Everyone (hopefully most clinicians) undertake wound images and measurements. Don’t get us wrong, these are important. But from our prickly position, they aren’t as robust in our clinical practice as many would like to think.

In this episode Monika and Donna provide an experience informed conversation on the common issues with digital photography and unpack the reasons why these affect quality practice and decision making for patients with wounds.

Episode 9 is jam packed with practical pearls for all clinicians to take and use no matter what their experience or setting. This episode is valuable for:

• novice to experienced healthcare professionals
• nurse, doctors and all clinicians involved in wound care
• managers focused on quality of care and practice improvement

Timestamps

00:00 Introduction

00:49 Wound measurement and photography as a component of wound documentation

02:40 Argggh rulers

04:51 Photos as important medico-legal documentation

05:10 Ban the Ruler!

07:37 If you really feel compelled to use rulers

09:15 Controversies and lack of standardisation in wound measurement

12:43 Is your photo a true and accurate record?

13:53 Photography tips

14:33 Wound chart v photos

16:05 Flash v natural light

16:35 Doing a retrospective on your photography

17:23 When it is important to use a flash

18:27 How to make wound measurement more consistent

19:36 Best time to measure and take a photo

21:06 How often should wounds be measured?

22:03 Do the world a favour

22:50 Context of wound measurement and questions that should be answered

24:16 Circumferential wounds and shout out to managers

29:06 Measuring depth

29:51 Probing wounds

31:16 Measuring pressure injuries within an interdisciplinary team

33:00 Wound measurement and photography in Chronic Oedema

34:12 Wound Hygiene consensus resource

34:35 Do you measure the height of hypergranulation?

35:19 Don’t just look at the numbers

37:52 Photographing pitting test

38:20 The value of clinicians undertaking a lymphoedema course accredited by the Australasian Lymphology Association

Resources mentioned:

• Murphy C, Atkin L, Swanson T, Tachi M, Tan YK, Vega de Ceniga M, Weir D, Wolcott R. International consensus document. Defying hard-to-heal wounds with an early antibiofilm intervention strategy: Wound Hygiene. J Wound Care 2020; 29(Suppl 3b):S1–28 https://convatec.showpad.com/share/NlEvPxvvOe4SF5SzTaRnK
• Australasian Lymphology Association - Accredited Training Courses https://www.lymphoedema.org.au/education-&-resources/lymphoedema-training-courses/

If you enjoyed this episode please like, subscribe, leave a comment or share with your colleagues.

Connect with us at:

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Connect with Donna's resources and sign up for the Woundy Wisdom's newsletter at https://goodwoundcare.carrd.co/

Disclaimer: The views expressed in this podcast are our own. This podcast is intended specifically for healthcare professionals. Always follow your organisation's policies and procedures. Please consult your own healthcare provider for individual wound advice.

Welcome to the 2Echidnae podcast. You're with Mon and Don, two advanced.

Practice nurses with decades of experience in hard to heal wounds burrowing into prickly conversations. Welcome back to episode nine on the two Echidnae Wound Podcast with myself, Donna and my colleague Monica, or otherwise known as One. And don't.

A little bit of a change of scenery for this episode we would love to get into, and we think this will be quite popular, into measuring wounds and wound photography. I don't know about you, but I often get asked for, you know, how, tips and tricks for taking a photo. But there's a lot to it.

There's also a lot to measuring wounds.

Oh, yeah.

Now, if we were to label this episode wound documentation, no one's going to listen. I can tell you now because I have been that person who up there and no one will come to the education session that's not very popular.

However, measurement and photography is part of that and we see a lot of that not so done very well. But yeah, we would like to introduce some concepts and, and talk about some of the intricacies and our experiences with that.

Some tips and tricks and I suppose.

Well, first of all, how do you measure a wound, particularly in these environments where some organisations have got software, so the software does it for them and even that is subject to human error, right down to measuring a wound and the controversies about whether you measure a wound with a ruler. And then often the question is asked, well, what would you prefer, a wound measurement or a photo?

Oh, yeah.

And then we get photos of all sorts of different quality, mind you, a lot better.

