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Vascular Matters1st Quarter 2018
S o c i e t y o f Va s c u l a r N u r s e s
w w w . s v n . o r g . u k
- True Impact of venous ulceration
- Are staff nurses forgotten?
- Impact of the patients voice
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svn.org.uk 4th Quarter 2016
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Contents
Page 5 President’s Welcome
Page 7 Ankle waveform versus ABPI
Page 14 APPG Update
Page 16 Staff nurse development update
Page 17 A year seconded onto the SVN Committee
Page 18 An interview with….
Page 20 Evening Symposium
Page 25 Four reasons to attend a nursing conference
Page 26 SVN AGM Agenda
Page 27 SVN Conference Agenda
Page 28 James Purdie Prize Presentation
Page 32 SVN Treasurer’s Report
Page 34 SVN Bursaries
Any articles, questions, queries or comments about Vascular Matters, please email the editors at [email protected] or [email protected]
Vascular Matters Editors
Leanne Atkin & Emma Bond
svn.org.ukThe official website of the Society of Vascular Nurses
Visit here for information on SVN membership, conference information, bursary applications and much, much more!
ContentsPage 4-5 Presidents Welcome
Page 6 Committee Members
Page 7
Page 9
Page 10-13
Page 16-21
Page 22-23
Page 24
Page 25
Page 26-27
Page 28-33
Page 36-40
Page 42-43
svn.org.uk 4th Quarter 2016
3
Contents
Page 5 President’s Welcome
Page 7 Ankle waveform versus ABPI
Page 14 APPG Update
Page 16 Staff nurse development update
Page 17 A year seconded onto the SVN Committee
Page 18 An interview with….
Page 20 Evening Symposium
Page 25 Four reasons to attend a nursing conference
Page 26 SVN AGM Agenda
Page 27 SVN Conference Agenda
Page 28 James Purdie Prize Presentation
Page 32 SVN Treasurer’s Report
Page 34 SVN Bursaries
Any articles, questions, queries or comments about Vascular Matters, please email the editors at [email protected] or [email protected]
Vascular Matters Editors
Leanne Atkin & Emma Bond
svn.org.ukThe official website of the Society of Vascular Nurses
Visit here for information on SVN membership, conference information, bursary applications and much, much more!
Call 08450 606707 to speak directly with a Customer Care Advisor or visit our website at: www.Lohmann-Rauscher.co.uk ADV260 V2.1
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Presidents ReportHappy New Year and welcome to the fi rst edition of Vascular Matters of 2018!
I would like to welcome, and introduce two new committee members to the SVN. They were nominated and then voted onto the committee at the AGM for the next year. Kate Humphries is a Vascular Nurse Specialist at Calderdale and Huddersfi eld NHS Foundation Trust and Siobhan Gorst, also a Vascular Nurse Specialist at Doncaster and Bassetlaw NHSFT. I join with the rest of the committee in wishing them both a warm welcome. We are looking forward to working with them in the months ahead.
Vascular disease fi nally should soon to be getting a slightly higher profi le, with a national project called the GIRFT (Getting It Right First Time) program, soon to publish its report on Vascular Surgery. The GIRFT program run by NHS improvement aims to help improve patient outcomes and quality of care for patients in the NHS. Recommendations will be made to help reduce unwarranted variations in care, as a result of the report, this is of course led by NHS England but hopefully the outcomes from this will help to shape national care. We will ensure, that through this journal and SVN website you are kept up to date on the contents of the report and how this will affect services in the future.
The society continues to work collaboratively and closely with other vascular professional bodies including the Vascular Society and the Royal Society Medicine (RSM) Venous Forum. This is important, in making a difference nationally to help raise the profi le of vascular disease, both arterial and venous. The RSM Venous Forum have recently published a guideline to help promote the best management for patients with venous leg ulceration, aiming to ensure that patients with ulceration have appropriate venous assessment and intervention. This can be viewed on the SVN website and is also within this edition. This can be used within your own area to help guide commissioners and to support local guidelines for the management of leg ulceration.
As well as working collaboratively with vascular colleagues, we also have a major piece of work underway with a number of other societies interested in lower limb disease these include the Tissue Viability Society. British Lymphology Society and the Leg Ulcer Forum and the project will be endorsed by NHS England. Trust me, this is something that will be of interest to you all, and we will be excited to reveal the full details of this in our next edition so please do watch this space.
As always, we want you to get involved with the SVN so contact one of us if we can help you with anything. We have been able to help Bradford Vascular Centre promote their study day recently; promote new job roles through social media and the newsletter and provide assistance with job outlines. If you would like to submit an article into the newsletter then please contact Leanne Atkin. If you are interested in fi nding out more about the SVN committee please contact us, and consider spending time in one of our staff nurse developmental posts.
