A PT’s experience in the traumacenter leads to new breakthroughs.

Diane Merwarth, PT, CWS, thought she had seen it all, experienced it all, and conquered it all. From the simple skin tear to chronic wounds often associated with diabetes; from common burns to necrotizing fasciitis—the dreaded flesh-eating virus; and from calciphylaxis to traumatic wounds on multiple parts of the body.

But nothing in Merwarth’s 20-plus years of physical therapy/wound care practice prepared her for the trauma that lay before her eyes. A woman in her early 20s, the victim of a “crush” accident, was wheeled into the intensive care unit at Austin, Tex’s Brackenridge Hospital. Large wounds on each of her thighs would eventually force amputation—one at the pelvis and the other at the thigh. Then there was the massive soft tissue hole in her back that required a skin graft. Little by little, Merwarth and the “Brack” staff helped manage her massive wounds and prepare her for ultimate surgical closure. It was small consolation that she lived.

“She developed a fungal infection that wasn’t recognized initially, so seeing her lose body part after body part without us having control over it because her injuries were incredibly massive was very frustrating,” Merwarth recalls. “But she survived and is doing well. She’s in a wheelchair and is functional in the community.”

Traumatic Experience

In Merwarth’s world, successes often are measured incrementally. As a physical therapist/certified wound specialist (CWS), Merwarth gets up close and personal with the victim within 24 hours of the patient being jettisoned through the emergency department’s electric doors.

Talk about being on the front lines. Life and death often hang in the balance. Most surely, a patient’s future physical and emotional well-being may be highly influenced by the decision Merwarth and her staff make as they devote attention to each patient’s special needs or situation. Which, as strange as it sounds, is what attracted the Binghamton, NY, native to this highly specialized field of physical therapy in the first place.

“When I started out, I originally was looking into medical school,” explains Merwarth, a senior physical therapist and program coordinator for wound care at Brackenridge. “But I soon found I wanted to experience a one-on-one relationship with patients. I know it may sound corny, but it’s the independence we have to help people, and the ability to evaluate people and target exactly what they need.”

After entering the world of physical therapy, dealing with wounds on a daily basis was the furthest thing from Merwarth’s mind. “The first time I saw a wound, I said, ‘There’s no way I’m ever going to do that.’ ” But once she saw that there was a positive cause and effect to her action, her sights changed and her outlook brightened.

The large majority of wound care specialists today are hospital-based. Private-practice physical therapists might treat a small wound while working upper-extremity rehabilitation, but most are far from wound care.

“There are too many regulations, too many supplies that you need, too many standards involved with infection control, that it’s not cost-effective for someone in straight private practice to manage,” adds Merwarth.

Hospital Setting

Many new physical therapists develop a love for wound care while working as a volunteer at a hospital. In fact, volunteers make terrific aides because they already have cut their teeth on wound care, Merwarth suggests.

“I always remind our volunteers that wound care is just a small piece of what a physical therapist might do,” Merwarth notes. “But at Brackenridge, it’s a huge part of what we do. I think they need to see it, they need to ask questions.”

Questioning the physician, however, is another matter entirely. “In our facility, physical therapists provide care under the order of a physician,” Merwath stresses. “But as a wound-care specialist, if I am given an order that I feel is not in the patient’s best interest, is not the most cost-effective procedure for a given patient, or is contra-indicated, then it is my responsibility to discuss this with the ordering physician and work with him/her to revise the order.”

Making Merwarth’s specialty rewarding is that the physical therapy begins as soon as the patient enters Brackenridge’s trauma facility.

“We actually do the wound care,” she adds. “We have the anatomy and physiology in our education to be able to assess not only what the wound looks like but also the anatomical and physiological factors that contribute to the wound. It’s a matter of putting all those pieces together.”

Those pieces can be expensive, Merwarth admits. That’s one reason her facility continues to use gauze for its dressings even though most of the country has turned to more higher-priced wraps. Merwarth adds that because the majority of the patients her facility treats are either unfunded or underfunded, cost is a constant consideration.

