Vacuum-Assisted Closure of a Wound

Wound VAC Process, Benefits, Side Effects, Complications, and Cost

Vacuum-Assisted Closure of a Wound | Johns Hopkins Medicine

Vacuum-assisted closure (VAC) is a method of decreasing air pressure around a wound to assist the healing. It’s also referred to as negative pressure wound therapy.

During a VAC procedure, a healthcare professional applies a foam bandage over an open wound, and a vacuum pump creates negative pressure around the wound. This means the pressure over the wound is lower than the pressure in the atmosphere. The pressure pulls the edges of the wound together.

Most clinical trials on people and animals have found that VAC for wound healing is equally or more effective than conventional wound closing techniques. VAC therapy can help healing in several ways, such as reducing swelling, stimulating the growth of new tissue, and preventing infections.

In this article, we’ll examine how VAC helps wound healing. We’ll also look at the benefits of VAC therapy and answer some common questions you may have about this technique.

VAC gained popularity as a wound treatment option throughout the 1990s and 2000s. This type of wound treatment might be suitable for people with the following conditions:


A retrospective review looked at the effectiveness of VAC for children with burn wounds or soft-tissue trauma.

The researchers found a link between third-degree burn wound size and the number of VACs received. They concluded VAC could be a safe and effective option that doesn’t cause excessive discomfort in children.

Cesarean delivery (C-section)

VAC may help prevent infections after giving birth via cesarean delivery (more commonly known as a C-section).

A review of studies looked at the effects of VAC in women with obesity who were at a high risk for developing wound complications. Overall, the researchers found that VAC seemed to be able to decrease the number of infections and complications.

Traumatic and surgical wounds

VAC might be useful in the healing of traumatic injuries and postoperative wounds.

One review concluded that VAC has the potential to reduce infections after surgery. It also found that VAC may be more cost effective than traditional treatment options when hospital costs are taken into account.

Pressure ulcers

Pressure ulcers are sore skin spots caused by continuous pressure. VAC may be a suitable treatment option in some cases.

One study looked at the use of VAC to heal a patient’s ulcer. Using VAC healed the ulcer in 6 weeks at half the cost of reconstructive surgery.

Types of wounds not suitable for VAC

VAC is suitable for a wide range of wounds. However, some types of wounds aren’t suitable for VAC. These include:

  • wounds near joints that may reopen with limb movement
  • cancer tissue
  • infected wounds
  • exposed organs or blood vessels
  • fragile skin
  • areas with poor blood flow

A VAC therapy system includes a vacuum pump, a special bandage, a canister to collect fluid, and tubing.

A healthcare provider first fits a layer of foam dressing over the wound, which is sealed with a thin layer of film. The film has an opening that rubber tubing can fit through to connect to a vacuum pump.

Once connected, the vacuum pump can remove fluids and infections from the wound while helping to pull the edges of the wound together.

A person undergoing VAC therapy wears the device for close to 24 hours per day while they’re healing. The optimal level of negative pressure seems to be about 125 mm Hg for a duration of 5 minutes on and 2 minutes off.

Share on PinterestHere a wound vacuum is attached to a wound that goes down to the muscular layer. The foam and the negative pressure promote wound healing.

Does using a wound VAC cause pain?

When VAC therapy starts, you may feel stretching and pulling around your wound. VAC therapy shouldn’t hurt, and if it does it can indicate a complication.

Many people experience discomfort when VAC bandages are changed. In some cases, a medical professional might administer pain medication 30 to 60 minutes before changing the bandages.

Wound VAC has the potential to be a cost-effective treatment option to help treat various types of wounds. Potential benefits include:

  • decreased swelling and inflammation
  • decreased risk of bacterial infection
  • increased blood flow to the wound
  • decreased overall discomfort
  • less changing of wound dressings compared with other treatments
  • gentle pulling together of the wound’s edges

VAC therapy is generally safe, but complications can occur. One study presented two cases of people who developed sepsis and hemorrhage after having VAC therapy for burns.

Other potential complications include bleeding, bacterial infections, and a lack of wound healing, which can lead to more invasive treatment methods.

