OFFLOADING TOOLS | Wounds Africa

Tools to aid with offloading

Suppose you are working in a workplace where you meet patients at high risk of developing pressure injuries or already have pressure injuries. In that case, you must ensure that you have a selection of tools available to make offloading easier. In the simplest cases, an extra pillow to elevate a heel from the mattress can make a big difference. In more complex cases, a dynamic air mattress may be necessary.

Obviously, we are aware that a dynamic air mattress with a price tag of at least 2000 US dollars is unrealistic for most patients in Africa. We will nonetheless present you with these standards of care recommendations, and then you have to make the best out of whatever resources you have. Not having access to a modern mattress is not an excuse for not being able to offload a patient. Remember that we could perfectly well offload a high-risk patient long before dynamic air mattresses were readily available. And do not feel too sorry for yourself or your patients if you feel underprivileged just because you do not have access to a fancy mattress. All the regular editors at Wounds Africa work at a government hospital in Norway- one of the wealthiest countries in the world. For many years, however, a dynamic air mattress was scarce at our hospital, and after the two mattresses, we had developed leaks we were without for several years. It was first when the government suddenly had an increased focus on pressure injuries as a response to an international awareness program that we suddenly had unlimited access to these. Today, in most hospitals in Norway, these mattresses are leased and returned to the supplier for cleaning between each patient. In this way, we only pay for the mattresses whenever we use them, and we do not have to purchase the mattresses. This is a financial model which would work well in Africa also.

In general, we can divide positioning aids into the following categories:

Tools to turn or move the patient
Special mattresses ( this is a confusing jungle of products)
Positioning pillows/pads/wedges
Orthotics ( another jungle of products)

Figure 1 Under ideal circumstances offloading/ positioning aids like special pillows, dynamic air mattresses, and offloading orthotics should be readily available to patients with high risk or existing pressure injuries. A dynamic air mattress is close to impossible to build yourself, but many of the other aids can be made by you with some improvisation.

Tools for turning patients

Repositioning regimes are an international standard measure for preventing and treating pressure injuries worldwide. It is commonly advised to reposition a patient every two hours, which obviously requires some resources. Therefore, we must have the tools to make this easy. Patients with a lower risk of pressure injuries may be repositioned at longer intervals.

Turn sheets/slide sheets

These were commonly made of satin and are therefore also called satin sheets. Today other low friction materials are also used. This simple but ingenious tool is an invaluable aid in comfortably turning patients. Remember also that some patients who need less help more easily can turn themselves when a turn sheet is placed under them permanently.

In general, these aids are indicated for anyone who has problems turning in bed, be it because of pain or a functional disability. Typical patients who will benefit from a satin sheet are patients with stroke, after hip operations, cancer patients, after spinal surgery or acute spinal problems, patients with polio, MS, or other neurological disorders.

There is hardly any other aid in healthcare that has such a high cost/ benefit value as a turn sheet/slide sheet. They are relatively cheap, but you can also sew them yourself from satin or silk fabric.

If you start googling turn sheets and slide sheets, you will get pretty confused - there are many systems available, and although they all work on the same principle, they use different terms to stand out from the competition.

Let us try to shed some light on this. In its simplest form, a turn sheet is a single layer of silk or other low-friction material which can be used for patients who are capable of turning themselves but find it difficult and just need a little help to achieve this. For these patients, a turn sheet (which does not need to cover the entire length of the mattress) can be permanently placed beneath the patient. The reduction of friction is significant, and the patient will use much less energy when turning.

Then we have sliding sheet systems - these usually consist of two components: base Sheets and Draw Sheets. Base Sheets can be used alone to aid in side-to-side movement and increased mobility in bed. Draw Sheets are used alongside Base Sheets to make assisted movement easier. A Base Sheet is a cotton/polyester sheet fitted on the mattress with a low friction sliding panel in the center, allowing sideways movement. The cotton edges on each side of the sheet act as a brake to stop the user from sliding off the bed whether they are lying down or sitting on the edge. It has a non-slip surface on the underside, which helps keep it in place on the mattress. The person lies directly on the satin panel, which reduces the friction between the bedding and nightwear; this makes turning and moving easier. Draw sheets are designed to be used on top of a Base Sheet. The user lies on top of the Draw Sheet, which can then be gripped, pulled, or eased using micro-movements by the carer to move, reposition or provide assistance to turn a user in bed. Hopefully, this has cleared up some of the confusion. In video 3 below, the sliding sheet system by Immedia is demonstrated.

