Norman Levine, M.DA 64-year-old man sustained a burn to his legs from an exploding stove while vacationing in Mexico. He returned home a few days later and immediately consulted with his primary care provider who promptly referred him to one of the wound care centers in our community. The caregivers developed a rather involved (and expensive) treatment program which consisted of complicated and painful twice-daily dressing changes using various types of bandages over silver sulfadiazine cream. The patient was also instructed to follow up twice weekly with them. This program was both physically and emotionally extremely difficult for him and greatly interfered with his ability to work and to perform other important activities of daily living. They also discussed with him the prospect of admission to a burn unit for additional therapy at a facility 100 miles from his home.
He sought a second opinion from me after a few days of the regimen. On examination, I observed fairly extensive but superficial second degree burns with mild erythema and edema and no evidence of infection. Clearly the burn was not at all serious and probably never was a major medical problem. I elected to treat him with petrolatum under loosely fitting compression dressings for three days, at which time the burns were almost 100% epithelialized.
The point of this vignette is to demonstrate that we dermatologists are fully versed in caring for superficial burns, and more importantly, the wound care center industry is capable of over-treatment in a major way. The concept of separate wound care centers is a relatively new phenomenon. Without any solid data to support the following notion, I suspect that the proliferation of these clinics was in large part a function of the large profits to be realized by the chronic treatment of all types of wounds.
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Understandably, severe burns, deep decubitus ulcers or severe diabetic foot ulcers need the extra care that these facilities can provide. However, when routine skin injuries such as mild burns, skin tears, uncomplicated stasis ulcers and minor post-operative wound complications become a routine part of the wound care center purview and are no longer considered a part of what we dermatologists can do or wish to do, the dermatology discipline shrinks further toward a marginalized specialty. My plea to all is that we do not allow this to happen. I am aware of the fact that wound care services are often labor intensive and time-consuming. Wounds may never heal completely. Patients may become discouraged, frustrated, depressed and angry after months of treatment without tangible results. Guess what? That is part of the responsibility of being a dermatologist, and one of its biggest challenges. Caring for these patients can be extremely gratifying as well. Stasis ulcers do heal with simple Unna boot therapy and without proteolytic enzymes, expensive dressings and frequent invasive debridement that are the stock-in-trade of wound care clinics. Dermatologists can differentiate between inflammation and infection, which results in the patient being spared prolonged systemic antibiotic use.
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Perhaps the most important variable in this discussion is who is actually treating the patient. Many wound clinics are primarily staffed by physician extenders and virtually all of the home health visits as extensions of these clinics are made by nurses rather than physicians. At the risk of a gross generalization, dermatologists know more about skin wound issues and can use that knowledge base to better serve these patients.
I cannot begin to describe how grateful my patient was after learning that he did not have to continue his wound care as a semi-fulltime job. The nurses caring for him lacked the flexibility and background to understand what his real needs were. We dermatologists are able and should be willing to care for these types of patients. They will appreciate it.