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Wound Care in 2000, a Wish for 2020
Know from whence you came. If you know whence you came, there are absolutely no limitations to where you can go. — James Baldwin, novelist, playwright, and activist (1924-1987).
Each day provides opportunities to begin, discover, and envision anew, but the start of a new year inspires us to look back at the past and consider the future. Two (2) decades ago, this journal published a 96-page supplement on recalcitrant wounds. Its editors, reflecting on the previous millennium in wound care, observed the frustration in debating issues regarding recalcitrant wounds but acknowledged the importance of considering the long history of the art and the short history of the science of wound healing.1 Yet 20 years (!) of art and science later, it is unclear whether we have established that nonhealing wounds are recalcitrant, chronic, or not understood, nor do we have valid and reliable definitions for the words recalcitrant and chronic.2
Despite these uncertainties, we do know a little more about wound fluid in chronic (or recalcitrant?) wounds. We knew 20 years ago that the contents of wound fluid help indicate the status of the wound and that inter- and intrapatient variability is high; in fact, it was noted that, “If you have seen the wound fluid of 1 wound, you have seen the wound fluid of 1 wound.”3 Information about how wound fluid information can be used in clinical practice remains somewhat elusive, but many studies have been conducted and some progress has been made. For example, a prospective study4 of 42 patients with venous ulcers found wound fluid biomarkers correlated with changes in wound size.
Whether assessing biomarkers offers significant clinical benefits above and beyond measuring wounds remains a research topic for the next decade that may help shed light on another phenomenon, the stunned wound5 (ie, the wound that starts on a normal healing trajectory and then plateaus to become recalcitrant). Twenty (20) years ago, Ennis and Meneses5 hypothesized that, in instances of stunned wounds, clinicians need to consider the least common denominator model and look at tissue oxygenation, pressure and neuropathy, immune status and nutrition, and psychosocial variables and analyze the wound bed.
The fact that local, systemic, and clinician-induced factors overlap to affect wound healing processes is now widely accepted, as is the concept that evidence-based practice includes the provision of a moist wound environment. Twenty (20) years ago, Bolton et al6 observed the term moist wound healing was frequently used but poorly understood. Sadly, this reality has not changed much, and we continue to see descriptions but not the practice of true moist wound healing strategies. The evidence provided for operational definitions of dressing moisture retention and moisture vapor transmission rate6 bear revisiting and prospective validation. Clearly, of all the care involved in optimizing a patient’s chance of healing, providing the best local wound environment should be the easiest to address.
Despite the 20 years that have passed since that supplement was published, the history of the art remains longer than the evolution of the science of wound care. Then and now, the need for unambiguity and valid and reliable definitions remains. How are we clinicians to measure deviations from normality if we do not know what normal is?2 How are we to provide moist wound care if we do not know what it does (and does not) include? The possibility for greater understanding is there; we have achieved clarity through validation of other wound-related variables such as wound size reduction and wound care endpoints for clinical studies.7
There are no limits to where we can go once we know where we came from. The promise and potential exist for us to progress from a past in which we operated “the way it always has been” and lacked clear definitions to a future where we understand and accept evidence-based nomenclature and practice. May the next decade help us come to terms (so to speak) with important basic definitions to provide a solid foundation for a future of evidence-based, optimal wound care for the millions of patients who count on us to do just that.
The opinions and statements expressed herein are specific to the respective authors and not necessarily those of Wound Management & Prevention or HMP. This article was not subject to the Wound Management & Prevention peer-review process.
References
1. Harding KG, van Rijswijk L. Millennium 2000: the next era of wound care. Ostomy Wound Manage. 2000:46(1 suppl A):3S.
2. Harding KG. Nonhealing wounds: recalcitrant, chronic, or not understood? Ostomy Wound Manage. 2000:46(1 suppl A):4S–7S.
3. Stainano-Coico L, Higgings PJ, Schwartz SB, Zimm AJ, Goncalves J. Wound fluids: a reflection of the state of healing. Ostomy Wound Manage. 2000;46(1 suppl A):85S–93S.
4. Stacey MC, Phillips SA, Farrokhyar F, Swaine JM. Evaluation of wound fluid biomarkers to determine healing in adults with venous leg ulcers: a prospective study. Wound Repair Regen. 2019;27(5):509–518.
5. Ennis WJ, Meneses P. Wound healing at the local level: the stunned wound. Ostomy Wound Manage. 2000;46(1A):39S–48S.
6. Bolton LL, Monte K, Pirone LA. Moisture and healing: beyond the jargon. Ostomy Wound Manage. 2000;46(1A):51S–62S.
7. Driver VR, Gould LJ, Dotson P, Allen LL, Carter MJ, Bolton LL. Evidence supporting wound care end points relevant to clinical practice and patients’ lives. Part 2. Literature survey. Wound Repair Regen. 2019;27(1):80–89.
