Hi, I'm Mary Anne Obst. I'm the Complex Abdomen Specialist at Regions Hospital, a level 1 trauma center in St. Paul, Minnesota, and I've been a nurse for almost 40 years. And I've been doing wound care for the last half of my career. My first half I did ICU nursing and I was a flight nurse. But I really love wound care, so I'm just glad to be here talking about wound care stuff.

Yes, there are 4 stages of wound healing. Hemostasis is the first, which is really just stopping the bleed, and so that's all about the function of making a clot at the vessel site. In the surgical world, I work for a surgery team as a wound care nurse, we are wounding patients every day, right? I mean, doing surgery, debridement, hydrosurgery, that's very wounding to patients. And so we've become very efficient at this phase of wound care. And so we use different things, such as obviously the electrocautery. The surgeons can cauterize vessels that are bleeding. They can suture bigger vessels. We also have, we will take laparotomy towels and soak it in a concentration of epinephrine and saline and then lay that over the patient's wounds, just causing vasoconstriction where we put on the dressing after that. And the other dressing we use a lot of is an oxidized regenerated cellulose, which looks a little bit like cotton candy. And you lay it on the wound wherever the bleeding is. It's kind of ripped it apart and laid on the wound. And this will, it's almost like it's an external clot. So the cells come out of the body and then they attach to this product. And then you leave it in place. You don't take it up again. You just leave it there and put your dressings up and over the top. And what's nice about this product is also that it decreases the pH of the wound itself. And so that does encourage nonbacterial growth. And so it kind of is a win-win. So we do use a lot of that product as well. 

The second phase is inflammatory phase where, you know, the wound is a little bit hot and swollen, all of the cells of the body that are trying to heal the wound are rushing to the wound itself at this point. And I would say this is where the body gets confused the most. And I would say that a stalled wound will stall in this phase. And because this phase isn't a growth phase, it doesn't do much if it gets stalled in this phase other than make more exudate and delay healing. So you really want to make sure that you're moving past the inflammatory stage when it's appropriate. 

The third one is the proliferative phase, and this is my favorite phase if I could call one out. And I love to watch wounds contract and grow. I love when I take down a dressing and I can tell that it's really the underneath there. We do a lot of installation negative pressure at our facility, and so you can really see the difference in just a couple dressing changes. 

And then the last phase is the remodeling phase kind of where the collagen starts to get really organized and you have wound closure and a scar formation. In this remodeling phase, many times wound care nurses or wound care providers don't get to see the patients because they're healed. We definitely see our patients back for up to 18 months, so many times we get to see them. And I use a lot of the silicone sheets to decrease scarring and soften the scarring. Patients really like it. We have a full protocol on how they ramp up and how they wear them, which makes a big difference for some patients.

I think understanding when a wound is stalled, it takes a couple different things. And I'm not a really great charter, I'll just be honest with you. And so I do appreciate how important it is to document measurements. And that's part of the, I would say it's a dual-faceted method to know if your wound is stalled. A, you have to be watching your numbers, make sure that the wound is contracting appropriately, think like 25 % in the first month and by half by 4 months. And so you really need to document your numbers and take a look at them. And then the second is looking at the wound itself, you know, if you're having more exudate, if you're having more slough, if suddenly you have odor or you didn't have odor before, I think those are all good indicators that you probably have a stalled wound. 

So identifying the cause is a little bit about being a detective. Sometimes it's as easy as talking to your patient and saying like, hey, when you go back to the nursing home, are they changing your dressings this many times a week, 3 times a week, whatever. And a lot of times the patients will be like, “No,” or something like that. Or you'll say, at home, are you elevating your legs and they're like, “No.” So sometimes just a little bit of a patient interview. Another indicator or another cause that I would think about is infection. So having good cultures taken to identify if that is part of the problem. Understanding if you have a microbial overload on your patient. One of the things that we have now that we haven't had in the previous years is cameras that can actually tell us what the microbial load is for the wound and the skin around it, and honestly some of the pictures from some of those cameras it's amazing how much bacteria is on the skin all around the wound, and really making sure that you're not only washing your wound but the skin around it as well.

Yeah, biofilm is a community of bacteria that is protected by an extracellular matrix. That's very tough. It's like a tough dome that covers them. And what's kind of crazy is that even though we can't penetrate this biofilm with many of our antimicrobial washes and different techniques, the bacteria can still shoot out of it, and so if you have a biofilm starting in the corner of one of your wounds, it can keep spreading the bacteria and then covering itself with the biofilm so it can roll across your wound pretty quickly. 

We've started using some products like collagenase underneath some of our dressings if we're suspecting biofilm, because remember biofilm is not something that you can technically see. I think we've all read the literature that Dr. Greg Schultz put out about what biofilm is and that you really can't see it with the naked eye. You're really assuming it by the status of your wound itself. And so if you suspect it, sharp debridement is the gold standard, hydrosurgery is right behind it, and we do a fair amount of hydrosurgery with pure hypochlorous acid solution as the fluid in it, which I think works really well. Our team at the facility I work at just got certified for conservative sharp debridement, and so we are doing that bedside, and then we're just starting a new ionic-based debriding dressing, so I'll have to let you know how that goes, because I don't know yet, but that's some of the things we do, also coupling with installation negative pressure wound therapy. So if you suspect biofilm, you know, first is to get the biofilm up as best you can. And then the next thing is to really think about the dressing that you put on afterwards that can prevent it from regaining strength on your wound itself.

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