Category Archives: General

Why has wound training to be so hard?

Wound education is supposed to support a professional in answering the question:

What am I going to do next?

In practice, “what next” often appears straightforward.

In the Netherlands approximately 2 to 3% of the Dutch report to their GP with a wound. Obviously, the vast majority of these wounds are not problematic. They will heal regardless, even though a reassuring word from the doctor and a bandage may offer some help.

A small number of wounds close more slowly or not at all. For this, the cause of the wound must be examined, whether it is still present and what can be done about it. But here too, if you remove the cause, the wound will close relatively easily.

Problems can subsequently arise as a result of the wound itself, there may be a bacterial or fungal infection or edema that impairs wound healing. That too requires no rocket science to solve.

Finally, a small group will remain where we cannot (completely) remove the cause or where we do not understand exactly what is happening. Those will be the difficult wounds.

It will be clear that in practice most wounds are easy to heal.

“What now?” is in practice a timely diagnosis and intervention that prevents the development of problems as a result of the wound itself. Over 90% of the wounds at a GP level can be closed within a month or so.

One may almost assume that a badly healing wound cannot occur in the Netherlands. But that is not true, all in all, there are somewhere between 200,000 and 400,000 patients in the Netherlands struggling with a wound.

It is quite possible to reduce this number, but this requires knowledge, skills, and facilities.

These patients occur due to the apparent simplicity of wound treatment. Most wounds are not much of a problem. The question about the cause and thus the treatment of a wound is often easy to answer. The problem arises when the question is not easy to answer, while the practitioner is not aware of it.

False security (IKEA: is a Dutch saying for someone who believes he or she can really close every wound: Ik Kan Echt Alles) is the mother of the problem. As mentioned, most wounds will close by themselves, if there is a cause, even more wounds will close by themselves after the cause has been been removed. After these steps, you may be left with a dirty wound with thickened wound edges, but cleaning and a bottle of iodine will often be sufficient.

So, for these cases you do not really need in-depth wound training, here exudate management will with the help of a bandage and possibly an antiseptic, whether or not integrated into a bandage will be sufficient.

An education where you learn about general causes of a wound and matching dressing to the color of the wound is more than enough. As icing on the cake, you get the stages of wound healing during such training, after which you are allowed to enter the field as a “wound nurse”.

You will be successful because, even with a pack of gauze and a bottle of iodine, you can close at least nine out of ten wounds quickly. If you do not ask yourself too critical questions, you logically think you are doing fabulously. And that’s how the IKEA professional is born.

That single patient who does not heal then is the exception. Unfortunately, an exception affects thousands of Dutch people. An unnecessary problem for which you can arm yourself. But for that, you need knowledge, a lot of knowledge.

Knowledge which enables a practitioner to answer the one simple question on what to do next?

Knowledge about diagnosis and treatment options, but also other knowledge.

Knowledge far beyond the three, four or six stages of wound healing.

Knowledge about more and more in-depth (but still relatively simple because it can be written down in lists) matters such as anatomy, physiology, microbiology, comorbidities, lab values, and medication.

But wound medicine requires more knowledge. Knowledge to reason, to understand what is happening, knowledge about the rules of the game. Knowledge needed to assess your observations in a broader context; to see the analyses in their mutual relationship. Then it’s about wound_levels, math, feedback loops, organizational levels, time scales, and much more.

This will enable you to see what really is happening with your patient. In addition, you will be better able to assess the options available to you. This allows you to take the next step in a more targeted manner.

That knowledge also gives you access to many more options to intervene. Unfortunately, it also creates more impossibilities because you also learn that practice in wound medicine lags the science.

The tricky part is that this knowledge does not seem practical at all to an average practitioner. What are the benefits of growth factors, complement, feedback loops, cell types, immune system, and what not?

There is currently little you can do with that, while in practice the choice of the right bandage actually always works fine.

That is always the tricky part, training people for something they do not consider paramount, but which in the meantime makes the difference for many patients. Difficult knowledge for practitioners who want to understand what they are doing.

