A wound is not a disease; it is a symptom. If a patient has a nonhealing wound, there’s a reason for it and our job is to figure out that reason. We can list the likely reasons statistically, depending on the location of the wound and a few other factors. Often, there’s more than one reason for a nonhealing wound. In fact, one of the things I love about wound care is that every week I have the chance to solve a riddle.
Several cases in the past month have me deeply troubled, and I’m not sure what to do about them. All the patients saw multiple providers (including wound care practitioners) before I saw them. In all of them, obvious problems went missed or ignored.
There is the elderly patient with an exposed Achilles tendon who was treated for several weeks with a variety of dressings, but never got an angiogram. The photograph of her exposed Achilles is sufficient evidence that she is missing at least part of the supply from her peroneal artery.
There’s the young woman with a history of Crohn’s disease who has had a fistula from her labia to her thigh for months. A biopsy did not demonstrate cutaneous Crohn’s, but when I saw her, everything about the lesion screamed, “inflammatory!” A tunneling wound like that in a young patient who has known inflammatory bowel disease and no other medical problems is the cutaneous manifestation of her bowel disease. She has a condition known to cause this, and no other risk factors for a wound. I sent her back to her gastroenterologist for a colonoscopy.
Then there’s the patient with obvious ischemic rest pain who had been sleeping in a chair for weeks, but who was told his angiogram was “not abnormal.” I sent him to a different invasive cardiologist who opened both his peroneal and posterior tibial arteries the following day.
There’s the former professional golfer with a venous ulcer that had not healed despite a year of adequate compression at a wound center in another state. He had a history of local radiation more than 20 years ago (he isn’t sure why), and sure enough, the lesion was malignant (and thankfully curable).
There’s a worrisome focus on “the hole in the patient,” and a lot of discussion about the dressings we use, but not a lot about how to take a history. I can talk to a new patient for 15 minutes before I even look at the wound, and usually by then I have a pretty good idea why the patient has a wound and why it hasn’t gotten better. That was certainly the case in a patient I saw a few weeks ago for a persistent pressure ulcer, who gave me a textbook history of the onset of shingles. Sure enough, his remaining open lesion was on his buttock cheek, in the perfect distribution of a dermatome.
I could go on with many more examples. It’s not that I am smart. These are all “wound care 101.” What do you think we should do about this problem? There will be many fantastic presentations at the Symposium on Advanced Wound Care (SAWC) Spring that provide the necessary training for a clinician to avoid these pitfalls. However, the “catch 22” is that the clinicians who most need that education will not be at the SAWC. It’s the wound care practitioners who are not at the meeting who most need to be at the meeting.
In any case, we have a problem. There are ways that analytics inside the electronic health record can help us, but there’s currently no incentive for a hospital to pursue better tools. There’s no requirement to train in wound care, and no requirement to report wound care-relevant quality measures. It doesn’t seem likely that we can we make a dent in the $28 to $96 billion per year problem of nonhealing wounds if we can’t do a better job for these patients. However, it will probably require different incentives to be put in place for us to really raise the bar on quality in the field of wound care.
What do you think we should do about this?