Part three of a four-part series about an athlete’s fight to beat a leg infection and save his leg. In parts one and two, JH, age 62, was hit in the shin by a baseball. Treatment included three surgeries to open and drain the contusion, another to remove necrotic tissue and a third to graft a vein, artery and skin from his thigh to the wound. Nearly healed, JH was preparing to get back to baseball when a curve ball came his way.)

Managing a busy life with what JH called a hoagie roll on his lower leg, presented its own set of challenges. The hoagie roll created an environment to feed the wound area with blood and enable it to heal, covering what had been exposed bone with viable tissue. Despite the new appendage, he could see the end game, with full healing on the horizon and with a return to the routine of family, work, and sports. Sutures out and the wound healing, the hoagie roll was unattractive and in the way of socks and trouser legs, but it was to be surgically reduced in a few weeks.

After a morning shower 10 days after returning home, JH noticed some orange-tinted, clear fluid oozing from the incision line. Peeling back one of the many butterfly bandages to take a look, the wound opened up along the incision line, releasing more fluid. In the wound, he saw something moving. Then he noticed a handful of somethings disappearing into the wound and returning to the surface again and again. Maggots and hundreds of small, oval white maggot eggs filled the wound.

JH sent a picture while simultaneously calling his physician. In denial, his physician said, “It can’t be.” A Friday, JH was to see the doctor the following Tuesday. He was told to wipe the incision line clean and keep the Tuesday appointment. But, the doctor said, it would also be fine for him to go to an emergency department for evaluation if he would be more comfortable with that.

Horrified both with what he was seeing on his leg and what he was hearing from his doctor, JH headed back to Philadelphia.

On examination, the physician assistant exclaimed, “There are maggots in there!” For the first time in weeks, JH expressed dismay with the resident and became animated – an understatement at best, belying weeks of frustration. He shouted, “I told you – and you wanted me to wait five days to be seen?”

When it occurs, maggot infestation, known as Myiasis, is considered to represent a breakdown in standards of care. As a result, there are few statistics on the frequency of these occurrences [Myiasis: maggot infestation]. Myiasis typically results when a common female housefly lands on a wound or wound dressing to feed and lays eggs there. One fly can lay between 50-300 eggs at one time. The eggs hatch within 12 hours and are fully grown within 60 hours. Shortly thereafter, they migrate to drier feeding territory.

While conceptually a thoroughly disgusting situation, maggots have been historically used to facilitate wound healing. Prior to antibiotics, maggots were intentionally introduced to some wounds and were found to promote healing by eating only necrotic—not viable—tissue, increasing exudate, digesting some forms of bacteria and secreting certain enzymes to break down necrotic tissue [Myiasis: maggot infestation].

While myiasis would resolve itself within weeks as maggots seek other environments, both patients and caregivers typically find the wait intolerable and removal is necessary. In JH’s case, waiting was not a consideration [Myiasis: maggot infestation].  

Immediately rushed back into surgery for the fourth time, the surgeons tried to clean the wound of infection again, and to remove necrotic tissue, maggots, and larvae. Remarkably, there was still no infection in the bones, but new tissue cultures revealed the infection was now caused primarily by E. coli; it’s unclear whether this was a polymicrobial infection from the start, or if the prior antibiotic therapy had been effective against Staphylococcus and now a new infection had been introduced.  Common in the digestive tracts of healthy individuals, E. coli in an infection can typically be treated with antibiotics.

During this latest surgery, twenty antibiotic beads were placed into the wound. Antibiotic beads were developed for use with joint replacement surgery to reduce the potential for infection in patients undergoing hip replacements [Tiny antibiotic beads fight infections after joint replacement]. The beads release antibiotics slowly over a period of up to six weeks. JH’s wound remained undressed for three days while it was watched closely for indications of healing from the deep parts of the wound towards the skin, and, of course, for signs of a new infection.

A fifth surgery later closed the wound. JH’s leg was cast, and he was sent home with instructions to return in 10 days to remove both the cast and sutures. The cast was an ultraconservative measure intended to prevent any chance of additional infection or infestation.

(In the final segment of this series, JH will face additional surgeries and learn whether he will ever return to his busy and athletic life or whether the infection will enter his bone and bloodstream.)

Part two of a four-part series about an athlete’s journey to save his leg. 

(In part one, JH, age 62, was hit in the shin by a baseball. A hematoma developed that became infected; treatment included opening and draining the hematoma and discharge to home to self-administer IV antibiotics through a PICC line.)

Sitting on the sofa in his den the day after discharge, JH had his leg propped up. Looking at the wide-open wound, he knew something wasn’t right. With waning confidence in the situation, JH thought the injury looked worse after the treatment to drain it than it did before the hospital visit.

Though JH and his wife had videotaped the home care nurse’s instructions to administer the IV medication, the effort did not go well. Unable to make the tubes connect, blood began pouring from the PICC line, saturating his clothing. In the midst of this, his physician friend responded to the photos. He told JH to go immediately to the hospital, not to stop for breakfast, not to change clothes – but to go immediately.

Having gotten the PICC line capped, JH took an Uber to a Philadelphia medical center. After a long wait in the ED, JH was admitted, evaluated, and quickly scheduled for surgery to debride the wound. In surgery, tissue from the shin was debrided to the bone. The wound was covered but did not begin healing the way his care team had hoped.

Three days after the first surgery, a second surgery was required for additional debridement. This time a vacuum drain was inserted into the area and sealed with a clear wrap with suction applied to the wound. Lab cultures returned positive for Staphylococci. JH began to comprehend more fully the conversations with the physicians about the infection spreading more seriously into the bones in his leg and the growing concern that amputation might be required to prevent systemic infection or even death.

JH is part of a well-connected long-time Main Line Philadelphia family. Those connections enabled him to be placed in the care of a renowned physician known most recently for successful pediatric hand transplants. JH was evaluated and a course of action was determined. In a third surgical procedure, a full-thickness flap, with vasculature, was harvested along with a graft of skin shaved from his thigh, all transplanted to the lower leg. The purpose was to create a “biologic dressing”—the patient’s skin, that would protect against bacterial contamination and hasten to heal.

After seven hours of surgery, JH awoke in the ICU. In the event of flap failure, JH needed to remain under close watch. The care team monitored the pulse in the surgical area.

The flap was an ecosystem – a living environment around the initial bruise site that supported tissue repair and healing and covered that bone. JH called it a “hoagie roll” – a protrusion on his lower leg that extended about six inches along a left to right down angle across his leg. The plan seemed to be working. The swelling decreased, the infection seemed to be clearing.  For the first time, the wound was sutured closed and wrapped. Discharge care included topical antibiotic ointment for the sutures and instructions to keep the wound covered. The pain was gone. 

For the next 10 days, JH healed. Back at work with the wound covered by the “hoagie roll,” he was on a trajectory toward full recovery. With sutures out and butterfly bandages along the repair line, JH was confident he would soon return to the baseball diamond. Instead, he was to return to surgery for a fourth, fifth and sixth time.  He and his leg remained in danger.

(In part three, JH faces emergency surgery, a maggot infiltration and the specter of a polymicrobial infection. His game is far from over and a win, even with the best players and tools, is not a sure thing.)

About the Author
Dr. Pollack is certified in Emergency Medicine and is a founding board member of the Hospital Quality Foundation. Visit: www.hospitalqualityfoundation.org.

Part one of a four-part series about an athletes journey to save his leg.

THWACK! The sound of the baseball off the bat warned all the players on the field that the ball had been hit on the screws – baseball parlance for hard and fast. So fast that relief pitcher JH had no chance to move out of the way, let alone field it. The ball careened into his right leg with frightening speed and force.

Looking down at his shin, JH had two thoughts: is the leg broken? And if not, let’s finish the game. His team had not played particularly well, was going to lose, and it was time to get it over with. Bones unbroken, he finished the game.

A utility player (outfield and pitcher mostly), JH, 62, is a competitive athlete. He plays in four baseball leagues, one for those age 28 and older, two for those age 50 and older, and another for those age 60 and older. He is a nationally ranked squash player and enjoys competitive tennis and both water and snow skiing. Physically, he is sound. Fit throughout his life, he maintains healthy eating and active and competitive exercise habits.

At home after the game and with a more focused self-inspection of his lower right shin, JH noted a red bump with no break in the skin. It looked like it would be a typical bruise: a bulging red mark which would turn purple, then yellow, and then fade from view and memory. There was no pain and he could walk normally.

In the days immediately after the incident, the swelling had receded although he noted some stiffness and sudden onset of almost unbearable pain when getting out of bed. JH admits he has a high tolerance for pain – something he views as more of a hindrance to living than a sign of a problem. By moving around and walking for about 10 minutes, he could ease the pain as the leg seemed to loosen up.