A helpful aid are special gloves that have a low friction exterior material. The glove makes it easier to place the hands between the user and the mattress or cushion. Minor re-positioning adjustments, movements, and smoothing out the bedsheets are common activities for which the gloves are handy.

Another alternative to slide systems is glide cushions. These are used to turn in bed, move up or down a bed, and transfer from bed to wheelchair. Glide cushions can be used to support independent movement or to aid assisted movement.

The most advanced glide cushions are so-called 4-way glide cushions which also make it easier to reposition a patient towards the head or end of a bed and sideways. There are many producers of such solutions, and the choices are quite confusing.

We find that ETAC has done a good job of providing us with a good overview of which products are available. Go to their website www.etac.com to get an idea of all alternatives available if you are interested in learning more about these aids. You can click on the logo or images below to get to their website. They also have many good instructional videos available.

Figure 1 There are many aids available to turn or slide a patient in bed. An invaluable tool is a satin or silk sheet ( left upper corner). A further development of slide sheets are special glide cushions. A helpful tool are special low friction gloves which help the carer to gently put a hand beneath the patient, for example.

Video 1 A instructional video on how to turn a patient without any special aids. We have shown this video earlier in the chapter on pressure injuries but want to repeat it here to underline that it is quite easy to turn most patients without special aids.

Video 2 A demonstration on how to use a turn sheet. The video also shows how the sheet can assist the carer in raising the patient out of bed.

Video 3 Demonstration of the Immedia sliding sheet system

Figure 2 The website of etac.com gives a useful overview of the many tools available to reposition a patient if you want to learn more about the different alternatives. Click on the image above to go to their website

Automated turn aids

It is usually easy to turn a patient with the correct technique, especially if you are working with a colleague. However, when you have a very heavy patient and work alone, it can be advantageous to use an electrical turning aid. In recent years many such automated turning aids have come on the market - all of them have in common that they are relatively expensive. Although we know that this is not an option for most African patients, we want you to be aware of what is available - to keep you up to date with all medical developments.

One of these systems - the TurnAid- is demonstrated in the video below. The video shows how easily a patient can be turned by only one carer and that this is done in a gentle and dignified manner for the user.

Video 4 Demonstration of TurnAid - an automated system that allows for extremely easy turning of also heavy patients without putting any strain on the caregiver

Mattresses

In this chapter, we are entering another jungle. The choice of mattresses is downright confusing to most people, and we find this topic confusing ourselves. The range of products available and the different materials options are overwhelming, and we could write an entire book about this.

Mattresses for everyday use are expensive in Africa, and for most people, they are a considerable investment. A special offloading mattress is obviously out of reach for most people on the continent. Nonetheless, we will dwell a little on this topic. One of the goals of the WoundsAfrica website is to broaden your horizon even though these are tools most likely are not available to you. Also, some of our readers in Africa actually work at healthcare facilities where a choice of mattresses, including dynamic air mattresses, are available.

Figure 3 Many people in Africa do not have access to regular mattresses because they are considered expensive even though they are often manufactured locally. If you have a patient who has an increased risk of pressure injuries, they should at least invest in a regular mattress- which is better than having no mattress. In most African countries, the choice of mattresses is surprisingly good. We also advise you to talk to the producers to check which of their regular models would be considered ideal for offloading. The image above is from the factory of Panafrica enterprises in Arusha, Tanzania.

Mattress categories

To follow international guidelines, we need to know which risk category the patient falls into before choosing the correct mattress. To do this we use a risk analysis scale like the Norton og Braden scale ( see our chapter on risk staging). Then you have to decide if it is sufficient to use a matress pad or a whole mattress.

As we mentioned earlier - many people in Africa today cannot even afford a good polyurethane foam mattress, so aquiring a special off-loading mattress is most likely completly unrealistic for most of your patients. Again, in this situation you have to provide the patient with other alternatives. A soft sheepskin placed on a regular polyurethane mattress can be an adequate solution for many patients. Sheepskin not only reduces pressure and friction but can also prevent dampness under the body. Furthermore, sheepskin can be washed although not at high temperatures. Wash sheepskin with mild detergents that do not contain enzymes in cold or lukewarm water up to 40 degrees Celsius. Some medical grade products can be machine washed. Line dry sheepskin in the shade, and never tumble dry or iron sheepskin. In areas where there are mango flies ( also known as human maggot flies, tumbu flies or putzi flies) not being able to iron an item before use can pose a risk of maggots penetrating the skin - here we recommend that the sheepskin is hung up to dry underneath a mosquitoe net for example.