Best wishesNikki Fenwick, SVN President
President
Vice PresidentJames Purdy Prize &Circulation Foundation
MembershipNHS England CRG
Secretary electServices to VascularNursing
Vascular Matters EditorWebsite Co-OrdinatorLegs Matter Campaign
Vascular Matters Editor
Nurse Competencies Lead
Conference Organiser
Conference Organiser(Shadow)Research & Development
Evening SymposiumOrganiser
Social MediaWebsite Co-ordinator
Treasurer & BursariesNon-Committee Role
Nikki FenwickVascular Nurse Specialist
Louise AllenVascular Nurse Specialist
Sue WardVascular Nurse Specialist
Kate RowlandsVascular Nurse Specialist
Leanne AtkinVascular Nurse Specialist
Emma BondVascular Nurse Specialist
Claire ThomsonVascular ANP
Gail CurranVascular Research Nurse
Jane TodhunterVascular Nurse Practitioner
Suzanne AusterberryVascular Nurse Specialist
Aisling RobertsVascular Nurse Specialist
Stephanie HoustonStaff Nurse
Jayne Burns
Sheffi eld Vascular Institute, 2nd Floor Nurses Home, Northern General Hospital, Herries Rd, Sheffi eld, S5 7AU. 01142 434343 Blp 2773 [email protected]
St Mary’s Hospital, Praed St,London W2 1NY0203 312 [email protected]
C/O Mr Brooks’ Secretary,Royal Sussex County Hospital,Eastern Rd, Brighton01273 696955 Blp [email protected]
C/O Ward B2, Cardiff Regional Vascular Unit UHW, Heath Park, Cardiff CF14 4XW02920 742699, L/R Bleep 07623906342 [email protected]
Division of Podiatry, Dept of HealthSciences, Ramsden building, RG/11,The University of Huddersfi [email protected]
Glan Clwyd Hospital, Sarn Lane,Bodelwyddan, N.Wales, LL18 3PS01745 445405 [email protected] [email protected]
Wd 14, Royal Bournemouth Hospital,Castle Lane, Bournemouth, Dorset,BH7 7DW01202 303626 bleep 2620
The Cambridge Vascular Unit, Box 201, Addenbrooks Hospital, CambridgeBiomedical Campus, Hills Rd, Cambridge, CB2 0QQ
North Cumbria Acute Hospital Trust,Cumberland Infi rmaryNewtown Road, Carlisle, CA2 7HY01228 814424
Manchester Vascular Centre. Division of SurgeryCentral Manchester University Hospitals NHSFoundation Trust Manchester Royal Infi rmaryOxford Road, Manchester M13 9WL 0161 [email protected]
Wren Unit, The Great Western Hospital, Malborough Rd, Swindon, SN3 6BB01793 [email protected]
Vascular Surgery, Royal Victoria Hospital, 274 Grosvenor Road, Belfast, BT12 6BA.02890633156 [email protected]
Committee Members
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Are staff nurses forgotten in the field of vascular?Stephanie Houston, Deputy Sister, Vascular Surgery, Royal Victoria Hospital, Northern Ireland
As a ward based nurse working in vascular I have found over the past number of years that a lot of information and courses are geared towards specialist nurses in the field and unfortunately due to time constraints and staff shortages throughout, many ward based nurses’ do not get to avail of these resources.
A lot of units have run their own study days at ward level to encourage further educational development but for many this still lacks.
I decided to put a few questions to some junior staff nurses who I work with to gather their opinions on vascular nursing and why they decided to join the field. Recruitment has always been difficult being a unique specialty and retaining staff into specialist roles even more difficult.
Suzanne Warwick:
1. Q: Why did you decide to work in vascular and how long have you been there?
A: I completed my management placement in vascular surgery and got offered a post when I qualified. I have been in vascular for 3 and a half years.
2. Q: Where do you see yourself in the future?
A: I see myself heading into a nurse specialist role. I loved cardiology as a student nurse so perhaps something within that.
3. Q: How would you like vascular nursing to develop?
A: I would like to see the vascular unit in the area I work become larger. I feel 26 beds for a regional unit cannot cope with the sheer volume of planned and emergency surgeries and treatment. Perhaps also to see a separate section to have a diabetic foot ward.
4. Q: Are you a member of a nursing society and do you feel it important as a staff nurse?
A: The only member I am personally with is Unison. I do feel being part of a society is good to keep you up to date with practice or even to have someone within your area involved that helps keep staff updated.
5. Q: Is there anything you feel could be done to encourage nurses into this specialty?
A: Jobs fairs have been successful for the unit I work in recently. Having plenty of information to show people as I think some don’t quite understand what vascular entails. Plenty of awareness about the operations and all what we do is helpful.
Hannah Myers:
1. Q: Why did you decide to work in Vascular and how long have you been there?
A: I attended the Belfast trust fair walked round the different tables, with the information about the wards. I knew I wanted to work in a surgical ward, but never considered vascular. I decided to take a change on it as I didn’t know anything about it and I found the staff at the fair the most approachable. I have now been working on a vascular ward for just over a year now.
2. Q: Where do you see yourself in nursing in the future?
A: I think I’d like to stay in vascular for another few years, as I like the wound care element and fast pace. I came into Nursing liking the idea that I could change paths eg ward, environment, specialise. I’m not sure yet as I’m only starting out in my nursing career where I see myself in the future, but I have always thought district Nursing later in life.
3. Q: How would you like vascular nursing/services to develop?
A: I feel there isn’t enough aftercare for amputate patients, with regard mental health eg, counselling, information on what happens next. Nurses unfortunately don’t have the time or the knowledge sometimes to answer or deal with the questions patients have with losing a limb. There’s a need for more training in relation to this for nurses, also the different stages in healing of a stump and when the limb is suitable for Prosthesis.
4. Q: Are you members of any society’s and do you feel it is important as a staff nurse?
A: I’m a member with unison I used to be with RCN, but I thought the membership fee had went up in price and wasn’t worth that cost. To be honest I have never availed of the services they provide, but I think it will be of benefit to me.