JH didn’t know – or possibly chose not to know – these signs were indicators of infection, a potential life-and limb-threatening condition. An intrepid spirit, JH has climbed mountains and volcanoes around the world, is known to ride helmet-less around town on his Vespa, and spent the morning of his wedding day on the roof of his house clearing gutters with a leaf blower. So it is no surprise that a week later he was back on the diamond, pitching in one game and playing in the outfield in another.

But by the end of the second game, he knew something was different about the way the bruised area looked and felt. It was very red and expanding beyond the initial impact site.

A quick visit to an urgent care clinic resulted in antibiotics for infection at the bruised area and a recommendation to go to the emergency department if it didn’t improve. Coincidentally, or serendipitously, he was scheduled for his annual physical that week. The examining physician confirmed the infection and felt he should visit the ED at the local hospital.

Contusions caused by impact rarely become infected when there is no break in the skin. However, staphylococcus and streptococcus are the most common types of bacteria to enter a skin break. Contusion’s pool of blood becomes food for the bacteria. It can ordinarily be treated with oral antibiotics [click for more on bruise infections].

As an owner of a successful ironworks company, JH was less concerned about the leg than he was about being away from the office. Reluctantly going to the hospital emergency department, he expected IV antibiotics and immediate discharge.

Instead, he was admitted and underwent a procedure to lance and drain the area. The contusion was a hematoma – a pool of blood that becomes walled off. While time and heat can enable healing, opening it for drainage is indicated when it may be infected [click for more on blood bruise infections]. 

While the treatment seemed logical and appropriate to him, the pain after inactivity returned with great intensity. After two days, he was released. The wound was open, deep nearly to the bone, and left uncovered with no bandage or covering at all. Discharge instructions included pouring hydrogen peroxide into the wound, self-administration of antibiotic fluids twice per day and care of a PICC line by which the IV fluids would be dripped.

But before leaving the hospital, JH was concerned. It did not seem right that he would be released with a wound open nearly to the bone. Further, the injury seemed worse than when he entered the hospital. From his hospital bed before discharge, he took pictures of the wound and sent them to three physician friends.

JH returned home ready to proceed with the self-administered IV antibiotics. What he didn’t know was that he was facing his toughest opponent ever and that the outcome of this match was far from certain.

(Coming up in part two, the seriousness of the injury becomes clearer, heightening the level of concern among caregivers. JH begins a series of six surgeries which may or may not be enough to save his leg.)

About the Author
Dr. Pollack is certified in Emergency Medicine and is a founding board member of the Hospital Quality Foundation. Visit: www.hospitalqualityfoundation.org.

Enterocutaneous (ECF) and entero-atmospheric fistulas (EAF) can create a challenge for the certified wound clinician. The hope is always that the fistula will spontaneously close while at the same time managing the current situation.

Back to basics…

A fistula is an abnormal connection between two structures. In wound care, we see many types of fistulas, often classified by the structures that are connected or by the amount of output noted. Two types that are often seen are the enterocutaneous (intestine to the skin) and entero-atmospheric (intestine to the open wound). These may then be classified further into high, moderate, and low output fistulas. A high output fistula is one that produces >500ml/day, moderate is 200-500ml/day, and low is <200ml/day.

Spontaneous closure is the goal for the patient with an ECF or EAF and is often achieved with time, patience, and conservative management. Many factors contribute to the development of EC and EA fistulas and therefore should be considered when managing and encouraging spontaneous closure. For example, was the fistula caused by a surgical event or does the patient have a history of Crohn’s Disease? Has the patient had previous radiation therapy, or do they suffer from malnutrition? Do they have a history of peptic ulcer disease or an intra-abdominal abscess? Each of these factors, if applicable, will affect the treatment plan and how the patient responds to therapy.

Several general management guidelines are appropriate for any fistula, regardless of the etiology. They are defining the fistula, fluid andelectrolyte replacement, infection control, skin protection, and nutrition.

Defining the fistula refers to identifying the communicating structures, and in so practitioners gain a better understanding of the specifics of management. For example, a small bowel fistula will likely have higher output, need greater nutritional management, and meticulous skin protection.

Fluid and electrolyte replacement is extremely important, as well, particularly when managing those fistulas involving the small intestine or whose output is >500ml/day, or high output. Patients with high output fistulas are at risk for dehydration, as well as electrolyte imbalance and its sequelae, much like a high output ileostomy.

It is also important to identify and treat sepsis. Often the infection is a concern due to spillage of intestinal contents into the abdominal cavity and the resulting inflammation decreases the chances of spontaneous closure while increasing the chances of further fistulation.

Small bowel contents are very corrosive to the skin and require meticulous skin care to prevent skin breakdown.

And finally, nutrition…

The nutritional variables that one might evaluate are the current nutritional status, current health status, past medical history, amount of fistula output, and how nutrition will be administered, enterally versus parenterally. How is the mode of nutrition determined? If utilizing parenteral nutrition, for how long?

Each of the steps to managing fistulas, previously listed, requires consideration of nutritional status:

1. Ensure there is no active sepsis. If so, treat it. Sepsis causes hypercatabolism which carries with it increased nutritional requirements. A high output fistula may require as much as twice the baseline protein and caloric intake, approximately 2.0g/kg/day and 40kcal/kg/day respectively. Can the patient obtain these requirements with TPN? Would an enteral diet cause an increase in output?
   
   
2. Optimize fluid and electrolyte status. Fistulas, especially those that are high output, can lead to excessive loss of protein-rich fluids and electrolytes. Not only can loss of fluid lead to hypovolemia and circulatory failure, but the corresponding loss of electrolytes may also cause any number of problems from weakness to EKG abnormalities. Is the patient physically able to take in the required fluid and nutrients?
   
   
3. Protect peri-fistular skin. Different modes of nutrition can affect the amount of fistula effluent which may then influence skin integrity and cause skin breakdown. Is the patient’s diet affecting the amount of output? Are there pouching issues and leakage due to increased output?

Now that we see how important nutrition is in the management of EC and EA fistulas, how should it be administered? Shouldn’t the bowel have an opportunity to rest? With input into the bowel, won’t there then be output? And won’t the output flow through the fistula minimizing the chance of spontaneous closure? In the mind of this wound nurse, this is a dilemma…

Current evidence suggests that for a low output fistula (<200ml/day) a short course of bowel rest may be attempted with or without TPN. The patient should be monitored during this time for decreased output and spontaneous closure. If no spontaneous closure, consider reintroducing oral intake and manage the fistula like an ostomy until the nutritional status is optimized. One may then consider surgical closure after approximately six months or so.

For a high output fistula, which often involves the small bowel, nutritional maintenance with an enteral diet is more challenging due to the greater losses of nutrients via the fistula and the likelihood of further increased output with increased oral intake. TPN is a viable option for longer periods, in this scenario, leading to surgical closure after approximately six months as well.

The bottom line is that the patient needs adequate nutrition for maintenance of life, wound healing, and fistula repair, whether spontaneous or surgical. Each patient will be different and each situation unique. It is important to look at the “big picture” and not assume each patient will respond in the same way to the same therapies. Personalize therapy to meet the individual needs of the patient while considering the ultimate goal of successful fistula closure.

References:

Bryant, R.A. & Nix, D.P. (2016). Acute & chronic wounds: Current management concepts (5th ed.). St. Louis, MO: Elsevier.

Stein, S.L. (2019). Enterocutaneous and enteroatmospheric fistulas. Retrieved from https://www.uptodate.com/contents/enterocutaneous-and-enteroatmospheric-fistulas?source=history_widget.

Willcutts, Kate, Scarano, K, & Eddins, C.W. (2005). Ostomies and fistulas: A collaborative approach. Nutrition Issues in Gastroenterology, 33, p 63-79.

Surgical site infections (SSI) increase medical costs, length of hospital stays, and readmission rates. Although this rate may be under-reported, the incidence of SSI in the US is estimated to be 2.8%. In the inpt setting or generally?

There are many factors involved in the development of an SSI. Bacterial factors include the inoculum size. Bacterial load at the site of infection of greater than 105 is considered to be indicative of infection rather than colonization. Virulence characteristics, resistance characteristics, and enzymatic activity also play a large role in the development of superficial surgical site infection. (superficial vs deep?)

Patient factors that increase the risk of SSI include age, nutritional status, significant weight loss within 6 months of surgery, immunosuppression, comorbidities (especially obesity, DM, and peripheral artery disease), and post-operative anemia. Each of these factors has been shown to play a significant role in increased risk for an SSI.

Surgical characteristics can also increase the chance of developing an SSI. Poor surgical technique, operative procedure length >2Hr, operative field contamination, and poor skin preparation/shaving have all been shown to increase the risk of an SSI. The American College of Surgeons (ACS) has classified surgical cases based on infective risk.