Figure 4 Sheepskin has fairly good pressure reducing capabilities and is excellent for reducing shear and friction and maintaining an optimal climate under the body. The sheepskin in the image is a medical-grade sheepskin that is specially treated to be able to withstand machine washing. copyright: ultimatesheepskin.com

There is a confusing variety of mattress solutions available for reducing pressure. To systematize the choices, it is helpful to divide them into the following four main groups.

Foam top (overlay) mattresses (users with low risk- middle risk

Static air top (overlay) mattresses (users with low risk- intermediate risk)

Dynamic (alternating air) top (overlay) mattresses (users with intermediate-risk- high risk)

Dynamic (alternating air) whole mattresses (users with middle risk- high risk)

Be aware that there are quite significant differences between mattresses within the same category. Even an alternating air mattress may not be approved for all stages of pressure ulcers. This is something not all caregivers are aware of. Many think that as long as it is an alternating air mattress, it is approved to treat all pressure injuries stages. In reality, some dynamic air mattresses are, for example, only approved for the use of up to stage II pressure ulcers. Mattresses from serious producers have clearly specified on the label for what degree of severity of pressure ulcer they can be used. Note that there are also restrictions as to how much weight a specific model of alternating air mattress is approved for. There are also quite considerable differences in how much noise the pumps make. Some mattresses are only available in one size, while some companies produce mattresses in all sizes. If you are working at a clinic where you are considering investing in one or more alternating air mattresses, it is wise to check all options thoroughly. You can buy alternating air mattresses for a lot less at Chinese sites like alibaba.com, but you will obviously not have any service available if you have problems with the pumps.

We obviously cannot be so "picky" in an environment with limited resources. We may have to use an alternating air mattress classified as approved for up to stage II ulcers for a patient with a Stage IV ulcer. That is if we can get hold of such a luxury as an alternating air mattress at all. For most patients in Africa, an alternating air mattress is simply not a realistic option, and they may be lucky if they can afford a foam top mattress or a soft sheepskin. Some patients may not even own a foam mattress and should be enticed to invest at least in this. Again, know the international recommendations and improvise with what you have available.

The following are general recommendations of what a patient should have as a mattress- under ideal conditions- depending on which risk category the patient is in.

Low risk: Foam top (overlay) mattress

Placing a top mattress on an existing mattress gives some pressure reduction. There are special top mattresses that have a documented effect on reducing pressure injuries. These will not be available to most patients, and they may have to buy a soft-top mattress from a regular supplier to improvise. The mattress which is beneath the top mattress is also an important factor. A good top mattress cannot fully compensate for a worn-out or very hard mattress.

Figure 5 Overlay foam mattresses are intended for users who only have a low risk of developing pressure injuries. However, in a situation with limited resources, this may be your only tool available even for high-risk patients or even patients with existing pressure ulcers. These types of foam mattresses come in many different materials, although they all have in common that they are made of some sort of foam. The cheapest are often convoluted ( egg-crate shape) like the mattress on the upper left. Others use more advanced gel foams. Some have a modular geometry like the mattress at the bottom left.

Intermediate risk: Static air top mattress

A static air mattress is, in principle, a bit like an advanced air mattress that you use on the beach. It is made of several air chambers - the more chambers it has, the better it usually is. You have to fill it with air - many models have a manual handpump while the more advanced models have an electric pump. Unlike an alternating air mattress, the air pressure is constant in a static air mattress. Static air mattresses are placed on top of an existing mattress.

There are quite significant quality differences between the different models available. Use some time to check out what is available on the market before investing in such a mattress. As mentioned above, the better models have more chambers. Some models have three or more zones that can be pumped up individually, making it possible to, for example, alternate the pressure in various body areas throughout the day.

Some mattresses have to have a pump connected all the time to keep the pressure constant. The best static air mattresses have a pressure monitor connected, which keeps the pressure consistent and gives an alarm if the pressure sinks.

At some point in time, you will get a leak in the mattress, not rarely due to the use of safety pins, scissors, or other sharp items. Be aware that the better mattresses can be easily patched while the cheaper models often cannot be repaired once they are punctured.

