The History of Wound Care from My Perspective
Part 7: Wound Caring Is More Than Wound Care: The Human Connection
While planning for the 1997 SAWC, the planning committee discussed the need to get the patient more involved in his own care and why so many were noncompliant (the term was still accepted in those days). Dr. Jeff Davidson, research scientist, began talking about the placebo effect on some patients and the Provider as a Placebo. The topic became our opening session for that year’s SAWC. Dr. Larry Scherwitz, Dr. Robert Roundtree, and Pali Delevitt presented “The Science of the Mind-Body Connection: The Practice of the Provider as a Partner and the Experience of the Patient… Healing from the Inside Out.” Dr. Scherwitz provided scientific information that validates the intricate relationship between the body and mind. He concluded his remarks, “When we understand what provokes the placebo response, we can use it to increase the power of our active treatment for healing our patients.” H. Benson (author of Timeless Healing: The Power and Biology of Belief) wrote, “There are three components of the healing response: Belief and expectancy on the part of the patient, belief and expectancy on the part of the caregiver, and belief and expectancies generated by the relationship between the patient and the caregiver.” Caregivers’ attitudes and relationships with patients can be key factors in positive outcomes.
The mind-body-spirit connection is not new. Plato and Socrates wrote about it centuries ago. Plato noted, “You ought not to cure eyes without head. Or head without body. So you should not treat body without soul.” Socrates wrote, “To treat the head by itself apart from the body as a whole is utter folly.”
Thus, incorporating the human connection and the mind and soul into the best practices we use in healing the body is an absolute must when providing wound care. It is how we approach wound healing and it is how we approach the SAWC — that is, we believe in the impact of face-to-face learning and the opportunities for colleague/peer interaction the Symposium provides, as well as the evidence-based research it proliferates. We use our whole being to learn about and provide care: our hearts, our hands, our minds. It is why we have been able to establish wound care, not just as an answer to a postoperative or disease-related adverse event, but as a subspecialty that cuts across every healthcare field and setting – and why the care we provide continues to improve.
1997 to 2012 and Beyond
Thank you for allowing me to reflect on my perception of the art of wound caring. I hope I have demonstrated the benefits of a sharing and mentoring relationship. I hope I have encouraged you to revisit the impact of mind-body-spirit connection and see yourself as a key intervention. Lastly, I hope that sharing my journey from “just do it” will encourage you to become grounded in evidence-based wound care. However, while striving for evidenced-based wound care, continue best practice until accepted research catches up.
We need to rely on more than tradition and sentiment to see wound care through the next 50 years. Our past is our strength, but tradition and sentiment no longer suffice. The wound care community must continue to carve out new programs, new research and, in a sense, become pioneers once again.
Part 6: Fostering and Nurturing Individual and Organizational Relationships
The Symposium on Advanced Wound Care (SAWC) was not the only wound care-oriented entity for long. During the same time frame, other groups were forming. The National Pressure Ulcer Advisory Panel (NPUAP) was a vision of the late John Whitney, President of Gaymar Industries. He had the foresight to involve Tom Stewart, PhD and Louise Colburn, RN, MS. The NPUAP was a not-for-profit organization dedicated to the prevention and treatment of pressure ulcers. The government already had established the Agency Health Care Policy and Research (AHCPR), which identified pressure ulcers as a major problem. The AHCPR gathered a team of experts to develop guidelines on pressure ulcer prevention and treatment. Many wound care experts (all familiar names) were involved in both organizations. I was fortunate to be a panel member of the NPUAP. Some of the founding members were Patricia Goode, MD; Davina J. Gosnell, PhD, RN, FAAN; Diane Krasner, PhD, RN, CWOCN, CWS, BCLNC, FAAN; Steven I. Reger, PhD, CP; George Rodeheaver, PhD; C. Andrew Salzberg, MD; Joseph A. Witkowski, MD; and George Xakellis, MD, MBA.
