Challenges in wound management of stalled wounds

“If you change nothing, nothing will change”

“We’ve tried everything” is a claim we often hear when we meet clinicians who struggle with one or several challenging and stalled wounds that won’t heal despite several approaches in the wound management plan. The clinicians express resignation and the patients hopelessness and maybe also depression. When we get into the details of the different approaches of the wound therapies conducted, a few similarities often stand out:

  1. Insufficient debridement is often described
  2. Antimicrobial products have been used, often over extensive periods
  3. The different therapies described are basically one and the same

Insufficient debridement may arise from several factors, but the two main drivers seem to be pain during procedure expressed by the patient, or that the debridement skills of the carer seem to be inadequate. The importance of debridement and the craftsmanship that goes into correctly performing this procedure have been described extensively1, however in this post we’ll focus on the latter two points, particularly number three.

In discussion with clinicians, what we encounter is that many have actually just tried two different approaches, and repeated this over weeks and months, even years. Typically a treatment plan based on the initial assessment is initiated, using basic/standard dressings like hydrogels, foams, hydrofibers or similar. When there is no satisfactory improvement after several weeks, a switch to an antimicrobial is common, often for extensive periods of time and sometimes even without confirming an infection or a critically colonized wound. Then when that also fails, different dressings all intended for optimal moist wound healing conditions, but with no extra push to help the healing process, are used intermitted with antimicrobials.

Thus in principal only two different therapies have been applied:

  • leaving the body to fix the wound itself with optimising the healing environment (moisture)
  • anti-infection agents.

With so many products to choose from, it’s no wonder the care-givers get lost sometimes. When you add the complexity of chronic wounds and the lack of education or implementation of current guidelines of wound management, the prospects of getting it right might decrease2. However, doing the same thing over and over again and expecting different results will most likely get you nowhere in helping your patient heal the wounds. The challenge may be to recognise what the different therapies actually provide, beyond the glossy marketing messages and compare this with what the needs are for your particular wound. One way of doing this may be to look critically into the mode of action of the different dressings and compare it to your wound assessment.

The factors causing wounds to stall and cause frustration for both clinicians and patients are many, thus there will never be one simple solution that fits all. The healing of stalled wounds is an art, a costly and time-consuming art as well. However, progress has been made both in the knowledge of how to best treat wounds, and in the active therapies available. But to best utilize the knowledge and available treatments, a thorough wound assessment and reassessment is crucial at regular intervals in the wound management plan, or else you may end up just repeating the same old song.

So be like Einstein: “If you want a different result, make a different choice”.

Try something new, try something active:


References
  1. Analise B. Thomas, MD & Wesley P. Thayer, PhD, MD; Debridement of Chronic Wounds: A Review of Past & Present Treatment Strategies. Todays wound Clinic Volume 8 Issue 5 – 2014
  2. Flanagan M. Barriers to the implementation of best practice in wound care. Wounds UK 2005 1 (3): 74–82

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