While static air top mattresses are meant to be used for patients with an intermediate risk of developing pressure injuries - if you have nothing else available - you may have to use such a mattress for a patient with an existing pressure ulcer. And be assured that this is a better solution than having no offloading mattress at all. In other words, this sort of mattress is meant to prevent and NOT treat existing pressure ulcers, but if you have nothing else, you will have to use this type of mattress for all cases.

International conceptions about what mattress type is best to prevent pressure ulcers were recently challenged by a study published in 2019 ( Dimitri et al.) They performed a multicentre prospective randomized controlled clinical trial comparing the effectiveness and cost of a static air mattress and alternating air pressure mattress to prevent pressure ulcers in nursing home residents. The study was performed at 26 nursing homes in Belgium with 306 patients enrolled. Half of the patients were supplied with an alternating air mattress (control group), and the other half with a non-electrical static air mattress (intervention group). Surprisingly only 8 (5,2%) patients in the intervention group developed stage II-IV pressure ulcers, while 18 (11.7%) in the alternating air mattress group developed pressure ulcers. These are highly interesting findings, and they challenge everything we thought about alternating air mattresses. And if you may think that they used a fancy static air mattress in this study- think again. They actually used quite a cheap model with only a few chambers. Like always with science and statistics - we have to interpret such results with care, and one study in itself is not enough to conclude that alternating air mattresses are not useful. Also- the study says nothing about the effectiveness of offloading an already existing pressure ulcer- i.e., is a static air mattress equally effective or even better at offloading an existing pressure ulcer.

However, we did not have alternating air mattresses available at our hospital until 2017. We had two old alternating mattresses, but as we explained earlier, these had a leak and could not be patched according to the manufacturer. So for many years, we were without alternating air mattresses and improvised by only using static air mattresses. Because our management did not want to invest a lot into such mattresses, we had to buy a cheaper model with only a few chambers and a manual hand pump (Repose). Incidentally, this is the same model as was used in the study above. Remember that no mattress, no matter how advanced it is, does not replace the need to reposition the patient regularly!

Figure 6 A relatively simple static air overlay mattress like the Repose mattress with a manual pump can perform excellent if standard care regimes like repositioning the patient every two hours etc., are carried out. At our workplace, the Repose mattress was the only offloading device we had available for many years -also for patients with existing ulcers! This type of mattress is actually only indicated for preventing pressure injuries, but if you have nothing else, you use what you have.

Figure 7 The more advanced static air overlay mattresses have electrical pumps and usually many smaller chambers which distribute pressure better. The image above shows only a small selection of the number of static air mattresses available. The models from above left to bottom right: ToppAir, CuraCell SAM, Carebed, ROHO Dry Flotation, Rhombo Fill, Apex.

Figure 8 Is it possible to improvise with a non-medical static air mattress sold for everyday home use or camping? We at WoundsAfrica cannot write that it is advisable to buy a regular air mattress and use it in high-risk patients. That is because nobody can say for sure how good pressure distribution such mattresses give. Also, the material used in such mattresses is not ideal concerning cleaning - so these mattresses cannot be shared between different patients. However, if we were in a dire situation and needed something but could not afford a medically static air mattress, we would definitely check the air mattresses sold in regular shops. These come at prices from about 20 US Dollars - for example, at pricecheck.co.za.

Intermediate to high risk: Dynamic (alternating) air top (overlay) mattresses

In contrast to static air mattresses, the dynamic air mattresses pump air through the chambers at a rhythm such that pressure points vary all the time. Alternating air mattresses are thought to provide the best pressure offloading of all mattress types. As we mentioned previously, this concept has been challenged by a study by Dimitri et al.2019 where static air mattresses performed surprisingly well and better than alternating air mattresses.

Should you use an alternating air overlay mattress or a whole alternating air mattress? Although a whole alternating air mattress is thought to give the very best pressure distribution - and is generally recommended for high-risk patients and patients with existing pressure ulcers - dynamic overlay mattresses can be just as effective. The latter is also usually considerably cheaper than whole mattresses.

There are times when a whole alternating air mattress can be indicated - for example, if you have a very heavy patient, then an overlay mattress is usually not sufficient, but this will depend on the model you have.

In conclusion, if you wish to acquire several mattresses for your institution, we recommend you buy many dynamic air overlay mattresses instead of only having funds for one or two whole dynamic mattresses.