Yes, I would agree with that, a lot better.

But I sometimes marvel still at the quality I get when people, when you ask for a wound photo. And I'm sure if you ask for a wound photo of their dog, it would come out a lot clearer in focus.

Or maybe the food they ate at the restaurant last week.

Yes, yeah, yeah, yeah. So look, I think there are different motivations for taking good photos.

Basically, I wanted to tell everyone that you're wasting your time if you send a photo that's out of focus, in poor light.

And can I say. Yeah, go on, can I say it? Cause I think we haven't talked about this, but I think we're gonna be on the same page. Covered in rulers.

Oh, covered in rulers. Now 2 rul. Going to get right into it, I guess I've had it come up for me recently. So let's talk about the rulers.

It's actually, I'll first say it's really hard to find articles, standards, guidelines etc for this.

Yeah.

You know how many rulers I recently have had an experience across a number of sites in aged care and I actually find it in all the sites that I go into and I even notice it in other people's photographs when they're putting things up at conferences and that a lot of most residents have two photos, a length and a width. Sorry? They have two rulers in their photo, a length and a width and that's part of the standard photo.

And I have been told by someone high up in clinical governance in aged care, but we have to have the two rulers in the photo because firstly, how would the staff measure the wound? Got a big issue with that. But secondly, the aged care auditors demanded. I just. I would love it if someone knows information about that.

I've not been able to find information about that, do I. It could be true. I'm not doubting that that could be an issue but I can tell you I can't find any clinical evidence for it.

What I do know is I have a lot of experience with rulers that aren't. They aren't placed up against the wound margins but they are obscuring a hell of a lot of clinical data on the periw around.

They even cover the wound sometimes so that's not even included. They cause shadows when they're placed in properly.

We're not even getting into causing damage perhaps if they're taped on and coming off but they're not used to measure the wound and they're obscure. Sometimes I can't even tell the body part that the wound is on because the ruler is obscuring the anatomy. Now photos do stand up in a court of law.

I have, you know, done medico legal reports and work on wounds and photos do stand up in a court law. They are really important and I can tell you a lot of those photos would be not a good reflection of what the wound looks like.

So much so that I can often not even tell what the wound looked like.

Oh look, I'm. This is it. If I had my way, if I had my magic wand, I'd ban all rulers because I think in the end it forces people to be lazy. It gives us.

That's no information at all. Often the depending on the ruler. I mean especially if you're looking at circumferential leg wounds. Waste of time.

What's it offering you?

Yeah, parallax error where the.

The camera's not parallel to the wound surface and I mean there are clinical photographers in A lot of metro environments but us people in regional environments, we don't have that luxury and that's, you know, the vast majority of people out there. I would ban rulers, I hate rulers.

And even I've seen people when they measure wounds, they get their little piece of paper and they'll put it on the ground, but a dirty surface, a non clean surface, non clean surface and then they put it against the wound or it's not.

Oh, now you've said that. I've seen them hanging around at stations or pre prepared and labeled out. Yeah, yeah, they're on, yeah. Unsanitized surfaces. Yeah, yeah.

So it's really tricky and look, I would have thought my understanding of them and my exposure to them in regional tertiary centres has been they're primarily there in the procedure as the ID component, not for the measuring component. And there's been guidelines around how to use them but I think they've become more than what they've originally intended to be.

And just as. Just at the conference we went to last weekend I had, I saw people walking out with, you know, trade. Really? Yeah, no, I don't want to see that. So.

But also, you know, I've asked for wound measurements and all I get is a crappy photo with these two, you know, the L shaped ruler.

Yeah. When did that start? I do not know because that's a.

Really new thing relatively.

But I wonder if there's an aged care. That's what I'm saying. I don't know, I just.

That's the only place that I see it done routinely and across different organisations, large organisations and look if, look if.

You really have to. But my bare requirements are.

And I was really excited at the conference went to over the weekend where a person, a lymphedema therapist talking about photography of the leg made the comment please take a photo of an entire leg. That gives us that at least.

And I mean if you really are compelled to use that L shaped ruler system because you're mandated to by your organization or by whatever standard you adhere to, please complement that with a photo that's totally. That has got no ruler next to it.

