Invaluable Nursing For The Local Rough Sleepers

It was a lovely session we thought tonight. In all, 46 through the door, even though it was so busy it was a nice atmosphere. Some weeks there can be an underlying tension and a few issues that we have to manage but this week everything ran smoothly and the evening was jovial.

Jan made a Parsnip Soup due the change of the season and drop in temperature, Ham and Mushroom Tagliatelle. We also had Potato Salad, Red cabbage and a Green and Tomato salad. Meryl made a Plum and Apple Tart with a Summer Berry Curd accompanied with cream and/or custard. All the food went tonight, every morsel.

The HOLT nurses came in today, we had four people come to see them which was great. One person who has not been to see them before, so it is good news that the word is getting around. Usually they are timetables for an hour every other week but this week the nurses stayed for two hours. Consultations do seem to take longer than a standard doctors appointment. With complex needs and requirements the flexibility that the nurses are able to give is invaluable. It is coming more and more apparent that this Outreach service is very important to the homeless and vulnerable community and desperately needed. We have a few more clients come to us during the session itself this evening who need to see a nurse or doctor. Reminding people when the HOLT nurses are at The Soup Kitchen is one thing, remembering and turning up at the right time is another. They are with us 4-5pm bi-weekly.

Many of our clients get sores on their legs from Alcohol or Needle usage. These need to be monitored carefully and dressed appropriately. The HOLT nurses are trained to do this. Some people can have sores like this for years but they can eventually be the cause and a person losing a leg. 

Poor injection technique increases the risk of damage to the veins. Common problems include:

  • ‘Digging’ – an injector penetrates the skin repeatedly trying to find a vein;
  • ‘Flushing’ – the injectate is pushed forward through the syringe into the vein and then the plunger is drawn back, sometimes several times. This increases turbulence within the vein and can damage vein.
  • Missing a vein or the needle going through the vein and puncturing the other side of the vein wall – bleeding can occur, and a granuloma may form around the site. Missing the vein also increases the risk of infection.

Injecting drug users are encouraged to vary their injecting sites to preserve veins and limit tissue damage. Some sites, such as the feet or the groin, are riskier than others due to a heavy bacterial load on the skin. Injecting in the feet is also risky because the veins are peripheral and very small – it is easier to miss or puncture both sides of the vein and thereby inject into the surrounding tissue.

Risk factors associated with injecting drug use

Injecting in the legs or groin (femoral vein) are known risk factors for development of leg ulceration. Injecting in the groin is strongly associated with the development of deep vein thrombosis (DVT), which often occurs in the thigh. LClots may form because of the narrowing of the femoral vein from repeated injecting and the sluggish flow of blood in the thigh, possibly combined with long periods of inactivity. DVT is also a risk factor for leg ulceration.

Injecting in the femoral vein is becoming increasingly common among people who have been injecting drugs for a long time, as well as those who are new to injecting. This may be because:

  • The femoral vein is large and can tolerate repeated puncture;
  • The injection site is hidden from view and easily accessed without a tourniquet so those who inject in public places – such as people who are homeless – find it easy to access and quick to inject into.

Over time, a sinus may develop over the femoral site, making access more visible. The vein can scar and thicken, and injectors report finding the vein harder to puncture, resulting in their need to use longer and larger-bore needles to inject successfully. Larger needles are associated with an increased risk of damage to the vein.

With repeated injecting the femoral vein becomes narrowed, leading to back pressure and venous hypertension in the lower legs, causing collateral veins to swell and become varicose. Feet may become discoloured and purple due to venous congestion. Further disease of the venous system may develop and other signs become visible on the lower legs such as skin staining, flared ankles and an inverted champagne bottle-shaped leg.

If the needle penetrates the artery, the injecting equipment may be forcibly ejected due to the high pressure within the artery. If the injector has injected into the artery, the limb is at risk as the drug is dispersed to the peripheries rather than into the central venous system. This can cause blockage of the arterioles and capillaries, leading to cell death and necrosis. There is also a risk of femoral aneurysm (Woodburn and Murie, 1996). If this occurs surgical intervention may be required.

People who inject drugs are at risk of serious infections, such as necrotising fasciitis, wound botulism and cutaneous anthrax due to the nature of the substances they inject. Those caring for this group need to be aware of systemic signs and symptoms that may alert them to potentially life-threatening illness.