Figure 9 Some of the alternating air overlay mattresses available. Note that there are considerable differences in specifications and price between models. Also, you would generally prefer to be from a supplier who is not far away to aid in the service of the products. From above left to bottom right: Opticell 2, Hill-Rom P280, MicroAir 50CE, CuroCell, Eole, Talley PULSAIR Choice, Talley Quattro Overlay

High risk - existing pressure ulcers: Dynamic ( alternating) air whole mattresses.

Whole dynamic ( alternating) air mattresses are the ultimate tool for off-loading patients with a very high risk of developing pressure injuries or those who already have pressure ulcers. However, the choice of products is downright confusing. Be aware that there are considerable differences in specifications between these mattresses and that not all whole mattresses are approved for treating stage III-IV ulcers. In reality, in Africa, you would use the mattress that is available to you, and you would have to ignore what your specific mattress type is approved for.

Some aspects that vary between models are the number of cells, the strength of the pump, rhythms, alarm functions, cover material, and how easily this is cleaned. The more advanced mattresses have a pressure monitor that varies the pressure according to how the patient is lying. When the patient is repositioned or moves, the cells are inflated accordingly. Some mattresses have a special zone around the feet to give extra good protection and off-loading to the heels. Some mattresses allow for making the mattress extra stiff, which is useful when washing or clothing the patient or when sliding the mattress and the patient over into another bed, for example. There are also significant differences in how much noise the pumps make, which is no small matter. The patient ( and family and caregivers) can find constant noise from the pump very disturbing. The quietest pumps have a noise level just above 20dB. If you are buying the mattress for an institution, it should also have a so-called CRP -valve that allows for quick deflation in case of an emergency when a manual heart massage is needed. It is impossible to perform an effective heart massage with the mattress inflated!

Figure 10 A small selection of whole dynamic ( alternating) air mattresses available. There are significant differences in specifications and price, so it is important to take the time to do thorough research when acquiring such a mattress. From above left to bottom right: Opticell 3, Alpha Response, Eole DC Dynamic, Quattro Plus Dynamic, SOFTAIR Excellence, Curacell Auto 420.

Figure 11 To get an overview of what is available in, for example, South Africa, we went to desertcart.co.za. Click on the image above to go to their website for more information on what is available and prices.

Local off-loading devices

With local pressure-relieving devices, we mean cushions and orthoses which specifically off-load an area of the body. The term "orthosis" is confusing to many people. It is a broadly used term to describe aids that we attach to the body to provide support, protection, or off-loading.

Again, the choice of products is quite confusing. In the following subchapter, we present the essential aids for off-loading, which all caregivers should know something about.

Positioning pillows and wedges

Regular pillows can be used to position a patient in a good and safe position. Still, the result can be somewhat unpredictable because the consistency and quality of regular pillows vary a lot. Special positioning pillows and wedges are helpful for high-risk patients and those with existing pressure ulcers. There is a vast choice of sizes and shapes of such pillows available. It is wise to ask a physiotherapist or occupational therapist for advice if you have such a colleague available.

If the patient has minimal resources, one can improvise by cutting the required shape of support ( for example, a wedge) out of a polyurethane mattress and making a cotton cover for this.

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Figure 12 What may look like regular pillows in the image above are actually special positioning pillows (VersaForm) which give more consistent results.

Figure 13 Wedge pillows are useful for retaining a patient in the lateral position. You can quite easily make these yourself if you can get hold of polyurethane foam blocks or other suitable filling material.

Figure 14 Positioning pillows are available in all shapes and sizes. Again, if such special pillows are not available to you, then you will have to improvise by making them yourself or getting a local tailor to make these.

Tools for offloading the heel ( and ankle)

Pressure injuries at the back of the heel are so common that your institution/workplace always should have some sort of off-loading device available. With " available," we do not mean that you know where to order these from but that you actually have them in storage where you are and that everybody knows where to find them and when to use them.

Patients with a low risk of pressure injuries may have enough protection to the heel area if they have a pillow under their legs. A pillow under the legs is NOT enough for patients with a high risk of pressure injuries and those with existing heel ulcers. You can simply not guarantee that the pillow will move or the heel will slide off the pillow.

Which type of offloading tool should you use? If the patient is at high risk or already has an existing pressure ulcer on the heel area, you need to use something that keeps the heel area elevated at all times. Any aid that does not elevate the heel, no matter how soft and cushioned it is, will not be enough.