Practitioners who know when “What next?” is a bandage and a reassuring word, but also when “What next?” is something completely different.

What is a wound?

In order to develop a better understanding of wound medicine, we may have to rethink some of the basic concepts.

Today; the wound. The main question is to make a definition of a wound that is better suited to today’s knowledge and available interventions.

A wound; definition:

Tissue damage resulting from harm due to (usually a combination of) intrinsic and extrinsic physical, chemical, and biological phenomena, breaching the skin is what we call a wound. This leads to two notions:

  1. a wound is a form of tissue damage and
  2. if and how much damage is caused by harm depends on the individual subjected to it.

So the definition of a wound as a breach in the skin is far too simplistic to cover the events. Similarly is the term injury a result and not a cause. Injury is caused by harm. If you focus on the result you will never solve the cause.

Secondly, if you realize a wound is a form of tissue damage, why not focus on tissue damage?  This might help you to treat the wound instead of the lesion. Or better to treat the patient instead of the wound.

Do not attribute magical qualities to wound dressings.

This is a translation of the article published by the Dutch Branche organization for wound care companies.

Harm Jaap Smit is a wound biologist, CEO of BioMedServ and a member of the Wound Care Expert Group of the Netherlands Wound Platform. He also teaches at the Erasmus Medical Center and the Fontys Paramedic university of applied science.  Despite the encouraging developments in recent years, Smit sees that much has remained the same in “woundland”. According to him, the biggest gain can be achieved by making the correct diagnosis earlier.

“I always start the first lecture of the wound care course with the same case. Someone applies a bandage from knee to foot for a wound and then keeps it moist with water from a tea kettle, so I explain to the participants. What actually goes different nowadays, I ask them then. It often remains remarkably quiet, despite the body of practical experience gathered in the lecture hall. Sure, nobody uses a tea kettle anymore to achieve a moist environment. But otherwise, little has changed in the way we treat wounds. And that is telling, since this case dates from 1796. It is also easy to notice that little has changed when you open an average wound cabinet. Most of the products are still the same as they were 25 years ago. Not because no new products are being developed, on the contrary, but because it often proves difficult to incorporate new products into daily practice. ”

“Don’t get me wrong, we have pretty good wound treatment in the Netherlands. Even when you look at things like financing. If you have a problem, we will take care of you, no matter the cost. When I meet with colleagues from abroad I do realize the quality of care here. Still, at many points in the chain there is simply a lack of specialist knowledge in regard to wound care. Whether it concerns general practitioners, home care or medical specialists. No one needs to be blamed for that, it is just something like that has grown historically, but it is the situation we are in now. We all worked hard in recent years to bring about change, but at the moment there is still room for improvement. ”

Wrong conclusions

“Things go wrong in many ways. On the one hand, you have the doctor, who is not able to close a wound for months and then concludes that the dressing does not work. Then a vascular surgeon comes in, sets a proper diagnose, and both observe the wound does close. Here casual observation reinforces the faulty initial conclusion. On the other hand, you see that sometimes there is just too much faith in the products. “Wound care” which begins and ends with the selection of the proper dressing.  So we also should not attribute magical qualities to wound dressings. ”

“Of course, bandages can do a lot for a patient. I recently cut off a piece of my little finger while making a beetroot carpaccio. It is painful and takes quite a while to heal. At such a moment you think about the more serious cases you know. If the right dressing can relieve pain, remove it or make it unnecessary to redress the wound three times a day – that means something for a patient. Yet that is mainly caring, and not necessarily treatment. Keep in mind that although a wound dressing does contribute to faster healing, it is not uncommon for that effect to be masked by all other events happening in a patient with difficult wounds. If you only look at that nurturing aspect, at increasing the quality of life, you run the risk of missing something elsewhere – an infection or a tight vessel – and unintentionally cause new problems.  Conversely, this also applies if you carelessly reject the added value of bandages. “If you only have a hammer, every problem looks like a nail” is a serious challenge in wound care. ”