5. Q: Is there anything as staff nurses that could be done to encourage more into this specialty?
A: More incentives such as specialised training and more recognition for added responsibility as it’s a specialist field. Pay scale for nurses needs to be improved to encourage recruitment. I feel greater awareness for new nurses about the field through advertising, and being highlighted on the trust website for the work being done, also that it is the only vascular ward in Northern Ireland which can limit the scope of nurses joining.
– continued overleaf
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Méabh McNulty:
1. Q: Why did you decide to work in Vascular and how long have you been there?
A: I had a placement in Vascular in Ninewells in Dundee & really enjoyed the aspects of care although it mainly centred around issues with the misuse of IV drugs and since being qualified 14 months I have been working in RVH Belfast.
2. Q: Where do you see yourself in nursing in the future?
A: At the minute I see myself staying in Vascular as I think I have a lot of learning still to do, I would like to continue my education and consider a masters soon.
3. Q: How would you like vascular nursing/services to develop?
A: With RVH being the regional unit for Vascular in Northern Ireland I would like to see it to be the forefront of vascular nursing & an example for throughout the UK.
4. Q: Are you members of any society’s and do you feel it is important as a staff nurse?
A: I am currently not a member, but I think if you want to develop in a specialty it helps to be a member of a society as there are more resources readily available for up to date evidence based practice.
5. Q: Is there anything as staff nurses that could be done to encourage more into this speciality?
A: I think the avenues of developing as a nurse in Vascular could be identified and explored.
Its clear to see that we need to do more for staff nurses to retain them. Further education is required, mainly directed to ward level nurses, to peak their interest in vascular nursing. We need to make vascular nursing more than just a job to them.
The 3 girls I asked these questions to are all only beginning their careers and already recognise the need to expand vascular service due to the ever-increasing demand but they all identified that they need further education to do this. Knowledge surrounding societies seems limited and I feel more awareness of the benefits they all provide to nurses would be a great advantage to them.
Many seem to confuse unions and societies and refer to them as the same organisation. Many staff nurses feel conferences are for those specialist nurses and topics discussed are not for them. This culture needs to change within nursing to allow ward nurses working in specialist fields feel more included and required. Throughout my career in vascular nursing I hope to highlight the importance of the ward based nurse, particularly within vascular and enhance their role on the ward.
For Consultants, Higher Trainees and Nurses in Vascular Surgery
Solihull Hospital, Birmingham, UK
Cost: £250 (Trainees £150, Nurses £100)To book: email [email protected]
Tel: 01432 373555
STD Pharmaceutical Products Ltd, Plough Lane, Hereford HR4 0EL
Foam Sclerotherapy Workshop
Saturday 10th March 2018 10.30 – 4.30
Faculty includeProfessor Andrew BradburyMr Philip Coleridge SmithMiss Katy Darvall
Includes Live Case
Demonstrations streamed to the
lecture theatre of foam sclerotherapy
treatments of the GSV, SSV and
recurrences
For Consultants, Higher Trainees and Nurses in Vascular Surgery
Solihull Hospital, Birmingham, UK
Cost: £250 (Trainees £150, Nurses £100)To book: email [email protected]
Tel: 01432 373555
STD Pharmaceutical Products Ltd, Plough Lane, Hereford HR4 0EL
Foam Sclerotherapy Workshop
Saturday 10th March 2018 10.30 – 4.30
Faculty includeProfessor Andrew BradburyMr Philip Coleridge SmithMiss Katy Darvall
Includes Live Case
Demonstrations streamed to the
lecture theatre of foam sclerotherapy
treatments of the GSV, SSV and
recurrences
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Impact of a chronic leg ulcer: a patient perspective and the impact it had on me!Jane Todhunter – Vascular Nurse Pracitioner, Carlisle
Nurses are encouraged to be reflective, and following the SVN conference in November I have been reflecting on what had lasting impact upon me. There were two presentations that resonated. One was the inspirational and moving work of Mr Viquar Qurashi founder of the Naya Qadam Trust which provides prosthetic limbs for the third world. The other was Tracy Goodwin, a patient who presented her story of living with a chronic venous leg ulcer. It is a story that you can read within this newsletter, but it had a profound and lasting effect listening to it live. This is a story that many of our patients could tell us any time we choose to listen, but it seems that somehow, we don’t always have time to hear or perhaps we don’t ask.
The impact of venous disease on self- esteem and identity was highlighted during the presentation. It is an effect that is difficult to quantify and for health care professionals may be difficult to address. In the literature patients living with a leg ulcer speak about a loss of confidence and self- esteem and indeed in one study they talked about a loss of self (Briggs & Flemming 2007). A recent article in the Venous News written by a patient who suffers post thrombotic leg syndrome describes the drop in self-esteem as she tries to reconcile her new “ill” identity with who she was before (Bayley 2017). Having a chronic leg ulcer can challenge the sense of self and requires a shift in thinking as patients are forced to accept the new altered “them”. Bayley (2017) describes the battle and victory to re-adjust her self-image but it is against the bittersweet backdrop of a world moving at a pace she can no longer match.
The nurse-patient relationship played a pivotal role in Tracey’s story. The literature suggests that patient-professional relationships are a mixed bag and can be both negative and positive. The negative impacts result when patients feel they are not being listened to and perceive there to be a lack of time, trust, empathy and understanding (Briggs & Flemming 2007). The positive impacts appear to be made when nurses shift the focus of care from healing to helping patients gain control over their lives (Briggs & Flemming 2007).