• Class I (Clean) Operative field is uninfected, there is no inflammation, no hollow viscera are entered, and the respiratory, GI, reproductive/GU are not breached. There are no major breaks in sterile technique. Operative incisions after blunt trauma where the respiratory, GI or GI/GU tracts are not injured also fall into this category. Infective Risk is
• Class II (Clean Contaminated) Operative field is uninfected, there is no inflammation, but the respiratory, GI, reproductive/GU tracts are breached but in a controlled manner as part of the operative plan, and without excessive or unusual contamination. There are no major breaks in sterile technique. Infective risk is < 10%
  
  
• Class III (Contaminated) Recent open (traumatic) wound, traumatic wounds older than 12 hours, surgeries or procedures with major breaks in sterile technique or major spillage from the GI tract, or incision into actively inflamed tissue (without purulence). Infective risk is 15-20%
  
  
• Class IV (Dirty/Infected) A wound where the organism causing the post-operative infection was present in the operative field before the procedure. There is an uncontrolled entry into hollow viscera. Active inflammation, as well as gross purulence, can be seen. Infective risk is up to 40%

It is common practice to utilize dressings to cover a surgical incision that has been closed by primary intent (skin edges are reapproximated using sutures, staples, skin glue, or other means). It is a common belief that the benefit of a post-operative dressing is to control exudate and bleeding, protect the incision from external contamination, protect healing tissue, and prevent infection of the incision.

However, a 2016 Cochrane Review does not support the use of a post-operative dressing, or any specific type of dressing, as a factor in preventing an SSI. The review included 29 articles (5718 subjects) published up to September 2016. While included studies were randomized and controlled, many were underpowered due to small sample sizes, varied surgical case types, and study bias and imprecision. As a result, the evidence quality was graded as low or very low for many of the studies. The authors could not find sufficient evidence that covering a surgical incision with any dressing reduced the risk of an SSI. They also could not support any specific type of dressing as reducing the risk of an SSI.

Due to the morbidity of SSI, interventions such as the Surgical Care Improvement Project (SCIP) have been instituted with the stated goal of reducing SSI. The use of a post-operative dressing is standard practice for most surgeons. While the postoperative dressing does control exudate and bleeding and provides a physical barrier while the incision epithelializes, further research is needed to determine if this practice is beneficial in the prevention of SSI.

References:

A Report from the NNIS System. Am J Infection Control. 1996 Oct 24(5):380-8.

Barie PS. Surgical Site Infections: Epidemiology and Prevention. Surg Infect. 2002; 3(Suppl) 1: S9-21.

Cruse PJ, Foord R. The epidemiology of wound infection. Surg Clin N Am. 1980 Feb 60(1):27-40.

Dumville J, Gray TA et al.  Dressings for the prevention of surgical site infection. Cochrane Systematic Review. 20 December 2016.

Malone DL, Genuit T et al. Surgical site infections; Reanalysis of Risk Factors. J Surg Res. 2002; 103(1): 89-95.

Rosenberger L, Politano A et al. The Surgical Care Improvement Project and Prevention of Post Operative Infection, Including Surgical Site infection. Surg Infect. 2011 June; 12(3)L 163-168.

As a talented group of professionals in our areas of specialization, we have formed a common goal to conquer any wound, regardless of the location, source, chronicity, or barriers to healing. At least, this may be our belief. Did any of us have a burning desire as aspiring professionals to work to advance the cause of evidence-based wound care? As a team of multidisciplinary professionals of physicians, nurses, pharmacists, physical therapists, researchers, and industry personnel, we were able to recognize an area of need for patients who suffer from chronic wounds. For each of us, there was something which ignited the passion to serve, to research, and to lend our expertise to this subject. Our strides to promote wound care from a multidisciplinary approach have led us to improved overall outcomes for our patients.

To my knowledge, there is not one aspect of higher education in the subject of wound care for everyone to attend. It appears we have all come to this crossroads in our respective professions. Some attend to the clinical aspects of wound care, some research, while others may possess a formalized training in business and are able to identify a need in the area of wounds and wound healing. Simply expressed, there is not a formal institution of higher learning for wound care. Fortunately, there are educational programs, certifications, and extended classes and degrees which promote the spectrum of wound care.

I dare say, as we embarked upon the road less traveled, we developed a desire to care for patients with wounds and to promote wound healing holistically. As professionals, we may have provided care to a patient who performed a “do it yourself” technique on their wound, such as preparing a full-strength bleach soak for their feet, which caused more harm than good. There is the non-compliant patient and family, although educated repeatedly about their disease process, prefer to remain non-compliant.  I encourage you to reflect upon the patient with multiple co-morbidities who managed their underlined disease of diabetes or congestive heart failure and still experienced disappointments of limb loss.

As clinicians, we are at the forefront of identified problems and the exploration of various ways and means to solve the problems. Perhaps, a short term or long-term goal of care was determined for treatment. Did the patient need antibiotic therapy, local wound care, or surgery? What type of therapy was needed for the patient? What did the labs show? There were many ways to explore a singular problem. However, through a multi-disciplined approach, we likely determined to connect our desires with others who shared the same goal to bring healing and awareness to this important category.

You may ask, what led to my passion for wounds? I was the nurse in a critical care unit where patients with chronic, surgical, or trauma wounds were my norm. Where others shied away, I could care for the entire patient without any bias toward their wounds. This was a time to provide timely assessment and care while noting any changes to the area of concern. It was not always pleasant, but my goal was to provide the needed, direct patient care with compassion. I began to read evidenced-based literature to determine the findings of my peers. This led to my attendance to a wound, ostomy, continence educational program and ultimately a certification in wound care to solidify my passion and my commitment to additional education.

Some may argue the need for a more formal educational program for all specialties. But the modality of wound care and management is ever-changing. An all “boots on the ground” approach is needed to assist patients onto the path of healing. The Association for the Advancement of Wound Care (AAWC) is available to those in the healthcare field with a mission to assist persons with wounds and identification of at-risk persons. Ongoing educational programs are held in various forms to foster new advances in this area of wound care to those who are at the bedside, research, or any aspect of care.

For the reader, I ask, what led you to this pathway? Was it a specific patient or the types of patients seen with chronic wounds? Was your area of expertise in business management or research which caused you to discover your pathway? The development of your concern for wound care and healing may provide endless areas of discussion. As you go about your day, week, month, and years in the subject of wound care and healing, please remember the passion which placed you in this needed field of care.

Despite the vast amount of advanced wound care products available as well as an evidence-based practice that supports wet to dry dressings are substandard, I still receive daily calls from clinicians reporting new wound care orders for wet to dry dressings to be performed in the home setting, usually twice daily.

What exactly is a wet to dry dressing?

A typical wet to dry is a saline moistened dressing, which is placed in the wound bed. It is left to dry and removed usually every 4 to 6 hours. Removing this dried gauze acts as a mechanical debridement agent.

Now let’s discuss what happens to and in the wound with this removal process. 

First, non- selective mechanical debridement. When that dry gauze is pulled from the wound bed, it also pulls any tissue that has adhered during the drying process. Often it is newly formed, healthy viable tissue that is removed, causing trauma and/or bleeding to the wound bed as well as increased pain for the patient.

The second thing that occurs is local tissue cooling. Wounds are very picky about the climate of the environment in which they can heal. Cells tend to do their best work at a normal body temperature of 98.6 F. When the wound temperature decreases, it may take up to 4 hours to return to an optimal temperature. During this time, healing stops. Therefore, the more frequent dressing removal, the less time the wound is healing.

Finally, the risk of infection is greater with wet to dry dressings due to strands of gauze that maybe be left in the wound. The local tissue cooling discussed above leads to vasoconstriction and lower oxygen amounts being delivered to the tissue, which also increases susceptibility to infection.

Shying away from wet to dry dressing can lead to decreased healing times, decreased infection risk, decreased over-utilized home health visits, as well as decreased pain with dressing changes which may increase compliance.

When discussing why wet to dry dressings are not the standard with providers who tend to write for wet to dry dressings exclusively, I have found discussing the topics above has allowed me to further educate on the products available to provide a moist wound environment, therefore increasing healing rates. As the saying goes, a little extra knowledge goes a long way.

 

I am that person, the one who is thrilled the more challenging the wound looks. But I guess we all are, right? That is what has brought us together, this group of people who have never met, we are all connected through one simple thing, a passion for those hard to heal wounds. Unfortunately, we likely all have had those wounds that we have tried hard to heal and failed. That’s right, I have failed, we all have. I wish I was perfect; I wish I got it right from the start every time, but I don’t. It’s these really difficult wounds that help us grow as practitioners and I hope that as I share my mistakes with you, you don’t have to make them as well.

Let’s go back a few years. I am a new practitioner, excited to go into the wound care world and ready to fix everyone, or so I thought. I knew I would specialize, eventually, but I had my doctorate and I wasn’t going to wait to change the world. I noticed right away that I was having difficulty healing those pesky foot wounds. You know the ones—on the fifth metatarsal head or the tips of the toes. I was using the right dressings and I thought I was offloading appropriately, but I still couldn’t get them to heal. Skip ahead a few years, and I now realized I was forgetting a very important part of it all – understanding what was causing the wound in the first place. Perhaps they had decreased first toe extension, leading to a change in their pressure distribution; I would forget to address that, thus doing a disservice to my patient.