“In  95 out of 100 wounds; tracing and removing the cause is sufficient. If you have a wound that is difficult to heal, there is a good chance the root cause is an insufficient diagnose. And then there are the many underlying factors, ranging from behavior to (epi)genetic defects. The underlying issues are very difficult to identify. In the Dutch Journal of Wound Care, among others, I have therefore argued for the classification of wounds into five levels. At the lowest level, this is a normal wound without underlying pathology and at the highest level, for example, a wound with molecular pathology. Such a model forces treatment providers to think about the relevance of the interventions to be taken, thereby increasing the effectiveness of the treatment. ”

Costs of dressing materials negligible

“If you take a good look at the Dutch financial landscape, you will see that there is little reason to worry about the availability of dressing materials. There are around 500,000 patients in wound care each year, which together account for a cost of 3.2 billion euros. Within this, the proportion of dressing materials is 88 million euros. Relatively negligible. And the real gain in terms of costs, therefore, are to be found elsewhere

“We all know that the longer a wound exists, the harder it is to close it. If you consider that GPs hold a patient with a wound for an average of thirty weeks and/or home care often lacks specialist knowledge, you will see where the problem lies. It is therefore important that we move towards a system where expertise is more widely available and is deployed faster. Initiatives such as regional expert teams or the certification of wound professionals can play an important role in this. Such a change does not happen from today to tomorrow, but also a foot trip to China starts with the first step. “

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.

Straight Talk Tuesday; Caroline Fife

Carolyne Fife demonstrates in her columns “the horror of providing wound care”. In two blogs (below) she describes the impact the apparent low stature of wound healing has. Basically; the lack of underpinning of interventions leads to a dramatic reduction of funding. As it should. However, in the case of wound care the lack of underpinning is not a result of lack of efficacy but a lack of research outcomes. So here the reduction of funding is a result of the dysfunction of research. The cause is very simple; having a wound is generally regarded a complication and therefore not interesting. Sadly society and (have to say) most doctors are not interested, lack knowledge, do no research and are astoundingly unaware of the numbers. As a result, the science of wound healing is under-represented and under-developed in the medical profession. (Why don’t we have regeneration specialists? ) Therefore, even if Caroline would have generated data and healed patients (which should not be the same) we still lack a proper framework to translate findings in a wider context. This would be no problem if having a wound was a rare phenomenon. But it is not, wounds lead to massive human suffering and consume a relatively big part of health care spending. But the latter is a financial issue. Luckily the financial guru’s know that if you cut the budget the cost will go down, as simple as that. Doctors agree and push the patients out of their budget (back to home care) asap. The fact that budget cuts cause massive suffering (but numbers do not cry or die) and that the costs resurface somewhere else in the system in a 10-fold time or so is not interesting because that is NIMB-cost. (Not In My Budget) And since 2008 we all know who pays for the final NIMB budget.

Straight Talk Tuesday

The second blog mentioned is below. Is this what you get when one applies regulations instead of knowledge: if you only have a hammer, every problem looks like a nail? Is this the future of EU healthcare funding?

Monday Musings

Monday Musings

Diabetic foot guideline reveals poor state of wound care science

Everyone knows diabetic foot wound treatment is challenging and should be undertaken with the utmost care. Even something seemingly simple as callus removal can lead to dramatic complications. The recommendations of the latest guidance on wound healing “IWGDF Guidance on use of interventions to enhance the healing of chronic ulcers of the foot in diabetes” are clear. Provide basic wound care for diabetic foot ulcers, this means clean, debride and take care of callus.  In this guideline there is no text regarding offloading,  vascular, neurological, immunological assessment etc. This does not mean it is not important, it means diabetic wound management is complex and those involved have to make sure they are competent. Do not apply any intervention lightheartedly.

In summary: Never forget to apply basic wound healing principles and know the limits of your expertise, you could very well be liable.

So far the good news.

The underpinning of the first part of this recommendation is as follows: GRADE strength of recommendation: Strong; Quality of Evidence: Low. 

