Editorial Message: How Is Your Foundation?

Dear Readers:   A few years ago, a local emergency room physician bought a house down the block from me. Soon after moving in, he noticed the back door would not close, part of the back of the house seemed lower than the front, and two of the walls had very large cracks! Experts were consulted and they found that the foundation of the house was not on solid ground. As a result, part of the foundation had sunk several inches, causing the broken walls and floors. To manage the problem, engineers dug out all the dirt around the broken foundation, jacked up the sunken part of the house, and poured huge amounts of concrete in the holes to support the house. Once the foundation was repaired and solid, the house was fine, but it was still a very difficult and expensive problem. If only the foundation had been on solid material from the beginning.   Believe it or not, this applies to wound care. Our treatments of wounds must have a solid foundation of evidence-based principles if we are to have the best chance of helping our patients. Many in wound care are drawn to the newest, most technologically advanced and, many times, most expensive treatments, only to find their use does not help the patient. Treatment of wounds depends on applying the tried and true, evidence-based basics of wound care. If these fail to get the desired results, which unfortunately happens,^1,2 then advanced therapies can be tried; however, I can assure you that skipping the basics will result in an unsatisfactory outcome, even when using the newest and most advanced therapy.   In our work here and around the world, we have tried to point out the basics of wound care on which to build a foundation. These include 1) enhancing the systemic conditions of the patient, 2) protecting the wound from trauma, 3) maintaining the optimal moisture balance in the wound bed, 4) restoring the bacterial balance and completely debriding the necrotic and poorly functioning tissue, and 5) treating edema/lymphedema.^3,4 Although these may seem simplistic, in one form or another, they have been recommended for years, as noted by Schultz et al⁵ and, more recently, by Steven S. Gale, MD (unpublished data, 2012). Unfortunately, the message is often overlooked with everyone wanting to jump to the newest and brightest therapy. Just look at the programs of most educational meetings for wound care practitioners. There are topics on tissue engineered skin products, extracellular matrix products, interesting topical products, stem cells, and the like, but few lectures on basic wound care such as the techniques for adequate wound debridement, management of the wound bioburden, or determining appropriate moisture levels for the healing wound. We tend to forget that the basics must be mastered before one turns to these advanced therapies.   As we enter the “season of education” with all the fall wound care meetings approaching, I would encourage you to examine your own strengths and weaknesses regarding the basics of wound care and see how solid your foundation is. Once you have done this, you can outline your educational needs for the near future. I assure you that if you do provide yourself with a “firm foundation” with the basics of wound care, you will discover more successes in the treatment of your patients, and you will experience more success as you build on the basics with more advanced therapies.

References

1. Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. The accuracy of venous leg ulcer prognostic models in a wound care system. Wound Repair Regen. 2004;12:163-168. 2. Margolis DJ, Kantor J, Berlin JA. Healing of diabetic neuropathic foot ulcers receiving standard treatment. A meta-analysis. Diabetes Care. 1999;22:692-695. 3. World Health Organization. White Paper: Best Practice Recommendations for Wounds and Lymphedema Management. John M Macdonald, Mary Jo Geyer, eds. November 2007. 4. Treadwell TA. The Basics of Wound Care in Infants and Children. Presented at SAWC Spring, May 2012; Atlanta, GA. 5. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen. 2003;11 Suppl 1:S1-28.