Some people undergoing VAC therapy may develop enteric fistula, a condition in which the skin and intestinal tract becomes abnormally connected.

Another possible complication is macerated skin, which is the softening and breaking of skin around the wound due to moisture.

One retrospective analysis looked at the treatment costs of VAC at the University of Chicago Medical Center between 1999 and 2014. The researchers estimated that the average price of VAC therapy was $111.18 per day.

Most insurance policies, as well as Medicare, cover at least part of the cost of VAC therapy.

VAC therapy can be performed in a doctor’s office or in a medical facility.

You may also be able to have VAC therapy at home depending on the size and location of a wound. Your surgeon will determine if it’s suitable for you to continue VAC therapy at home.

The length of time the procedure takes varies widely on the size and location of your wound. Your doctor should be able to give you an estimate for how long you’ll undergo VAC therapy your wound.

Living with a wound VAC can cause challenges to your daily life, but understanding what you can and can’t do while undergoing treatment can make treatment easier.

Can you shower with a wound VAC?

It’s possible to shower with a wound VAC by disconnecting the VAC system. (Note that you shouldn’t leave your VAC system unplugged for more than 2 hours per day.)

It’s not a good idea to take a bath with a wound VAC, however, because sitting in water can expose your wound to bacterial infections.

Wound VAC dressing change frequency

VAC bandages should be changed two to three times a week. If your wound gets infected, the bandages may need changing more often.

Who changes the VAC dressing?

Usually, a healthcare provider will change your bandages. In some cases, a family member or a caregiver can be trained to change your dressing.

VAC therapy uses pressure to help close wounds and increase healing. It can be used for a variety of wounds, such as those caused by burns, cesarean deliveries, and traumatic injuries.

You generally don’t need to prepare in advance for VAC.

If you’re undergoing VAC therapy, ask your doctor any specific questions you may have about your wound healing.


Simplify dressing use by categorizing products

Vacuum-Assisted Closure of a Wound | Johns Hopkins Medicine

There are thousands of choices of products to dress patients’ wounds. So how does an agency teach its nurses which to use and recommend? At Johns Hopkins Home Care in Baltimore, nurses have focused on a few categories of important wound care products and learned to look for the best alternative to the traditional gauze and saline order given by physicians.

The need for more potent alternatives stems from the difference between wound care in a hospital setting and under the very different conditions of home care, explains Brenda J. Hensley, MSN, RN, CETN, clinical nurse specialist at Johns Hopkins Home Care. She says hospitals are sending home patients earlier with more complex wounds that can take longer to heal.

“We’re doing more extensive surgeries on people who are more and more debilitated, compared to maybe 10 years ago,” she says. “Of course, the older you are and the more compromised you are, the more difficult and slower the healing process.”

Meanwhile, she says, hospital physicians are not always as knowledgeable about the more technologically advanced — and substantially more expensive — wound care supplies now available. “At the hospital, you have a wonderful nurse who goes to change dressings three times a day.

You also have medical residents and interns, and they all want to look at the wounds. The newer products are designed not to be changed very often, so if you’re in a hospital, it’s not going to be cost-effective to use these dressings.

They don’t have a reason to use them [in the hospital], so they don’t know that much about them.”

But in home care, where a nurse’s time is at a premium, the added expense of the newer dressings can be more than offset by the savings due to fewer visits.

Most importantly, Hensley says, the use of newer dressings can actually help wounds heal more quickly. “Wounds heal faster when the dressings are changed less often. The less you disturb them, the faster the cells can regenerate.

It makes sense, if you can maintain a good environment, to only change them two or three times a week.”

At Johns Hopkins Home Care, all new employees take a three-hour wound class. The agency also has a trained group of resource nurses, including one on each of its geographically defined teams.

Those resource nurses receive an extra one-hour training session every month.

The program consists of case studies and product reviews, so the resource nurses can go back to their regions and serve as a resource for other staff.

At the next level of training are six certified wound, ostomy, and continence nurses (WOCN), wound care specialists such as Hensley who meet monthly to sort through the vast array of new products on the market.

“We are introduced to new products in different ways,” she says. “In our system, we have an outpatient wound healing center. That’s all they do is treat chronic wounds.