Now, when I treat a foot wound, the first thing I do is check their 1^st digit extension and dorsiflexion mobility. It has significantly decreased the healing time for my patients. I look at the callus formations on their feet as this is an easy way to see where they are getting high pressure and shear. These calluses may not be the site of a current wound, but they are sites for potential wounds in the future. If I can change their mechanics to prevent further breakdown, of course, I am going to! 

Let’s look at how these changes in mechanics change the pressure through our foot. With normal gait, we start with our heel strike, then roll through our foot, at which point we start dorsiflexing to about 15 degrees. At the end of the stance phase, our ankle starts to plantarflex, and our 1^st toe must extend 60 degrees. When all of these components are working, we distribute pressure through the foot the way our body was designed to do; i.e. no wounds. The moment we remove or change a component of this pattern, we must compensate to complete the stance phase, thus changing our pressure distribution.  For example, when a patient has limited dorsiflexion, they may roll through the outside of their foot rather than through the first toe at the end of the stance phase, leading to increased pressure at the fifth metatarsal head. Or maybe they compensate by externally rotating their hip; this is going to increase the pressure at the first metatarsal head. These changes are common with diabetic patients due to glycation of the ankle joint and thickening of the Achilles. When you combine increased pressure and repetitive stress, a wound is going to occur.  If we do not address these orthopedic issues, we will have a difficult time healing the wounds and leave our patients at risk for developing the same wound again and again.

Once you have decided that your patient has decreased mobility, the next stage is treating it. The simplest way to increase mobility is to stretch the structures, but oftentimes this alone is not enough due to the soft tissues not being the only structures limiting motion. Despite this, I do give the patient some ownership of the issue by having them stretch at home. The best results for stretching would be a 90-second hold, 1-2 times per day, if the patient can tolerate it. Which stretch do I have them do? It depends on the patient and what they can do; I might have them do a standing gastric soleus stretch or one with a belt. If they have the mobility, I will have them manually stretch their toe into extension, if they don’t, I might recruit their caregiver to assist. As with any treatment, we must tailor it to our patients, their needs, and their abilities. Generally, I will also incorporate joint mobilizations and soft tissue work in the clinic to work towards improved mobility. I also give the patient strengthening for their foot intrinsic musculature, as deterioration often occurs in conjunction with the aforementioned issues. Unfortunately, these changes don’t happen overnight and you must have something in the interim for offloading. For me, Dr. Jill’s Offloading Felt has been a lifesaver, with my preference being the ½ inch felt. One side is adhesive, and you can stick it right to the foot so there is no need for the patient to adjust it or concerns of it shifting on the insensate foot. I cut out a piece the size and shape of the patient’s foot, as well as an additional cutout to offload the wound. There are a few downsides, you need to have good scissors and strong hands as the felt are not easy to cut. With an additional half-inch of material on the bottom of their foot, getting shoes on can be difficult as well.

There will be patients that we cannot get their mobility back for various reasons. I had one patient with a wound on his first metatarsal head who had a fused 1^st toe and neurological damage that led to a very stiff ankle. With him, I enlisted the help of a prosthetist to help create a device that would offload the foot. Over time, the prosthetic created new pressures and new wounds, so we instead transitioned to a custom orthotic with a plastizote lining and cut-outs to offload the area. I have also seen numerous patients over the years who have a deformity that is no longer mobile; I see this frequently with claw toes. I am lucky enough to work in an orthopedic clinic with multiple surgeons who can assist me with these patients that may require a surgical cleanup of the joint, lengthening the Achilles, or techniques that may be outside of my scope.

Please don’t repeat my mistakes.  Ensure that each patient who walks through the door with a foot wound has their foot mobility checked. You will see a change in the way you practice and how easily your wounds heal.  Apply these principles, and you will be “a cut above” the rest.

Nursing homes are among the most tightly regulated institutions, and any healthcare provider in this setting knows the dreaded F-word…F-tag. (Insert shudder here). Regarding wound care, what used to be F-tag 314 is now F-tag 686. Within the 749 pages of the State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Section 483.25(b) Skin Integrity with 483.25(b)(1) Pressure Ulcers involves twenty pages of explanation. The good news: CMS typically utilizes the terms and definitions established by the National Pressure Ulcer Advisory Panel (NPUAP) and implements those terms and definitions into the Minimum Data Set (MDS). The bad news: Not understanding and following the guidance could be costly.

One of the most critical actions a healthcare provider in long-term care can take is to proactively document all aspects of wound management. Aside from knowing that wound documentation is required at least weekly and having a wound sheet, there are additional aspects of the regulations to know and understand in order to ensure compliance. Several will be highlighted in this blog.

1. Concisely document how wound healing is impacted by tissue perfusion, nutritional status, co-morbidities, inflammation, and age, among other factors4. For example to address one section under 483.25(b)(1) which reviews modifiable and nonmodifiable risk factors that “…increase a resident’s susceptibility to develop or to not heal pressure ulcers…”, wound documentation should specifically identify and discuss factors that are present that potentially impede wound healing such as arterial disease, diabetes, end-stage renal disease, medications, etc.).
   
   
2. Wound documentation should review both the patient’s prognosis as well as the wound prognosis. For example, under Nutrition and Hydration, the 483.25(b)(1) regs state, “continuing weight loss and failure of a pressure injury to heal despite reasonable efforts to improve caloric and nutrient intake may indicate the resident is in multi-system failure or an end-stage or end-of-life condition warranting an additional assessment of the resident’s overall condition.” Describe how wound healing is impacted by a patient’s end-stage disease that requires a more palliative approach. A great phrase to utilize in documentation is “delayed wound healing expected” with a succinct but clear explanation. Residents with advanced dementia are expected to lose weight as the disease progresses. It is important to connect how advanced or progressive illnesses (i.e., end-stage dementia) impact wound healing for the surveyors. In addition, collaboration with the dietitian to follow the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines, as well as patient-centered nutritional goals, are valuable components in wound documentation.
   
   
3. Document and describe pressure injuries that occur at the end of life and the Kennedy terminal ulcer (KTU). Powerful pieces of documentation include the location and appearance of the KTU, that appropriate preventative measures were in place, and that the KTU appeared suddenly, within hours. The website, kennedyterminalulcer.com is a great website for further information on this condition. Though skin failure and other end of life skin conditions are not listed or described (example: 3:30 syndrome or Trombley-Brennan terminal tissue injury), surveyors do have two paragraphs explaining potentially unavoidable pressure injuries. As the regs state, “it is important for surveyors to understand that when a facility has implemented individualized approaches for end-of-life care in accordance with the resident’s wishes, the development, continuation, or worsening of a pressure injury may be considered unavoidable.” Thus it is critical to explicitly describe in the medical record the wound, its healing potential, and all factors that contribute to or impede wound healing. NPUAP supports not turning residents every two hours at the end of life, emphasizing the importance of documenting why…that turning causes more distress and pain and is not beneficial for comfort at the end of life.
   
   
4. Documentation should clearly how “resident choices” impact the appropriateness or feasibility of interventions and wound healing. The section, “Resident Choices,” describes how care plans should establish relevant goals and interventions for pressure injury management. In addition, facility staff and practitioners should document clinically valid reasons why an intervention may not be appropriate or feasible. For example, when a patient chooses to smoke despite education on the detrimental effects of smoking on wound healing, the healthcare provider should objectively document that education was provided, that the patient comprehended the education and has chosen to continue to smoke. As an example: “Delayed wound healing expected due to smoking, which causes vasoconstriction and reduces blood flow to the extremity.” The resident has every right to continue smoking. The provider also should absolutely provide the standard of care. The treatment plan will then need to be developed based on the patient’s preference, the goals of care, and what fiscally makes sense.
   
   
5. Time parameters reflecting the duration of the activity, sitting schedules and progress toward healing should also be documented. The 483.25(b)(1) regulations include comments on specific time recommendations. For example, under “Healing Pressure Ulcer/Injuries”, the regs state, “residents with pressure injuries on the sacrum/coccyx or ischia should limit sitting to three times a day in periods of 60 minutes or less.” Therefore, documentation should include when the patient is in bed and that the patient is in a less than 90-degree position when in the chair or bed. There is wiggle room in the regs that allow for modification of sitting schedules per patient/family preference. Another time interval to be mindful of within the regs: “if a pressure injury fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident’s overall clinical conditions should be reassessed. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions.” A thorough wound evaluation also includes the rationale for the treatment plan, especially when the wound does not appear to be improving using the current treatment plan.

