Dr. William Marston is an assistant professor in vascular surgery at University of North Carolina-Chapel Hill. In his time there, he helped to create the UNC Wound Management Clinic, where he continues to be a practicing physician.
Wounds1: What made you decide that you wanted to pursue wound care as a specialty?
I choose wound care mostly out of necessity. When I finished my general surgery training and started to do vascular surgery, our clinic had quite a lot of patients that had diabetic foot ulcers or venous ulcers and the clinics weren’t focused on our treatment. This is not to say that patients were not receiving good treatment, but that they had a different person managing them every month. This was about the time that specialized wound centers were cropping up around the country, and it became clear to me that it would be better to treat those patients in an organized fashion. Choosing wound care was not something I set out to do, but I saw where people needed help and we needed to have a better system to manage them.
Wounds1: Traditionally, wound care has been left on the periphery of health care. Is there a movement to increase awareness about non-healing wounds in the health care community?
If you look at who has been focused on wound care over the years, it has not been physicians. There has not been a specialty of wound care, so from a physician’s standpoint this has not been their focus. People of all different modalities treat wounds but it has been primarily nurses who have specialized in wound care. Nurses have managed wounds very well, but for financial reasons and reimbursement reasons you need physician involvement. It is difficult enough to have a ptient with severe medical problem. It is even more difficult when you compound that problem, with another, such as a non-healing wounds. Wounds require a lot of manpower because they have a lot of issues surrounding them including their dressings, as well as teaching patients. You just do not have the time to do that in a clinic where you are seeing all kinds of different patients. So the critical thing about a wound clinic is to have nurses, therapists, orthotists, and physicians all working with the patients to give them optimal care.
Wounds1: What do you do for patients in the clinic?
Our clinic is an outpatient clinic and we a see a whole spectrum of patients and wounds. Typically the patients come to us initially and get a comprehensive evaluation of the medical problems causing their wound or involved in poor wound healing. Also, we evaluate the wound itself and determine what treatments will help heal it. That’s the medical aspect. The teaching and education aspect is just as important, and that goes on over a period of weeks. We like to see the patients weekly, but many of them travel a distance to the clinic, so we work it out with them to see them as often as they can, and reinforce the teaching every time they return.
Wounds1: At what point should a patient consult a wound care clinic as opposed to their regular doctor?
In general, if a patient has no other medical problems, an injury or a small wound is generally going to heal. Certainly every person who gets a small wound does not need to go to a specialist—the majority of them will heal with basic wound care. If a patient has a wound that doesn’t heal for a couple of weeks time or if they have diabetes, vascular disease or other medical problems, they should consult their primary physician and work with them. Usually their primary physicians will refer patients when they have not responded to their initial therapy.
Wounds1: Does any cut or scrape have the potential to become a non-healing wound?
Any minor wound in a patient with diabetes or peripheral vascular disease or other medical conditions has the potential to become a major problem. The most important thing for those patients is prevention. For a diabetic that has some neuropathy or some other problems with their feet, we certainly recommend they see a foot specialist at least every six months—just for prevention. But for somebody who is otherwise healthy, its pretty rare for a minor injury like that to become a non-healing wound.
Wounds1: What are some of the best things that people can do to prevent developing non-healing wounds?
The first thing is to use common sense. You wouldn’t believe how many patients we get every year here in the beginning of the summer, walking around barefoot on hot roads. They forget that they are diabetic, they do not have feeling in their feet and it’s a hot road surface. They get burns, so number one is just common sense. Patients should always wear their shoes, make sure they fit well, and replace them when they get worn. It is really worthwhile to invest money in your footwear if you have diabetes or other problems that place you at risk for foot problems. Unfortunately, that can be difficult for some patients. Thankfully in many areas now, Medicare reimburses for diabetic footwear, at least for a certain portion of the footwear, so we are better able to get those patients in good footwear. Otherwise, we recommend patients with diabetes inspect their feet at least two to three times a day, look for any abrasions or minor irritations. Sometimes it may just be a little pebble that gets in the shoe that they didn’t notice or some other problem that they can correct. For some patients, prevention is avoiding activities that place their feet at risk, and that’s very different for different people. Somebody that has a lot of foot problems in terms of bone changes and things can’t be very active, whereas other people can be normally active and not have problems.
Wounds1: Does the clinic focus upon diabetic foot ulcers more than other wounds, such as venous leg ulcers?
We see a large number of both and they are both very serious problems. Venous leg ulcers are more common, but the reason we are so focused on diabetic foot ulcers is that they much more commonly lead to amputation. Not to minimize venous disease—it is a common problem, and the ulcers are recurrent. The patients lose a lot of work time and activity because of them, but they don’t often lose the limb over a venous ulcer, unless there are other associated problems. Venous disease is a common problem and they have a lot of pain, and loss of social activity and everything else, but thankfully they don’t lose their legs too often.
Wounds1: What are some common mistakes people make in treating their own wounds?
You go to different parts of the country and there are different home remedies that people use. There are classic stories about people using potato skins or salt in the wounds—those sorts of remedies. Mostly we get people using things like peroxide and betadine and mercurochrome, and things like that. Those substances can be used in some limited circumstances, but the use of those in the long term is often detrimental to wound healing. So we will have a patient who will say they’ve been putting peroxide on their wound for six months—which got rid of the bacteria but it also got rid of any cells that could help the wound heal. So basically, there’s that and a lot of products out there that do not help. They don’t necessarily hurt, but they don’t help. So it really is important if you have a wound that has not healed in a normal amount of time, which for a small wound should be a couple of weeks, to see a doctor and get some advice.
Wounds1: What are the advancements in wound care, what direction do you see as the future of wound care?
Right now it is kind of an exciting time because we are starting to get some sophisticated new products and tools to help us heal wounds. I think we’re just at the very beginning of having more active wound healing products like growth factors and tissue substitutes. Before this we did not have anything other than products that prevented injury and allowed normal tissue to heal. Well, now we have and are starting to get products that may actually stimulate new tissue to grow in an active fashion. There’s a lot of research going on and I think within the next five to ten years we will have more of these products available and hopefully it will mean faster healing times and better healing rates.