They get a lot of the newer products, and we get them and try them that way, too.”

Some successful products are added to the agency’s inventory. Others are dropped after proving to be less than effective.

When teaching nurses to deal with different wounds of varying complexity, the agency has tried to reduce the number of dressings to four major types that Johns Hopkins Home Care calls its primary dressings:

• The gauze and saline combination typically ordered by physicians.

Calcium alginate, which Hensley says is the most common dressing recommended for home care patients with draining wounds such as pressure ulcers and surgical wounds. She says the seaweed-based dressing absorbs 10 times its weight in wound drainage while lowering the pH in the wound bed, which retards the growth of bacteria.

“So it actually decreases the incidence of infection in the wounds, and, therefore, we don’t need to change it so often,” she explains. “If you use a traditional gauze dressing, it’s very much compatible with bacterial growth.

If you use calcium alginate dressings, because you’re not going to have that problem with bacteria, it’s safe to change it two or three times a week instead of two or three times a day, which is what the traditional gauze dressing requires.”

Wound hydrogels, used on drier wounds that aren’t draining as much, where the goal is to continue healing.

“[The wound] is clean, it’s pink, it’s healing, and we just want to keep it that way,” Hensley says. The gel comes in tubes or sheets or is impregnated in gauze.

It absorbs a small amount of drainage but won’t stick to the wound bed and promotes healing. It generally requires daily dressing changes.

Dry hypertonic solutions for wounds that are grossly necrotic, infected, or malodorous. This is a solution that’s placed on gauze then dehydrated.

When placed in the wound, it pulls drainage the wound through osmotic pressure and helps debride dead tissue. Hensley says such dressings clean up infections faster than traditional gauze dressings.

The most common such product used at Johns Hopkins Home Care is called Mesalt.

She says nurses are taught that when they assess a new patient with a standard order for gauze and saline, they should look for signs that another type of dressing might be more effective and to call the physician for an order change.

“Our nurses know automatically to call the physician or the nurse practitioner, whoever is sending the patient, and immediately try to make an order change for one of these three products, depending on what the wound sounds . If we’re not sure what we have to deal with, we might just leave it with the original saline and gauze until somebody gets out to the house to evaluate it,” she explains.

After changing to a new type of dressing, the nurse continues to reevaluate the wound, to look for improvement or for signs of infection.

If after a week to 10 days there are no signs of healing, the nurses can request that a WOCN come out and look at the patient to determine what to do next.

In those cases, the agency can turn to an arsenal of secondary dressings, usually much more intensive and expensive than the first, to see if they will do a better job. Some of those options include the following:

Regranex gel, specifically used to treat diabetic foot ulcers that won’t heal.

Iodasorb gel, which Hensley describes as a favorite first choice for wounds that aren’t healing using the normal primary dressings. Iodasorb gel has a small amount of iodine in it and has some antiseptic properties, while also keeping the wound bed moist and absorbing wound drainage.

“You’re combining a hydrogel with an antiseptic with absorptive properties, so you get kind of three effects,” she says. “You don’t want to dry your wound out, and a lot of traditional dressings we used in the past are very drying to the wound bed. In the olden days, we thought that was good, but now we know you want it to stay moist.”

Iodasorb gels have been found to work quite well on lower leg wounds, diabetic foot wounds, or post-op surgery wounds that aren’t healing properly.

Collagens, which promote wound healing through the stimulation of fibroblasts. Used in a gel or sheet form, they can sometimes jump-start healing in a chronic or non-healing wound when nothing else is working, Hensley says.

“The collagens need to be applied twice a day, but you teach the families how to do that. If you don’t have a compliant patient or an individual that’s caring for them, you might not even be able to use some of these products.

Everything kind of gets weighed when you’re trying to decide what to use.”

Vacuum-assisted closure (VAC). In this procedure, a sponge is inserted into the wound, connected through tubing to low-level, continuous suction through a portable suction machine. “This actually will increase the amount of red blood cells that are feeding the wound, speed up the healing process,” Hensley says.

“What I’ve learned is that it works really well on wounds that have tunnels, steep tracks that take forever to heal.