Because we, as you was talking about, we get more information from the periwound and we know that there's biofilm, you know, probably more active polymicrobial biofilm in the periwound than in the wound itself. There's so much information we get that it's just being obscured.

So if you have to take a photo of the wound close up, mid range and Then long range on the body part. And while we're at it, take a photo of. If you're taking two body part, two legs. If you're taking a photo of one leg, take a photo of the other leg.

We always want to see.

And including the foot.

Yes.

The foot just gives so much information. Yes. Especially if you've got a gaiter wound and. Yeah. And having both, both. Both limbs. I would completely agree.

And then I suppose then there's the controversy about.

Do you.

Because there are two ways of doing this. If you are going to measure a wound, the most basic way you can do it is the longest length and the longest width.

I love this controversy. Keep going.

Yeah. Or do you take it at 12 o', clock, 6 o' clock and head to toe? Hip to hip? Yeah, yeah, yeah.

My experience is when I stand up in education and I'll put one of those, I'll put a mock wound photo up or I'll draw it on the whiteboard and I will say exactly that. Is it length by width, head to toe or is it longest by widest axis?

And they'll just kind of throw it to the audience and they'll just look at you and no one's going to answer because they don't know.

Yeah. And there's even a senior level.

They're not game to call it out.

And yes, even at a senior level too, I, I would find most people I know, and it's not just aged care, but in community as well, would just measure the longest part of the wound to the widest part of the wound. I don't find people are doing head to toe, hip to hip measurements, but they're not even able to articulate that. But I wonder if.

And tell me if you experience this too, Mon, I'll go in and look at charts. Now.

This can be in any area and I'll have a wound that will say on chart on, you know, ten days ago it'll be five by five and then on two days later than that it'll be six by eight. Two days later than that it'll be three by four. Two days later than that it's be six by 2.5. And I'm looking at.

There's no way those are accurate and so is some of that because we've got an, a non uniform way of measuring and that's not stipulated or taught like, you know. So I think it's a massive untapped area. I really, really do. I would love people to audit rulers and audit measuring.

Yeah, we audit so many other things. So I reckon they would be absolute gold mines.

Yeah. And look, I think then there's we. We really haven't talked about fully bettering circumferential wounds and they're unfortunately a lot out there.

And also undermined and tracking wounds, pressure injury and even, you know, Sandy Dean.

Yep.

Beautiful. Sandy Dean taught. For those who don't know Sandy Dean, she was a highly regarded wound consultant.

And yeah, most of us, a lot of the work that we do here in, particularly in Victoria, we owe to the work of Sandy Dean.

But I remember her teaching me that even when you measure a pressure injury, particularly on the sacrum coccyx, that you always place the person on the same side and you always are consistent with measuring that person's pressure injury, particularly if they've got tracking, because it doesn't take.

Much to move in their body position to change the dimensions of that wound. One thing I always remember with Sandy was she was.

One thing I often use in my education is that if you're taking a photograph, are you documenting that it's a true and accurate record of what you saw with your eyes, of the actual clinical presentation? And you know what, sometimes, look, I'm going to say devil's advocate here, wound photography can be really tricky.

I would say many years ago, we used to, when smartphones and other easy cameras came out, we used to probably overexpose a lot. Now I think we underexpose a lot. There's more dark issues happening, but maybe that could just be in my area.

But sometimes if you've done everything that you can, you still can't get a good photo. And I will do this in my clinical practice.

I will document in the notes or on the chart that the photo that I've uploaded or used as part of the legal clinical record is not a true and accurate representation.

And then I'll say, why it appears more red or it appears less red or it appears more shiny than whatever it might be, than what the photo or it appears like there's more slough or less, you know, whatever it might be. So, yes, you've still put up the photo. You've done the best you can. I don't find people play around with the flash enough.

Sometimes you can pull the device further back and zoom in. And you can, if you still need the flash, so there's less reflection off people. Don't walk over to the curtains and adjust the curtains.

Curtains, the position of where you stand with your body can stand in front of a window or it can deflect other light. So it just takes a little bit of time to play around with that.

