Keeping an eye on ugly wounds
SOMETIMES IT'S the little things that get you. Like a wound that doesn't heal up properly, which can lead to months of misery, and possibly even amputation of a limb. But often such dire outcomes could be avoided if wounds were better managed from the outset, according to experts.
"About 2 per cent of people at any one time have a wound that is being treated," says Dr Georgina Gethin, president of the Wound Management Association of Ireland, who estimates that we spent about €490 million, or about 4 per cent of the annual healthcare budget, on wound care here last year.
"The majority of wounds will heal uneventfully. But there are chronic wounds that are very slow to heal or can just go on and on," she says. "And studies on quality of life with chronic wounds show that people with them are more depressed, anxious, socially isolated, that they experience a lot of pain and loss of time from work."
Common wounds that turn into longer-term problems include leg and foot ulcers - particularly in diabetic patients - and ingrown hair follicles on the backside, a condition that crops up mostly in lorry and taxi drivers and which can lead to loss of earnings, according to Gethin.
But even though wounds are treated in almost every healthcare setting from hospital to community, wound management lacks its own speciality, and is often low on the list of priorities, according to Gethin.
In addition, managing wounds is hardly a glamorous aspect of healthcare, and it has to compete for attention with more dramatic, acute conditions. "It's harder to get people excited about chronic conditions. You won't get Cindy Crawford to wear a T-shirt saying 'Support your local leg ulcer clinic'," she says. Patients with troublesome wounds of the lower limbs may also have other underlying conditions, like diabetes, which bring a raft of other complications, she adds.
"Traditionally in diabetes care, things like the eyes and cardiovascular problems have gotten all the attention, and rightly so, but when it comes to feet, they are the Cinderella of everything."
In diabetes, the person may also have lost sensation in the foot, which means wounds might go unnoticed initially. "There have been people going around with a stone or a syringe stuck in the foot and they have not felt it, that is how severe it can be."
But skimping on wound care can be a false economy, particularly if the wound becomes chronic, warns Gethin. Wounds usually heal over in about three weeks, but sometimes the healing process can get stuck "like groundhog day", and the wound is locked in an inflammatory cycle, she explains.
Gethin took part in a study that found treating a patient with a severe pressure ulcer over five months here costs about €119,000. "In a 600-bed hospital you would have two or three people at any one time with a very severe pressure ulcer," she says. "But about 95 per cent of them are avoidable."
Treating chronic wounds can be relatively simple, but often best practice is not implemented, she says, citing venous leg ulcers as an example. "The treatment is bandaging with compression therapy. It has been shown without a doubt that it actually works. But about 40 per cent of people in Ireland still don't get that treatment, because the clinic isn't there, or because people think it's just an ulcer, let's put a dressing on it."
Yet a study in Limerick showed that training public-health nurses in compression therapy reduced the frequency of dressing change from an average of three to four times a week to about twice a week, according to Gethin.
"The proper intervention is most cost-effective in the long run and that goes across all areas of wounds. And at the very base level, just by people having the service and being educated, there's a huge lot that can be done," she says. "And the causes of the wounds are not going away, our population is increasing and we are living longer, so this is something that is going to go on and on into the future."
However, treatment of leg and foot wounds should get a boost from Ireland's first crop of home-grown podiatrists, who will start their four-year degree course next month at NUI Galway.
Many patients in need of lower-limb care have diabetes or rheumatoid arthritis, where deformity, circulation or nerve problems can exacerbate a chronic or infected wound, explains NUIG's head of podiatry, Dr Caroline McIntosh.
And getting the right treatment from the start makes sense, she adds. "In podiatry, we have the skills of being able to debride the wounds and to understand the mechanics of the lower limb and the foot. So we can use offloading devices to take pressure off the foot and encourage healing, and we do regular vascular assessment of the lower limb, so we can often pick up problems before they have manifested into a chronic wound."
The Wound Management Association of Ireland will host a conference on diabetic foot ulceration on September 9th at the Clayton Hotel in Galway. For details see www.wmaoi.org
They say time is the best healer, but sometimes nature has a few other tricks to help.
In recent years, Manuka honey from New Zealand has been shown to aid wound healing, and it is now available in dressings.
Regular honey has some topical healing properties, but Manuka honey, which is produced by bees that visit the Manuka tree, contains an additional factor that is thought to help ward off the bugs.
"Honey has hydrogen peroxide in it, and for most honeys, that's what gives the anti-bacterial effect. But for Manuka honey, when they took out the hydrogen peroxide, it appeared to still have an anti-bacterial effect," says Dr Georgina Gethin, a lecturer at the Royal College of Surgeons in Ireland.
Her studies on using Manuka honey to treat wounds have found it to be effective against MRSA, and also in the wound becoming more acidic, which is associated with healing.
However, she cautions against using food-grade honey on chronic wounds, as it could harbour bacterial spores. "If you buy a jar of honey, it was manufactured and packaged for eating. Whereas in wound care the honey now comes in tubes or dressings, and it has been sterilised so any potential spores have been eliminated."
Meanwhile, researchers in The Netherlands have identified a protein called histatin in human saliva that speeds up wound healing in the lab. Commentators believe the discovery helps explain why animals lick their wounds and points to saliva as a potential source of therapeutic drugs.
The dangers of diabetic ulcers
Diabetic leg and foot ulcers may appear to be a minor affair, but the Wound Management Association has some statistics that could make you revise that opinion:
* Every 30 seconds in the world a limb is lost to diabetes
* 85 per cent of amputations started as an ulcer
* One in every seven people with diabetes will develop a foot ulcer
* There are about 24,000 leg ulcers in Ireland at any given time - many of the patients also have diabetes
* If you have diabetes, you are 15 times more likely to have an amputation
* Approximately 250,000 people in Ireland have diabetes, but only about half have been diagnosed