This chronic approach allows for the fact that not everyone will achieve healing and helps prevent falling into a cycle of hope and hopelessness which comes from aiming for healing at all costs. As well as the patient, the health professional may also suffer a sense of failure if the ulcer does not go on to complete healing. For those of us who treat patients with leg ulcers I am sure that we can all think of at least one patient who despite our best efforts and even surgical intervention has failed to heal. I don’t think I am alone in experiencing the heart sinking feeling of re-measuring an enlarging ulcer and watching the patients face fall. Instead of viewing wound healing as the only desirable outcome perhaps it is more appropriate to focus on alleviating the distressing symptoms. Perhaps we should be assisting patients to live with and manage their condition which may in turn have a positive effect on healing (Persoon et al 2004).
Bayley (2017) from her personal experience describes venous conditions as demoralising, disabling, disenfranchising and isolating and suggests it is the health care
specialist who understands the psychological toll from the patient’s point of view who provides the support to enable the patient to continue the fight beyond the hospital walls.
References
Bayley, J (2017) ‘Thrombosis: both a physical and psychological event’, Venous news, Sept: Issue 2, p.10.
Briggs, M. & Flemming, K. (2007) ‘Living with leg ulceration: a synthesis of qualitative research’, Journal of Advanced Nursing, 59(4), pp.319-328.
Persoon, A., Heinen, M.M., van der Vleuten, C.J., de Rooij, M.J., van de Kerkhof, P.C.M. & van Achterberg, T. (2004) ‘Leg ulcers: a review of their imoact on daily life’, Journal of Clinical Nursing, 13(3), pp.341-354.
Don’t forget to visit www.svn.org.uk
for up to date information on courses, conferences, bursaries and more!
Follow the SVN onTwitter: @vascularnurses
&Facebook: Society of Vascular Nurses
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Feedback from bursary award:Avril Colfer, Ward Sister, University Hospital Southampton.
I have worked on a vascular ward since qualifying in 2010 at University Hospital Southampton (UHS), it is here where my passion for vascular become apparent. As someone who is always keen to develop my knowledge and skills further, I applied to be complete this vascular course. After being successful in gaining a place on this module, I applied for the SVN bursary to help fund my place in the Specialist Practice in Vascular Nursing Care course at BPP University. The course ran over a period of 12 weeks which was all online based, which enabled me to work full time and participate in this course without having to travel. This included tutorials, group discussions, and analysing research studies. The course was divided into 10 topics which included topics such as; the physiology and management of peripheral arterial disease, complex aortic disease, carotid endarterectomy and renal impairment in vascular patients.
Through participating in this course it has aided my development greatly by increase my network to other vascular nurses throughout the country and being able to hear about how their units run. I have gained a better understanding of the complexities and comorbidities that relate to vascular patients. It has aided my insight in to the various different procedures to help revascularise patients and identifying when surgery many not be the most appropriate treatment. By enhancing my knowledge has allowed me to help educate and support other members of staff in their own development. All these areas have aided me to understand the intricacy of nursing the vascular patient in terms of their own conditions. Since UHS has become the Wessex Vascular Network, there has been an increase of service uses from emergencies and elective patients. A topic in particular that I was interested was AAA. As a vascular unit, we seem many EVAR and open repairs, with some patients after an open AAA repair having an epidural insitu and others have rectus sheath catheters. This then became my topic for my essay where I discussed the difference between using rectus sheath catheters over epidurals in open AAA repairs.
Thanks to the SVN bursary I was able to enrol on this module and had the great opportunity to achieve the above. I would recommend this course to anyone who has a keen interest in vascular and wanting to increase their knowledge and also learn from other nurses working on different Trusts across the UK and learning how their units or services work.
Feedback from SVN bursary awardJude Day, Vascular Clinical Nurse Specialist, Bristol
I applied for a bursary from the SVN in order to attend the Venous Forum at the Royal College of Medicine in London, in order to give further insight into the management of venous incompetence. Currently at North Bristol NHS Trust we are attempting to implement a Clinical Nurse Specialist (CNS) led venous service. My CNS colleague and I are using a competency based learning set in order to prepare us for undertaking both RFA (radiofrequency ablation/endothermal ablation) and foam sclerotherapy.
The day was extremely informative with a range of experienced speakers. Some, expert surgeons in the field, others very accomplished nurses working autonomously. There were also trainees at the beginning of their career. All provoked thought and questioning of existing practice, which was incredibly enlightening.
On a personal level, my objective was to see my colleagues approach to interventional practice treating venous incompetence, paying particular regard to training and duplex ultrasound (DUS) provision for those of us who are not clinical scientists. This was to ensure that we would be able to offer a high calibre, safe and effective service.
Having written competencies with regard to performing radio frequency ablation and foam sclerotherapy, I felt it necessary to ensure that whilst in the process of set up, the competencies are being aligned with current training/practice. Despite my colleague and I having many years of duplex experience through graft surveillance and pre-operative vein mapping, we have no formal qualification regarding duplex ultrasound.
According to a Rouleaux club presentation, its members were asked how much training they had with regard to performing basic duplex ultrasound. The majority had only had 1-2 days informal training, but did work to specific competencies as laid out by the vascular curriculum/Interventional Radiology curriculum (2016). Of those asked, 67% felt that duplex ultrasound training was essential for varicose veins while 9% felt it was of little or no use. When asked whether DUS training was important for endothermal ablation 82% voted essential, and 18% voted it was very important. Furthermore when asked what they found most challenging when undertaking endovenous treatment, they stated duplex ultrasound. With regard to formal certification in venous duplex imaging, 67% had none, 30% had undertaken a 1-2 day course and only 3% had done a Post graduate certificate.
