• Two nurses at St Luke’s Hospital did not expect to end up specialising in wound care when they took up nursing
• Now they are helping to advocate the importance of introducing good wound care early
• It is estimated that at least 150,000 people in Singapore will be affected by chronic wounds each year
• The hospital is setting up a Lew Foundation Community Wound Hub to extend its expertise to the community
   

SINGAPORE — Tending to patients with rotting flesh and gangrenous skin ulcers is not meant for the faint-hearted. It is a task that most people would find icky, including some healthcare professionals and nurses who may not have the expertise or stomach for it.

Not Ms Kavitha Sanmugam and Ms Caroline Tan though.

Both have chosen to specialise in this area of healthcare and relish the challenge of tackling more complex wound cases such as those that do not heal — some so infected that they are crawling with maggots.

The nurses have no qualms removing their masks to smell the wounds.

“It helps us to assess and diagnose the wounds better. Certain types of wounds can have a particular odour. For example, bacterial wounds may have a fishy smell,” Ms Tan explained.

The 52-year-old is an assistant nurse clinician and Ms Kavitha, 32, is an advance practice nurse at St Luke’s Hospital in Bukit Batok. They are among the three dedicated wound care nurses there.  

Both Ms Tan and Ms Kavitha did not expect that they would end up specialising in wound care when they took up nursing.

Despite her aversion to blood, Ms Tan said that the satisfaction of watching the most horrific sores and ulcers heal under her care keeps her motivated.

In the early days as a nurse, Ms Kavitha recalled that she was taken aback by some severe cases she saw.

“Some cases were so complex that I often felt like the smell of the wound was following me home after work. I was a bit traumatised back then, but at the same time, I realised the importance of introducing good wound care early,” she said.

Chronic wounds are considered a significant health threat worldwide. In Singapore alone, it is estimated that at least 150,000 people will be affected by chronic wounds each year.

WHY WOUND CARE SKILLS MATTERS

The first community hospital in Singapore with a dedicated wound ward, St Luke’s Hospital sees 2,000 inpatients and 3,000 outpatients each year, most of whom have chronic illnesses.

The wound patients may have conditions such as diabetes, stroke or lower limb ulcers from arterial or venous insufficiency that arise from slow or poor blood flow and may be a complication caused by diabetes and heart disease. There are also patients who are admitted for treatment of surgical wounds.

As part of an initiative to enhance wound care in the community, the hospital started providing wound consultancy services from June this year.

The aim is to improve the quality of life for patients including those who are bedbound and wheelchair-bound in nursing homes or at home.

Last week, the hospital announced that it received a $1.5 million grant from the Lew Foundation, a charitable foundation set up in 2015 that supports institutions and non-profit organisations to improve the lives of the needy. The grant, to be disbursed over three years, will be channelled towards the set-up of the Lew Foundation Community Wound Hub.

The funding will enable the wound care team to extend its expertise beyond the hospital to the community as well as fund research work in this area.

Emphasising the importance of having more nurses with such skills, Ms Kavitha said: “There has been a rise in chronic diseases (such as diabetes) and with that, a rise in the complexity of wounds (related to these diseases) as well in our population.

“Having skilled nurses are critical because they would be able to craft treatment plans specific to the disease and patient.”

While registered or staff nurses are trained in basic wound care, more complex wounds are usually managed by those with enhanced training in the area.

As part of the community initiative, St Luke’s Hospital aims to train around 40 nurses from St Andrew’s Nursing Home in Taman Jurong on wound care techniques and best practices for different types of wounds.

These nurses would, in turn, train other nurses.

St Luke’s Hospital also plans to launch an onsite wound consultancy service with other nursing homes including NTUC Health Nursing Home in Geylang East and Chai Chee to build up best practices and skills in wound care management. 

WHAT KEEPS THE NURSES GOING

Without proper treatment, longstanding and non-healing wounds are prone to infection and cause not just physical pain but also significant psychological distress that could drastically reduce a patient’s quality of life.

Patients with chronic leg ulcers that do not heal for more than a month, for example, frequently experience negative emotions such as shame, embarrassment and loneliness. A 2017 report published in peer-reviewed journal Wounds found that they also had higher levels of depression and anxiety compared with healthy individuals.

Ms Kavitha and Ms Tan have witnessed such physical and psychological distress among some of the patients they treat.

One who stood out was a woman who had lived with an extensively infected foot wound for more than a year.

Ms Tan was tasked to provide home care for this senior who was referred to St Luke’s by another organisation that had trouble managing the complex wound.

By then, the woman’s toe was so severely necrotised (where cell tissues are dying) that it underwent an “auto-amputation” and dropped off on its own, leaving a gaping pus-filled wound.

After a few months of providing regular home care at the patient’s home, her wound managed to heal. It closed up and stopped oozing pus.

Recalling the patient’s relief, Ms Tan said: “She expressed that she was happy to be relieved after putting up with the odour, pain and discomfort every day.”

In the last months of her life, it gave her some comfort. “She regained her appetite and could stand up. Her family also expressed gratitude.”

Although the patient eventually died due to other medical complications months later, Ms Tan said that was one of the cases that had strengthened her resolve to do wound care after she did a mid-career switch from doing graphic and multimedia design work to nursing in her late 30s.

She underwent a two-year diploma in nursing course under the Professional Conversion Programme (PCP) now run by government agency Workforce Singapore. The programme was first launched in 2003 as the Strategic Manpower Conversion Programme before being renamed in 2008 as PCP for Registered Nurses (Diploma).

For Ms Kavitha, she also witnessed the positive impact of well-administered care.

“Along the way, my passion for wound care grew. I feel very honoured to be part of my patients’ recovery journey, from the start until their wound gets healed.”

Presently, the advance practice nurse is also taking part in ongoing wound care research, which is a key in the search for better outcomes for patients.

With the grant from private funding, St Luke’s Hospital can test new healing products and techniques, study patient care outcomes and look into cost-effectiveness of wound treatment.

When asked if the Covid-19 pandemic has affected how wound care is carried out, Ms Tan said that the team’s work in caring for such patients remains business-as-usual.

“We have continued to see patients, even those in home care, for wound management. The only difference, especially during the circuit breaker period (in April and May) when people stayed home, is that the nurses seeing the inpatients and outpatients were divided into different groups and they do not intermingle,” she said.

“Some patients and their families expressed concerns (over the potential risk of infection) during the early months of the coronavirus outbreak, so we would explain the precautions that the nurses take, such as taking down the travel history of the family members and patients we visit, and the use of protective equipment to set them at ease.”