Trench foot, amputations the latest challenge for homeless care in London

A young man hobbles across the parking lot of the homeless hub on Queens Avenue.

He’s bent over and favouring one leg, barely managing a forward locomotion that can best be described as an awkward hop.

After a long and slow advance, he manages to reach the front door of the HOME bus, a rolling clinic that provides outreach healthcare for the estimated 2,000 Londoners who regularly sleep outside. It’s name is an acronym for Health Outreach Mobile Engagement.

The man, who prefers to only be known as Jay, is finally able to struggle up the stairs where he sits down to be examined and interviewed by the team of paramedics and nurses. 

The health concern that brings Jay to the bus is trench foot, a skin condition that thrives when feet are left wet over a period of time. Untreated, it can lead to painful sores, serious infections and, in extreme cases, even amputations. As its name suggests, it’s a condition from another time, one that first appeared among soldiers fighting in the First World War. Now, with a nationwide homeless crisis that’s left so many sleeping outside, it’s making an unfortunate comeback. 

“I have a multitude of lesions,” Jay told CBC News moments after the HOME care team cleaned, dressed and treated painful wounds that cover his feet. “It’s scary. You see characters out there with amputations, with their toes gone and their walk is different. It’s something that’s very real.” 

Trench foot and other lower-limb skin conditions are generally treatable and preventable for people who are housed, but they’re growing among London’s homeless population. It’s a problem leading to serious health problems and ER hospital visits. 

Brandi Tapp is a nurse practitioner with London Intercommunity Health and a member of the HOME team which operates the mobile care unit in a converted bus.  Although specific stats aren’t kept about the conditions they deal with, she estimates about half of the 3,000 people the mobile care team sees in a year have some kind of skin condition. 

“The frequency of conditions like this has really increased,” she said. “We had to come up with our own best practices for an effective way to treat this because it was causing risks to life and limb.”

Risks because among people who are housed, most skin conditions can be diagnosed and treated quickly. 

Wounds that are kept clean and dry, treated with the proper medications and covered with sterile and regularly changed dressings typically get better. But for people like Jay who often sleep in the cold and wet with little access to clean clothes, bedding or potable hot water, it becomes a challenge to maintain optimal conditions for a wound to heal. 

Wounds that don’t get better can quickly get worse, to the point where they can develop into serious infections that in extreme cases, can lead to infections that require amputation, Tapp said. 

“It’s devastating to see people with these conditions,” said Tapp. “It’s beyond belief. In a well-resourced country one would hope this wouldn’t be as commonly occurring as it is.”

Trench foot is just one of a long list of skin conditions that Tapp and others on the mobile care team see regularly.

Others include: 

• Cellulitis: A serious bacterial skin infection that can spread and lead to serious skin problems. 
• Venous stasis ulcers: Open wounds on the leg that are vulnerable to infection. Drug use can and poor sleeping conditions can restrict blood flow to the legs which can inhibit healing. 
• Frost bite: From outdoor exposure. 
• Burns: Often from trying to stay warm outside while using unsafe heat sources. 
• Parasites: Such as scabies, bedbugs and lice, often associated with sleeping in places that are unclean or crowded. 

The number of clients dealing with skin conditions increased during the COVID-19 pandemic, when shutdowns added new barriers to care, Tapp said. 

To try and improve treatment, Tapp and her team developed their own best-practices for treating skin ailments, tailoring the care plans for those whose living conditions make it harder to keep wounds clean and dry. 

They soak injured feet in warm water, supply patients with medication and antiseptic ointments and give the clients instructions in how to use them. 

“We keep clean socks on the bus,” said Tapp. “It’s one of the most important things we have.” 

To be effective, wound care has to be consistent and sustained. For people who sleep outside and face other health challenges, sticking to a routine can be difficult. 

“It’s not that they won’t do it, it’s that they often can’t,” said Tapp. 

Their visits to the care bus can be sporadic. Sometimes, patients’ medications and ointments for skin care get stolen.

A big part of the solution is educating clients about the importance of wound care along with a discussion about what can happen if their conditions go untreated, Tapp said. 

“It’s a lot of getting creative and thinking outside the box,” she said. “We need to think not only about wound care but also wound hygiene in a climate of limited resources.” 

Tapp is hopeful London’s plan to set up a series of homeless hubs will help the situation by providing more places for people to get inside and stay clean and dry long enough for skin conditions to heal.

For Jay, the instructions about the importance of proper wound care and hygiene won’t go unheeded. 

“The damage does multiply pretty quick,” he said. “I pay attention to what’s going on but I still got into some trouble. Knowledge about this is important.”