Resources for Physicians

Although many physicians routinely treat acute wounds in their day-today practice, the variety and complexity of non-healing chronic wounds presents a particular challenge. As with any chronic disease process, a wound, regardless of its cause, requires intervention by multiple health care disciplines to address the many conditions and co-morbidities that impact wound healing. This paper illustrates the need for and value of a specialized, physician-driven, interdisciplinary approach to outpatient wound care.

Patient history: A female in her fifties presented with a small ulceration of 6 months duration on posterior left lower extremity which occurred as a result of a fall. Patient is wheelchair bound but has the ability to transfer herself. Co-morbidities include COPD, IDDM x 5 years, HTN, CVA, MI, right above-the-knee amputation, and peripheral vascular disease. Patient had left femoral-popliteal bypass one month after original wounding. Wound has been treated with Silvadene and antibiotic therapy in the past.

Patient history: A female in her fifties with a 1 year history of a non-healing medial right calf wound. According to patient, the wound was precipitated by an insect bite which resulted in a failed surgical closure. Patient has a significant history of HTN, osteoarthritis, fem-pop. Bypass and right femoral angioplasty. Patient ambulates with a walker and brace support and has significant financial limitations due to inability to work.

Comprehensive wound management requires a physician driven, multidisciplinary based program that directs critical resources required for evaluation and treatment to patients suffering from wound healing failure. Traditional approaches to the management of these patients have typically been ineffective. Successful management of these challenging problems can easily exceed the capabilities of the individual physician’s office due to the complexity and time consuming nature of the care required. The Wound Care Center will be providing this highly specialized care that many of these patients require.

Ulcerations of the feet, wound infection, and progressive tissue loss represent a major source of morbidity and mortality in patients with diabetes. While data is incomplete, more than 50 percent of all lower extremity amputations are linked to underlying diabetes. Foot infections represent a major reason for diabetic hospital admissions and health care expenditures. Recent literature suggests that if more attention is provided to foot care in this high risk patient population, serious morbidity and even mortality can be prevented.

Acute wounds normally proceed through an orderly and timely sequence of events involving hemostasis, inflammation, proliferation, and remodeling that ultimately results in the restoration of nearly normal anatomic and functional integrity. Chronic wounds are wounds which have failed at some point to proceed through this orderly sequence and demonstrate arrested healing in one of these stages.

Non-healing wounds of the diabetic foot are considered one of the most significant complications of diabetes, representing a major worldwide medical, social, and economic burden that greatly affects patient quality of life. Given the abnormalities of the microvasculature and other side effects of diabetes, these wounds take a long time to heal and require a specialized treatment approach for proper healing.

Chronic Radiation Proctitis (CRP) is a debilitating complication of radiation treatment of the pelvic region for many urologic, gastrointestinal, and gynecologic cancers. It occurs in up to 10 percent of postradiation patients despite advances in administration technique and delivery. It can continue from an acute phase or begin after a variable latent period of at least 90 days, although years may pass before symptoms become apparent. The underlying pathology consists of submucosal injury and endarteritis with associated fibrosis, ischemia and ulceration.

Pressure ulcers are an area of localized damage to the skin and underlying tissue caused by unrelieved pressure. The management of these wounds requires a comprehensive approach to treatment. This approach is proven to heal these ulcerations quickly and reduce the incidence of infection and recurrence. Thus a comprehensive approach substantially reduces the cost burden to those individuals with pressure ulcers.

Lower extremity arterial disease (LEAD) represents a later manifestation of peripheral arterial disease (PAD). LEAD is a spectrum of chronic limb symptoms caused by progressive narrowing and eventual occlusion of the arteries to the lower extremity. Arterial occlusion leads to ischemic tissue and eventual ulceration. Recent studies suggest that 8-12 million Americans have the condition and that for individuals 65 years or older the prevalence of LEAD is 12-20 percent.
 
The management of LEAD ulcers mandates a comprehensive approach to treatment. This approach is proven to heal the ulceration and reduce the incidence and level of amputation, thus substantially reducing the cost burden to those individuals with lower extremity arterial disease.