We group these products into the following two groups:

Heel protectors that should only be used for prevention ( low- intermediate-risk patients)
Heel protectors that provide total off-loading ( high risk- existing pressure ulcers)

Figure 15 Placing a pillow under the legs to elevate the heels - the so-called floating heels technique- is not acceptable for high-risk patients and those who already have heel ulcers. In these cases, it is at best a temporary measure while you run to the storage to get a full-offloading aid.

Figure 16 Simple off-loading devices protect the heel in patients with a low- moderate risk of pressure injuries. These devices have in common that they only cushion the heel but do not keep it elevated from the surface of the mattress. They are NOT sufficient to treat high-risk patients and those with existing heel ulcers. There are many different varieties ranging from a sock with pads sewn into the heel to polyurethane foam and air pillows. You can improvise by making similar cushioning aids from soft polyurethane foam or soft pillow material and use velcro to fasten these.

wounds africa sheep skin heel protectors

Figure 17 Sheepskin is an excellent material for offloading heels in patients with a low-moderate risk of developing pressure injuries. Again, these products are NOT meant for patients with high risk or existing pressure ulcers as they do not elevate the heel! Sheepskin products are surprisingly expensive, and you can easily make them yourself if you have access to soft sheepskin and some velcro for fastening them. If you cannot make this - placing a whole sheepskin rug in the feet area of the bed is also an option.

Figure 18 When preventing pressure injuries in the heel area in high-risk patients and those who already have a pressure ulcer, we have to use a device that offloads the heel area a 100%- that is, something that elevates the heel. This is the gold standard for off-loading heels! The device above (Medline Heel Raiser) is a very illustrative example of this. The device has an opening for the heel, and you can see that the heel is well lifted off the mattress. Figure 19 below shows other examples of heel-raising devices.

Figure 19 Other examples of devices that provide total offloading of the heels - are designed for high-risk patients and those with existing heel ulcers. The image above only shows a small selection of what is available. There is a confusing selection we can choose from, and they differ a lot in design and materials used. Some, like the Molly Heel raiser ( left middle row), are a ring that is placed at the ankle level. Others, like the three models in the bottom row, are inflatable. Heel offloading devices are often surprisingly expensive. Be aware that the costs do not only involve material/production costs, but the products also have to come with documentation that they indeed provide the degree of off-loading intended. These studies are often expensive for the companies producing these devices.

Video 4 Demonstration of the Molly Heel protector

Figure 20 The choice of offloading devices for heels is confusing. At our workplace, we searched for years for an ideal all-round model which fitted the needs of most of our patients. We tried many different models, but in the end, our choice fell on the Maxxcare Pro Heel Evolution. The device is very lightweight, can be washed, and dries very quickly. Also, it has a non-slip sole making it safe when the patient gets out of bed. It is furthermore one of the cheaper devices available. You can click on the image above to go to the producer's website.

Figure 21 The design of a popular heel offloader - the Heelift Suspension Boot - shows the design on the inside. If you have minimal resources and no other choices, you will have to improvise and try to make something similar yourself out of soft polyurethane foam and velcro fastening. The tricky area is the cut-off point in the Achilles heel area - a sharp edge here can cause a pressure injury, and it is wise to cushion this area with some other material- for example, sheepskin.

Offloading elbows

Another area of the body prone to pressure injuries is the elbows. Again, a wide range of products is available to protect and off-load elbows, from simple pads to more elaborate devices. A sheepskin device fastened with velcro straps can provide good protection in many cases. We are not going to go into great detail here - we just want to give you an idea of what is available.

Figure 22 A small selection of what is available for offloading elbows. Note that sheepskin products also are a good choice here and can be made by yourself.

Other offloading devices

There are aids for offloading any body area in any kind of situation. If you have read this chapter so far, you will realize by now that there are very many products available. We have not yet covered special products like offloading cushions for wheelchair users or patients with other special needs. Much information about such products is readily available on the internet.

Figure 23 There is no excuse for not providing adequate off-loading to a patient who requires this, even if resources are very limited. All that is needed is a will to make a difference and some ingenuity. A good example of the creativity common in Africa is Lincoln Wamae from Kenya - a self-taught mechanic who converts scrap into electric wheelchairs. He is also an inspiration for us working in wound care - having to use whatever means we have and making the best of it. copyright: yen.com.gh