Extra time documenting goes a long way to avoid F-tags, litigation, etc. Wound care is an interdisciplinary effort. Nursing should not be the only profession commenting on pressure injuries (or other wounds for that matter) in nursing homes. Physicians, advanced practice providers, therapists, dietitians, and nursing staff should all be looking at the wounds as well as documenting them. In addition, there should be a consensus on the staging and periodic discussions to ensure everyone is on the same page and agrees with the staging and plan for the pressure injury. Lastly, be consistent with terminology in the documentation. Call a spade a spade…if it’s due to pressure, then it is a pressure injury, and everyone should describe it as such. The F-word (i.e. F-tag) does not have to be a dirty word in long-term care if the team is documenting appropriately.

Members of AAWC are known for top tier commitment, specialization, and passion for wound care. Yet among the greatest of challenges advanced wound care professionals face, one is how to demonstrate and communicate the impact and value provided to administrators and clinicians managing or overseeing multiple clinical services.

After all, it’s only recently that advanced wound care has begun to become recognized as a specialty and service line -- and there is still a long way to go, not only scientifically or clinically.

Getting the proper buy-in, which in turn unlocks resources for staffing, products, technologies, training, and infrastructure, requires more than the ability to deliver evidence-based, patient-centric wound care. While a short post is not enough to tackle this important subject, what follows are some actionable ways to ensure recognized value:

1. Determine baseline metrics and KPIs (key performance indicators):
   
   Tracking clinical (e.g. healing rate, healing velocity, average days to heal, etc.), operational (e.g. new patients, visits, cancellation rates, staffing ratios, etc.), and financial (e.g. revenue, expense, profit, cost per dressing change or per healed wound, etc.) metrics and KPIs makes a difference. Starting with baseline historical stats from prior to when the current wound care program (or the new investment in staff, technology, training, etc.) began is a must, though it’s never too late to start. Aside from hospital-acquired pressure ulcers (HAPUs), surgical site infections (SSIs), and a couple others which all are influenced by many factors that can be tough to control for, healthcare administrators - especially in care settings that are not hospital-based - have very little insight into the correct ways of telling whether investments are paying off (or if budget cuts are costing more than they’re saving). Part of delivering wound care is to ensure administrators have the information to make decisions and see the return on investment (ROI) for advanced wound care.
   
   
2. Ensuring a proper organizational and financial structure:
   
   What is the chain of command for wound care services in each care setting? Is it seen as a function of clinical education? Quality and compliance? A revenue stream? A way to attract patients to the facility? This affects alignment (or lack thereof) with senior administration, key executive goals, and ultimately impacts the availability of resources. Likewise, the smaller the wound care team, the less likely there is to be a separate budget. Tracking an individual and separate budget for wound care apart from ancillary services, nursing administration, education, or other umbrella departments avoids unnecessary politicization and more difficulty/time spent to obtain unique resources necessary for wound care.
   
   
3. Use a dashboard report to regularly share (in person) with institutional administration:
   
   Once items one and two are in place, it’s important to distill them into a concise dashboard which can be used as a framework for discussions with administration and clinical leadership. Today, there are more tools than ever for tracking and visualizing changes in your data and outcomes over time.

As with many industries, the more senior the executive or administrator, the less familiar management will be with specific challenges and needs. At the same time, they tend to rely more on data (clinical + operational + financial) to gauge whether investments are being deployed in an impactful manner. Whether part of a large clinic or hospital team, or the sole specialist in an SNF or home care agency, the ability to regularly articulate a wound care program’s needs and performance to administration, using real-world metrics, in a relatable and useable form is a key component of ensuring wound care efforts are properly resourced.

About the Author
Rafael Mazuz is the managing director of Diligence Wound Care Global. To contact, email: [email protected].

As the premier voice of wound care, AAWC offers the hands-on education that elevates a practitioner’s wound care knowledge and skills. Most recently, AAWC held Wound Care Tricks of the Trade on September 11, 2019. This Wild on Wounds pre-conference workshop gave nurses and physicians insider wound care tricks and expert training. View photos here!

The workshop was a day-long educational session lead by seasoned wound care practitioners, Catherine T. Milne MSN, APRN, ANP/ACNS, CWOCN-AP, Kara S. Couch, MS, CRNP, CWCN-AP, and Marta Ostler, PT, CWS, CLT. During the workshop, attendees benefitted from educational sessions and hands-on training that covered:

• Selecting topical dressings
• Basic Negative Pressure Wound Therapy
• Advanced Negative Pressure Wound Therapy
• Choosing and applying compression
• Managing Lymphedema
• Clinical management of diabetic foot ulcers and Total Contact Casting

Each session provided unique “tricks of the trade” including useful tips on how to identify, dress, manage, and treat wounds both quickly and effectively. Throughout the day, seasoned instructors helped attendees navigate difficult wound care choices and learn how to adapt without specific wound care supplies. Towards the end of the program, attendees had the opportunity to learn about Total Contact Casting (TCC). Many nurses performed TCC casting for the first time with guidance on proper procedure and application from AAWC instructors.

Wound Care Tricks of the Trade educational sessions reinforced the idea of creativity. The premise that if a practitioner doesn’t have all the tools, then the solution relies on creativity. Hands-on sessions encouraged attendees to be creative and get in the habit of choosing the best course of action given select resources when practicing wound care.

In addition to hands-on, expert-led training, attendees benefitted from:

• Registration that included a one-year AAWC membership
• AAWC members have access to the monthly Journal Club, Trip Database, event discounts, and more
• The opportunity to earn up to 6.75 ongoing education credits
• $100 off Wild on Wounds Conference, an exclusive offer for AAWC members 

AAWC has many educational opportunities throughout the year. Near or far, join us for our September Journal Club "A Standardized Approach to Evaluating Lower Extremity Wounds" tomorrow evening, 8:00-9:00 p.m. EST, presented by Marta Ostler CWS, CLT, PT, and Mary Haddow, RN, CWCN. Register to get a unique preview of the topics that will be covered at AAWC’s Lower Extremity Summit (LEx), November 2-3, in Sacramento California.

This year’s Wound Care Tricks of the Trade would not be possible without the generous support from its sponsors.

Thank you, Wound Care Tricks of the Trade Sponsors!
KCI An Acelity Company
Integra Life Sciences
Tissue Analytics
Molnlycke
Prism
Medline

For more information visit AAWC.

 

 

When fans take the stands and players take the field at sporting events, the focus tends to be on the pitcher, the quarterback or the goalie. A win or a loss begins with these positions. The arena for wound treatment is not very different. The eyes of the care providers tend to go direct to the center of the wound, the wound bed. But the action on the periwound or the wound sidelines can make a difference in how rapidly the patient may heal.

The periwound offers key information crucial to overall wound healing. Following these recommendations can make the wound care team take home a win.

Maintaining the moisture balance of the periwound is essential to wound contraction and epithelialization. If the skin around the wound is too wet, the epithelium cannot crawl across the wound bed and the wound cannot contract appropriately. 

Heavy moisture is an indicator of other issues such as venous insufficiency in a leg wound, an unaddressed bioburden causing heavy exudate, systemic fluid overload, or a primary dressing that is perhaps creating an inappropriate moisture balance for the wound.

Once adequate arterial flow to lower extremities is confirmed, compression can be utilized to help with edema to periwound skin. A liquid adhesive can be applied to protect the periwound skin and will control maceration. Removal of the callus ring enables visualization of the real periwound and minimizes pressure, and using a dressing with more moisture helps wounds that are dryer.

Bioburden is a factor in any wound healing, particularly in the perineal areas or the feet. A foul odor from the wound is a hint of a bioburden. Sharp debridement and physically breaking the biofilm then dressing the wound with an antimicrobial dressing can help optimize wound healing after the biofilm is broken.

If bioburden has been ruled out and the periwound is red, other factors are at play. Offloading pressure and reducing friction even when it is not the primary etiology can help. 

Necrotic tissue in the periwound or wound bed that is resistant to treatment may indicate cancer or autoimmune disease. Though rare, these should not be discounted. A biopsy can provide answers.

Necrosis also can be caused by arterial insufficiency from large or small vessel disease. A toe brachial index in addition to an ankle brachial index can reveal the problem and potential for healing.  Particularly with foot wounds, small vessel disease requires a lower level of negative wound pressure therapy so there is no clamping of the periwound small vessels.

Edema is another consideration. Localized edema treatment is more effective once the patient is euvolemic. With lymphedema, specialists are required to assure the proper treatment.

Crunchy sounds caused when there is gas under the skin is called crepitus, and it is an emergent condition. It can indicate gas gangrene, requiring systematic antimicrobial therapy and possibly surgery. Fluctuance, or sensation of a pocket of fluid trapped in the tissues in either the periwound or under the wound itself, with or without erythema, may require surgical intervention.