Informal training appears to be the most common, though more formal training opportunities should be considered. Working with the competency based framework, DUS appears to be key, enabling the practitioner to optimise greyscale, colour flow, pulse wave in setup and further more able to perform superficial venous and arterial ultrasound. Percutaneous puncture of the saphenous vein under DUS control is a skill strongly recommended to master at level 4 competence.
As nurses are taking the next step from leg ulcer management to venous intervention this conference was able to highlight some of the key components in the set-up of a safe effective service. Aligning practice with our trainee surgical colleagues in this area seems common sense.
I would like to thank the SVN for this opportunity. There were so many interesting presentations regarding venous insufficiency, leg ulcer management and what people are doing around the country to manage this condition. I would highly recommend this forum to anyone interested in venous disease management.
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The Challenge• Leg ulcers are non-healing wounds on the lower leg usually due
to an underlying problem with veins (and sometimes the arteries).
• Most leg ulcers are caused by chronic venous hypertension.
• Leg ulcers usually take many months to heal.
• Without appropriate care, up to two-thirds of healed ulcers will recur within a year.
• Most patients with leg ulcers are managed in community healthcare settings.
• Data from GP records suggest that at least half these patients do not receive the care they need.
• Chronic wound care is estimated to cost between £4.5- £5.1 billion per year; a third of these wounds are leg ulcers.
Managements Recommendations1. Every patient with a leg ulcer should have an ankle brachial
pressure index (ABPI) assessment (‘Doppler’) on initial presentation to assess the arterial circulation.
2. All patients with an adequate arterial supply (ABPI>0.9) should be offered effective compression.
3. All patients should be referred to a vascular service for assessment of their veins.
4. All patients with treatable venous hypertension should be offered minimally invasive endovenous interventions (such as endothermal ablation or foam sclerotherapy).
Management of Patients with Leg Ulcers
Academic DepartmentDirect Line: +44 (0) 20 7290 3918 Direct Fax: +44 (0) 20 7290 2989Email: [email protected]
Address: 1 Wimpole Street, London, W1G 0AEWebsite: www.rsm.ac.uk Telephone: +44 (0)20 7290 2900Charity no: 206216 VAT reg no: 524413671
Summary• Leg ulcers cause great distress to patients and cost the NHS millions of pounds each year. The prevalence of leg ulcers is
increasing.
• Most patients have an underlying vascular cause for their leg ulcers.
• All patients require specialist assessment and most would benefit from compression and treatment of their veins.
• Despite evidence-based guidelines for referral and treatment, current service provision remains poor.
Suggested Patient Pathway
PATIENT PRESENTS WITH LEG ULCER
EARLY ASSESSMENT (INCLUDING ABPI) &
APPLY COMPRESSION
REFER TOVASCULAR SERVICE
(Assessment including Venous Duplex)
TREATABLEVENOUS
HYPERTENSION
NO
YES
VENOUS TREATMENT
CONTINUE COMPRESSION& NURSING CARE
_ @RoySocMed X /RoyalSocietyofMedicine ^ Royal Society of Medicine
Rationale: Doppler assessment of ABPI is a valid and reliable way to detect arterial impairment in the lower limb.
Urgent action is needed to ensure that all patients with leg ulceration are offered the most appropriate care.
Rationale: Good compression doubles the chance of healing venous leg ulcers.
Rationale: Duplex examination is the gold-standard method for identifying treatable venous problems.
Rationale: Superficial venous treatment halves the risk of ulcer recurrence.
1 Version 2
Statement from the Vascular Society 16th June 2016
The Vascular Society of Great Britain and Ireland firmly believes that the care of patients having endovascular intervention for vascular disease should be led and provided by vascular surgeons. These surgeons should be trained to the highest standards to provide safe and effective treatment to patients with vascular disease no matter where they reside in the UK.
There are many examples of harmonious practice within the UK where surgeons and radiologists work together to provide safe and effective patient care. POVS 2015 describes these models and we would fully endorse those centres where collaborative working practices are able to effectively provide both elective and 24/7 emergency endovascular care. However, the population, geography, degree of specialization and the workforce arrangements to meet service demands will differ across networks. In some units vascular surgeons will be required to deliver the majority of elective and emergency vascular intervention in the future.
The recent events at St George’s Hospital, London have been reported in the national press and are raising concerns about the tensions that exist between radiologists and surgeons in the delivery of modern vascular intervention. An external review of the service has taken place and until that is published we are unable to comment on the local issues. We would however state our total support for vascular surgeon led endovascular units.
We are working closely with BSIR/RCR to deliver a number of service models and we believe that all major vascular centres will need to employ vascular surgeons with an endovascular skill set capable of delivering this modern care. We are also working with the vascular SAC to ensure that the modern vascular curriculum reflects the training required to continue this natural evolution in UK vascular surgery in keeping with international vascular surgical practice.
All of our vascular trainees need to be trained in endovascular surgery and collaboration with our interventional radiologists is required in order to deliver the best possible safe care to our patients. Vascular surgeons lead the clinical service and this leadership must continue.