And I know everyone's pushed for time, but you know, gee, when we're sitting looking at the photos, you know, over six weeks of what's been uploaded, we can't even tell what the wound looks like. That, that's not great documentation. And the other really good tip that I will say is that it's great that we have access to so many more photos.

However, they should not take the place of your wound chart. They supplement the wound chart. And if you were to go in, I'm going to get a bit more controversial here, seeing we're going down that vein.

And with measuring wounds, if you didn't see a photo, if you're going in, you could be just new in that organization or have not seen that particular patient resident client before.

And if you didn't see a photo of the wound and if, if you just looked at the wound chart, which we should all be reading the history before we go in and do a procedure and reassess something. But if you only saw that wound chart and you went in and looked at that wound and got a surprise, I do not believe that's a good wound.

That's a wound chart that's filled out well. Or there's something foundationally wrong with the way that wound chart records data, because I find that a lot.

I will look at wound charts, referrals sent to me. Sometimes I don't have images or there's been a period of time from when the image was taken.

So I know it might not be recent, But I'll get the referral information, I'll look at the chart, I'll look at the notes, I will look at everyone's documentation first and then I'll and the chart. But I'll go and then look at the wound and I get a surprise that it looked the way that it did.

So I, I do feel as though there's a big gap in our documentation. It's a shame that photography doesn't always.

Fill, you know, and I just think too, like you were saying, you, you often choose flash photography. For me, I often, always preference natural light because with flash photography you get that reflection.

And also I think colors, all colors are expressed. Whether flash photography or natural light are always over expressed, particularly on some of the newer phones.

But one thing I used to get a shock about, and this is even in the early days, but even now I feel a lot more comfortable.

You'll take a photo and you've Debrided the wound, you know, taken a photo and then you go back and upload the photo into the clinical record and you go, oh, I didn't notice that.

Oh, have you had that phenomenon all the time? So it's often in the background or on further down the body part? Yes.

Oh, no, but I think him sometimes in the womb. Really?

That's fascinating.

But look, I'm just again saying to the listeners, it's a thing because I've shared this with other people. It is a thing that don't be surprised if you then go back and you have a good look at the photo again and you go, ooh, I didn't notice that.

That's fantastic. Look, I reckon I'm a 50, 50 mix between flash and natural light.

Sometimes if I'm not happy with one or the other, I'll then take the other and pick the best one. I will say, though, I do have a cohort of people who have a stage three or four pressure injury with some depth to it.

If it's in a deeper body part, like, you know, an ischium. And because the wound, the wound may only be like 2 x 1 cm and I can't visualize the base in the photo, it's.

Yes, it's taking the surrounding skin but with a flash it's picking up the wound base. So it's, it's that clinical decision making that's.

Yeah.

What is the most representative. Sometimes it's flash, sometimes it's not. So.

But you, I thought you were going to mention this and I know you'll know what I'm talking about soon as I say it. Sometimes though, the wounds actually heal because you can't see the base.

Because some of these pressure injuries, if you take a flash photo and you don't get any reflection back then, you know, that's epithelium and not granulation.

That's it. That's it. Because often that scar tissue is really tethered. Yeah, for sure.

So, and the other thing I was going to talk about is, you know, sometimes you. I loved your example that wounds 1 1/2 by 2 centimeters. Next thing it's 10 by 8 centimeters, next thing it's 3 by 2 centimeters.

Saying it's funny but it's really serious.

Oh yeah.

And it does happen a lot, unfortunately.

And look, the way we overcome that in the areas that I work is that I'd rather have the same person measure the wound inconsistency or one or two key people because we've got a part time workforce now that's the reality in a casualised workforce.

But if you can, I would rather the same person measure that wound according to their roster when they're next on, because that's still more consistent than every time. Yeah, and we've tried, you know, wound Wednesdays, measurement Mondays in organisation. Ah. Just the itinerant workforce makes it very difficult.

So, you know, sometimes it's better the same person and then frankly, honestly, like, I know they can't do the dressing, but then that could be a personal care workers responsibility, you know, like as.

