In about 1991, I was a new faculty member at the University of Texas Health Science Center in Houston. One quiet Saturday morning I took my Mom and Dad to see the original section of Hermann Hospital, a Spanish Colonial building dating to 1925. A distinguished looking gray-haired man and his wife were also admiring the mosaics, and he introduced himself to us. Even though I was only vaguely familiar with the history of total parenteral nutrition (TPN), I knew the name of Stanley Dudrick, MD, and so did my father, a former Air Force physiologist. In one of my most memorable chance encounters, Dr. Dudrick summarized the history of parenteral nutrition.1
In the 1960s, what Dr. Dudrick termed the “prevailing dogma” of the medical community was that feeding entirely by vein was impossible, impractical, and unaffordable. As a surgical intern, he watched 3 patients die despite successful operations because they literally starved to death. He was determined to find a better way. The story of TPN is a story of passion and tenacity in the face of setbacks. In 1967, he and his team saved the life of a 3.5-lb. newborn with a congenital anomaly that prevented oral feeding. It’s estimated that his work has since saved over 10 million children and perhaps as many adults.1
In the 1960s, my father was part of an experiment in oral feeding. It’s hard for anyone nowadays to understand the meaning of the term “space race.” Dad was a physiologist at the School of Aerospace Medicine in San Antonio, Texas, and even as a little girl, I felt the sense of urgency that drove those men to break survival records in the centrifuge and the rocket chair. But there was a nagging problem: what were the astronauts going to eat? There was almost no storage space and frankly, the space toilet had not yet been invented. Research focused on chemically defined diets or elemental, low residue diets, and my Dad was among the volunteers who tried them all, sometimes going weeks taking nothing by mouth except a reconstituted white powder. The Apollo 11 crew landed on the moon in 1969. Not long after, my Dad went to visit his brother, who was dying of throat cancer. Uncle Earl was being fed a white liquid via a nasogastric tube, the result of advances in nutrition made during the space race, tested by people like my Dad and informed by the work of Dr. Dudrick.
I am sorry to say it has taken me years to understand the importance of nutrition in patients with nonhealing wounds. Dehisced surgical wounds affect 15% of Medicare patients and are the most prevalent and most expensive wound type in the U.S.2 Most surgical dehiscences are due not to infection, but nutritional problems. The next largest category of chronic wounds is the “Wounds With No Name.” These are wounds that result from accidents and trauma that just never heal and chronic ulcers that are not due to diabetes or vascular disease. All these lesions are a symptom of the patient’s underlying disease. Many, if not most, are due to nutritional deficits. When Susan Horn, PhD, and I developed the Wound Healing Index, a series of mathematical models that can predict whether a wound is going to heal based on factors you can determine at the initial visit, markers of poor nutrition were significant in every model.
An article in Today’s Wound Clinic on the importance of vitamin D caused me to check the vitamin D level in a young woman with juvenile rheumatoid arthritis who was unable to heal after a total knee replacement.3 She had been back to surgery 3 times, but each time the incision kept falling apart. I stood there looking at her thinking, “There’s something I am missing that is right in front of me.” And then I realized how white her skin was. She told me that as a result of her illness, she had not been outside for two years. Her vitamin D level was in the single digits. All I did for her was raise her vitamin D level to normal, and she healed. I prescribed a vitamin D formulation that cost less than $10.
After that I began checking vitamin D levels in nearly every patient with a nonhealing wound, and they are below 30 about 85% of the time. I’ve also been able to graph the stalled healing in a patient with a large pressure ulcer whenever her family stopped giving her L-arginine. Nowadays, every wound center patient I see gets a lecture on nutrition.
The US Wound Registry has developed a nutritional screening quality measure for patients with nonhealing wounds and ulcers that can be used as a Practice Improvement Activity (IA) reportable in the Merit Based Incentive Payment System (MIPS). The American Academy of Dietetics has spearheaded a quality initiative focused on the nutritional screening hospitalized patients. This issue of TWC has articles on both of those initiatives.
I struggle with the fact that I am not sure exactly what to test for in my patients and I don’t feel qualified to assess them or recommend specific supplements. In addition, the payers protest or deny payment for expensive labs, and sometimes the patients can’t afford the supplements. It’s frustrating. But like Dr. Dudrick, I see patients undergo successful procedures with the finest technology we have to offer and fail to heal for the simplest of reasons. They just need better nutrition. Let’s work harder to ensure they have it. n
Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.
1. Gosche JR. Stanley J. Dudrick, MD [interview transcript]. Available at https://www.aap.org/en-us/about-the-aap/Pediatric-History-Center/Documents/Dudrick.pdf. Published 2006.
2. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health. 2018;21(1):27-32.
3. Regulski M. Addressing vitamin D deficiency in the wound care clinic. Today’s Wound Clinic. 2016; 10(11):21-24.