If you’ve got a lot of wound drainage you can’t control with any other type of dressing — the family tells you they’re changing dressings three times a day, it’s draining everywhere, and you’re having nurses going in more frequently — those are reasons we might try the VAC.”

That high-tech relief comes with a high price tag — Hensley estimates that it costs about $3,500 a month to operate the VAC. But the dressing only needs to be changed twice a week.

“Think about an insurance company that is paying for 14 nursing visits a week, and the wound isn’t healing,” she says.

“If we go down to two a week, even though the treatment is much more expensive, if you cost out the visit, the cost of the nurse, $100 a visit, that’s $200 a day. The VAC is still cheaper.

Plus, it will help the wound to heal faster. There’s nothing more expensive than a wound that won’t heal.”

Such intensive efforts are discontinued if they don’t make a significant impact on the wound in up to two weeks, Hensley says.

Knowing that, insurance companies have been agreeable to paying for the pricier options, if it results in reduced visits.

“That’s exactly what they’re interested in: How can we heal the wound, prevent infection, prevent complications, and have as few nursing visits as possible? Those are everybody’s goals.”

Fortunately, doctors have become more knowledgeable in recent years about the benefits of newer dressings and are more willing to order them. “Some of the physicians will say, It doesn’t matter what I order. One of your nurses is going to call me to change the order,’” Hensley says with a laugh.

Even with the use of more advanced dressings and wound treatments, Hensley stresses that every wound is different, and the same products won’t work for every patient.

When evaluating a patient with a wound, nurses should look at a number of other factors, such as nutrition, since bodies need calories and protein to promote healing; resources, including caretakers and the money or insurance coverage to afford the dressings; and the cleanliness and safety of the home.


Sea Turtles Need High-Tech Medical Treatments—STAT!

Vacuum-Assisted Closure of a Wound | Johns Hopkins Medicine
A veterinarian performs laser therapy on an injured Kemp’s ridley sea turtle.

Bruce Smith/AP/REX/Shutterstock

Sea turtles have been around for more than 100 million years, since well before humans discovered fire or came up with the wheel or even evolved into humans. Some of our more recent inventions are now putting these reptiles in danger of extinction—but others may be helping to save them.

Of the world’s seven species of sea turtles, the International Union for Conservation of Nature considers two critically endangered (hawksbill and Kemp’s ridley), one endangered (green), and three vulnerable to extinction (leatherback, loggerhead, and olive ridley). The flatback sea turtle is the only one to escape the Red List, but probably only because scientists don’t have enough information about it to make the call; technically, the flatbacks are considered data deficient.

Point being, sea turtles need all the help they can get—even if that help includes tools and techniques that sound they belong in a Bond villain’s arsenal. Yes, I’m talking lasers.

Scientists have found that low-level lasers can promote healing by increasing cellular energy and promoting blood flow to wounds. Although we’re still learning exactly how so-called photobiomodulation therapy works, the technique is already being used to treat strokes in humans, burns in bears, and toe lesions in bald eagles.

Veterinarian Terry Norton, director of the Georgia Sea Turtle Center, says he and his colleagues have even conducted side-by-side studies that compare different treatments on the same wounds.

The part of the injury that receives the laser always heals faster. Trouble is, turtles get a lot of injuries. “Trauma is probably the most common thing that brings a turtle into our facility,” says Norton.

“Between 20 and 40 percent are due to boat strikes.”

Georgia Sea Turtle Center director Terry Norton treats a Kemp’s ridley turtle.

Courtesy Georgia Sea Turtle Center

Cuts, scrapes, and lacerations to the head and flippers are obviously bad news, but damage to a sea turtle’s thick, protective shell is even more serious. In fact, when a shell is punctured, it can release the natural pressure built up inside the animal’s body cavity and cause the turtle’s lungs to collapse.

When this happens, the turtle needs more than lasers. Norton says vets at the center pack a shell puncture with foam and then seal it up with a substance called Bioglass, a synthetic material that bonds to bone.

The veterinarians might also stuff the shell full of medical-grade honeycomb, because of its natural antibacterial properties.

Once the injury has been stuffed and sealed, they’ll sometimes also apply something called a wound VAC, or vacuum-assisted wound closure.

