I chose this story because I wanted to honour the huge efforts made by a man to change the path of his life.
The worst part was the smell as he peeled off his dressings – the awful odour of a large colonised wound that has been neglected. It permeated everything and stayed long after he had left my room as if to remind me of what needed to be done. He looked utterly dejected as we surveyed the extensive leg ulcer. ‘Am I going to have my leg amputated?’ he asked.
John had been homeless for about three years when he first presented with a small wound on his leg. He was sleeping rough and saw no prospect of getting into housing as he had a very large amphetamine and heroin habit. This meant that rent and bills were highly unlikely to be paid. He also had arrears from a previous tenancy. John was a persistent and prolific offender (PPO) with a long list of drug-related offences. He also had a childhood history of neglect and physical abuse. His physical health was poor. He had a deep vein thrombosis (for which he was prescribed injections but his compliance was irregular), a blood-borne virus infection contracted through injecting drugs (for which he had been referred to the hospital for ongoing care but had failed to attend any appointments) and now this large infected leg ulcer. He felt that no one cared.
John viewed the failure of agencies to provide him with housing as the reason no one cared about him. In all probability this was just the tip of the iceberg – he had little contact with his family and few friends. The odour from his wound had meant that he had been isolating himself from others, including services designed to help him, and this merely reinforced the notion that he was difficult and unwilling to engage and that, consequently, no one cared. In truth, I felt as overwhelmed by the difficulties of John’s situation as he clearly did on that day.I had seen him intermittently to dress his leg wound but he always failed to return until weeks, or even months later, for his next dressing. That day, though, he seemed desperate.
I cleaned up the wound and applied dressings which I hoped would reduce the odour and then, as I had done on many occasions before, I explained that the wound needed specialised bandaging to get it to heal much more quickly. The only thing preventing us doing that is that he would have to come to have them changed twice a week without fail. ‘Will it get rid of the smell if I do?’
Malodorous wounds can have ‘enormous psychological impact on quality of life causing embarrassment, social isolation, withdrawal and poor self-esteem’ (Gethin, 2010) so it was unsurprising that John felt desperate.
We agreed that he would attend the following week for a Doppler scan of his leg and assessment for bandaging. If he turned up I would ask the housing team to place him in temporary bed and breakfast accommodation for a short period to help his wound heal. This would be a start, and if there were no issues I would call a meeting of all of the services involved to see if we could find a longer term solution to his housing problems.
Thursday arrived, and so did John. He was compliant with the various procedures required to assess his circulation and left with his leg safely bandaged. I contacted housing and, in spite of some misgivings, they agreed that he could have bed and breakfast accommodation for the weekend. We decided that they would issue accommodation letters only if I had been able to dress John’s wound twice a week. If he complied for a period of a month then they would consider offering him the opportunity to go into a hostel.
It was a bit irregular at first but over time he stuck rigidly to his twice weekly appointments with me and within a month the improvement in his leg wound was evident. He was thrilled.
Over the previous three years, many attempts had been made to get John into a hostel or housing. It was clear that housing alone was not the answer and that, rather, a ‘package of care’ was required. This involved ensuring that he was given an Opiate Substitute prescription as soon as possible after being given accommodation such as a hostel bed. This would help to ensure that he had sufficient funds to pay his service charge for the hostel. This seemed like a good place to start and I met with and arranged this with his PPO officer and the local criminal justice prescribing team. Initially, Opiate Substitution Prescribing was the main focus of his support package and once on a prescription it was possible to get much more engagement with John. The team agreed to allow him to pick up his medication from his local pharmacy rather than walk back and for to their premises every day because of the pain in his leg.
A personable and chatty man
Combined with an improvement in his hygiene, clean clothes and no odour from his wound, a personable and chatty man developed over the weeks. He appeared to enjoy contact with staff at the pharmacy where he collected his dressings and this daily contact with the pharmacist meant that his drug compliance also improved and it was possible to change him from injections to tablets for his DVT.
Whittington (2011) suggests that to work effectively with someone who is homeless it is often necessary to depart from or adapt traditional ways of working. Agencies who had worked with John before were reluctant to do so again and needed some persuasion. Placing trust in him and negotiating with services required an element of risk taking on my part. If this strategy had failed then it is likely that the same agencies would be more reluctant to assist me and my patients in the future. Settling into a hostel after a long period of rough sleeping and a chaotic lifestyle was difficult but with the regular support meetings and a dedicated worker, days turned into weeks and weeks into months. Throughout he maintained attendance for his twice-weekly dressing changes. It was during one of these sessions that he asked me if I could get help for him to ‘get his head sorted’. As I turned the bandage around his heel he told me that had been sexually abused whilst in prison and that he felt unable to wipe the memory; that he felt dirty and ashamed. The discussion went on long after the bandaging was complete and eventually he agreed that I could refer him to a specialist rape counselling service. Locally, such services have an 18-month waiting list however, staff suggested that John be referred to the same service in the next county whose waiting time was only six weeks. His support worker at the hostel agreed to take him to his assessment appointment. He returned to the hostel elated.
It took ten months to heal his leg wound but in that time much more had been achieved by John and the many agencies that have produced a complex patchwork of care to help him move on in his life. Last week when he came for the fitting of the support hosiery that will replace his bandages he brought me a bag of sweets to say thank you. “None of this would have happened if it hadn’t been for you. We make a great team don’t we?’
According to the Revolving Doors Agency report Complex Responses (2011), it was suggested that ‘adults with multiple needs wanted consistent, positive and high-quality relationships with staff, in which trust and respect were key factors’. Certainly I had tried on many occasions over the years to provide care for him based upon these central tenets but it is this last simple statement made by John that demonstrates that whilst he valued my help in addressing his many complex needs he also recognised the value of his own contribution to the improvement in his health and wellbeing.
This time HE had made all the difference.Back to Resources