Frustration and Venous Ulcers

     Have you grown tired of treating someone and given up on him or her? Have you ever decided that treating a certain patient’s wound is just too much trouble? Recently, Dr. Tania Phillips and Dr. George Cullen wrote an article1 that is both enlightening and disturbing and should be required reading for all wound care clinicians. The article addresses the attitudes and experiences of clinicians who treat venous ulcers in the United States, Great Britain, and Germany. The researchers discovered that frustration was the general attitude among clinicians treating venous ulcers. As a clinician who treats many hard-to-heal venous ulcers, I certainly understand the problem. We want our patients to do well and show improvement. Several issues must be appreciated at this point, one of which is that a venous ulcer is simply a symptom of an underlying disease and is not the disease process. The underlying problem may be ambulatory venous hypertension or a disordered microenvironment due to edema fluid and unresponsive cells or an exaggerated response to minor trauma. The list could go on and on, but the bottom line is that a venous ulcer is the outcome of a cascade of a poorly understood, if not unknown, series of events occurring among patients with different risk factors. Why should anyone get frustrated treating a problem like that?!      Clinicians and patients alike must realize that since the venous ulcer is only a symptom of an underlying problem, a “cure” for the problem is unlikely. One may resolve the symptom (ie, the ulcer), but if the underlying cause is not treated it will most likely recur. Many times we are lax in having that discussion with our patients. They come to us for a “cure” for their ulcer; when the long-term results are not what we or the patient anticipate, frustration ensues. Phillips and Cullen point out that “the degree of frustration felt could also manifest itself in a dislike and even avoidance of these patients.”1 When clinicians fail to meet their own expectations and those of their patients, they want to avoid future embarrassment and may refuse to treat patients who have venous ulcers. This course of action is not beneficial to anyone.      Dissatisfaction with the available treatments for chronic venous ulcers was another factor. Numerous advances in venous ulcer treatments have been made in the past decade, but compression therapy remains as the primary treatment. Frustration with compression therapy may be universal. Although newer compression bandages and devices continue to emerge, the reliability of compression bandage application can be less than optimal. The sub-bandage pressure at the ankle for optimal compression and healing is defined as 35–45 mmHg pressure.2,3 A recent study demonstrated that only 9.5% of compression bandages applied by experienced wound care nurses were at optimal pressure.4 Clearly there is room to improve and optimize compression treatment.      Unquestionably, many problems wound care clinicians treat need better therapies. Instead of becoming frustrated and walking away, invest that energy into improving the treatments currently available and discovering new, more effective therapies. Is a clinician’s ego more important than helping patients? I hope not. Treatment of venous ulcers is a continuing challenge but should not be considered a hopeless situation. Let’s all work together to find the cause of this “symptom” and then the best treatment for the disease and the symptom.