Managing Non-Healing Wounds in Rural Areas

How would you define a chronic or non-healing wound?

Chronic or non-healing wounds are those wounds that do not heal, heal very slowly, or they heal but recur soon. Wounds are described as discontinuity of skin or normal covering tissue that occurs due to a variety of causes.

How long does a normal wound take to heal?

The normal healing process has the following stages (1):

1. Inflammatory stage: Here, the surrounding blood vessels first constrict to prevent blood loss. Platelets that are found in the blood gather to form a clot and a temporary covering over the wound. The blood vessels then expand and cover the wound, and more white blood cells collect there to take care of the infection. The skin cells then start growing and start covering the wound from the sides.
2. Fibroblastic stage: In this stage, the collagen fibers start growing. They extend from one end to the other and shrink as they grow, and attract new blood vessels.
3. Maturation stage: Here, more collagen and blood vessels are added. Remodeling occurs, depending on the need and stresses that act upon the wound.

How long do these stages take?

There is significant overlap, as the stages are not clearly demarked. The rule of the thumb is that the inflammatory stage lasts for about two to three days, and the fibroblastic stage about one to two weeks. The maturation stage could go on for two years or more.

Another thing to remember is that it takes about 48 hours to form a temporary seal, so that infection from outside does not get in, and it takes about 10 days to have fifty percent of the strength of the scar, and three months to achieve 80% of the strength. Generally, wounds that last longer than three months are considered non-healing or chronic (2). Another definition is that chronic wounds are those that do not improve after 4 weeks and do not heal in 8 weeks (3).

What are the barriers to wound healing?

The following are some of the factors that contribute to poor wound healing:

1. Dead tissue: This, along with presence of foreign bodies, are the most common causes of poor wound healing. Dead tissue could be skin, bone, etc. Maggots are sometimes seen in the wounds.
2. Infection: This is another common cause. Most of the bacteria that cause infection get in during the first 48 hours, and hence, it is important to keep the wound covered and cleaned, so that infection does not occur during this period.
3. Bleeding: Continuing bleeding keeps the edges open and makes the wound more prone to infection.
4. Mechanical damage: Those who are immobile are prone to pressure sores.
5. Medical conditions: Diabetes, anemia, lower immune status, vascular disorders, etc., impair wound healing significantly. Leprosy or Hansen’s disease impairs sensations and is often associated with non-healing wounds.
6. Age: Wounds take a longer time to heal in the elderly.
7. Smoking: This interferes significantly with wound healing and also increases the chances of complications.
8. Varicose veins: They restrict blood flow and impair wound healing.
9. Dryness: Most of the cells involved in wound healing require some moisture, and hence, dry legs are often a cause of poor healing.
10. Presence of chronic infection: Some chronic infections, like tuberculosis, would prevent wounds from healing.
11. Presence of underlying causes: Fistula that is connected to the bowel passages would prevent the wounds from healing. Similarly if the source of infection is inside the body, they would prevent the surface wounds from healing.
12. Presence of cancer: Rarely, chronic non-healing wounds can become low grade cancers.
13. Diet: Poor nutritional status, especially low iron, zinc, Vitamin C, proteins, etc. can contribute to poor wound healing.

What should be done with non-healing wounds?

When there are non-healing wounds, blood tests are carried out to rule out diseases like diabetes, anemia, etc., and if these are normal, then tests for immune diseases are carried out. In addition to the local treatment of the wound, control of diabetes is very important.

The following are the available treatment modes for the wounds (4):

1. Radical debridement: There are lots of local causes for poor wound healing, and hence, debridement under anesthesia is carried out. Here, all the dead tissue and foreign bodies are removed, and the wound is thoroughly cleaned.
2. Antibiotics: These are necessary if pus is present, and cultures could help in identifying the correct antibiotics to use.
3. Mechanical offloading: This helps in reducing the pressures and can involve devices or just simple things like elevation (4).
4. Modern therapies that are available: The following are modern therapies that are available:
   1. Collagen
   2. Biological dressings
   3. Biological skin equivalents
   4. Keratinocytes
   5. Platelet derived wound healing factors
   6. Platelet rich plasma
   7. Intermittent pneumatic compression therapy
   8. Negative pressure wound therapy
   9. Electromagnetic therapy
   10. Hyperbaric oxygen therapy
   11. Topical oxygen therapy
   12. Ozone oxygen therapy

Just the fact that so many hi-fi sounding therapies are available should imply that none of them are very effective or so much better than the others. However, the common denominator is that these are not commonly available and would be very expensive.

What to do in rural areas?

The radical debridement, of course, could be carried out anywhere and would need to be very meticulous in rural areas, as frequent visits to the operating room might not be cost-effective.

Low-cost vacuum therapy has dramatically changed the outcome of treatment of non-healing wounds in rural areas (5, 6, 7). This helps by increasing the blood flow to the wound, removing the unwanted materials from the wound and decreasing the swelling around the wound.

A modified low-cost vacuum therapy unit (8) could be used at a later stage at home, to continue the treatment. Once good granulation tissue forms, skin grafts help to cover the open wounds.

What are the facilities available at SEESHA?

At Karunya Community Hospital, at ICC hospital in Coimbatore, the Bethesda Hospital at Aizawl, Sielmat Christian Hospital at Churachandpur, Family health hospital Dimapur and other places where the SEESHA health care team provides surgical camp and diagnostic camp facilities, the treatment modes mentioned above like the radical debridement and low-cost topical negative pressure therapy are available. A separate dedicated team takes care of the wound management at the Karunya community hospital, thus improving the results. Various herbal and other medicines incorporated into dressing materials and 3-D printer enabled medicine incorporated dressings are available too.

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.