Reflections of a Wound Care Fellow: Notes From the Clinician’s Journal (Part 3)

Editor’s Note: This is the final article in a series that has shared the insights of a physician as she navigated her wound care fellowship and transitioned into a full-time wound care practitioner.

I meet a middle-aged man who has been living with an ulcer on his ankle for quite some time — years, in fact, he tells me. “It started as a bug bite, and since then it has not healed,” he says. He has been to many different wound care doctors, and at one point was labeled as “noncompliant.” I read through some notes on his chart, and his wounds have been diagnosed as “venous ulcers.” He has tried many different dressings and has undergone multiple debridements, but his wounds have not closed. In my head, the wound does not look like your typical venous ulcer. Upon further questioning, it is revealed that the patient also has a history of hepatitis C stemming from intravenous drug use and has just started seeing a gastroenterologist. I perform biopsies, which come back negative. His MRI, however, shows osteomyelitis, and a serum cryoglobulinemia test is positive. After IV antibiotics, the wound on his medial ankle where osteomyelitis has been found is now closed. I advise him of the importance of seeking treatment of the hepatitis, which may be contributing to the persistence of his lateral ankle wound.

I see another patient who has been living with a chronic wound — four years to be exact. She has a history of rheumatoid arthritis (RA). Her wounds have been very painful and have continued to worsen. Because of the pain, she has refused biopsies. The ulcers are fibrinous and the edges have a purplish hue. I ask her if her wounds improved at all when she was placed on steroid bursts for her RA, and she confirms. I inform her she likely has pyoderma gangrenosum and that her treatment will involve a longer course of steroids and immunosuppression. I speak with her rheumatologist, who is also in agreement with the plan.

Then comes in a woman living with advanced dementia who is being cared for by her husband and an aide at home. She presents with multiple pressure ulcers, the largest of which is at her sacrum — very close to the bone. She is frail, bedbound, and nonverbal. I speak to her husband, informing him that given her current medical condition her wounds are not likely going to heal by dressings alone and that surgery is not going to be a good option. I talk to him about palliative wound care, explaining that the goal is not to heal the wound but to take care of it by controlling odor and drainage, and trying to prevent infection.

GRATEFUL FOR THIS JOURNEY 

Yes, it has been a busy day at this wound center, with a lot of first-visit patients. As I sit down to type up my notes, I am overwhelmed with a feeling of gratitude. During the last six months that I have worked as a wound care attending physician, I have seen my first case of p. gangrenosum, acute and chronic osteomyelitis, and livedoid vasculopathy. Now that I am on my own, I have realized how much I have learned from William Ennis, DO, MBA, FACOS, and his team at the University of Illinois at Chicago (UIC). I feel very blessed to have been given the opportunity to train under the wound care fellowship at the university. Looking back to when I began, I really did not know what to expect and felt a little apprehensive. I know there is a lot of variation to the practice of wound care, and I wondered if I would fit in appropriately to how the wound care center I am joining operates. During my first few months, I was asked by some of the nurses why I ordered a particular dressing, one they did not typically use. Early on, I also second-guessed myself, thinking maybe I should use dressings that the staff members are accustomed to. I wondered if my wound closure rates would be lower if were to utilize the more basic dressings. But then I reminded myself that wound dressings are only secondary to uncovering the etiology of a wound. As the months went by, I continued to practice what I had learned, ordered wound biopsies for chronic wounds (if not already done), and conducted venous reflux studies for wounds that were likely venous (always assessing for circulation). In my head, when confronted with a difficult case, I would look back at what I had encountered during rounds, clinics, and rotations while at UIC. I then started gaining the trust of the nurses. Now, I can say with certainty that the year of training has made me appreciate and enjoy the field of wound care.

I remember my mentor, Dr. Ennis, saying, “At a point in your career, you will develop your own way of practicing, but you should always remember the basics of wound care.” The fellowship has definitely given me the education I need to be able to look at a wound and decide on my course of management. If, in the end, I am told that I practice like my mentor, I have then received the utmost compliment.

Karen Imma C. Gellada is a former fellow for the section of wound healing and tissue repair at the University of Illinois at Chicago. She finished her family medicine residency at the University of Illinois College of Medicine at Peoria. She is board certified in family medicine and previously worked in primary care and urgent care. 

Gio F. Manguerra is a recent graduate of the University of Illinois at Urbana-Champaign, where he majored in molecular biology and psychology. He is currently working as a home care medical assistant and compliance officer for a visiting physician’s office. He aspires to become a physician.