Mike Wyatt, President Rob Sayers, President Elect Kevin Varty, Honorary Secretary (On behalf of the Council of the Vascular Society of Great Britain and Ireland)
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SVN MILESTONE 25TH ANNIVERSARY Celebratory Event The SVN will reach its Quarter Century in 2018, join us in Glasgow to celebrate this fantastic milestone. Details will be released at the earliest opportunity, so that you will be able to save the date.
SVN 25TH ANNIVERSARY
JOIN US IN GLASGOW TO
CELEBRATE
1994-2018
DETAILS WILL BE RELEASED EARLY 2018
SVN 25TH
ANNIVERSARY——
JOIN US INGLASGOW
TO CELEBRATE——
1994-2018
DETAILS WILL BE
RELEASED
EARLY 2018
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Lower limb ulceration: The impact to the individualDr Leanne Atkin, Lecturer practitioner/Vascular Nurse Specialist, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire NHS Trust, E mail: [email protected]
Mrs Tracy Goodwin, Patient at Mid Yorkshire NHS Trust
Introduction
Leg ulceration affects 1.5% of the adult population and the management of these wounds is costly to the National Health Service (NHS) (Guest et al., 2017). The impact to individuals quality of life has been frequently reported and the literature documents that lower limb ulceration can affects a wide range of patients quality of life including self-esteem, pain, sleep, social isolation, physical mobility, less vitality, restricted social function, and restrictions with social interaction, work capacity, and psychological well-being (Herber et al., 2007, Hopman et al., 2016, Persoon et al., 2004, Green et al., 2014).
Even though many practitioner are aware of these factors and try to empathies with the individual patient, at times the true impact of living with a chronic wounds can be over looked or even forgotten, as the nurse focuses on the clinical aspect of wounds care. This article will share a personal account from a patient who has been suffering from leg ulceration for over a decade. The aim of this article is to raise the true individual impact of living with a chronic wound and to try to ensure this remains paramount in the minds of all practitioners caring for patients with lower limb ulceration.
Hi, my name is Tracy Goodwin and I am 38 years old. I have 2 children, 2 dogs and along with my husband, I run a business. I have been living with a chronic leg ulcer for almost all of my adult life. At the age of 20, I suffered a deep vein thrombosis (DVT) when I was 8 months pregnant with my son and despite blood thinning treatment, it re-occurred when my son was 6 weeks old. Although this was a traumatic time (my son was also in hospital with a urine infection), I had no idea of the complications I would suffer in years to come. For the next few years, the main problem I had was throbbing and aching in my left leg which caused me to start needing pain relief on a daily basis. I was also left with silvery, paper-thin skin on my left ankle.
A few years later, I had a simple knock to this ankle- and that became the ulcer that has been the bane of my life ever since. It was just a tiny cut to my inner ankle that refused to heal and for several weeks, I tried to carry on as normal (albeit with smelly exudate running into my shoe). After a few more weeks, I was sent to the hospital to have it dressed. I hadn’t even heard of leg ulcers and had no concept of the affect that such a small wound could have on a person’s life. The ulcer healed after 12 weeks which at the time seemed like a lifetime – you can only imagine now what I would pay for a 12 week healing time! After this, I was left with an even worse throbbing venous pain in my left leg and very thin, delicate skin on my ankle.
I went on to have my second child in 2004. During the pregnancy, I had to inject myself with a blood thinner every day as I was on lifelong blood thinning medication by this point. When my children were 6 and 1, I unfortunately suffered a second knock to the same ankle in the same place. The wound became infected and very quickly went from the size of a small dot to the size of a 50p piece and I was on IV antibiotics in hospital for several days. This time, the ulcer didn’t heal. It has closed over for a matter of weeks a few times but never permanently.
Leg ulcers are misunderstood in many ways, it seems madness to most people that, in this day and age, a small wound cannot heal. I probably could have broken and healed every bone in my body in the time I have had this evil, infuriating, stubborn little ulcer (Figure 1). I do not have any pre-existing medical conditions, I wasn’t overweight when this all started and I have never used drugs – I’ve not even smoked a cigarette! I have just been unlucky. Obviously I am overweight now which I know doesn’t help the blood flow but it is no great surprise given the fact I cannot exercise much, I have a busy home and work life and I am a bit of a comfort eater. In all honesty, living with a chronic wound, I need a lot of comfort! I have tried to lose weight over the years (2 years ago, I lost 3 stone) but unfortunately, it never seems to make any difference to the ulcer.
There seems to be a pre-conceived idea of leg ulcers – a) they only happen to old people and b) they can be healed with maggots and manuka honey! If I had a pound for every time someone has suggested that to me, I’d be rich!
Living with a chronic wound has affected my life in every single way. First and foremost, it has affected my confidence. Many people wear nice clothes or shoes to make themselves feel special and to feel good about themselves. I cannot do that. For many years, the only shoes I could wear were flat backless mules. In fact, in the beginning, I distinctly remember wearing flip flops (which were the only shoes I could fit over the four layer bandage) in all weathers - even in the snow. I haven’t been able to wear heels or strappy shoes for over 15 years. I cannot wear shorts, cropped trousers, skirts or dresses without my leg and my highly unattractive compression stockings being on show. It makes me feel old and ugly.
It has also made a big difference to my social life, I haven’t been able to drink alcohol since being on warfarin (prescribed after my first DVT) so along with not being able to wear ‘dressy’ clothes or shoes and not being able to
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Figure 1
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stand for long, I have stopped going on nights out. Unfortunately, as I am also allergic to make up, I feel very underdressed in an evening social situation.