Long as the wound's been cleaned, you mentioned.

Oh, yeah, good point. Yeah, yeah, good point.

Yeah. So do your.

Yes, you can take a pre and post debridement, pre and post cleaning, but if you're going to take one, it needs to be after that wound's cleaned.

And measure after you've cleaned, measure after.

It's clean because you'll be getting off scabs, dry skin, you'll be cleaning up that maceration old dressing products. Yeah. How many times? And I, you know, see, we thought.

We'd have nothing to talk about.

We did and we're on a roll. Absolutely. Management medical officers, are they hanging around because they really want to see the wound? Fantastic motivation.

But the minute that dressing comes down, they're all snapping at it with their phones. So I'm not mentioning phones here. They're all, they're all taking a picture because they want an update.

And I just want to say, can you please go away and come back in minimum 15 minutes because this wound is going to look entirely different.

And if you're making a clinical judgment on that and you're going to take that and show your colleagues or use that as a comparison, it's totally not accurate. Because how different will that wound look when I've cleaned it?

Yeah.

And I haven't even cleaned, say the old idea sorb off or the extra date or the gummy. The gummy crap that's on it. And you look so much better.

And what are we teaching our patients and our newer nurses that that's when you look at the wound and take the photo. We're not teaching them the value of cleaning. It's like when someone says, oh, the wound's odorous.

Clean it first, then check it, you know, do that cleaning first. But just tracking back. Loaded question.

You were talking about measuring Monday and all of that and you know, perhaps this regular person doing it, which I could not agree more. Is there best practice for how often to measure a wound? I told you, it Was loaded.

Yeah. Look, it depends on the context. If it's a very itinerant workforce and no one's tracking that.

Yeah, but at the same time, are you going to get consistency with wound measurement? You know, who goes in and looks.

At the wound chart to work out if they haven't seen that wound before, whether it's changed or not. Because irrespective of when the last assessment was done, if something has changed significantly, you've got to do a reassessment.

Yeah.

And then.

Okay, so even talking about change and how we talk about change, please, everyone, please do us a favour, do your colleagues a favour, do the world a favour, stop talking about that the wound looks better this week or worse. Please.

I know. Stop, please.

Always give either information that's objective. Give us. I would prefer an inaccurate wound measurement number than you telling me it looks better, it looks worse.

It's just not scientific, it's not consistent.

Or be prepared to back it up. So I'll often follow that question up. I completely agree. I think it's very contextual with regard to how often do we measure.

It depends on so many factors. You have to follow your organisation's protocol. Do I think it needs to be measured every time? I really don't. Oh, I agree.

Unless you're changing maybe weekly and it's changing frequently, but you know, weekly to two. Weekly, probably. But again, it's very, very contextual. You may want to measure it more often. So you've got to make that decision.

But I have many people who say it looks worse. It looks worse. It looks better. It looks better.

And then I'll ask them, because everyone knows that if they ask me one question, I'm going to ask them 10. And my first one usually is, tell me about that, like, how does it look better? Well, it just looks better. What do you mean?

Yeah.

Oh, look smaller. So you've done the measurements now it just looks smaller. It's about the size of a 5 cent piece.

It was about a 10 cent piece before I used to memorize how. I haven't for a while because I haven't had it happen so much recently, but I used to memorize how many millimeters?

A 50 cent, a 5 cent and a 10 cent piece were.

Yeah.

And I used to quote that back. Oh, so that, you know that it's 12 millimeters. Oh, you know, there you go for 5 cent piece, something like that.

So you know, well, has it got less extra date or more extra date? Has it got less slough or more slough? What's the pain doing?

You need to be able to describe why it looks better, even a couple of those parameters, or why it looks worse. If you can't, how can you say it looks worse?

And look, the other thing is we were talking about circumferential wounds. This is what I recommend. So I do want to talk about using those grid dressings. Yes.

But also be good to cover circumferential wounds because we have the same practice there.

So circumferential wounds are difficult the best of times and they do change their shape depending on the swelling and the chronic edema management of that leg. But essentially, if you can imagine the limb, the leg in four planes.

