A Surgeon’s Perspective On Non-Healing Wounds

Recently, on the tail end of a 30-year career in chronic wound care, I’ve taken the opportunity to ponder the thousands of patients that I’ve seen throughout my clinical lifespan. Along their healing journey, we have shared both abundant successes and failures. I’ve learned that effective care is really “compassionate education.” We teach our patients about their healing challenges, and how their decisions and actions can lead to a better outcome. If we allow it, those under our care can teach us as well – not only about what works and doesn’t, but also how to care for wounded people during a challenging time in their lives. With this in mind, I’d like to share my top 4 patient care lessons with you.

1. Establish a wound etiology

As human beings, we are designed to heal. And we do so very effectively…until we don’t. Moreover, we fail to heal for a relatively concise (and usually predictable) list of reasons. These contributors to healing failure are referred to as wound etiologies. Examples include venous leg ulcers, diabetic foot ulcers, and pressure injuries – and their respective impacts to healing are well-recognized. As such, it’s critical to assign one or more etiologies to your patient’s wound, as their care path is ultimately directed by their underlying pathophysiological derangements. Better said, a wound without a cause leads to care without a plan.

2. Sequence your care decisions

Wounds typically follow a timely and orderly four-step repair process consisting of hemostasis, inflammation, proliferation, and remodeling. It’s critical to understand where your patient dynamically exists in this physiologic continuum, and to time your therapeutic modalities and interventions accordingly. In other words, a critically ill, malnourished patient with an infected diabetic foot ulcer is simply not ready to benefit from the topical application of an expensive cellular-based product. It would be better to consider such an application when the patient is in an anabolic state and the infection is controlled. Furthermore, it’s ideal to pose the following questions every time I evaluate a patient’s wound:

• What does this wound need today?;
• Can I provide it (and if so, how?); and
• Can the patient tolerate and/or afford it?

3. Focus on the process, not the product

Clinicians new to the practice of wound management tend to be “product thinkers.” It is their somewhat-misguided understanding that the chief aim of care is simply to decide the best dressing for the wound in question. Rather than addressing the more important underlying (“process”) issues such as limb ischemia or the removal of non-viable tissue, wound care newbies drift from one product to another with the unwavering expectation that this product (which he/she may have never used nor fully understands) will surely make all the difference. The better approach would be to sequentially address the totality of the patient’s wound needs, some of which require the removal of something (pressure offloading and necrotic tissue debridement), rather than the application of something.

4. Engage the patient’s mind and heart

Despite how it may feel on occasion, it is the patient’s wound—not yours. As such, they need to own the problem. They need to care more about their healing and overall wellness than you do. It’s tempting to take over on occasion and set aggressive healing objectives for the patient. While well-intended, these goals (which the patient must work towards, and not you) may seem unattainable to the patient. Unfortunately, they frequently give up hope in getting well – at least, in your timeframe. As providers, we then place blame on the patient for poor progress, label them “non-compliant,” and dread their next clinic visit. 

A better approach would be to set reasonable expectations with the patient, after first asking them about their personal healing goals and timelines. Only then can you effectively team up with the patient to pursue mutually-desired clinical objectives. Not all patients will heal – and of those that do, not all will do so when and how we dictate. 

Finally, enjoy the experience of helping your patients heal. Regularly celebrate the little victories (e.g., “the wound hurt less this week”)! The good and bad news is that healing takes time. While we may occasionally get tired of seeing our patients over a protracted period of time, to do less would also deny us the blessing of personally walking this journey with those wounded people entrusted to our care.

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