We tend to have mixed feelings towards recent converts, admiring, say, the newly reformed smoker for their hard work but being irritated by their lecturing of those recalcitrants still puffing away. Our vegan teenage niece is close to being shoved out the door but what would we do without the passion of youth? Our colleague returns from a weekend workshop and is suddenly giving us lectures on the value of manual handling and OH&S.
I must now confess to finding myself a convert – to the wonderful world of chronic wound care. After 23 years in the one practice in Nimbin I was somewhat adrift when I left it almost two years ago. I landed on the shores of a multi-disciplinary wound clinic in Brisbane (Wound Innovations) and it has become my new medical home.
thought I had a pretty good understanding of wound care, having done a diploma in dermatology, sewn up hundreds of acute wounds, written a multitude of scripts for fluclox and cephalexin, swabbed wounds, wet wounds, I’ve dried wounds and covered nearly all of them with hopelessly inadequate dressings that have probably made them worse.
I’ve looked into the dressing cupboard of our clinic or the hospital and wondered what all these things were for. I’ve leapt to action with my script pad when presented with wound swab results showing a Staph or a Pseudomonas, emptied whole tubes of Solugel onto wounds because I remembered that “wounds need moisture to heal”. I’ve found myself peering over a circumferential weeping angry wound with a nurse on the other side, both of us thinking the other was the expert and hoping they will come up with a solution.
I now realise there is much more to wound care than I thought. It’s also simpler. Our clinic has lots of fancy equipment such as ultrasonic debriders and Vac dressings but we seldom resort to these. A systematic and consistent approach with dressings that anyone can apply generally works very well. I’m horrified to think that I really knew so little and there is virtually no teaching of chronic wound care in undergraduate or postgraduate education. I’d like to change that.
As GPs we are regularly at the coalface of managing difficult longstanding wounds. My wound management was a long way from optimal and I suspect that’s true for many of us.
So as a convert I would like to spread the word.
There are a few principles of chronic wound care that make a wonderful difference. At the risk of sounding like that pedantic surgeon we tried to avoid in 4th year tutorials, a thorough history and examination of the wound and the patient is vital. As most chronic wounds are on the legs, vascular assessments are imperative. It is almost impossible to heal an arterial wound unless the supply of oxygen is corrected. Looking and feeling goes a long way. A hand held doppler is also very useful, as is a good relationship with a vascular surgeon.
As for that cupboard with its confusing array of foams, pads and gauzes, good dressing choice helps us manage the wound bed, keeping the bacterial load in check and wicking away the exudate. While bacterial biofilms are a common cause of delayed healing in chronic wounds it is rare that we use antibiotics, regardless of swab results.
We do however regularly debride wounds. Chronic wounds love it. Taking a simple scalpel blade to a wound and clearing out slough, debris, hypergranulation and scale can make a big difference.
Venous ulcers need oedema and exudate control. It is as simple as that. Compression is the mainstay of treatment. 80% of venous ulcers will heal in twelve weeks if provided with best practice, yet 70% of venous wounds do not even get compression. While a script for the pharmacy can provide the patient with a good long term pair of compression stockings, Tubigrip makes a wonderful short term option while we are dealing with the wound.
We know that pressure injuries require pressure offloading but so do diabetic foot ulcers. Here a podiatrist can be very helpful. These wounds are some of the most stubborn wounds but I have seen some fantastic results with total contact casting applied by a skilled podiatrist. The result can not only mean a healed wound but also avoiding amputation.
A small but painful chronic wound that needs regular dressings can be a nightmare for many people. Patients long for the day they can take regular walks, go swimming or just play with the grandchildren. It is very rewarding to be able to turn that around. Some wounds have been there for over twenty years and patients are often resigned to them never healing.
Always consider the possibility of malignancy in a non healing wound and biopsy if in doubt. Many malignant wounds don’t look like those typical rodent ulcers we see in the text books.
Wound Innovations provides in-clinic and telehealth services as well as wound education particularly to aged care facilities. Our number is 1300 968 637