that’s happening. Really quickly, you’ve mentioned CMS a few times. For anybody that doesn’t know what, when you’re talking about, let’s refer to CMS. What are you talking about?
Kelso:
CMS is the Centers for Medicare and Medicaid services.
They may also be referred to as the department of health and human services. And those are the people that govern or regulate the post acute care. They regulate a lot of things, but one of the things they regulate is the post acute care sector. And so they create and publish the state operations manual that governs long term care, assisted living, long term acute care hospitals.
But essentially they write the federal regulations for long term care or guidance to surveyors that then regulate or survey the long term care arena.
Schenk:
So when you say CMS was recently updated, you’re talking about in part, the regulations the word for word with what the nursing home should do, but also the interpretive guidelines of how, if they’re being surveyed or they’re being inspected, what that surveyor inspector should be looking for.
Kelso:
That’s correct.
Schenk:
Okay, Martha. This has been a fantastic episode. I really appreciate you coming on and talking to us once again. Welcome to the new era of zoom, with the podcasts and we’ll see you next time.
Kelso:
Thanks for having me, Rob. Talk to you soon.
Schenk:
I hope you enjoyed this episode of the podcast.
If you want to get in touch with Martha Kelso for more information, please go to her website, which is mywoundcareplus.com. That is my mywoundcareplus.com. New episodes of the nursing home abuse podcast come out every Monday on whatever platform you get your podcast from, as well as our website, nursinghomeabusepodcast.com and YouTube. So you can not only just listen, you can also watch.
As well, if you have any suggestions for content or people that you want to see me talk to on this show, please be sure to let me know. And with that folks, we’ll see you next time. Thanks for tuning in to the nursing home abuse pod.
Nothing said on this podcast, either by the host or the guest should be construed as legal or medical advice, nor is intended to create an attorney-client relationship between the host or their guests and the listener. New episodes, for now, are available every other Monday on Spotify, Apple Podcasts, or on your favorite podcast app, as well as on YouTube and our website, nursinghomeabusepodcastcom. Again, that’s nursinghomeabusepodcast.com. See you next time.
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