Epibole Is when the periwound curls in. In a healthy periwound, epithelial cells should be observed as moving across the wound bed. If they have stopped or the periwound is curled in, something is preventing normal contraction and epithelialization from happening. Scraping the curled area with a curette and then treating with an advanced dressing and an antimicrobial component will disrupt the potential biofilm as well as help correct the defect.

Like other players on a sports team, the periwound may not be the central attraction. But what it does and how it plays impacts the healing of a wound as much as the other players impact the outcome of the game. The periwound needs to be evaluated with the wound bed, treated at different stages of healing, and supported as it plays its crucial role in the wound healing challenge.

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When something is lost, it is always found in the last place searched …because once found, searching is no longer necessary. With diagnoses: once identified, looking further is unnecessary. Unless something rare can masquerade as many other things, causing a false find – a diagnosis that looks like one thing but is really something else.

So it is with Martorell’s Ulcer. It is so rare and atypical, it is frequently missed when it presents. One of the rarer lower extremity wounds, Martorell’s Ulcer is often unrecognized, leading to ineffective treatment and prolonged, intense pain for patients.

The wound associated with Martorell’s Ulcer is an ischemic lesion appearing on the lower leg and sometimes near the Achilles tendon. Historically, it was thought that women between the ages of 50-70 were more likely to develop Martorell’s Ulcer. However, current literature suggests the average age is 74 and there does not seem to be evidence that women any more than men are likely to develop them. A significant marker for Martorell’s Ulcer is the disproportionate level of pain as compared to the size of the wound; Martorell’s Ulcer causes extreme pain

In all cases, the patient will have severe, long standing, systemic and uncontrolled hypertension and nearly 60 percent will have diabetes. The Ulcers can be triggered by trauma, however, 50 percent will be spontaneous in formation. The wound will be of varying depth, have a necrotic base, bluish or purple edges, an irregular shape, and can be singular or present with satellite sites.

Before being treated by a wound specialist, a patient may see a general practitioner. The generalist will assess a patient presenting with a lesion and leg discoloration and ulceration. Being unfamiliar with Martorell’s Ulcer, the generalist may diagnose it as a more common venous wound.

Even wound care specialists may determine the evidence to be something other than Martorell’s Ulcer. Frequently, Pyoderma Gangrenosum is diagnosed first. While the symptoms of both Martorell’s Ulcer and Pyoderma Gangrenosum are similar, the treatments are very different. Proper treatment for Pyoderma Gangrenosum is contraindicated for Martorell’s Ulcer.

A proper diagnosis for Martorell’s Ulcer is possible only with a large specimen sample biopsy. The specimen must be large and cut to the fascia, and include healthy skin from the wound border into the necrotic area of the wound. The specimen must remain intact, imbedded for histological examination and be of longitudinal orientation. A punch biopsy is insufficient to diagnose Martorell’s Ulcer and if used, has been shown to wrongly diagnose it as Pyoderma Gangrenosum.

Once diagnosed with the biopsy, treatment calls for surgical removal of the necrotic skin followed immediately by a split skin graft. Post-surgery, negative pressure treatment has been shown to help. While pain management was crucial prior to diagnosis and surgery, patients report pain reduction very quickly after surgery. Long term management requires blood pressure and diabetes control, cessation of smoking, and compression to the area. Wound area bacteria can be managed with topical anti-microbials or systematic antibacterial agents.

When a patient presents with longstanding hypertension and diabetes along with a very painful necrotic wound on the lower leg or near the Achilles tendon, health care providers should consider Martorell’s Ulcer and include it as part of the differential diagnosis.

It is rare, can masquerade as many other things, and is frequently found last and only after looking at everything else.

For anyone who watched television in the 90s, the phrase “The More You Know” likely drums up memories of a bright yellow star shooting across the night sky, big purple letters, and celebrities offering helpful information about current social issues. A side-effect of our emphasis on knowledge is that when a patient enters your care, they come with the expectation that you will know “more,” if not “all” about the complaint. It can be tempting to jump into that persona, to go along with “seeming to know everything” at that moment, and fill in the gaps later. But what if admitting how little you know opened up a new window toward better wound care outcomes?

Physicians obtain their knowledge from many sources: medical school, clinical rotations, patient experiences, literature, and conferences.

Staying current is essential to providing patients with the care they deserve. But it takes time. And when new protocols or pharma solutions are presented, a physician will want to know more before changing known and successful programs. There is a risk that sticking for too long with what is known to be successful can cause us to miss something new, but it is essential to incorporate new learnings and challenge our comfort level with the care we provide.

In recently published trial results, I, along with my colleagues report on How Little We Know About Bacteria in Chronic Wounds, and the challenge to increase the accuracy by which bacteria is detected in wounds. By acknowledging we need to know more, we step outside the use of Clinical Signs and Symptoms (CSS) standards to detect infection in a wound and guide decisions regarding treatment.

There are many challenges with this approach, to use a three-step process to determine if the use of fluorescent light could help increase the accuracy of bacterial detection in chronic wounds. By starting with CSS, using fluorescent light technology and concluding with a biopsy to confirm the diagnosis, we were able to see the variance between what their professional opinion might have been on initial analysis and the reality of the wound.

In the first round of trials nearly 20 percent of the wounds that were originally determined not to be infected turned out to have significant amounts of bacteria present. Based on the photos from the fluorescent camera, many of the professionals participating in the trial were able to adjust treatment recommendations to better suit the patients’ needs and described feeling more confident they were making the right decisions.

The knowledge in the treatment room extends beyond what the physician knows. It is an illustration of the importance of a multi-disciplinary approach to wound care and treatment. It turns out, it is not The More YOU Know, it’s The More WE Know together.

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Correction: In a recent article entitled "Madness Among Us" the article should have reported a recommendation to wait 4-6 days to perform wound closure, not to do the change of dressing. AAWC regrets the error.

It is hard to believe but 1 in 5 infants in the Neonatal Intensive Care Unit and pediatrics units will develop a pressure ulcer (PrU).  What is even more alarming, is that there are very limited studies of risk, prevention, and treatment in this patient population.

Neonates are not mini-children just as children are not little adults. Nonetheless, nearly all known risk assessment scales and PrU prevention plans for neonates are adapted from adult protocols. For both legal and ethical reasons, research in the pediatric and neonatal patient population is limited creating a lack of knowledge among one of the most vulnerable patient populations.

While there is evidence that pediatric skin is resilient and tends to heal quickly, the skin is also more fragile than that of an adult and immature systems can complicate wound care in pediatric patients.

As with the adult, a wound will cause increased risk for complications such as infection and water and electrolyte loss. However in the pediatric and neonatal population these risks are escalated due to their decreased surface area. In addition, the premature neonate’s skin is under developed which will reduce the skin’s barrier function, reduce their ability to regulate temperature, and increase their risk of water loss through the skin. In fact, absorption of seemingly benign topical medicines, lotions, creams or emollients can be dangerous in the neonate. The infant’s limited mobility and age appropriate mobilization patterns also present challenges to the prevention and management of wounds. Expression of discomfort and pain also complicate prevention, assessment and management of wounds in the neonatal and pediatric patient population.

When a neonate or pediatric patient develop a wound the treatment goals start with alleviating pain, reducing emotional distress, and minimizing scarring. To prevent additional trauma to the skin, dressings should be as small as possible to cover the wound and adhered using silicone or other gentle, non-skin stripping adhesives. In neonates, adhesives should be avoided altogether and replaced with loose or tubular bandages.

Pressure ulcers in hospitalized neonates and pediatric patients are significant and are frequently caused by immobility and medical devices necessary for their care. Of the various risk assessments used in adults, the Glamorgan Scale is reported to be the most readily adapted to infants and children.

The most common areas for pressure ulcers in this population occur on the heels, occipital region, and the sacrum/coccyx area. Medical device-related pressure ulcers can develop on the arm where blood pressure cuffs are applied or on fingers where pulse/oxygen meters are affixed. They may also develop in and around the nostril area from the prongs of oxygen tubes and masks.

Preventive efforts include padding prominent bony areas and rotating the patient to different positions or rotating the location of the medical devices. This population should receive a head-to-toe skin assessment on admission and again at 12 hour intervals with special attention to the sites where medical devices are in skin contact.

Pressure ulcers should be cleaned with room temperature sterile normal saline using a soft cloth or syringe. In the first two weeks after birth, no antiseptics or soaps should be used on the neonate. If emollients are necessary, careful evaluation is needed and must be applied sparingly to avoid systemic absorption – and avoided altogether in pre-term neonates.

Nutrition is key to healing of pressure ulcers, particularly among those with low birth rates or after neonate weight loss. Breast feeding can assist in promoting healing.

Infection risk is high in neonates necessitating close monitoring of the skin around the wound for subtle changes such as swelling or drainage, increased paleness around the wound or in the wound bed or increased redness around the wound. Healing is enhanced by using a moisture retentive dressing and close observation every 12-24 hours.

