One of my favorite songs is “A Puzzlement” from “The King and I,” because, as the song says, “I am no longer sure of what I absolutely know.” At least I am no longer sure of what I have been taught. We are taught that there are wounds, and then there are ulcers – which are different entities entirely. We are taught that ulcers come in distinctly different varieties: diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), arterial ulcers, and pressure ulcers/injuries. It must be true since every regulatory authority agrees with this paradigm. The ICD10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) code book provides different diagnosis codes for them, the U.S. Food and Drug Administration (FDA) clears/approves drugs and devices based on wound diagnosis, and The Centers for Medicare and Medicaid Services (CMS) issues coverage policies based on the diagnosis code. Every clinical association has developed exhaustively referenced treatment guidelines specific to each ulcer type, every organized medical meeting offers clinical teaching sessions unique to each category, and every scientific paper studies one of these well-defined entities. It’s all so tidy!
It all works very well – until I walk into the exam room of a patient with a chronic ulcer – and I am no longer sure of what I absolutely know. Over 80% of patients have more than one wound or ulcer, and often more than one “type.” More than 40% of venous leg ulcer patients have diabetes, most diabetic patients have edema, and many have VLUs. The lesions we call “pressure ulcers/injuries” on the foot are usually due to arterial disease and deep tissue injuries on the torso are ischemic infarctions of anatomical angiosomes. Every chronic ulcer is a symptom of the patient’s underlying medical condition(s). In many cases, we are forced to put a round peg in a square hole to assign a diagnosis code, which is particularly difficult when diagnosis codes for entities like diabetic foot ulcers and arterial ulcers do not even exist (yes, there is a code for “diabetes with a foot ulcer” – but that’s a diagnosis code for diabetes, not a diagnosis code for a diabetic foot ulcer.) Regardless of what diagnosis code we give the ulcer, the patients nearly always have a similar constellation of medical problems often involving some type of nutritional deficit (neither the lab tests nor the treatments for which are typically covered by insurance) and/or metabolic syndrome, manifested as a constellation of comorbid conditions that require the same list of medications.
Yes, it’s true that we should be providing care specific to the needs of the wound – but not necessarily by the name we give the lesion. Perhaps the reason we do such a bad job of providing basic care is that we are struggling to assign the “correct” diagnosis code to the ulcer, and due to the way we have been taught, we can’t implement the treatment guidelines without the right name. We need a new generation of treatment guidelines focused on evaluating the barriers to healing (e.g., ischemia, edema, lack of protective sensation/repetitive trauma, nutritional deficits, etc.) and not based on the pet name of the ulcer. We need to address the systemic reasons for chronic ulcers – including why 40% of patients get new ulcers while we are still taking care of the original ulcer, and why a staggering percentage of patients die within the relatively short period of time during which we are treating their ulcer(s).
And here’s the biggest reason I’m confused. In 35 years, I have yet to see a wound by any name that did not close by first creating vascular granulation tissue and then epithelial tissue. Yet, we continue to perpetuate the myth that treatments which are developed for DFUs must be proven to work for VLUs, pressure ulcers, burns, and every other category we have seen fit to create – as if the name we give the lesion indicates that they have completely different mechanisms of closure. The result is that we have no treatments indicated specifically for generic “chronic ulcers,” which are actually the most common type of ulcer – the ones which fall into none of the identified categories. Manufacturers must spend billions on multiple different studies which increases the price of the treatments developed, we are forced to perform prospective wound care trials on subjects that are not representative of the real world, real-world outcomes are much worse than clinical trials, and payers develop coverage policies that align poorly with actual patients. This may explain why, despite the fact we are spending billions more than we did a decade ago, healing rates are not demonstrably better. The entire field of wound care is a Potemkin village – the fake portable village façade erected along the Dnieper River so that Russian Empress Catherine II could float along and see only happy peasants – rather than the very real suffering of the people. Our current façade is not a useful construct to aid treatment, coverage policy or innovation, and our patients are suffering. How are we going to move forward?
“There are times I almost think
I am not sure of what I absolutely know.
Very often find confusion
In conclusion, I concluded long ago.
In my head are many facts
That, as a student, I have studied to procure.
In my head are many facts
Of which I wish I was more certain I was sure!”–Lyrics by Oscar Hammerstein II
A Puzzlement – Song from The King and I by Rodgers & Hammerstein
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
Love this!
When I teach wound management to non-specialists, I tell them to evaluate for, and eliminate when possible, the 3Ds – easy to remember: Dirt, Dry, Damage.
Dirt is eliminated with initial sharp debridement (if possible, and only once), followed by a thorough saline or drinkable water irrigation, until the fluid that drains out is clear (or pale pink if there is a bit of bleeding), then a moisture balancing dressing that promotes autolytic debridement (debridement is further enhanced if they can obtain polymeric membrane dressings).
Dry is alleviated by the irrigation and moisture balancing dressings, and encompasses periwound protection for overly wet wounds too. I find that wound specialists are often so afraid of maceration that wounds in their care are kept too dry for optimal healing.
Damage elimination includes using a soft, flexible dressing with an outer semipermeable membrane to prevent continued direct trauma and contamination, as well as addressing causes of poor circulation, such as edema, direct pressure, and ischemia from arterial disease as well as possible.
With these basic principles in mind, my learners, many of whom are lay health care workers without the skills to make fine diagnostic distinctions, can manage any wound, any where. The name is irrelevant if all the bases are covered.