Plus, she notes, “I’ve used lots of those new dressings and sometimes gone back to gauze because it works better. Gauze is cheap, and it’s easy for a patient to use.”

A Lifetime of Experience

A 1982 graduate of the State University of New York at Buffalo, Merwarth has spent the bulk of her working life at Brackenridge, which she says is, “either the busiest or the second-busiest level 2 trauma center in the country.” With a load that averages 60 to 65 patients a day, and cases spanning the medical spectrum, the most important aspect of treatment is getting involved as early as possible in the process.

“There’s definitely a benefit for us getting involved early,” insists Merwarth, a member of the Wound Healing Society and the International Society for Burn Injuries. “For example, with burns we have specific protocols. The sooner we can get in there and get them cleaned up, the quicker they can be in a position to heal.”

Merwarth admits that while the body “still heals at its own rate,” certified wound specialists often make the healing process less problematic. “We’re here to make sure the body heals at the fastest rate possible.”

Toward that end, Merwarth has helped spearhead the MultiDisciplinary Wound Management Clinic at Brackenridge. Created in 1998, the Clinic brings together a collection of medical professionals from different fields to discuss and suggest treatment for difficult cases. The once-weekly clinic includes a plastic surgeon, as well as occupational therapists, physical therapists, podiatrists, orthopedists, and nutritionists. The cases run the gamut from referrals from physicians unfamiliar with wound care to doctors who are getting unfavorable results with generally accepted modalities.

Extreme Cases

Patients seen in the clinic environment constitute the “atypical” cases. While Merwarth admits there’s no such thing as a “typical” case, the majority of her day is spent handling patients with diabetes-associated wounds, venous leg ulcers, and wounds common to burn victims.

Patients suffering from diabetes will usually have wounds on the feet, either because they have poor circulation or don’t have sensation in their feet. There also are physiological considerations, such as blood sugars, nutrition, and structural changes that are causing wounds either not to heal or to heal at a slower rate.

Venus leg ulcers are due to poor venous return in the leg, which is a product of either past blood clots or a failure of the calf pump mechanism. In these cases, the veins get lax and the circulation in the lower part of the leg becomes poor. The patient scratches his leg to relieve the discomfort and develops a wound. Common side effects include lymph edemas and arterial problems.

Not all cases are as easy to diagnose. Take the case of necrotizing fasciitis, or flesh-eating virus. More common than you think, the trick is for physicians to diagnose the ailment as quickly as possible.

“Once they get to us, we know what to do wound-care wise,” explains Merwarth, who has taught at Southwest Texas State University and Austin Community College. “But the diagnosis has to be made as early as possible; otherwise, the patient is at risk of dying. They have to have surgery, and they usually have to be on the right antibiotics to stop the process.”

WHERE DO WE GO FROM HERE?

Considered one of the country’s leading experts in wound management, Merwarth spends much of her time educating those just getting into the field. Recognizing when to change modalities is a challenge for most physical therapists, she insists.

The object of her education focus these days is on trying to get physical therapists to understand how important compression is on the lower extremities when dealing with edema. In fact, she teaches courses just on compression, because she often sees what can happen when patients have been misdiagnosed or improperly treated at another facility.

“As soon as we start putting compression, the wound starts to get better,” admits Merwarth, who also spent time as a physical therapist at the University of Virginia Medical Center. “The wraps have to be done right. You have to understand the physiology of the patient and the wound—whether or not they can have compression. It makes a huge difference in leg wounds.”

Just as a qualified wound care specialist can make a positive difference, an ill-informed or sloppy caregiver can have a negative effect on a patient. When this happens, it can take weeks, even months, to reverse the process.

“We’ve had so many successes, so many patients who came in looking like they were going to lose their foot and didn’t. Or there were really large wounds, and the patient was horrified they had a wound like this,” she adds. “And to see their amazement as the wound starts to heal, get smaller, and finally becomes a tiny scar. They go on with their life. That’s very rewarding.”

You can contact Diane Merwarth at dmerwarth@seton.org.

Dave Cater is a contributing writer for Physical Therapy Products.