My foot and toes have actually changed shape because of the ulcer. I have spent so many years walking on the side of my foot that the ligaments have shortened and I find it hard to straighten my foot. This results in my left shoe being worn down more quickly and extra pressure being put on my left knee and hip meaning that I now suffer with back problems from bad posture.
In June 2017, I started suffering from a pain on the outside of my left foot. It quickly became unbearable so I visited Accident & Emergency (A&E) where I was told that it was soft tissue damage from walking on the side of my foot. I attended physiotherapy sessions and applied ice as directed but it continued to get worse. Four months later, I visited the General Practitioner (GP) and requested that I had a second x-ray. On this occasion, it was discovered that my 5th metatarsal was broken (Figure 2) and because I had been walking on it for several months, the 2 parts of the bone had come apart completely. I was given an air boot cast to wear but unfortunately, the bones didn’t fuse at all. The pain from the broken bone is bad and affects everything I do, even walking around the supermarket leaves me in pain. The bone needs to be fixed but the surgeons are reluctant to do it because of the risk of bacteria getting into the bone from my ulcer. Currently, I am seeing the plastic surgeon who carried out a re-cell skin graft. It is very frustrating because I am positive that the bone was broken because of the knock on
effects of the ulcer yet the ulcer is also the reason that the bone cannot be fixed.
This ulcer has had a huge effect on my family life. I have tried my absolute best to not let it and I have spent many days in agony walking around theme parks, museums, parks and shopping centres or climbing through soft play areas, walking the dogs and taking the children to clubs and activities. I pride myself on being the best Mum I can be and I will always put my family first. The last thing I wanted is for them to miss out because of my leg. However, there have been many occasions over the years where I have been unable to do certain activities with my husband and children. For example, skating, swimming, running, trampolining, dancing, sledging and exercising. Sometimes, this is because I cannot risk infection or cannot wear the footwear required and other times it is because it is a high impact activity. There have also been days when I have
been in too much pain to go out at all. These days have been my lowest.
The pain relief medication also has an effect on me. Thankfully, I am on a much lower dose now but I still take oral morphine and Ibuprofen twice a day. When my pain was at its worst, I could barely walk so I spent 18 months sleeping on the sofa downstairs. I wasn’t sleeping very well at this time and I spent many a night lying awake in pain (especially after a painful dressing change). Sleep deprivation is a horrible thing and I wouldn’t wish it on anyone. It affects you in every single area of your life but mainly your concentration, emotions and diet. I was taking way over the prescribed amount of painkillers just to try and take the edge off. I am not proud of it and I am obviously grateful that I no longer have to take as many but at one point, I used to take 8 ibuprofen before I even walked my children to school. I dread to think what damage I could have done to my stomach but I had to take them in order to get through the day. I also used to take a much higher dose of oral morphine which used to make me feel very drowsy. This was far from ideal when I had 2 small children in my care. It also didn’t impress the children when I would take them to the cinema and fall asleep before the trailers were over!
Holidays should be a wonderful time and luckily, I have still been able to travel a bit. It has not been without trouble though. One year, we went to Lapland for the day. It was wonderful but it was really hard work being on my feet all day especially after a 4 hour flight. Before I went, I made sure I was fully prepared with dressings and padding as I knew I would have to wear snow boots. Wearing boots my own size was out of the question due to the pain of pulling them on and the pressure on the ulcer. In the end, I had to wear a size 11 boot on my left leg just to make it comfortable.
When we have been on summer holidays, I have tried all different ways of keeping the ulcer dry but nothing has ever worked. We tend to stay in a private villa so that I can relax around the pool but I always feel extremely self-conscious in public beach areas and waterparks with my compression stockings on. I also daren’t go on the slides because I am so scared of banging my leg and making it worse.
The ulcer has also affected my marriage. Luckily, my husband is very sympathetic and understanding but it has still taken its toll over the years. I have many days when I am over emotional, irritable and have low self-esteem. It is also very hard to feel attractive when you have a smelly, painful wound on your leg. There have been many times when I have felt that I have let my husband down because we can’t go for a night out like ‘normal’ couples. I also feel like a failure because I don’t work full time now that the children are older.
It has completely ruined my career. Before my pregnancy and the DVT, I was half way through my nursing diploma. Nursing was all I ever wanted to do. I went back to university when my son was 1 to finish my Higher National Diploma but unfortunately, I just couldn’t cope with the pain of being on my feet all day when I was on placement. Luckily, soon afterwards, my husband and I set up our own business and ever since, I have been doing the administration for it. It has allowed me to be at home when my children were young and has fit in wonderfully with inset days, school pick up & drop off times and school holidays. However, it is not what I want to do. The problem is, I honestly don’t think I would have been able to hold down a normal job with all the times I have hospital appointments, blood tests, not to mention the sleepless nights and
Figure 2
drowsiness caused by my painkillers. I also would have been unable to do a job where I was on my feet as I would be in too much pain. It makes me feel as if I cannot achieve anything, that there is no point in trying because my leg makes everything so difficult.
Over the years, I think we have probably tried every cream, ointment, spray, dressing, lotion and potion known to man. Throughout the whole of this time, I have been in full strength compression – first in 4 layer bandaging and then in compression hosiery kits. The treatments sometimes work for a while and the ulcer starts to show signs of improvement. To be honest, I have stopped getting my hopes up when this happens as I have been disappointed so many times when it starts to deteriorate again. It’s always a case of 2 steps forward, 2 steps back.
