Each issue of Wounds International features a typical day in the life of a different wound care clinician from around the world. This series looks at the variety of techniques that are required in different settings and asks clinicians about the type of conditions they work in, the types of wounds they see and the challenges that they face when providing wound care to patients. This issue features Catherine Ratliff, a Nurse Practitioner and Certified Wound Ostomy Continence Nurse at the University of Virginia Medical Center, 
Charlottesville, USA.

Can you outline where you practice?
The University of Virginia Medical Center provides primary, specialty and emergency care throughout Central Virginia through a network of clinics as well as a main hospital that has more than 500 beds. The hospital serves as a Level 1 trauma centre for the region and is accessible to critically ill and injured patients via ambulance as well as by air and ground transport services.

The Chronic Wound Care Clinic at the University of Virginia Medical Center is a university-based outpatient clinic that has been in existence for over 15 years. It provides 'one-stop shop' allowing patients to benefit from coordinated care provided in a single setting.

Can you explain the make-up of your team?
The team at the wound clinic is made up of physicians, a nurse practitioner with a Wound Ostomy Continence qualification, a PhD researcher, nurses, patient care assistants and an administrative assistant.  

The advanced practice nurse, in collaboration with a plastic surgeon, assesses the patients and prescribes therapies. Nursing staff from the plastic surgery clinic help with assisting patients into examination rooms and removing and reapplying dressings.

The administrative assistant answers the phone and schedules patient visits for the wound clinic.

Once the wound care programme has been determined, specialists outside the clinic may be consulted on the treatment of the wound. Home health agencies, occupational therapy, physical therapy, nutritional services, prosthetics and social services may all play roles in the rehabilitation of an existing wound and the prevention of recurrence.

What types of wounds do you regularly see?
The majority of the wounds seen in the clinic are pressure ulcers, venous ulcers, diabetic foot ulcers and arterial ulcers.  

What are the main types of equipment, dressings and techniques that you use on a day-to-day basis?
Negative pressure wound therapy, quantitative wound cultures and most major classification of wound dressing types are used routinely in the clinic.

What is the most unusual wound you have seen recently and how did you manage it?
A 54-year-old female presented to the wound clinic after falling on concrete and sustaining scrapes to her knee. Her medical history included a liver transplant, hepatitis C, diabetes and seizures.

She reported having a 'goose egg' swelling on her left anterior shin, which was later drained. The swelling disappeared but a wound remained. The wound initially had an 8cm diameter area of full-thickness skin necrosis and it was thought it would require debridement and skin grafting. However, the patient was reluctant to undergo this procedure, therefore enzymatic debridement was commenced.

After two weeks, the wound was clean and the patient was started on collagen dressings. The wound healed within eight weeks without the patient having to go to the operating theatre for debridement or skin grafting.

Do you feel your service/practice has any unique obstacles that hamper your work?
The biggest obstacle is that we would like more time in the day and more days to the week to treat all the patients with chronic wounds.

What equipment/resource/education would make the most difference to your everyday work?
Ultrasonic equipment to cleanse and debride wounds in the outpatient setting would decrease the time spent performing conservative sharp debridement as well as improving healing times. 

Catherine Ratliff (second from left) and the team at the University of Virginia Medical Center