My Scope of Practice: Taking Wound Care On the Road: the WWCA

  This April marks the one-year anniversary of the World Wound Care Alliance (WWCA), an initiative within the mission of the Association for the Advancement of Wound Care (AAWC). The WWCA is dedicated to bringing the science of wound care to the underprivileged in developing countries and North America, similar to the efforts of a non-governmental organization (NGO) for international healthcare. The program provides opportunities for teams of medical professionals (AAWC members) to volunteer for short-term (5 to 10 day) visits to pre-selected medical sites throughout the world.

  The goal of these visits is twofold: to present an outlined teaching curriculum to both the medical and surrounding community and to teach modern wound care. AAWC volunteers serve as educators in the clinical setting. The mission of the volunteer is to identify and train local healthcare personnel who can, in time, train others.

  One of the first site visits was to Christian Medical College (CMC), Vellore, a rural area of South India. The hospital at this institution has close to 3,000 beds; patients travel as far as 2,000 kilometers to CMC and must pay for their treatment. If they cannot pay the bill in its entirety, the bill is partially or wholly written off as charity by the attending physician. The institution is financed almost wholly by patients paying for services. There is differential pricing for general and private patients.

  AAWC President John Macdonald, MD, FACS, says the choice of CMC as one of the first pilot study sites was a combined decision of the AAWC and Health Volunteers Overseas (HVO). The AAWC has partnered with HVO to bring wound care programs to sites already established by HVO over the past several years. Christian Medical College was selected as a first site because it is a comparatively advanced facility with a staff of extremely dedicated professionals.

  Dr. Macdonald traveled to CMC with Harriett Loehne, PT, DPT, CWS, FACCWS. Even though the two did not have intimate knowledge of the location, there was never a question that CMC would need the WWCA’s help. “My experiences through volunteer efforts in Haiti since 1985 have given me insight into the need for wound education in developing countries,” says Dr. Macdonald. “The location of a developing country will not change the need for basic wound care education. The types of wounds seen and their causes may vary but never the need.”

  Dr. Macdonald and Harriett received an enthusiastic greeting from CMC clinicians. What the volunteers saw at CMC reiterated the absolute need for wound care education: acute and chronic wounds related to trauma, venous disease, diabetes, and tropical and other causes. “The staff at CMC was intrigued by the multidisciplinary approach to wound healing in North America,” says Dr. Macdonald. “Wound care in most countries is relegated to betadine, peroxide, or Dakin’s solution. Having a team approach that incorporates numerous product considerations is a novelty.”

  Dr. Macdonald met with a general surgeon who has a special interest in colorectal surgery and a growing interest in wound care (the physician’s name has been withheld at his request; the facility is adverse to undue publicity). The physician had received his undergraduate and postgraduate training at the facility and has been in academic surgery there since 1988.

  The comments of the doctor from India in many ways reflect the sentiments of his American counterparts. He says, “Practice in a large teaching hospital in India has its challenges. While we may be up-to-date in our knowledge of recent advances, many technologies are not available or affordable in our practice, where we see a great many diabetic feet, chronic wounds, and ulcers that require prolonged and special care.”

  One of the technologies that has intrigued this clinician was negative pressure wound therapy for use in open wounds. Cost has made purchase of products such as the wound vac prohibitive but “it occurred to me that it would be possible to create a similar system,” the physician says. This idea remained a dream until he encountered a young technician in his hospital who, “in a few minutes understood what I was looking for and said he could have a prototype machine ready in a few days.” True to his word, the technician created a machine that would provide intermittent negative pressure when attached to wall suction.

  Around this time, a medical student from the US doing a year’s research in Vellore approached the surgeon/physician for a project. The decision was made to test the newly created device on chronic wounds in a randomized study. Stoma nurses were enlisted for the project. “We chose stoma nurses because they are attached to my unit and have had some exposure to biomaterials in wound/stoma care,” says the Indian doctor. “They are also young and keen to learn. At present, we do not have wound care nurses. Wound care has traditionally been the surgeons domain in our hospital. The elaborate rituals surrounding dressings are performed on rounds or after rounds by the surgical team, usually by a junior member of the team (intern, resident) under supervision.”

  The study to test the new topical negative pressure (TNP) device involved 48 wounds (data are most complete for pressure ulcers), randomized to TNP versus conventional dressings in 1:2 ratio. Wounds that could not be closed primarily were included. The study found that TNP reduced time to healing in pressure ulcers. Patients were discharged from the hospital before the endpoint was reached for financial reasons; other factors considered included comorbidities, length of time with wounds, how was negative pressure used, what other treatments/options were used. “The study showed that the apparatus worked safely and reduced healing times, at least in pressure ulcers,” the physician says. “Analysis of the data is ongoing. We hope to learn more.” Another randomized study on the usefulness of autologous bone marrow in chronic wounds to shorten healing times is also being conducted as an offshoot of an earlier non-randomized experiment in which three feet were saved from amputation.

   “Because of my interest, I became the local wound expert,” the surgeon says. “But the medical/surgical team at CMC soon realized that wound care could not be provided to all patients by one person with a vested interest,” the physician says. “Having the enthusiastic, creative medical student dedicated to wound care in different wards made such a difference. A mechanism had to be put in place whereby wound care could be provided as a service in the hospital – a program of care that did not necessarily have to be physician-run.”

  Thus began the surgeon/physician’s quest to convince the nursing services to start a wound and tissue care facility and to identify a nurse to run it. The idea had been accepted fairly quickly in principle and a budgeted post also was approved. The facility acknowledged that their strength is a factor of their people who, as the physician says, “are committed, interested clinicians willing to go the extra mile. They are people determined to overcome our weaknesses – the lack of funds, personnel, and a horizontal integration between departments in wound care. They have ideas in wound care to pursue and develop.”

  Enter the WWCA. The CMC physician hopes the WWCA will help, “first in spreading modern concepts of wound care in our hospital to a broader audience and second in facilitating horizontal integration of care. The WWCA can help us find ways to fund small studies in wound care. It could raise awareness of CMC around the world – that we are a Christian institution serving a large, mostly poor population. Also, patient services could improve vastly if a tissue viability service could be established.”

  Dr. Macdonald says the hopes expressed by the Indian physician are the hopes expressed by every physician in a thousand villages in countries all over world. “Wound care is a basic need, under-appreciated by academic medicine until now.”

  The AAWC plans to work closely with HVO to finalize the establishment of a wound program at CMC and to create educational materials to assist medical volunteers assigned to CMC in the near future.

  The WWCA does not plan to stop with CMC in India. Pilot studies also have been conducted in Peru and Cambodia. Several site visits are planned for the coming years. Fundraising will be critically important to the efforts of the WWCA. This includes corporate support; wound care companies need to understand the emerging opportunities with the WWCA. Dr. Macdonald notes a misconception – that is, developing countries cannot and will never be able to afford even their most basic products. He believes that support of the WWCA will boomerang and companies will be repaid many times over. In a final word, Dr. Macdonald cautions everyone to remember, “All medical standards rise with the tide of knowledge, particularly in the global scope of practice.”

My Scope of Practice is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.