Meanwhile, I had been trying desperately to get a research arm to further legitimize the Symposium and attract a multidisciplinary group of scientists and clinicians. After 10 years of coercion, Dr. Eaglstein, from the University of Miami Wound Care Institute, agreed to a joint conference with HMP. In 1991, the Medical Research Forum on Wound Repair was born, bridging the gap between clinical experience and research. We knew we needed to be grounded in research and realized that reimbursement follows research — ie, unless the wound care community can prove the product/technique is research-based, the government will not reimburse for the use of the product or device.
April 7, 1991 marked the first linking of a major wound research meeting with a clinical wound care symposium. At this first meeting, the Research group brought 30 faculty members presenting papers at the forum, along with 83 poster presentations on view throughout the meeting. Registrants of the Medical Research Forum were welcome to attend any session and events of the SAWC. The hope was that the juxtaposition of these two meetings would result in informal intellectual and social networking among people whose normal professional lives most often preclude such broad contract. To this end, we encouraged participants of both meetings to meet and get the latest news from their usual colleagues, as well as to attend sessions and events to meet people from among the full assembly of scientists, physicians, nurses, therapists and industry representatives.
Following one of the SAWCs, Dr. John Boswick and some of the members of the SAWC Planning Committee discussed the success of the Symposium and the importance of supporting relationships; about what the caring, sharing, mentoring, networking meant to each of us; and how we had all grown because of the support such relationships provided. Dr. Boswick was a well-known burn surgeon and one of my advisors. He was an early link between the WHS and SAWC, a great educator, and an early advocate of the multidisciplinary approach to wound care. We talked about the love and camaraderie we felt for each other. We kidded one another about the possibility of presenting a demonstration of the mentoring process. Thus, “Women Who Run With The Wounds” was presented at the next SAWC. What a memorable experience — colleagues helping colleagues grow and achieve. We invited the participants to share their personal experiences with mentoring and distributed our Wonder Women Shirts.
The birth of the AAWC. Our confidence in our mission to educate, inform, and validate the role of wound care providers grew by leaps and bounds. SAWC planners were fulfilled by the response to the way we were engaging people in our goals. We knew we were part of the biggest and best wound care conference in the country. But something seemed to be missing. With the encouragement and support of HMP, and industry, a group of like-minded colleagues gathered to discuss the idea of a multidisciplinary wound care community that would work together, regardless of the extent of experience or type of degree, and contribute to better wound care and research. In 1997, the American Association for Wound Care (AAWC) was born. Anyone interested in wound care could be a member of the organization. The AAWC was an organization and SAWC was a separate wound care conference already established by Health Management Publications, Inc. The adage “Imitation is the highest form of flattery” proved true: the following year, under the direction of Dr. Gary Sibbald, the Canadian Association for Wound Care (CAWC) was formally established. Wound care as a subspecialty had arrived! Enjoy some of our promotional efforts.
Part 5: A Conference is Born
Walking the Exhibit Hall at one of the IAET Conferences in the 1980s, I saw a booth featuring Health Management Publications. The journal Ostomy Management was on their tabletop, the very journal in which I had published an article on fistula care. The publisher, Harry Hurley, and I sat down and talked. He asked me where I thought the organization was going. I told him about my dream to have an advanced wound care conference. We kept in touch. Within 2 years, we were planning the first Symposium on Advanced Wound Care (SAWC).
1988 was a very special year: I accepted the position of ET Nurse at Kaiser Hospital, Bellflower, CA to establish the Ostomy and Wound Care Service, and the first SAWC was to be held in Long Beach, CA. Over the years, the service went from a nurse-run clinic to a full-service multidisciplinary wound care center; over the years, the SAWC went on to become the premier wound care conference in the nation, if not the world.
The SAWC planning committee consisted of ET nurses, close friends full of passion and enthusiasm committed to the care of wounds. We handpicked two senior advisors to help us: Dr. George Rodeheaver, Director of the Plastic Surgery Research Department, University of Virginia School of Medicine; and Dr. G. Allen Holloway, Jr, Department of Surgery, Washington School of Medicine. They were instrumental in program design and speaker selection.