With little research to rely on, wound care providers treating neonatal and pediatric patients, have done well by adapting adult protocols. Forums for sharing experiences in this category can work to improve care for all those advancing wound care in young patients.

The Pediatric Wound Conference (ISPeW) will be held in Houston November 14-15. For further information visit ispew.org.

https://pedsinreview.aappublications.org/content/26/2/43

https://www.woundsource.com/patientcondition/pediatric-patients

https://advancedtissue.com/2015/05/how-to-treat-wounds-in-children/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985526/

https://www.dovepress.com/neonatal-pressure-ulcers-prevention-and-treatment-peer-reviewed-fulltext-article-RRN

It happened again. Of course, the IT in this context is a mass shooting -- two, in fact -- in fewer than 24 hours last week. The horror of El Paso was swiftly replaced with the tragedy of Dayton. Any town, USA.

Who bears blame and responsibility, and whatever the politics, a fix is an issue for everyone. However, the physical wounds that result are the direct responsibility of wound care professionals.

Unless in a war zone, civilian injuries resulting from gunshots have been linked largely to handguns or rifles. It is estimated that of the 67,000 people injured from gunshot injuries each year, approximately 32,000 will die. Legislation in 2004 lifting a ban on civilian ownership of assault weapons now enables consumers to obtain them.

And since the ban on assault rifles was lifted, there has been an increase in the number of mass shootings in which assault rifles were used.

Injuries inflicted by assault rifles are very different than those received from handguns or other non-assault style weapons. Patients presenting with non-assault style wounds typically have a wound with a defined entrance and exit. There is bleeding from the laceration and there may be fragments in the wound. Provided no vital organs have been hit and provided the patient has not lost too much blood prior to being treated, there is a good chance the patient can survive.

Assault rifle victims often present to an Emergency Department with injuries so severe recovery is not likely. The damage done is beyond repair.

Bullets from assault weapons tend to shred organs as a result of the high velocity at which they leave the weapon. The speed creates more energy as it passes through the body. The injuries result from tissue moving away from the bullet as it passes and then settling – a process known as cavitation. It leaves the tissue damaged or dead, and the cavitation impacts tissue and organs several inches from the bullet path. It is like a pebble tossed in a lake and the resulting eddies or concentric rings moving outward from the point of where the pebble entered the water, followed by the water becoming still again. The result may be injuries to organs not touched directly by a bullet but injured by the eddies created by the bullet path. The entry wound may be small, not unlike that of traditional guns. However, exit wounds from assault weapons tend to be large. Some bullets are designed to expand and fragment on impact and the exit can be as much as 12 inches in diameter.

Even if an assault weapon victim arrives to an Emergency Department alive, the tissue and organ damage may be beyond repair. Those who survive and receive life-saving surgery face long recoveries and require unique and ongoing wound care.

Long term treatment of victims of assault weapons parallels war wound care. Post- surgery, there are many concerns for survival. For wound care, the concern is for infection. Infection can result from residual dead and contaminated tissue or from foreign body material remaining in the wound. If that occurs, additional surgery may be necessary to remove it.

Leaving a wound open for healing may be indicated. Doing so allows for unrestricted swelling, exudation of serum from tissue, avoidance of an anaerobic environment, and to assure there is no residual dead and contaminated tissue.

Open wounds still require dressing. Dry and loose gauze may be indicated for wounds over tendons or with exposed bones. The gauze may be kept moist with saline. Cavities should not be packed but the dressings should be able to absorb blood and serum from the wound. The dressings should not contain petroleum jelly but antibiotic ointment may be used. All dressings should be non-constrictive, never tight, and there should be no adhesive encircling a limb. Doing so increases the risk of constriction. Plaster of Paris (POP) may be used for large wounds and for injuries near joints. If used, POP should not encircle the wound but serve as a support and remain split to the skin so the wound remains open.

As the wound heals, it is recommended not to examine it until 4-6 days after surgery. When changing dressings, do so to the outer dressing, leaving intact that in direct contact with the wound. This reduces the chance of cross-infection, avoids disturbing the wound healing process, avoids causing added pain to a patient, and reduces the amount of time and resources expended by a wound care provider.

Measuring progress includes monitoring for fever, examining for redness or tenderness around the area of the wound, odor from the dressing, and visually determining whether the dressing remains clean.

When the recommended time has passed for the wound to begin healing, look to see whether the wound is clean and red – both indicators of granulation as new tissue is formed. Note whether the deepest dressing is dry and hard indicating exudation. Gauze should remove easily with gentle pressure. These are indicators of improvement and healing.

If the patient has a fever, the dressing is wet with little bleeding and if the wound appears wet and shiny, shows pus, and skin erythema, the wound is not healing and different interventions are needed.

The physical wounds are only part of the damage done by assault weapons in shootings, mass or otherwise. The mental trauma from surviving either from physical wounds or guilt that others did not survive can be almost as difficult to heal. As part of a collaborative treatment team, wound care providers and all members of the treatment team must tend to the mental healing of the patient too. As the visible wounds heal, the invisible ones need equal but different attention.

Wound care providers and trauma teams can go to work together after a mass casualty from assault weapons, and their exquisite skills can result in almost miraculous outcomes. But these are skills no health care provider wants to be called upon to deliver. Until there is multi-platform change, health and wound care providers stand ready to put the pieces back together. 

For additional information, see (co-authored by AAWC’s Ruth Bryant, PhD, MS, RN, CWOCN) Nelson V. et al, Traumatic Wounds: Bullets, Blasts, and Vehicle Crashed. In Bryant, R. Nix, D. Coeditors: Acute and Chronic Wounds: Current Management Concepts, 5th Edition. St. Louis, Mosby/Elsevier January 2016

 

https://reference.medscape.com/slideshow/gunshot-wounds-6008960#19

https://www.scientificamerican.com/article/data-confirm-semiautomatic-rifles-linked-to-more-deaths-injuries/

https://tcf.org/content/commentary/the-assault-weapons-ban-did-it-curtail-mass-shootings/?session=1

https://www.outsidethebeltway.com/the-difference-between-ar-15-and-normal-gunshot-wounds/

https://www.nytimes.com/2018/03/04/health/parkland-shooting-victims-ar15.html

https://www.icrc.org/en/doc/assets/files/other/icrc_002_0570.pdf

Gauze and Chicken Divan have some commonalities: both are easy, quick, inexpensive, and have French connections-- which somehow makes both seem perhaps better than they really are. But both Chicken Divan and gauze may be too easy and as such, create an unwillingness to try something new.

It was the Ancient Egyptians and Greeks who first used woven fabric as bandages for wounds thousands of years ago. However, the continued use of gauze is far more based on tradition than on its functionality. Ancient Egyptians were familiar with the classic signs of infection; however, it was not until the nineteenth century work of Louis Pasteur and Robert Koch that the link was made between infection and specific pathogenic microbes. Then, it wasn’t until the 1978 work of JW Costerton that the biofilm paradigm was discovered, named, and defined by this pioneer.  Ongoing research is now showing that effective treatment of a chronic wound requires aggressive treatment of biofilm.

The French connection comes from the French word “gaze” which means gauze and is linked to the concept of gazing through a gauze veil. It is this lattice work which allows bacteria to penetrate up to 60 layers of gauze. Further the gauze itself is a breeding ground for bacteria, allowing maturation of biofilm within access of host nutrition but above and separated from action of host immunity. Bacteria can be up to 1000 times more tolerant to antimicrobial treatment than planktonic/free floating microorganisms. The recalcitrance of biofilm cannot be effectively addressed by a simple gauze sponge therefore more advanced modalities must be added to routine treatment options. 

When it comes to topical wound and post op incisional management, gauze is used far too often. It is no longer considered the standard of care as a primary wound dressing. So why does it remain the go-to, top drawer tool for wound care providers? A simple answer is that wound care is not taught routinely in medical and nursing schools. Therefore, many providers are not aware that the science and practice has advanced to more sophisticated wound dressings which treat patients more effectively. There are times when gauze is exactly the right option. However, It can also be labor intensive, require ongoing monitoring and frequent change, can be painful to remove, can leave pieces behind in the wound, and increases the bacteria and bioburden in the wound area.

There are thousands of other options available and there are multiple options for each stage of wound healing. Some kill bacteria-causing infection and include antimicrobial agents. Others have electronic sensors that can indicate changes in the wound as it heals. Some are skin substitutes, others are regenerative material. These can decrease healing time, be cost effective, and improve a patient’s quality of life.

The current challenge is in selecting from among these myriad options. The acronyms NERDS & STONEES help with that determination. NERDS for Non-Healing, Exudate, Red Friable Tissue, Debris/Discoloration, and Smell; STONEES for Size Increasing, Temperature Elevation, OS (probe to bone), New Breakdown, Erythema/Edema, Exudate, and Smell. Is it topical? Or is systemic treatment necessary? Each wound requires careful assessment to determine proper care.

