After suffering a wound between his shoulder blades that he could not treat himself, this author went from wound specialist—with a track record of healing “wounds no one else could handle”—to patient.
Sir William Osler, also known as the Father of Modern Medicine, once said, “The doctor who treats himself has a fool for a patient.” This sage advice went through my mind after my own surgical wound dehisced and I was faced with the reality that this proud wound specialist had gotten himself a wound.
I was tempted to heal myself—after all, I had spent a career healing complex train wrecks that “no one else could handle.” I had built a reputation for preventing amputations that were given zero chance of salvage by other physicians. So why shouldn’t I give my own wound the best chance of healing, which would of course be if I treated it myself? When it comes down to it, shouldn’t we all want to be so confident in our abilities that we would not even think of referring ourselves to someone else?
There was only one problem with my arrogant plan. My wound was in the dead center of my back, right between my shoulder blades—the one place on my body that I literally could not reach. I couldn’t do my own wound assessment, debride myself, or even change my own dressings. Sir William Osler was laughing at me, or maybe it was my nurses—I’m not quite sure.
It took two mirrors to even see my wound, although I could feel the drainage on my shirt. When I showed the wound to my surgeon, he said wryly, “Luckily I know a great wound specialist who can get you healed quick.” Even he thought I should heal it myself. He removed the ruptured vicryl retention sutures and left the rest to me. Maybe I could rig a back scratcher and a selfie stick to change the dressings?
I went straight to my wound center and called my team into my office. Todd and Amanda are both nurse practitioners and certified wound specialists, and highly competitive. As soon as I showed them my wound, the look in their eyes told me that they were going to fight to the death for control over the treatment plan.
The first step was wound debridement, which required pre-procedure analgesia. After soaking in lidocaine for 15 minutes, the first pass of Amanda’s curette sent me through the ceiling with excruciating 100 out of 10 pain.
I yelled, “What percentage lidocaine was that?!?”
“Two percent jelly,” Amanda said with a smile. “You had us switch from 4% to save money.”
Wound cultures grew methicillin-resistant Staphylooccus aureus (MRSA), so Todd started me on doxycycline. I subsequently developed a photosensitivity rash from the antibiotic and had to be switched to Bactrim.
Lying face down on the treatment stretcher during each appointment, I realized how incredibly uncomfortable it was. The thin paper sheet that served as my bedding was crinkly, cheap, and didn’t come close to covering the thin mattress that I knew had just been wiped down after the previous patient. The pillow used to prop my chin up was way too firm and gave me neck strain. My face was 6 inches from a wall that had multiple black scuff marks on it from stretcher damage—it looked like someone had tried (unsuccessfully) to escape from prison. These not-so-Undercover Boss moments led me to see my clinic from the patients’ perspective, and I started noticing details of our service that needed to start focusing on patient comfort.
Once my wound was clean after serial sharp debridements (now numbed with 5% lidocaine ointment and bicarbonate-buffered lidocaine injections), the next step was application of negative pressure wound therapy (NPWT). The dome had to be tracked to my side to avoid pressure injury on the wound. It was difficult to get a good vacuum seal because of the constant movement of my back muscles.
I had to get used to the sound of the motor gurgling every few minutes to maintain a seal. I was at the dinner table one night and my 7-year-old son kept giving me a weird look. After the sixth gurgle, he said, “Really, Dad? Can you please stop farting during dinner?” The gurgling sound, which my cerebellum had long since filtered out, was now a source of intense embarrassment whenever I went out in public. It got even worse when Todd switched the setting to intermittent to stimulate more granulation tissue formation. Every time the motor kicked back on, I had a violent twitching from the painful suction onset, while simultaneously having to explain to the clerk at the grocery store that I had a medical device on, and that I really wasn’t seizing and farting simultaneously. They only seemed to half believe me.
Because I was ambulatory and functional, I did not qualify for home health to come change my NPWT dressings twice a week. My entire family was disgusted by my wound and wouldn’t touch it, except my 10-year-old daughter. She became an expert at tracking the dome and applying the drape with stoma paste to get a good seal. It also became clear which of my kids was the frontrunner to go to medical school and follow in my footsteps.