  • What drugs were injected;
  • When they were injected;
  • Which body sites were used to identify potential causes of leg ulceration.

Management

Venous ulcers are treated with compression; Multi-layer elastic bandaging may be suitable and, in fact, welcomed by some patients – particularly those who are homeless and sleeping outside. The warmth provided by multilayer bandaging may aid healing but health professionals need to be aware that a homeless person may be unable to afford to buy larger shoes to accommodate the bulk of bandages.

Compression bandages must be applied by a health professional trained in the procedure, but some patients can put on dressings and hosiery for themselves once the legs have been appropriately assessed, measured and the stockings have been fitted.

Some PWID may have chaotic lifestyles and find it difficult to engage with healthcare services. They may find it challenging to attend leg ulcer clinics regularly for a prolonged period for dressing or bandage changes. It is important to discuss with patients before assessment and treatment commences what leg ulcer management may entail, and ensure they understand that management will still be required after the ulcer has healed. 

Weekly attendance for compression bandaging may be difficult and some degree of flexibility in managing care may be required. Sometimes it can be helpful to delay the first detailed vascular assessment until patients have attended for a repeat visit. This will help to assess their willingness to attend and adhere to treatment. Subsequently, reminder telephone calls may be useful. Arranging appointments for treatment that take place in the afternoon rather than the morning may also be helpful for a patient who is misusing substances and may have disrupted sleep patterns.

Many people who inject drugs may not live in social environments that are clean and do not have facilities to wash themselves or their clothing. Similarly, storage facilities for dressings and laundering facilities for hosiery may be limited.

 

Barriers to treatment

Current and former injectors may not seek help for physical problems due to the stigmas associated with substance misuse. However, some problematic drug users also report feelings of worthlessness and shame, and suggest they are “not worth bothering with” Many also have co-existing mental health problems.

Nurses who assess the leg ulcers of PWID may have only one opportunity to engage them with services and encourage them to return for treatment this is where the HOLT nurses are so invaluable. 

Leg ulceration in drug users is a significant and potentially growing problem, Risk factors include injecting into the groin and legs, and DVT. This group may have multiple medical and social problems that can cause barriers to engagement in services, and need to be treated with sensitivity and understanding.  

 

 Key points

  • Leg ulceration in people who inject drugs is becoming more common
  • Prevalence of leg ulceration in this group has been estimated as 15%
  • Leg ulceration in this group is associated with injecting in the legs or the groin
  • Injecting drug users may be homeless and vulnerable and, as such, find it challenging to engage with healthcare services
  • Those with leg ulceration need a flexible and empathetic approach to their care (21 MAY, 2018 Nursing Times)

Christine started with us for her first session tonight. She will be coming in weekly and will also be another First Aid volunteer she is retired from a long nursing career so her knowledge will be a great addition to the First Aid Team. We will now have two first aid volunteers each session.

We are looking for donations of new kettle and toaster for a homeless client that we have found accommodation for. Moving into a property after uncertainty is a daunting thing. People worry about the commitment of bills and managing day-to-day situations that occur. Emotions can be overwhelming and people can experience a bit of a “Fight or Flight” reaction. Support and ongoing hand holding is very important. This is why any help we can give to make his home more comfortable is essential. 

Next week we will be hosting a Flu Clinic arranged for the third year running by the Public Health and Wellbeing Department of West Berkshire Council. The uptake has been better each year. Many people are cynical of the efficacy of the annual flu vaccine. So we have included myth buster facts. 

This week I went to Greenham Trust to get training as they are trialling a new contactless donation solution from The Good Exchange at #stepup4good2019,  it is a touch pad payment facility for as much money as you wish. Newbury Soup Kitchen is the only charity at the event that has been asked. We will get Match Funding too. Kâren and I are going to the Step up for Good event on October 14th. Tap & donate just £3 to make a difference to #homeless in Newbury.

 

Please remember our Amazon WishlistAmazon Smile and The Good Exchange which are all tools that are set up for support of goods and money donations – to give us the ongoing ability to expand, provide more outreach and support also to work towards and move into a building of our own.

 

Thank you 

 

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