GRADE is used because it appears to be better suited than the normal meta-analysis which provides even more dramatic results.

This means the working group cannot find any better evidence than “LOW” for a recommendation considered cornerstone to wound healing. For some reason I think; if they cannot find it, there is a good possibility it does not exist.

So today, 2015 the only thing we know about diabetic wound care is the experts have strong feelings but lack facts. We feel we should have a clean wound and select dressings based on absorption, comfort and cost. The latest facts could be over 60 years ago when captain Bloom made some observations using cellophane.

This leads to the following conclusions:

  1. We know very little about interventions to enhance healing.
  2. There is a lack of good research leading to recommendations. (cause 1 for finding 1, above)
  3. Most “hot” treatment options lack underpinning because a. they may not work or b. research is not well set up. (See finding 2, above)
  4. Lack of relevant and underpinned findings gives way to the wildest of treatment regimens. (See finding 3, above)
  5. The flurry of “research” and “protocols” might mask relevant findings. Therefore:
  6. We need clear and well-written guidelines until we have our research in order.
  7. To get our research in order, we have to stop doing the same type of research over and over again. (as we did the last 50+ years)
  8. If I am wrong (which I hope) please explain why the guidelines are written the way they are.

Finally, it just might be a good idea to do a reproducibility test on all wound care research. Like the recently done on psychology. Findings in this guideline point towards an even higher non-reproducibility rate for wound care research compared to psychology.

Guidance on wound healing 2015


Woundcare spending

How much do we spend on wound care in relative and absolute terms is a hard question to answer. Luckily we have some information thanks to the Welsh NHS system which provides some data.

The article in the total cost of managing patients with chronic wounds in Wales amounted to £328·8 million – an average cost of £1727 per patient and 5·5% of total expenditure on the health service in Wales.  With a prevalence of 6%. Not too far away from the Welsh expenses on Cancer. The figures for 2012-13 show the total spend has increased from £356.8m in 2011-12 to £360.9m in 2012-13.

So there you have it!

Wound care is expensive, it equals the cancer expenses (90%). Wound care costs were generally believed to be somewhere between 1,5-4% on any healthcare budget. This article adds the number 5.5%. If wounds were a disease it would be easily in the top five of any health care list. I am no specialist but I would bet these numbers are not that different for any EU country.  However, apparently it is not a disease because it rarely shows up on those lists.

First question to answer is: is this real? The answer is: we do not know. We have combined figures from very different sources, there may be logical errors in combining them. And wound care costs are varying from 1 to 5,5%… also not exactly strong data.  And then the question inevitably is: what costs are inside the data we compare?

But even if the data are questionable there are a few issues we should think about.: The sheer number of people literally suffering from wounds; not a few but a significant part of your population up to 6%. And even at low estimates the numbers demand attention.

So how are wounds looked at?
Insurers may see it as a cost disease (Baumol).
Most doctors see it as a complication instead of an indication.

Reality is, it is not a disease but an expensive complication where we, even though many suffer from it, know very little of. I would strongly advice to make it an indication, have a fresh look at the issue and start over. Research not progressing to the point where we have a strong underpinning is paradoxically a chance. I am happy to explain the intellectual challenges and opportunities this field has. Proper research will not magically shrink expenses or turn it into a disease, it will only justify why we spend so much on it. And hopefully bring the much needed attention.


Sources: Estimating the costs associated with the management of patients with chronic wounds using linked routine data – Phillips – 2015 – International Wound Journal – Wiley Online Library

Epic failure: Hyperbaric oxygen therapy for treating chronic wounds

The Cochrane published the review Hyperbaric oxygen therapy for treating chronic wounds (original article)

Here are the results:

  • For diabetes-related foot ulcers, we found that HBOT seemed to improve the chance of healing in the short term (up to six weeks), but not with longer term follow-up. HBOT may reduce the number of major amputations in people with diabetes who have chronic foot ulcers.
  • For chronic wounds caused by a disease to the veins of the leg, we found that HBOT may reduce the size of wounds.
  • For chronic wounds caused by lack of blood supply through the arteries or chronic pressure ulcers, we found no evidence to confirm or refute any effects of HBOT.

