A few fundamental issues in wound care

Recently I had a conversation with a Dutch wound care biologist, that means a conversation between two wound care biologists, that was fun, for us.

The conversation quickly went to a few of the fundamental issues in wound care. Here are some of the issues we discussed.

The first fundamental issue in wound care is that most people who are trusted to heal wounds are denied the tools to do so. I cannot help but wonder how a home care nurse is able to figure out the details about a complex patient which will allow him or her to produce a proper diagnosis. Following guidelines and using training as provided for home care nurses diagnosis technically impossible. They do not provide the knowledge and skills needed to asses a complex situation. For an example have a look at the differential diagnosis for a leg ulcer. The amount of knowledge needed for proper wound medicine is simply not always available, yet a diabetic wound can spin out of control in hours.

The second fundamental issue in wound care is that most people who are able to understand what is happening in any given wound are simply not interested and as a result lack insight. For instance, a GP often declares that he or she can close most venous leg ulcers by applying a compression bandage, literature gives a very different view on that declaration. And what do they do if their intervention is not enough to solve the problem at hand? This is one of the reasons many wounds heal “miraculously” in the hands of a wound care team after having suffered for almost a year in the hands of a GP (unpublished research). Plus there is no single medical specialist group responsible for wounds, most responsible medical specialists, usually dermatologists or some types of surgeons, are so by choice, not because wound care is an innate part of their field. (check that for pressure ulcers, or more precise force related tissue harm)

The third fundamental issue in wound care is that wound care related randomised clinical trials in a real setting, by definition are not able to produce results, simply because the relevant parameters are not controlled. Thus the results suffer badly from uncontrolled confounding factors. This is one of the ways wound care is different from other medical fields. To expect otherwise is, in the current wound care landscape, mildly put, scientifically doubtful.

The fourth fundamental issue in wound care is that the assessment of intervention outcome by means of randomised trials, which by rule of the third fundamental issue can only provide little or no results, is leading to the scientifically invalid conclusion that the intervention does not have any effect. This can be seen at the difference between “bench” and “bed” research.

The fifth fundamental issue is that the results of randomised trials and meta-analyses are used for policy. Simply looking and comparing numbers without a fundamental understanding of the underlying issues will cause problems.

The sixth fundamental issue in wound care is that we are using wound closure as an outcome, whereas any intervention usually involves only some of the processes in the wound healing cascade.

The seventh fundamental issue in wound care is that we do not undertake any activity to assess the delta and its causes. The wound healing speed should be monitored and plotted, any deviation from the expected wound healing speed has to be investigated. But it is not.

Here we ran out of time otherwise, there would have been many more fundamental issues to be listed. You may agree, which is fine. You may disagree, even better. You may add, which is best.

There are solutions to these fundamental issues, it is not that hard, but it requires some thinking. Our patients deserve that.

2 reacties op “A few fundamental issues in wound care”

I liked this comment. …cannot help but wonder how a home care nurse is able to figure out the details about a complex patient which will allow him or her to produce a proper diagnosis. I am working in home care in the US and wonder why a wound care centre can have a diagnosis and ignore the please of home care to not utilize 3 different expensive treatments daily or utilize a 4 layer compression system and look at the patients diuretic regimen!!! They have no idea how back breaking putting on 8 leg wraps on an obese patient in their home. Some wound care centres are woefully inadequate and there is a notion that nurses do not diagnose and are meant to follow doctors orders in some blind faithful way. I am reminded of a comment by the new CEO of a home health agency who was uninterested in a request to employ a second certified wound care nurse. “I will send the nurses on weekend courses”. When I pointed out a weekend course is not a masters degree and the wealth of experience a specialist could bring to the agency (and teach a weekend course), the CEO looked at me with disdain and I knew I had lost my position. It would have been good to be part of your conversation maybe we could fix the health care system (a term that indicates there is actually a system, which of course there is not really).

Margaret, you are very right. Thank you for your comment. The system is dysfunctional, to say the least. Another nurse told me, it is not even sure all nurses can read (let alone understand a complex text). Sadly, there are no shortcuts. I will keep producing new ideas for you to use in your daily struggle. Some will be useful, most will be not. But we are in this together. Comments like yours provide new ideas to think about.

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