“This is something used in human medicine as well, but it’s great for turtles because we can hook it onto their shells,” says Norton. The vet places a tube on top of a wound opening to create a vacuum.

According to Johns Hopkins Medicine, the procedure can help remove pressure from a wound to allow liquid and debris to seep out gently, reduce swelling, remove bacteria, and even help pull the edges of a wound together.

All in all, Norton says, a wound VAC can cut a turtle’s healing time by as much as a third. “In instances where we probably would have put the animal to sleep, we’ve been able to turn those cases around,” he adds.

And that’s key, because every one of these patients is important to the survival of its species. Female sea turtles grow more fertile with age, so it’s critical that they survive long enough to have many batches of little ones. But saving males is also imperative, because, well, they’re disappearing.

The sex of a sea turtle hatchling is determined by the temperature of the sand it incubates in, with higher temperatures creating more females than males.

As climate change looms, some scientists are predicting a dire future for these animals’ reproductive success.

Indeed, scientists in Australia recently discovered that the Pacific’s largest green sea turtle rookery is now producing females at a rate of at least 116 to 1.

“These are animals that are threatened or endangered from human-induced issues,” says Norton, referring to habitat destruction, pollution, and injurious boating and fishing practices. “That’s why it’s pretty important that we help them.”

His team’s goal is to do everything possible to help a turtle recover to the point where it can go back to the sea and, they hope, reproduce.

So even when they are treating a turtle for cold shock—a sometimes fatal condition that occurs when the ocean becomes unseasonably cold—the vets will also give it a full medical makeover.

That entails wound care, antibiotics, and even cleaning off what’s known as epibiota, the variety of barnacles, algae, tubeworms, crabs, leeches, and other creatures that live on sea turtles and can affect their health when present in great quantities.

Low-tech solutions, of course, can help boost sea turtle populations, too.

In addition to its lasers and high-quality honeycomb therapies, the Georgia Sea Turtle Center works to raise awareness among boaters about how to avoid harming wildlife, either through behavioral changes ( slowing their speed) or through simple tech fixes, such as propeller guards and turtle-friendly fishing tackle. Staying clear of sea turtle nesting areas and refraining from throwing cigarette butts and other trash into the sea are also great ways for everyday folks to help keep these saltwater reptiles around for millennia to come.

onEarth provides reporting and analysis about environmental science, policy, and culture. All opinions expressed are those of the authors and do not necessarily reflect the policies or positions of NRDC. Learn more or follow us on  and .


When Wounds Won’t Heal, Therapies Spread — To The Tune Of $5 Billion

Vacuum-Assisted Closure of a Wound | Johns Hopkins Medicine

PHILADELPHIA — Carol Emanuele beat cancer. But for the past two years, she has been fighting her toughest battle yet. She has an open wound on the bottom of her foot that leaves her unable to walk and prone to deadly infection.

In an effort to treat her diabetic wound, doctors at a Philadelphia clinic have prescribed a dizzying array of treatments. Freeze-dried placenta. Penis foreskin cells. High doses of pressurized oxygen. And those are just a few of the treatment options patients face.

“I do everything, but nothing seems to work,” said Emanuele, 59, who survived stage 4 melanoma in her 30s. “I beat cancer, but this is worse.”

The doctors who care for the 6.5 million patients with chronic wounds know the depths of their struggles. Their open, festering wounds don’t heal for months and sometimes years, leaving bare bones and tendons that evoke disgust even among their closest relatives.

Many patients end up immobilized, unable to work and dependent on Medicare and Medicaid. In their quest to heal, they turn to expensive and sometimes painful procedures, and products that often don’t work.

According to some estimates, Medicare alone spends at least $25 billion a year treating these wounds. But many widely used treatments aren’t supported by credible research.

The $5 billion-a-year wound care business booms while some products might prove little more effective than the proverbial snake oil. The vast majority of the studies are funded or conducted by companies who manufacture these products.

At the same time, independent academic research is scant for a growing problem.

“It’s an amazingly crappy area in terms of the quality of research,” said Sean Tunis, who as chief medical officer for Medicare from 2002 to 2005 grappled with coverage decisions on wound care. “I don’t think they have anything that involves singing to wounds, but it wouldn’t shock me.”

