Reflections of a Wound Care Fellow: Notes From the Clinician’s Journal

My most meaningful encounter so far as a wound care fellow came some five months into my program at the University of Illinois. That was when I held the hand of a patient shedding tears of joy, thankful that she had not lost her foot. I have seen the same patient cry before, back when she was a young mother afraid of losing her ability to walk. The day that patient came back healed, I saw through her teary eyes a mother walking hand in hand with her children. That moment provided the true glimpse of the impact my fellowship on wound healing and tissue repair allows me to make. Having practiced family medicine, I thought I had already been exposed to most types of wounds in the clinic setting. However, going through the fellowship, I have come to appreciate the much larger breadth and scope of this field. In this article and those that will follow in this series, I’ll share my experiences as well as my thoughts and impressions of the industry with providers in the wound care industry.

Fellowship Features

The fellowship is a 12-month training program that covers the full spectrum of acute and chronic wounds as well as uncomplicated and complicated patients. It involves rotations in different fields for 2-4 weeks in an attempt to strengthen the one’s understanding of the multidisciplinary approach involved in wound healing. Fellows are also familiarized with multiple treatment settings such as outpatient clinics, hospital operating rooms, and subacute rehabilitation facilities. The purpose is to allow fellows to monitor the progression of the wound while promoting continuity of care. As of this writing, I’m halfway through my journey. While I feel that I have already learned immensely, much knowledge remains to be gained. I spent my first two months training with the wound care team led by William Ennis, DO, MBA, FACOS, previous fellows who are now part of the department, and a nurse practitioner. During this time, I have been exposed to complex wounds, ranging from open abdomens to necrotizing infections, and severe arterial wounds requiring amputations in the hospital setting. Being a referral center, we have seen similar difficult cases in the outpatient clinics: circumferential leg ulcerations with muscles and tendons exposed; a wide range of atypical wounds; chronic wounds worsened by a complicated medical history. It’s during this time that I have been introduced to adjunctive treatments such as energy-based modalities, offloading techniques, and debridement skills.

Through the rotation I spent with the physical therapists, I’ve seen patients’ wounds change on a daily basis, which has allowed me to appreciate the different characteristics and descriptions of wounds. I have seen how a smooth wound surface would develop good granulation tissue and build up over time, as well as how wound edges turned from being rolled over to migratory. These experiences have made me appreciate and learn different physical modalities, such as electrical stimulation ultrasound therapy, ultraviolet-C light, and negative pressure wound therapy, as well as their effects. Wound care relies heavily on visual cues, and I can say that my everyday contact with wounds has made me more confident in identifying and managing them.

The palliative care rotation has helped me understand the goals of treatment for wounds in end-of-life care and how to convey this to the patients and family members. Pain rotation has given me valuable insight on different methods to ease discomfort associated with wounds, a vital component of treatment. The role of adequate circulation in healing wounds has also been one of the program’s areas of emphasis. I spent one month with vascular surgeons to understand this concept fully. While learning to interpret arterial and venous studies, I’ve seen different procedures such as angiograms, vein ablations, thrombectomies, bypass procedures, and different types of amputations firsthand. I started seeing beyond the wound and recognizing other vital aspects in deciding the treatment of vascular disease.

I have also spent time learning about the impact of infections in wound healing. I remember my attending physician saying: “Antibiotics should be the last part of the decision tree. One should first be able to determine whether there is an infection, diagnose what type of infection it is, and identify the organisms commonly associated with it.” Similarly, I remember once being told that I didn’t need a fellowship to take care of wounds — just place a dressing and the wound should heal. Going through this fellowship, I realize that wound care is so much more than dressings and regular debridement. To treat a wound properly, one needs to go back to basics to discover the underlying causes, understand the pathophysiology of the disease, and assess the patient’s functional status, nutrition, and physical — even social — environment. The dressings are only secondary. It’s clear to me now that wound care is more than the wound itself. Rather, it involves the treatment of the individual as a whole. Wound care specialists therefore need to establish relationships with patients, as wound treatment often requires multiple visits and long-term commitment.

Wound Care as a Specialty?

The debate as to whether wound care should be established as a specialty has yet to be resolved. Meanwhile, a growing number of individuals are becoming prone to wounds amidst an aging population, alarming obesity rates, and the rate of diabetes. Chronic wounds reportedly continue to affect some 6.5 million people in the United States at any one time. Obesity is a problem in one-third of American adults. Globally, diabetes prevalence is expected to increase by 9.9% by 2030. These data highlight and the dialog on wound care specialization presents the need to further educate ourselves in order to provide comprehensive quality care. As we head towards a healthcare system predicated on accountable care, where the focus for payment will be based on quality, there will be an emphasis on improving and standardizing wound care. Wound care will thus likely develop into a subspecialty of its own. Other programs have in fact adopted the present curriculum of the University of Illinois, including fellowships at Stanford University and Cleveland Clinic. Hopefully, more medical institutions will follow suit and collaborate to strengthen the field. However, wound care specialization is no “silver bullet.” My experience as a fellow has given me the confidence to look into any case given to me as well as the humility to accept that I cannot heal all wounds. This was made evident by a case I attended to recently of a man in his 80s, frail and living with dementia. His family came to us for a second opinion on closing a sacral pressure ulcer and we had to admit that we knew of no different way to treat his wound. We nonetheless assured them that while not all wounds can heal, all wounds can be treated. 

Karen Imma Gellada is the current 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. Elena Konrath, a junior studying neurobiology and physiology at Purdue University who recently worked as a summer intern in the wound healing and tissue repair department at UIC, contributed to this article.