Can We Talk?: Look Before You Label: Chronic versus Acute

  Many months ago, Morris Kerstein provided to Ostomy Wound Management a Guest Editorial entitled, “The Wounds of War.”¹ Although my response to his article is severely belated, I am grateful for the opportunity to comment. Having been an army nurse in Vietnam, I salute Dr. Kerstein from the soles of my feet to the soul of my being for reminding us to treat the whole patient and not just the hole in the patient.

  I am also responding to his use of chronic versus acute, adjectives often used by wound care experts. Mindful of our responsibility to treat the whole patient and in agreement with the classic definitions of these adjectives, I take issue with the wound care community’s inappropriate application of these adjectives. I propose the words chronic and acute have been misused, are being misused, and will continue to be misused without critical consideration of how they are applied.

  Now sometimes an argument which has been properly deduced is silly, if the assumptions are extremely implausible or false. — Aristotle, Sophistical Refutations, 183a14

  A chronic wound has “failed to proceed through an orderly and timely process to produce anatomic and functional integrity, or proceeded through the repair process without establishing a sustained anatomic and functional result.”² The converse definition is implied — ie, an acute wound proceeds through an orderly and timely process to produce anatomic and functional integrity and proceeds through the repair process, establishing a sustained anatomic and functional result. First, the classic definitions of the adjectives chronic and acute relate to timing and complications of wound healing. These same adjectives then are often applied to types and locations of wounds. For example, chronic wound is applied to pressure and venous ulcers; however, many pressure ulcers and venous ulcers do “progress through the healing process in a timely and uncomplicated manner.” In another example, acute wound is applied to military injures and surgical incisions. Conversely, many military injures and surgical incisions do not “progress through the healing process in a timely and uncomplicated manner.”

  Second and further complicating this issue is the fact wounds may have dual etiologies. A surgical incision or military injury also may be venous ulcer or pressure ulcer. Consider the woman who has an excisional biopsy on the lower extremity lesion of a limb with preexisting venous disease. Or consider the soldier who is trapped in his tank for 3 days with his arm wedged between the breechblock and the turret wall, sustaining tissue necrosis. In the first case, the surgical incision is also a venous ulcer, but is it chronic or acute? In the second case the military injury is also a pressure ulcer, but is it chronic or acute?

  I laud Dr. Kerstein’s challenge to continue “probing the depth of vascular biology associated with wounds.” Yet, before we can “address the role of chronic wound fluid and compare it to acute wound fluid,” we must address the terminology used as the typology for these wounds. Presuming a wound is “chronic” when with prompt attention it will not malinger or presuming an acute wound will heal expeditiously can lead to costly mistakes in terms of physical, financial, and emotional expense. Stop, look, and think before you label.

  This article was not subject to the Ostomy Wound Management peer-review process.

1.    Kerstein M. The Wounds of War. Ostomy Wound Manage. 2005;51(1):6.

2.    Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermat. 1994;130:489–93.