A 2016 review of treatment for diabetic foot ulcers found “few published studies were of high quality, and the majority were susceptible to bias.

” The review team included William Jeffcoate, a professor with the Department of Diabetes and Endocrinology at Nottingham University Hospitals Trust.

Jeffcoate has overseen several reviews of the same treatment since 2006 and concluded that “the evidence to support many of the therapies that are in routine use is poor.”

“I don’t think they have [any therapy] that involves singing to wounds, but it wouldn’t shock me.”

Sean Tunis, former Medicare chief medical officer

A separate Health and Human Services review of 10,000 studies examining treatment of leg wounds known as venous ulcers found that only 60 of them met basic scientific standards. Of the 60, most were so shoddy that their results were unreliable.

While scientists struggle to come up with treatments that are more effective, patients with chronic wounds are dying.

The five-year mortality rate for patients with some types of diabetic wounds is more than 50 percent higher than breast and colon cancers, according to an analysis led by Dr. David Armstrong, a professor of surgery and director of the Southern Arizona Limb Salvage Alliance.

Open wounds are a particular problem for people with diabetes because a small cut may turn into an open crater that grows despite conservative treatment, such as removal of dead tissue to stimulate new cell growth.

More than half of diabetic ulcers become infected, 20 percent lead to amputation, and, according to Armstrong, about 40 percent of patients with diabetic foot ulcers have a recurrence within one year after healing.

Carol Emanuele of Philadelphia shows a photograph of a wound VAC (vacuum-assisted closure) procedure on her left foot after the amputation of her big toe. (Eileen Blass/for Kaiser Health News)

“It’s true that we may be paying for treatments that don’t work,” said Tunis, now CEO of the nonprofit Center for Medical Technology Policy, which has worked with the federal government to improve research. “But it’s just as tragic that we could be missing out on treatments that do work by failing to conduct adequate clinical studies.”

Although doctors and researchers have been calling on the federal government to step in for at least a decade, the National Institutes of Health and the Veterans Affairs and Defense departments haven’t responded with any significant research initiative.

“The bottom line is that there is no pink ribbon to raise awareness for festering, foul-smelling wounds that don’t heal,” said Caroline Fife, a wound care doctor in Texas. “No movie star wants to be the poster child for this, and the patients … are old, sick, paralyzed and, in many cases, malnourished.”

The NIH estimates that it invests more than $32 billion a year in medical research. But an independent review estimated it spends 0.1 percent studying wound treatment.

That’s about the same amount of money NIH spends on Lyme disease, even though the tick-borne infection costs the medical system one-tenth of what wound care does, according to an analysis led by Dr.

Robert Kirsner, chair and Harvey Blank professor at the University of Miami Department of Dermatology and Cutaneous Surgery.

Emma Wojtowicz, an NIH spokeswoman, said the agency supports chronic wound care, but she said she couldn’t specify how much money is spent on research because it’s not a separate funding category.

“Chronic wounds don’t fit neatly into any funding categories,” said Jonathan Zenilman, chief of the division for infectious diseases at Johns Hopkins Bayview Medical Center and a member of the team that analyzed the 10,000 studies. “The other problem is it’s completely unsexy. It’s not appreciated as a major and growing health care problem that needs immediate attention, even though it is.”

Commercial manufacturers have stepped in with products that the FDA permits to come to market without the same rigorous clinical evidence as pharmaceuticals. The companies have little incentive to perform useful comparative studies.

“There are hundreds and hundreds of these products, but no one knows which is best,” said Robert Califf, who stepped down as Food and Drug Administration commissioner for the Obama administration in January. “You can freeze it, you can warm it, you can ultrasound it, and [Medicare] pays for all of this.”

When Medicare resisted coverage for a treatment known as electrical stimulation, Medicare beneficiaries sued, and the agency changed course.

“The ruling forced Medicare to reverse its decision the fact that the evidence was no crappier than other stuff we were paying for,” said Tunis, the former Medicare official.

