By Jean Walsh, DO
For many family physicians, the care of chronic wounds seems overwhelming due to lack of training/education, complex dressing options and the implication that only surgeons can heal chronic wounds. I would like to introduce the concept that primary care providers are actually the best specialty to manage wounds, and it isn’t as difficult as it may seem.
Non-healing wounds are a significant cause of morbidity, mortality and cost. Medicare alone spends more than $46 billion on costs associated with chronic wounds. For instance, a diabetic foot wound will occur in five percent of all diabetics. Twenty-five percent of all admissions of patients with diabetes will have a wound, and many of these admissions end in amputation. The 5-year mortality rate of patients who undergo an amputation due to a chronic lower extremity wound is almost 50 percent.
Primary care physicians help patients prioritize care and establish realistic care goals. The relationship that patients have with their physician is vital to understanding patients’ values, priorities and life goals. A patient’s involvement in shared decision-making depends on an understanding of factors, including what a chronic wound represents to a patient’s overall level of health, the risk of morbidity and mortality, and the cost and commitment required to heal a chronic wound. We are the best equipped to make sure the patient’s values and interests are served in a holistic approach while healing chronic wounds.
Family medicine is uniquely placed to manage chronic wounds. We already manage many chronic conditions, such as diabetes or venous insufficiency, and implement a team-based approach. We, as family physicians, are well-versed in coordination of multidisciplinary teams, which is what is needed to heal most chronic wounds. Not only does the healing of wounds take a team approach. but controlling the chronic conditions that impede healing also takes a team to control. Wounds typically won’t heal if chronic conditions are uncontrolled. Addressing those chronic conditions, including wounds, not only is done better with a team, but that team also works better with the coordination of a family physician.
Of course, as your patient’s doctor, you have the choice of directly caring for the wound or sending them to a wound center, but you will always face the responsibility of managing all aspects of the patient’s health, which ultimately affects the healing of chronic wounds.
There is little consensus regarding what defines a chronic wound, other than the vague phrase, “a wound that fails to progress in a timely manner or that doesn’t restore function and anatomy.” (Most acute wounds will progress within 25 days.) Although no tests are easily available to examine the cell structure of a chronic wound, it is the microenvironment that defines whether a wound is acute or chronic. A chronic wound environment has a high level of proteases, reactive oxygen species, low mitogenic activity and senescent cells. In fact, fluid from a chronic wound has been shown to dramatically inhibit growth of fibroblasts from neonatal skin. The most significant noted factor to delayed healing is inflammation. In the chronic wound environment, macrophages destroy healthy tissue and inflammatory cytokines degrade newly formed tissue.
When a wound has been present for several weeks, it will develop a biofilm made of dead tissue and bacteria. The bacteria within this biofilm interact to form a plaque that lowers the oxygen in the wound, creating an environment resistant to oral and topical antibiotics. For these reasons, sharp debridement done weekly is the bread and butter—and standard of care—of a wound clinic. In the primary care office, you can substitute sharp debridement with collagenase cream (i.e., SANTYL), which is applied daily and breaks down biofilm and dead tissue without affecting healthy tissue.
There are four basic wound types defined by billing diagnoses: arterial, venous, neuropathic (e.g., diabetes) and pressure. These types all involve high levels of inflammation due primarily to ischemic-reperfusion injury. Occasionally, foreign bodies are to blame. No matter the wound, addressing the causes of intermittent ischemia will aid in healing a chronic wound.
Addressing intermittent ischemia is important and may involve multiple specialties. The vascular surgeon can revascularize larger vessels in arterial insufficiency. The prosthetist can fit your diabetic patient with a shoe that prevents the patient from stepping on the wound. Off-loading—or getting the weight off the wound—will reduce pressure ischemia in both diabetic foot wounds and pressure ulcers. Lower extremity edema in venous insufficiency ulcers cause pressure on small vessels resulting in delayed healing. In addition to compression, vein ablation in a vein clinic may be helpful. The family physician is integral as the coordinator of this multidisciplinary team.
Once you have a patient with a chronic wound that you feel comfortable managing, there are specific steps to follow. Initially, the patient will need to be assessed for any uncontrolled chronic conditions and treated accordingly. The next step is a basic assessment of the wound, including a description of tissue type, exudate, surrounding tissue, size and presence of pain. Tissue is necrotic (black), fibrotic (yellow), granulating (redness of raw beef) or a combination. The amount of drainage is an important part of the assessment because this directs the type of dressing to be used. If an abdominal pad gets soaked in one day, the wound is draining a large amount of exudate and a highly absorptive dressing should be chosen, such as foam or alginate. If an abdominal pad gets soaked in 2–3 days, stick with an abdominal or a hydrocolloid dressing, such as DuoDERM®. If the abdominal pad doesn’t get soaked after four days, consider non-adherent or transparent film dressing. It is advised to not put gauze directly on the wound bed because gauze can leave fibers when removed. The wound should also be measured to determine if it is improving. In a hurry? Take a photo of the wound with a measuring device. Measuring devices can be found on the paper cover of a 4×4 gauze or cotton swab.
Remember that dressings can be expensive. If the patient can’t afford standard dressings, consider diapers or menstrual pads. As the patient’s primary care provider, we tend to be more sensitive to cost, and these are great alternatives in a pinch. Refer to the table below for a quick breakdown of each dressing type, when to use them and the advantages/disadvantages of each.
|Transparent Film||Adhesive, semipermeable, polyurethane membrane that allows water to vaporize and cross the barrier||Stage 1 and 2 pressure ulcers with light or no exudate; may be used with hydrogel or hydrocolloid dressings||Retains moisture; impermeable to bacteria and other contaminants; facilitates autolytic debridement; allows for wound observation||Not recommended if infected or drainage present; requires border of intact skin for adhesion; not recommended on fragile skin|
|Hydrogel||Water or glycerin-based gels; impregnated gauze||Deep wounds needing dead space filled and wounds with necrosis||Soothing, reduces pain; Rehydrates; fills dead space; easy to apply and remove||Not for moderate-to-heavy exudate; dehydrates easily if not covered; difficult to secure; may cause maceration|
|Alginate||Derived from brown seaweed; composed of soft, nonwoven fibers shaped into ropes or pads||Stage 3 or 4 pressure wounds or wounds with moderate to heavy exudate or tunneling||Absorbs up to 20 times its weight; conforms to shape of wound; facilitates autolytic debridement; fills in dead tissue space; easy to apply and remove||May dehydrate wound bed, especially with light exudate|
|Foam||Provides a moist environment and thermal insulation||Primary or secondary (on top of a packed wound) dressing, with variable drainage||May be used under compression; absorbs light-to-heavy exudate; ok with fragile skin||Medicare allows only 10 per month|
|Hydrocolloid||Occlusive or semi-occlusive dressing||Primary or secondary dressing, good for wounds with necrosis or with light-to-moderate exudate||Impermeable to bacteria and other contaminants; facilitates autolytic debridement; self-adherent; molds well||Not for wounds with heavy exudate, sinus tracts or infection; may curl at edges; may injure fragile skin upon removal; Contraindicated for wounds with packing|
Subsequent blog posts will expand on specific wound types and treatments in more detail.