So anterior, posterior, medial, the middle of the leg and the lateral side of the leg. And this is where you. Where I would do the 6 o', clock, 12 o' clock measurement. Just measure, give me the measurement or document the measurement.

And as managers out there, honestly, if you want to track your outcomes and the performance of your staff and their healing outcomes, ask what the wound measurements are. You know, yes, photos are good, but I don't know how skilled you are at interpreting wound photography.

But ask for the measurements and start expecting that to track the progress of your wounds. It's the most effective way. Even just again, just recently. Ah yes, that's right.

Even recently we had a, A, a situation where a woman's circumferential wounds had. Were huge. And I'm going to, to de. Identify the. The actual person.

I'm going to fudge the figures a bit but say it was 200cm squared and the way I'll talk about how the wound was being measured that circumflex wound. Then we came, well I came in as a consultant and the surface area had dropped down to 150cm.

Then Covid came, went into lockdown, person fell chest infection went back up to 210 cm. After that came back started best practice and the wound had decreased in surface area. So it was going up and down in wound surface area.

At that point a specialist had determined that the wound was unhealable. But we could tell with the numbers at every point why the wound had regressed.

And this was a circumstance where this was a nurse Using the, I won't mention the brand, but the dressings, the polyurethane dressings that have got the grid on them. Can I say that?

Yeah, totally.

And using that to trace the wound and then determining the surface area of the wound because each one of these, the squares on These grids are 1cm2 squared. And then just counting so you make a trace. It's really hard via audio.

But tracing the shape of the wound and then counting how many crisscross points are on the inside of that, that wound. And so any, if your line crosses a crisscross area, you still count that cross. So you know they were counting 200 crosses.

And it's still a much more objective measurement than.

I think it's looking smaller, I think it's looking bigger because I can guarantee you there were times where I thought the wound was looking smaller and then they'd give me the tracing and it wasn't, wasn't especially circumferential wounds. I think you're, you're a magician and.

Even sometimes you get that posterior measurement if you're doing those four points around the limb. I find that posterior one really, really challenging.

Oh yeah.

I had the measuring probe earlier today and the posterior measurement was bigger than the probe and it would have been bigger than the ruler. And so those are real challenges out there.

Yeah.

To get the measurements. But we do have to be a bit creative in that space. But getting something and if it can be as consistent, that's really the take home message.

And what do you use for measuring the depth of wounds?

If it's 1.5 to 2 centimeters, I will just use on average I'll have a wound ruler that's on the dressing on my aseptic, my clean field. And then I will use the tip of the dressing tray forcep and I might break that off and I'll measure that.

But I do use the foam tipped sterile probes as well. Yeah. Depending on the equipment I've got and the circumstances. Yeah, yeah. For undermining. That's. Yeah, much better.

Oh, this is another one that I suppose we're sort of digressing but when we are probing wounds. Yeah.

I.

Because podiatrists use metal probes.

Yes.

And it's much easier to probe fascia and, and bone. It's a very distinctive sort of.

Yes, it is. Tap, tap, tap, knock on wood.

With plastic probes, I find it just harder. But I just think nurses tend to not probe as many wounds, particularly nurses. Pods are very good at it. Well, yeah, more pods are than nurses.

I'll usually do a little bit of a. I'll run it over to kind of work out if it's still got that smooth periosteum.

Yeah, yeah.

So I'll try to feel the texture of it or whether it's rougher. Rougher or not. I guess in my scope, I don't tend to have access to that equipment as readily. But yeah, it's.

It's really interesting to compare practices.

And also going back, I know we're jumping around a bit, but we were trying to think of topics earlier today and we thought we might just go with something relatively easy, and we thought we'd clean this up very quickly. But now when I'm thinking about it, even measuring the tracking of a pressure injury, we.

I did.

We did say make sure that the person's positioned consistent on the same side and that you document what side that they like to be measured on. It's always very well worth asking the person with the pressure. What side would you like to be measured on as long as that's consistent.

And then also, you know, retracting the skin, like all the time. Do you want to talk to that? Yeah, because I've done enough talking.

Oh, no, not at all. I was actually thinking. So I will move.