In another case, Medicare decided to cover a method called “noncontact normothermic wound therapy,” despite concerns that it wasn’t any more effective than traditional treatment, Tunis said.

“It’s basically a Dixie cup you put over a wound so people won’t mess with it,” he said. “It was one of those ‘magically effective’ treatments in whatever studies were done at the time, but it never ended up being part of a good-quality, well-designed study.”

The companies that sell the products and academic researchers themselves disagree over the methodology and the merits of existing scientific research.

Thomas Serena, one of the most prolific researchers of wound-healing products, said he tries to pick the healthiest patients for inclusion in studies, limiting him to a pool of about 10 percent of his patient population.

“We design it so everyone in the trial has a good chance of healing,” he said.

“If it works, , 80 or 90 percent of the time, that’s because I pick those patients,” said Serena, who has received funding from manufacturers.

But critics say the approach makes it more difficult to know what works on the sickest patients in need of the most help.

Gerald Lazarus, a dermatologist who led the HHS review as then-director of Johns Hopkins Bayview Medical Center wound care clinic, said Serena’s assertion is “misleading. That’s not a legitimate way to conduct research.” He added that singling out only healthy patients skews the results.

The emphasis on healthier patients in clinical trials also creates unrealistic expectations for insurers, said Fife.

“The expensive products … brought to market are then not covered by payers for use in sick patients,  the irrefutable but Kafka-esque logic that we don’t know if they work in sick people,” she said.

“Among very sick patients in the real world, it may be hard to find a product that’s clearly superior to the others in terms of its effectiveness, but we will probably never find that out since we will never get the funding to analyze the data,” added Fife, who has struggled to get government funding for a nonprofit wound registry she heads. Not surprisingly, she said, the registry data demonstrate that most treatments don’t work as well on patients as shown in clinical trials.

Patients say they often feel overwhelmed when confronted with countless treatments.

Navy surgeon Capt. Pat McKay examines the healing progress of skin grafts on Navy Cmdr. Peter Snyder at Walter Reed National Military Medical Center. (H. Darr Beiser/for Kaiser Health News)

“Even though I’m a doctor and my wife is a nurse, we found this to be complicated,” said Navy Cmdr. Peter Snyder, a radiologist who is recovering from necrotizing fasciitis, also known as flesh-eating bacteria. “I can’t imagine how regular patients handle this. I think it would be devastating.”

To heal wounds on his arms and foot, Snyder relied on various treatments, including skin-graft surgery, special collagen bandages and a honey-based product. His doctor who treats him at Walter Reed National Military Medical Center predicted he would fully recover.

Such treatments aren’t always successful. Although Emanuele’s wound left by an amputation (of her big toe) healed, another wound on the bottom of her foot has not.

Recently, she looked back at her calendar and marveled at the dozens of treatments she has received, many covered by Medicare and Medicaid.

To help Carol Emanuele get around her Philadelphia home, she places a walker inside the threshold of the doorway to her bathroom so she can easily transfer from wheelchair or a walker in order to stay off her feet. (Eileen Blass/for Kaiser Health News)

Some seem promising, wound coverings made of freeze-dried placenta obtained during births by cesarean section. Others, not — including one plastic bandage that her nurse agreed made her wound worse.

Emanuele was told she needed to undergo high doses of oxygen in a hyperbaric chamber, a high-cost treatment hospitals are increasingly relying on for diabetic wounds. The total cost: about $30,000, according to a Medicare invoice.

Some research has indicated that hyperbaric therapy works, but last year a major study concluded it wasn’t any more effective than traditional treatment.

“Don’t get me wrong, I am grateful for the care I get,” Emanuele said. “It’s just that sometimes I’m not sure they know what they’re using on me works. I feel a guinea pig.”

Confined to a wheelchair because of her wounds, she fell moving from the bathroom to her wheelchair and banged her leg, interrupting the healing process. Days later, she was hospitalized again. This time, she got a blood infection from bacteria entering through an ulcer.

She has since recovered and is now back on the wound care routine at her house.

“I don’t want to live this forever,” she said. “Sometimes I feel I have I no identity. I have become my wound.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation and its coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

KHN’s coverage of aging and long-term care issues is supported in part by The SCAN Foundation.