Back in 2008, after a referral from my consultant, I went to Charing Cross hospital in London to have a vein transplant which was performed by Professor Alun Davies. This operation actually ended up being a deep venous bypass when a blockage was discovered just below my knee. Although the operation was a success and helped a lot with the everyday aching and throbbing (which was getting so bad that I had been to the GP to ask for a below-the-knee amputation), the ulcer still didn’t heal permanently.
Unfortunately over the years, I have experienced a few incidents where people do not seem to be knowledgeable enough when it comes to leg ulcers and compression. I once had a practice nurse at the GP surgery put a four layer bandage on my leg but her bandaging technique was rubbish. She left me in extreme pain and after a few days, I had to remove it. I was left with huge painful dents all down my leg. Just recently, after the re-cell skin graft, I was sent home with no compression on at all – just a loose bandage around my ankle. This could have jeopardised the success of the whole procedure.
I have been lucky enough to have been looked after by a team of nurses who I trust, I have been under there care since 2003 when I was first diagnosed with a leg ulcer. I have 100% trust in the service I am under and I know that she does everything she can for me. As soon as a suitable new treatment becomes available, I am put forward for it. They offer a flexible service to me where I can pop in or email if I have any concerns, as I prefer to do my own dressings at home, but if I ever have any concerns I know the specialised service is only a call away. This relationship has made a massive difference to my ability to cope with this condition. I hate to think how much harder this would be if I didn’t have a trusted professionals looking out for me. I recently had some bad news regarding my broken foot and she sent me a lovely email to cheer me up.
My account of my ulcer is very emotional to me and it makes me cry a lot, tears of frustration that it won’t heal, tears of self-pity when people are sympathetic and most of all, tears of sadness for the things that have been taken away from me. I am upset about the life I could have had, the career I should have had and for the person that I should have been. I always thought I would be somebody and achieve something in life but I feel like I have had that opportunity stolen away. I hate feeling self-conscious, disabled and unattractive and I hate that this leg ulcer has taken away my self-confidence. I know there are people much worse off than me and whenever I am feeling down, I always remind myself of that. I know I am lucky to have wonderful family and friends that love and care for me and of course I am grateful that I haven’t got any awful diseases that are life threatening. However, having a chronic wound that affects my life in so many ways is hard going and I really hope that I have given you an understanding of what it is like.
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I agreed to do write my story because I know I am in the minority having a chronic leg ulcer at my age. I think it is important to understand that elderly people have to be treated differently to people in their 20’s and 30’s so that the impact of a chronic wound on a person’s life is minimised.
The service and financial impacts of venous ulceration are high on the agenda within NHS England currently. There is an awareness that at times we are failing patients with lower limb ulceration in terms of lack of diagnosis, lack of appropriate assessment and lack of the use of compression therapy (Guest et al., 2015). Whilst we need to raise the standard of care we also need to ensure that we do not marginalise the quality of life impact of venous leg ulceration or think of this only as an older person’s disease. Unfortunately, Tracy is one of the few patients with venous ulceration that fails to heal even with appropriate compression, wound bed preparation and corrective venous surgery. However, hopefully her account and reflections of her ulceration will ensure that practitioners keep the patient at the heart of everything we do and that we never forgot the individual behind the ulcer.
ReferencesGREEN, J., JESTER, R., MCKINLEY, R. & POOLER, A. 2014. The impact of chronic venous leg ulcers: a systematic review. Journal of Wound Care, 23, 601-612.
GUEST, J. F., AYOUB, N., MCILWRAITH, T., UCHEGBU, I., GERRISH, A., WEIDLICH, D., VOWDEN, K. & VOWDEN, P. 2017. Health economic burden that different wound types impose on the UK’s National Health Service. International Wound Journal, 14, 322-330.
GUEST, J. F., AYOUB, N., MCLLWRAITH, T., UCHEGBU, I., GERRISH, A., WEIDLICH, D., VOWDEN, K. & VOWDEN, P. 2015. Health economic burden that wounds impose on the National Health Service in the UK. Downloaded from http://bmjopen.bmj.com/ on January 4, 2016 - Published by group.bmj.com.
HERBER, O. R., SCHNEPP, W. & RIEGER, M. A. 2007. A systematic review on the impact of leg ulceration on patients’ quality of life. Health Qual Life Outcomes, 5, 44.
HOPMAN, W. M., VANDENKERKHOF, E. G., CARLEY, M. E. & HARRISON, M. B. 2016. Health-related quality of life at healing in individuals with chronic venous or mixed-venous leg ulceration: a longitudinal assessment. Journal of Advanced Nursing, 72, 2869-2878.
PERSOON, A., HEINEN, M. M. & VAN DER VLEUTEN, C. J. M. 2004. Leg ulcers: a review of their impact on daily life. Journal Clinical Nursing, 13, 341-354.
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AmendmentsSociety of Vascular Nurses
Annual Accounts 16/17Please note there are two amendments to the previously published 16/17 annual accounts.
The total income from membership in 16/17 was £3,145.
After the venue and catering expenses had been paid, we received an income of £4,443 from our evening symposium, obtained through company sponsorship of stands.
Jayne Burns, Treasurer
Next Year’s Conference
Glasgow Scottish Exhibition Centre
Thursday 29th November 2018
SAVE THE DATE
Thursday 29th November 2018
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