Like medicine and wound care, treatment options evolve and improve. Gauze, like Chicken Divan, is likely to remain an option in the arsenal of wound care. But like other recipes, it is no longer the only choice and wound care must continue to provide the highest level of evidence-based care to patients.

Soon after his appendectomy, the eight year old’s mother was anxious for him to stand up tall and walk. He resisted, convinced his stitches would open and his insides would come out. When she lost patience with his hunched posture, he cried in fear while gradually standing ramrod straight. And his stitches gave way.

While nothing spilled out, the boy was traumatized not only from the appendectomy but from the reopening of the wound. Still an inpatient, new sutures were placed quickly.

Known as dehiscence[1], the reopening of surgical wounds is not uncommon. The boy’s fear of insides falling out, known as evisceration[2], is very serious and can be avoided with immediate treatment of dehiscence.

There are many options to close wounds, surgical or any other types. Catgut[3], manufactured from animal intestines has largely been replaced by synthetic materials which provide strength and yet are readily absorbed by the human body. But sutures are no longer the only option for closing a wound or incision. Other options include adhesive strips, staples and glue. Which option is used depends mostly on the type of wound requiring closure.

Sutures[4] are used to sew a wound closed. Dissolvable sutures are often used for internal wound closure. Non-dissolvable suture material must be removed by a medical professional. Sutures are used for deep incisions or wounds, can be done quickly, and are among the lesser expensive options for wound closure.

Staples[5], by look, feel and administration are exactly what one would find in an office supply store. Except those used with wound closure are larger, thicker, sterile, and applied using a medical device. Staples are especially strong and may be used in areas likely to move, such as abdominal incisions. Staples must be removed by a medical provider and done so in a timely manner so that new tissue growth does not grow around the staples causing further injury.

Surgical glue[6] may be used for small incisions that don’t require a lot of hold strength. Unlike other methods, the glue will dissolve and wear off over time, and does not need a medical person to remove it.

Adhesive strips[7] act like a tape to pull a wound closed. Areas where a wound is not in a high stress part of the body can use adhesive strips to close the wound. Caution is essential as individuals may be allergic to the adhesive on the strips.

Regardless of the method used to close a wound or incision, wound care is crucial for proper healing, to avoid infection, and to minimize scarring. Closed wounds establish a clean environment for healing internally and externally; open ones are a gateway for bacteria. Bandages must be changed regularly in a clean environment using clean tools and techniques. Beyond the bandages is the essential need to eat properly to fuel healing. Otherwise, healing can be delayed and there is greater potential for infection.[8]

The eight year old boy’s incision healed nicely with no infection and minimal scaring, and he recovered from both the surgery and the trauma of the reopened wound. His mother, however, is still working through the guilt.

Historian Thomas Carlyle is credited with developing what is known as “The Great Man Theory” when he said great leaders are born and not made. Having lived in the mid 1800’s he can be forgiven for not calling it The Great Man/Woman Theory. It suggests that certain traits or qualities are better suited to leadership, these are innate characteristics present at birth, and leadership will allude those lacking the genetics.

Legendary Green Bay Packers Coach Vince Lombardi had a different view of leadership. There on the frozen tundra, he claimed leaders are made, not born. That they are made by hard effort which is the price to be paid for achieving anything worthwhile.

And like any point of view, the truth is probably somewhere in the middle. It is leaders made and leaders born that the AAWC seeks with nominations for its slate of future directors.

“The AAWC board of directors are those charged with leading the organization in fulfillment of its mission,” said Victoria Elliott, R.Ph., MBA, CAE, and AAWC Chief Executive Officer. “Each board post reflects the composition of our membership and essentially provides each member with a voice and conduit to the organizational leadership.”

The AAWC Board of Directors includes president, president-elect, immediate past president, secretary, treasurer, and directors-at-large including positions for consumer, nursing, podiatry and physical therapy, research, international, and industry. A complete list of the current board of directors can be found at https://aawconline.memberclicks.net/board-of-directors .

The open positions for 2020 are secretary and these directors-at-large: industry, two nurse positions (each 2-year terms), two physical therapist positions (one 2-year term and one 1-year term), two physician positions (one 2-year term  and 1-year term), podiatric physician and research.

With the late 2018 transition to an independent status, the AAWC executive committee postponed elections till 2019. Incumbents are Tomas Serena MD, FACS, President, Ruth A. Bryant, PhD, MS, RN, CWOCN, President Elect, Gregory Bohn MD, UHM/ABPM, MAPWCA, FACHM, Immediate Past President, Kara Couch MS, CRNP, CWCN-AP, Secretary, and Tim Paine, PT, Treasurer.

“This decision enabled the AAWC to remain stable and member-focused during a transition year,” said Tomas Serena MD, FACS, AAWC president. “Each member of the board and the executive committee has been unwavering in support and commitment to AAWC with the needs of members as the primary focus.”

Short and long term goals have been established and are linked to membership input gleaned from a survey conducted last fall. The focus is on education and expansion of learning opportunities for membership, followed by two other pillars of public policy and research.

Ruth A. Bryant, PhD, MS, RN, CWOCN is president-elect and will assume the presidency in 2020. “We have a spectacularly strong organization,” she said. “Members have defined our future and have demonstrated keen insight in selection of solid leadership. With the call for nominations, we are excited to welcome new leaders to the board.”

A willingness to be nominated and then to serve presents opportunity and reward well-beyond wound care responsibilities. It is a chance to step outside a zone of comfort, face new kinds of challenges, and develop skills which may be dormant during the day-to-day. Further, these positions offer a chance to expand a professional network, change the industry, and try new things.

Nominations for candidates will be distributed to membership on July 11^th and will be accepted through July 28^th. Candidates must be AAWC members for no less than one year as of July 10, 2019.

Whether you were you born with or you developed the leadership skills necessary to help AAWC recognize its mission, consider how you or someone you know can take a larger role in impacting your profession in wound care.

When a patient presents with a wound, it is not surprising that the first field of focus is the wound itself. Assessing the wound indicates to the wound care professional what the wound condition is, whether it is chronic or the result of a recent injury, related to surgery, if infected and at what level, possible co-morbidities, and much more. The second field of focus is the computer screen to chart the course of treatment so the wound healing can begin.

All this can be achieved without ever looking beyond the wound or the chart. But limiting the focus and not including the patient’s complete condition is a mistake that can significantly delay wound healing. The injury from a wound goes far beyond the wound’s perimeter.

A study of outpatients in wound care clinics found 81 percent [1] of its patients tested positive for depression. Further, it found depression common in patients with wounds, especially those with wounds lasting more than 90 days[2].

“The visibility of the wound creates a negative self-image because much of our self-image is based on external appearance and is a reminder to the patient that they may no longer look like most other people, “said Tim Paine, physical therapist with Litchfield Hills Orthopedic Associates, Torrington, CT.

Chronic wounds are stressful for a patient. As a long term condition requiring ongoing care and medical attention, these individuals are often removed from their life’s routine, limited in mobility, and isolated from family and friends. It can result in depression and stress, especially in older individuals. [3]

“Healing a chronic wound takes a long time, and requires constant attention to help the healing process, and it is very common for the patient to become emotionally and physically fatigued, which often results in depression and loss of motivation. This in turn prolongs the healing process. This cycle of emotional fatigue, physical fatigue and change in self-image results in a cycle of slowed healing and loss of motivation,” Paine added.

Surgical wounds are likely representative of a co-morbidity meaning the patient is concerned not only with the healing of wounds at a surgical site but also the primary cause and disorder for which the surgery was indicated.[4]

The most common site for slower healing wounds are on the feet and lower legs.[5] Studies indicate patients with lower extremity wounds when combined with stress are 25 percent slower to heal than those patients in a healthy mental state.[6]

Pain associated with wounds can be severe, if left unmanaged. As healing begins, pain and itching can cause sleeplessness impacting emotions, energy and motivation – including motivation to heal.[7]

Mental health is among the leading causes of disability around the world [8],with depression and stress highly prevalent in those with wounds. And once a patient’s wound is considered healed, it is estimated that 12 percent [9] of those patients will have some sort of psychological impact from the experience.

It is long recognized that collaborative care improves wound healing when it includes nutrition, physical therapy, and other specialties.[10] Integrating mental and emotional health assessments in the initial stages of wound care and treatment has been shown to decrease healing time.[11] While mental and emotional health conditions are harder to detect, early intervention can help a wound care patient begin to adjust to potential long term life changes, work through acceptance and avoid withdrawal which may lead to deepening depression.[12]

Mental and emotional health may be overlooked as part of the collaborative care model. As wound care professionals, there is an opportunity to be aware and alert to potential injury beyond the site of the wound. Watch for hard to detect symptoms of emotional and mental suffering, and add to the care team appropriate care givers to treat the patient’s mind while the wound heals.

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