The day that Amanda discontinued my NPWT was one of the greatest days of my life. I now fully understand the huge sigh of relief my patients give me when I nonchalantly tell my nurse that we can “stop the vac.” It’s like being let out of prison. With my new dressing in place, I felt like I was on the fast track to recovery.
But while taking a shower I started feeling water leaking under the dressings. My nurses had used barrier wipes on the periwound to ensure a good transparent film seal, but apparently that wasn’t doing the job. Amanda suggested we go old school and use benzoin paint to the periwound, dried with a blow dryer for maximum tackiness. Todd applied “vac-drape” to get a good seal and voilà, the dressing stayed intact for a week at a time, even with daily showers. I developed a periwound rash, however, from the overly sticky drape and had to start using triamcinolone cream to control the itching and irritation.
Wound Healing Stalls
As several more weeks passed, the truth was becoming more and more evident to all of us. My wound had stalled. It was a collective embarrassment. I’m not diabetic, obese, or a smoker. I eat plenty of protein. There was no active infection. So why did the wound keep developing friable hypergranulation tissue every week despite chemical cautery with silver nitrate? By week 6 most surgical wounds I treat have normally healed. Yet here I was at week 16 and the wound was still present. The tension was building between me and my team.
I started to feel like my wound was never going to heal, and that my life would never get back on track. I wasn’t prepared for the depression associated with having a wound. I felt like I wasn’t a whole person, that I was somehow defective. I couldn’t run, work out, or swim. I had to cancel my beach vacation and my snowboarding trip. I had to stop coaching soccer. I couldn’t pick my young kids up or hug them. My life had been completely interrupted.
The Lightbulb Moment
One day, as my entire clinic staff huddled and stared at my wound, Todd noticed that the periwound scar tissue had the appearance of stretch marks. He asked me if I slept on my back, and I told him never. Always on my side or on my stomach. That ruled out direct pressure. But I did feel intermittent sharp wound pain in the middle of the night. Todd asked me if I toss and turn at night, and I told him I didn’t know—I was asleep, after all. So he called my wife and she said I sleep like I’m fighting a pack of ninjas, twisting and turning furiously.
The lightbulb went on. The main impediment to healing my wound was shearing tension. Wound tension is the one variable that is hard to measure and even harder to correct. Amanda suggested we start with Montgomery straps for tension relief. With the straps applied, I felt a noticeable tension relief in my back. But I felt the straps snap within 30 minutes of leaving the clinic and the tension returned. Additionally, Todd came up with a new approach to my dressing application, using benzoin, Steri-Strips, and a Tegaderm (see Figure 5). Amanda went online and found a posture-improving halter and I tried it on. The garment forced my shoulders back and visibly relieved tension on the wound bed in the center of my back.
With the tension successfully relieved, my wound started closing rapidly. The weekly hypergranulation tissue stopped forming as neoepithelialization marched across the wound bed. From the time aggressive tension-relieving measures were applied, it took 3 weeks to heal the wound. The day I got to ring the healing bell was such a feeling of accomplishment for all of us, and it reminded us why we do what we do—to get patients back to living their lives.
Having a wound made me realize on a personal level how important it is to invest in training one’s clinic staff. Train them as if they will be treating you one day, or someone in your family. Treat your brand new technician as the most important student in the room. Think out loud with your staff, learn out loud, and show humility when things start to stall and ask for others’ opinions. Develop a team of people you can consult when you get stuck. Always think about wound tension, and how to relieve it. Create a warm and comfortable environment in your clinic so patients feel at ease every week.
Hopefully, you won’t ever have to get a non-healing wound to see how you can provide better care for your patients. But for me, it was the perfect impetus to enact positive change in how I practice this amazing specialty. Tip of the hat to Sir William Osler, of course.
Shaun Carpenter, MD, FAPWCA, CWSP is the CEO of MedCentris©, a multi-specialty wound healing organization, and owner/co-creator of TeleWound©.