Hannah Pugh29th August 2013
What is your background in wound care?
I have worked in trauma and orthopaedic environments ever since qualifying, and worked my way up through the ranks at various hospitals in London. I started off at Guy's Hospital in an elective unit, which performed planned surgery, and as a result, most of the wounds I was involved in were simple incisional wounds, which healed without complication 99% of the time. However, when I moved to the trauma centre at the Royal London Hospital, things changed. I found myself dealing with huge soft tissue degloving injuries, vascularised flaps, maggots, leaches and more! A big part of my role was also looking after patients with Taylor Spatial or Ilizarov frames, which bring their own soft tissue challenges.
What does your typical day look like?
Currently I work at The Princess Grace Hospital in London. As an orthopaedic clinical nurse specialist it quite difficult to describe a ‘typical’ day. For example, I have recently had some patients over from the Libyan conflict who suffered horrendous traumatic injuries. They have been left with non-unions, limb-length discrepancies, shrapnel and chronic infections that refuse to allow healing to occur. Taking care of these patients can be particularly challenging.
However, on another day I can have a list of patients having elective procedures with minimal wound care requirements. Every day is different which is one of the reasons I love trauma and orthopaedics.
Do you have one practice experience that taught you something valuable about wound care?
I think I have become much more aware of patient compliance and how this can affect wound healing and the end result. For example, a patient who had a horrific septic knee drained ended up with two large wounds that transcended several layers. We decided to use negative pressure wound therapy for exudate and wound bed management while clearing things up, in order that grafts or flaps could be applied when ready. However, the patient was a prolific smoker and despite lengthy chats about the delays to wound healing that smoking can cause, and the importance of not regularly discontinuing therapy the patient continued to smoke. There’s only so much you can do, and frustrating as that can be, sometimes that means changing your management plan to something you consider to be less effective, but is more likely to fit in with the patient’s lifestyle.
What is the most important piece of equipment or technique that you regularly use?
One of the biggest groups of patients I see are those undergoing limb reconstruction with external fixators, such as the Taylor Spatial or Ilizarov frames. Pin site infection is the biggest complication of limb reconstruction and much work has gone into best practice and evidence-based guidelines to work out the best solution for keeping things clean and free from infection. If pins sites become infected, the worse case scenario is that the wire or pin has to be removed. If this happens repeatedly then treatment may have to be discontinued which is a disaster for the patient. If there’s one product that has made a huge difference to practice it’s the use of alcoholic chlorhexidine, followed by keeping pin sites covered through the duration of treatment. In fact, care of pin sites almost mimics that of indwelling vascular access devices, and I think it’s easy to see why.
What one thing would make the most difference to your practice?
I am quite lucky in my current role that if I deem a certain dressing or device to be the most suitable for a patient, then I can usually get hold of it fairly quickly and without too much hassle. That has not always been the case, and has made a huge difference to my practice.
What piece of advice/practice would you pass on to other clinicians?
I think patients with large external fixators can be quite daunting sometimes, especially if you have not looked after them before, and I can imagine turning up at someone’s house to look at a dressing and being confronted with a huge five ring Ilizarov frame can be a bit of a shock. When I discharge my patients from hospital I always give them my contact details and explain that they are for the patient themselves, but also for anyone else who is going to come into contact with the frame. My advice would be if you have a situation like this then make use of your specialist nurses. Most will just be glad that you called, and often can make time for teaching and education. I recently saw a patient in outpatients whose community nurse accompanied them. She left feeling much more confident and will be able to transfer those skills to other patient’s undergoing similar treatment in the future.