What Every Wound Patient Should Know

When do I need help to heal my wound?

A wound should show visible or measurable progress every week to ten days. A wound that progresses is considered acute and only needs medical attention if it is large enough to want stitches or sutures to reduce or prevent scar tissue from forming.

Any wound that does not progress as described above is considered chronic and should be evaluated by a wound care practitioner.

Regarding bandages or dressings

In order to be therapeutic and promote fastest healing, a dressing (aka bandage) needs to do three things:

1. it needs to keep the wound bed moist
2. it needs to keep the surrounding skin dry
3. it needs to fill up any cavity or open space in the wound bed.

Why?
1) Studies have shown that scab formation is the bodies last ditch effort to keep the wound bed moist, it takes longer to heal and causes more scarring. Although many people believe that drying a wound out is natural, swelling after breaking a bone is natural too, but we have found that a cast or splint is a much better way to heal a fracture, so too we have found that keeping the wound bed moist with dressing and or filling is best way to heal wounds

2) Anyone who has done the dishes after Thanksgiving knows that skin is meant to be dry and not wet. Intact skin at wound edges will break down and make a wound larger if it is constantly kept moist due to dressing or wound fluid.

3) Many people also do not understand that filling the hole in a wound with moist filler like gel gauze or moist wound filling product actually helps it close faster than if you left it unfilled. The filler provides a wick for bacteria and would fluids to leave the wound bed and move toward the cover dressing. Some unfilled wounds never heal at all.

Wound moisture needs to be managed. Any wound that is creating enough fluid to soak dressing/bandage daily or is making the surrounding skin pale moist and fragile (called maceration) needs a more absorptive bandage that keeps moisture away from surrounding skin.

Any wound that is dry or nearly dry when the bandage/dressing is changed needs a product that contributes moisture to the wound such as a gel or ointment

Never allow moisture in contact with dry leathery tissue on lower legs or feet, seek help of a vascular or wound specialist immediately.

Regarding germs:

ALL WOUNDS HAVE GERMS
ALL WOUNDS HAVE GERMS
ALL WOUNDS HAVE GERMS
THAT DOES NOT MEAN THAT THEY ARE INFECTED. This is very normal.

Using antibacterial ointment on every wound is a VERY BAD IDEA.

Antibacterial agents have been proven to have caused MRSA1, VRE2 and other resistant bacteria that are now killing people. They can cause an overgrowth of more bacteria or fungus that can be life or limb threatening.

Allergies to the agents in over the counter antibacterial wound ointments and creams are on the rise as well. Always check with a medical professional before using even over the counter antibacterial products.

If you are worried about germs, soaking in Epsom salts or Domboro solution or similar high mineral content baths several times a day are much safer.

A wound is considered infected when it shows signs and symptoms of infection such as redness, excess warmth, purulent (puss like) fluid, swelling, malaise, fever or streaks of red or purple showing from the wound towards the heart. If any of these occurs in any wound contact your physician's office or go to the nearest emergency room.

Regarding outpatient wound clinics

All outpatient wound clinics are not created equal. Commonly there are three types of wound clinics to be found

1. physician based
2. nurse based
3. physical therapist based

1) Physician based programs may be hospital run or run by an outside management company. Some of the problems with physician based programs include that there is no quality control on which physicians are allowed to practice in these clinics. All too often physician participation even including the medical director is based on popularity contest and hospital politics and the "good ole boy" network. When investigating a physician based program, demand to see how much recent and current wound care education your physician has participated in. Also physicians almost always bill separately from the hospital or clinic, so you and your insurance will receive a bill from both. Make sure to check that both the physician and clinic are on the preferred provider list of your insurance if you have a stepped copay or deductible issues. On the plus side, you doctor is licensed to practice medicine, no nurse or physical therapist can do this. Nothing is quite the same as attending medical school and passing the medical boards.

2) Nurse based programs are usually hospital run by a hospital employed registered nurse. Usually there are nurses in the program certified in wound care by either WOCNCB® Wound, Ostomy and Continence Nursing Certification Board, NAWC®

National Alliance of Wound Care or AAWM American Academy of Wound Management Do your homework and find out what certification your nurse has and what education that nurse had to have to sit the exam for that certification. Nurse based programs must work with your primary physician for prescriptions unless the program has a nurse practitioner (NP)or physicians assistant ( PA)who practices under another physician's license. Advantages to nurse based program is that a nurse is usually paid to keep up to date with latest information on wound care, and is thus has incentive to attend as much continuing education on wounds as possible whereas a physician must take time off from their paying private practice to attend continuing education on wound care.

3) Physical Therapist based programs are also usually hospital run, but by a licensed physical therapist rather than a nurse. Although physical therapists are not trained in case management or care planning for all of the patient's underlying diseases that may be preventing wound healing, physical therapists who specialize in wound care are trained in treatment modalities such as electrical stimulation of wounds, sharp nonviable tissue removal ultrasound and many more new innovations in stimulating new tissue growth, that few nurse have opportunity to learn. These treatments need to be done several times each week to be most effective, so plan accordingly.

The best programs need to be interdisciplinary including physicians, nurses and physical therapists all or most of whom are actively certified in wound treatment. Unfortunately at this time these types of clinics are rare. Party because debridement of tissue reimbursement can be a conflict between different practitioners. Partly because hospitals do not understand why having all three would benefit both patients and hospitals.

References

Krasner, D.L.; Roheheaver, G.T. Sibbald R.G. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals 3rd edition Wayne, PA: HMP Communications 2001

Sussman, C; Bates-Jensen,B.M. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses Gaithersburg, MD; Aspen Publishers 1998

The NPUAP Task Force. Thomas, D.R.; Rodeheaver, G.T.;Bartolucci, A.A.; Frantz, R.A. Sussman, C.;Ferrell, B.A.; Cuddigan, J; Stotts, N.A.; Maklebust, J. 1996

Bergstrom,N; Bennett, M.A.; Carlson, C et.al. 1994 Treatment of Pressure Ulcers. Clinical Practice Guideline, #15 Rockville MD; U.S. Dept. of Health & Human Services, Public Health Service, Agency for Health Care Policy & Research.

Krasner, D. 1999 The AHCPR pressure ulcer infection control recommendations revisited. Ostomy Wound Management 45 (1A Suppl): pps 88-91

Van Rijswijk, L; Braden,B.J. 1999 Pressure ulcer patient and wound assessment; an AHCPR clinical practice guideline update. Ostomy Wound Management 45 (1A Suppl): pps 56-67