These results are to be expected. Not because HBOT is not working, but because researchers lack critical information, simply because it is not available. The Cochrane results are inevitable and reproducible non-conclusive but Cochrane is not to blame. Let’s explain two of the many logical errors causing the failure of wound care research.

It starts with the inclusion criteria. If your inclusion criterion is “a non-healing wound”, you are lost from the start. (the real list is below) There are many reasons wounds do not heal. They can, for example, be patient related, wound related, mechanical or metabolic. (Levels 1,2,3 and 4 which are usually independent of each other)

The first notion regarding chronic wound is that wat caused it, is not necessarily preventing it from closing. Yet we place them all on a pile, sorted by cause of the wound (logical error 1) and then investigate if intervention x is functional. So you are testing in the blind, which is very different from double-blind. That is a gross neglect of reality.

Therefore, if you are lucky,  you will discover how many non-healing wounds accidentally fit your solution (logical error 2). This is very different from finding how effective your intervention is. In today’s setup, it is therefore almost impossible to discover how effective your intervention is. Because we lack markers and/or knowledge to diagnose and characterize the cause of not healing. Therefore, we have no choice but to pile wounds together. It is a pity we do not recognize this beforehand. If you cannot select the wounds which are lacking the solution you provide, the chances of success are next to 0. (logical error 1+2)

And now the real issue: it would be very interesting to figure out which wounds respond. And why and how they respond. This will enable us to recognise this the next time before we apply an expensive treatment. Or in other words, the non-responders are more interesting than the responders. Sadly research is acting in exact the opposite way.

It starts with the inclusion criteria. If your inclusion criterion is “a non-healing wound”, you are lost from the start. (the real list is below) There are many reasons wounds do not heal. They can be patient related, wound related, mechanical or metabolic. (Levels 1,2,3 and 4 which are usually independent of each other)


And now the real issue: it would be very interesting to figure out which wounds respond. And why and how they respond. This will enable us to recognise this the next time before we apply an expensive treatment.

If you need help:


Inclusion criteria varied in these trials. Doctor 1992 included any person with diabetes with a chronic foot lesion (time not specified); Faglia 1996a included people with diabetes and Wagner grade 2, 3 or 4 lesions (Wagner 1987); Lin 2001 and Kessler 2003 people with “early diabetic feet”, Wagner grades 0, 1 or 2, while Duzgun 2008; Abidia 2003 and Londahl 2010 included people with diabetes whose lesions had been present for more than four weeks, six weeks and three months respectively. In addition, Londahl 2010
required evidence of good standard wound care in a specialist clinic setting for a minimum of two months. Exclusion criteria generally followed from the specific inclusions detailed above, but Abidia 2003 also specifically excluded participants for whom vascular surgical procedures were planned and Kessler 2003 excluded all patients with transcutaneous oxygen tensions of < 30 mmHg. Ma 2013 included patients with diagnosed diabetes, at least one fullthickness wound below the ankle (Wagner grades III or less) for > 3 month, standard care for > 2 month, TcPO2 > 30 mmHg. Khandelwal 2013 included patients with a diabetic foot ulcer of at least 8 weeks duration, patients with only stage III and IV diabetic foot ulcer and the absence of vascular insufficiency.

5 levels

A simple rearrangement to five levels of wounds may help us better understand wound healing. It may also function as a sieve.

The levels are the following:

  • Level 0: wounds which will heal without any intervention
  • Level 1: wounds which will heal without any intervention but must be monitored
  • Level 2: wounds that heal by itself but may need additional care.
  • Level 3: wounds that will not heal due to perfusion issues.
  • Level 4: wounds that will not heal due to are metabolic issues.

This simple separation may help in understanding difficulties in wound healing because each level requires a different skill set.