We chose Long Beach, CA for our first SAWC because it was in the planning committee’s back yard and we knew we could generate an audience of interested clinicians. The dates were April 10–12, 1988. If my memory serves me correctly, the cost was $100. We provided CEUs using my California CEU Number: Nurses were awarded 13 contact hours for attending the conference and physicians were awarded 13 Category 1 units from the medical education department of the University of California School of Medicine, San Francisco (thanks to Dr. TK Hunt’s connections).
Fifteen sessions were planned. Many of the topics discussed are still addressed today: “Chronic Wounds: National Overview,” “Pathophysiological and Cellular Activity in Chronic Wounds,” “An Environment for Healing: The Role of Wound Coverings,” “Bedsores: Patient Rights, Professional Obligations.” The Grand Opening Cocktail Party in the Exhibit Hall with our 24 supportive vendors was a highlight. We were such a close wound care family at that time. Most everyone knew each other. It was such a high for all of us on the planning committee and the vendors that supported us by supporting speaker expenses or exhibiting at the conference. We could never have had such a successful conference without the financial and educational support of industry.
The conference was a tremendous success. We had approximately 500 attendees come from across the country and abroad. Once again, people were sitting on the floor and in the fire lanes. It was so exciting to think so many dedicated people were willing to take the time to learn more about wound care.
We decided the SAWC was a “go,” and as such it became a much-anticipated, much-respected annual spring offering… so much so that now there are two Symposiums every year.
Part 4: Sharing and Validating What I Was Learning
I began to write and share my experiences on my own. I even was asked to share my experiences from the podium at various wound care conferences, where I often spoke about wound debridement, moist wound healing, and advanced wound care dressings. It was a huge honor, with one major hitch: at almost every program, I either preceded or followed academic nurse researcher, Diane Cooper. She was so intimidating! She would always say, “Your care must be grounded in research.” Yet, there I was, sharing my “just do it” stories — there were no randomized, double-blinded studies on what I was doing. And still, wounds were improving or healed. I was proof of the value of sharing case reports.
Deciding to do a literature search to support my approaches to care, I found some information in a widely read publication: the National Inquirer. The story was titled, “A Dying Marine’s Wounds Healed by Mysterious Powder.” The article went on to say, “After all kinds of medical and surgical interventions were tried without success, Gladys Wallace, an RN at the VA hospital, used Karaya Powder on the Marine’s wounds and they healed.” Eureka! That was the powder we as ETs had been using on irritated skin for years. The information may not have come from a scientific journal, but as Dr. Treadwell noted in his June editorial in WOUNDS, information can be obtained from expected and unexpected places.
In the early ’70s, I was among the first 150 ETs in the country. The ET specialty embraced a very small but close group of colleagues. We knew each other through our International Association for Enterostomal Therapy (IAET) Journal and through conferences. We shared and networked readily. In 1974, Katherine Jeter, ET and I chaired the first IAET Conference in Southern California. It was a tremendous success. Attendees had to sit on the floor and in the fire lanes. We were ecstatic.
I was very active in the IAET and became vice president in the late ’70s. Throughout my ET career, I had worked with more wounds than ostomies. I was anxious to get a wound care tract presented at our IAET Conference. At that time, the organization was not quite ready to branch out, so Katherine Jeter, Donna Goupil, and I established an educational business called Dynamic New Dimensions in Healthcare. We developed a program and slide presentation about pressure ulcers and took it on the road. We found many nurses across the country doing what we were doing in wound management; it was validation for both the audience and us as educators. Gerrie Cameron, one of our ET colleagues, had just published an article on prevention of pressure ulcers using Stomahesive. More fuel … more experience- than research-based, but published.
Still, I wanted to “legitimize” my best practice, to find support for how and why I was using products. I came across some articles written about occlusive dressings by a group in Pittsburgh, PA that included Dr. William Eaglstein. A new product, DuoDerm Hydroactive Dressing, was being introduced. Lo and behold, it was from the same company that made Stomahesive. It looked a lot like Stomahesive as well. Turns out, this shouldn’t have been a surprise: Stomahesive was the precursor to this new product. Now I had the research I was looking for. I contacted Dr. Eaglstein, asked him about his experiences with occlusive dressings, and told him what we were doing. I called him often, and I became very familiar with his staff at that time, Patricia Mertz and Oscar Alveraz. I was so excited. At last I found research colleagues in wound care.
Part 3: Products and Partners
Some challenges exist regardless of experience. Just like today, in my early years of practice we had difficulty getting products. Early on, I learned to barter with the company representatives — education for products. I would take the reps on patient rounds, and they would tell me where and how their products worked and give me samples.
One day, an enthusiastic rep came in with a story about this fantastic new product, OP Site from Acme United. He showed me a video on how this transparent film was used; the results obtained looked incredible. I asked him to leave some samples for me to try. Not long after, I was making patient rounds, and I could smell that Pseudomonas odor wafting into the corridor. I was escorted to the patient’s room, where I found a little woman, curled up in the fetal position, drenched with wet, odorous dressing and linen. She had open wounds all over her body. I wanted to cry, but I used the Op Site Dressing samples to cover her wounds. The staff and I felt so good that she was clean and dry and could rest with dignity. I checked back a couple of hours later to see if she remained dry. She was, but to my surprise, in that short period of time, one of the dressings was half full of wound fluid.
I called the dietitian, who said she had never seen wounds and drainage like that before. We became a team. Together we would do walking rounds on the patients, and she would write the suggested nutrition needs.
On another occasion, I was called to the surgical clinic by one of the doctors. When I arrived, he was debriding yellow slough from a man’s leg wound. He asked me if I had any ideas for a dressing for this patient who was always wet and smelly. The patient was at home, ambulatory, and leaking constantly. Again I turned to the Op Site, covering all the open leg wounds. I was nervous about the treatment, because I had not worked with leg ulcers before and really didn’t know if I was suggesting the right thing.
The patient came back every day for a week. We inserted a needle into the dressing and aspirated out fluid and sent it to the lab for analysis. The wound was loaded with organisms, but not enough to overwhelm the patient. He showed no signs of infection. Within 3 months, the wounds healed. My successes led to my moniker: “Queen of Wounds” at HGH. Even the doctors were beginning to see the results of moist wound healing. Reaching out for more product information and reaching out for the help of my colleagues was a professional and personal triumph.
Part 2: The Healing Touch
With my mentors championing my efforts, I embraced my 6 weeks of training at the Cleveland Clinic. When I returned to work at Harbor General Hospital (HGH), I gave it my all. I was so passionate and enthusiastic about my new role and planned to implement everything I had learned. With Dr. Benfield’s (the Chief of Surgery) guidance, the enterostomal therapy (ET) service was established. He taught me to share our experiences so others might benefit. He encouraged me to write down our journey. He instilled pride in what we were doing. He showed me the importance of working as a team and encouraging others.
A prolific writer, Dr. Benfield documented our experiences and submitted manuscripts to various publications. We wrote an article together for the Archives of Surgery. When it was published, the issue cover had our names on it. I just couldn’t believe it! I brought the journal to my mother, who was in the hospital preparing for colon surgery for polyps. Unfortunately, when I showed her the publication, she thought it was my way of telling her she was going to have a colostomy.
HGH was a trauma center. Our patients were very sick with many complex conditions, many with draining wounds and irritated skin. It was so difficult to see the agony and pain those patients experienced. I would do everything I could to keep them clean, dry, and comfortable. If we didn’t have a pouch big enough to fit the wound, I went to the Central Supply Department to find the plastic they used to wrap instruments for sterilization and then use the heat sealer to make a pouch. Because one patient had so much drainage from his fistula, we devised a way to hook up suction. This patient went home with a fistula in the base of this wound defect. With Dr. Benfield’s support, we had a dental technician help me design a faceplate for this man. And it worked.
Through all these experiences, I learned that I had healing hands and a healing touch as I created containment devices and placed them on the patient’s body. I realized how important I was to patients and how my attitude, words, or actions could influence their healing. I was part of the human connection. I was there to support them during difficult times, instilling the belief that together we could see positive outcomes. I was providing interventions, with no thought of giving up. I attended to the whole patient, not just his wounds. I was practicing holistic care.
Dr. Benfield and I continued to document and publish our experiences. At the time, I did not realize all that Dr. Benfield was doing for me, as a mentor, teacher, role model, colleague, and friend. I just thought he was my boss. How fortunate I was to have been his mentee.
What were some of your more creative “early” approaches to difficult-to-treat wounds? Who would you consider your mentor and why?
Part 1: The Very Early Days
This year is the 25th Anniversary of the Symposium on Advanced Wound Care. As founder of the Symposium, I thought it would be fun to reminisce (walk down memory lane) through the early beginnings of our wound care community and offer a different (ie, personal) perspective — after all, of the 51 years I have spent caring for patients, 40 were in wound care. It’s been a journey of growing and mentoring, of the human connection and healing hands, of collaboration with each other, and of moving from “just do it “wound care to best practice and evidenced-based care.
I realize this is a community effort; my attempts to acknowledge all the significant people and events may fall short. Please accept my apologies. And also, please accept my gratitude. I am not alone in my nostalgic journey —the wound care community is a multidisciplinary group, and a number of colleagues in a variety of disciplines have agreed to share their take on the early years in wound care. I hope you will identify with me and take this opportunity to see that my story is our story. We invite your comments and responses to the questions at the end of each blog. Together, we can paint the portrait of wound care as it was… and as it promises to be.
Part 1: The Very Early Days
I graduated from nursing training in 1961 from Sister’s of St. Joseph, School of Nursing, Grand Forks, ND. That’s what they called it then — “nursing training.” After graduation, I began working on the surgical unit at St. Michael’s Hospital in Grand Forks. I can remember clearly how back then nurses didn’t change the first dressing after a surgical procedure; we would draw a mark around the edge of the stain and wait for the surgeon to change the dressing. The dressing was changed using a sterile technique. If there was an open wound, it was packed with betadine-saturated dressings.
In the late 1960s, I began working at Harbor General Hospital (HGH), in Torrance, CA, on the surgical service as an assistant head nurse on my way up the administration ladder. One day, the Chief of Surgery, Dr. John Benfield, came on the unit and asked me if I would like to be the enterostomal therapist (ET) of HGH. I asked, “What’s that?” He told me it would be someone skilled in the care and management of patients with ostomies. Around that time, we had a woman on the unit who had a colostomy right in the middle of her open wound. Every time she moved, the colostomy would drain right into her incision. The only pouch we had in the hospital was a Karaya pouch that didn’t fit her stoma. We couldn’t keep her clean and dry. It was devastating for both the patient and staff. Determined to learn how to help, I went home and talked with my family about going away to school for ET training. I attended ET School at the Cleveland Clinic in Cleveland Ohio and was taught by the “Father” and “Mother” of ET, Rupert Turnbull, MD, and Norma Gill. Norma was one of Dr. Turnbull’s patients. He recognized her commitment and enthusiasm and hired her to teach his patients about living with a change in body function.
Through my training, I learned to deal with issues such as peristomal excoriation. I saw, much to my surprise, that by placing a pouch with a stomahesive flange over the irritated skin and leaving it in place for 5 to 7 days, the skin under the flange would heal. We used the phrase, When you seal, you heal. This was my introduction to moist wound healing with occlusive dressings. I became an ET in 1972.
Readers: When and where did you receive your wound care training? What was the impetus for your specializing in wound care?
–Evonne Fowler, RN, CNS, CWOCN