I will get a sterile glove on and I will put my finger in the wound and feel and move the surrounding skin around so that it. Retracting into the different position. Feel. Where exactly is that bony prominence?

Because often if they're just lying down in more of an examinable position, you can't feel where that bony prominence is. But if you move the tissue around, you can absolutely feel where it is.

And sometimes sticking a finger in, you know, maintaining your aseptic technique. I have a sterile key part, which is my sterile glove going into the key site. So that's absolutely fine.

And that's really good to do with an occupational therapist with you as well, because many, many times I will be tapped, tagging with them, and they might not even seen the stage three or four wound in a photo. But I'll say, have you seen the wound? Oh, no. Well, let's go. Yeah, let's go.

Because you're the one that's prescribing the equipment and working with me on that.

So I'll actually take a photo of me retracting the skin.

Right.

So that people know that this is what you do to measure so that. Yeah, yep, yep.

Now, what about the times? The other maybe controversial thing could be. I'm going to make A parallel to lymphology world.

But I want to first say what happens when you're measuring a wound and this circumferences aren't necessarily coming in but you've got to improve. You clearly have an improved wound.

Ah, yeah.

When. When people.

And what I'm leading up to say is, is that sometimes the measurements, depending on what stage of wound healing and cleaning up you're doing in that wound, that is if there's a lot of non viable tissue that you're working on, the circumferences aren't going to be the first thing to come in.

And so wound improvement will be seen or deterioration will be seen in other assessment parameters such as pain extradite type and amount and tissue type.

And wound photography at that point will kick in because we then look to see whether the edges have got cliffs or beaches. Yeah.

Are they rolled or flat? Are they attached or unattached? All of that type of.

And again we'll link to the biofilm. Anti biofilm strategy.

Yes.

Document. We've done that before, but we'll do it again. Cliffs and beaches.

Refashioning the wound.

Yeah. And so. Yeah, yeah, you're right.

You don't always necessarily get wound contraction because we're still having to get granulation and the depth and the character of the wound. Oh, then you talk about hypergranulation. That's a topic.

Oh, height. How many times do you see height written on the wound chart? Zero. Except I do it. Maybe I'm an outlier. I will write the height of the granulation. Yeah.

Do you? Yeah, Well, I think it's quantifiable. Well. And I'm probably being a bit. A bit more maybe I guesstimate in that area. Yeah, but of course you will.

I'm not going to cut that out. Yeah, you do guesstimate a bit. You know, a couple. It could be a couple of millimeters. I think I'm pretty good at that. Yeah.

That's interesting.

Or is it? I've had hypergranulation where it'll be like 0.5 of a centimeter or.

Yeah, I. Or can we talk about hypergranulation soon? Boy, that's controversial.

Yeah, Put that down. Top of our list for another upcoming.

Okay. Yep.

So, yeah, stay tuned for hypergranulation. But I wanted to just finish off that point and why I mentioned that about not just looking at the. Those numbers of a wound.

So the length and width and the depth. Yeah. We've talked about linear depth versus undermined depth. So they're Two different things and using the clock face.

I just want to share an experience I had when I went to my first National ALA Australi association conference. I didn't know anyone there. I since know a lot of people in that space, which is lovely. It was a really good first conference to go to.

They're a great group of people to. To work with and learn from.

And it really stood out to me, my first ALA conference, that a number of years ago now, when they started saying at a conference that a lot of them are coming away now from measuring limb circumferences at every review. And I was just thinking, whoa, what. What's going on here?

And the more I listened, the more I understood that there are so many other parameters where you can assess whether a therapy is being effective or not than just putting the number on. And you may even have improvement. You may put the number on and the number might even be the same. I have found that time and time again.

And that while making the analogy to wounds, you might be putting.

Yeah, you might be putting the length and the width on or the circumference on, you know, of the B, the C, the D measurement, upper limb, lower limb, they might be the same, but there are other things that are telling you you're getting better. And they.

Those could be very subjective points, you know, like increased range of motion, decreased pain, increased mobility, decreased, like, heaviness decreased. The same with a wound, you know, more comfortable, less pain.

Less pain. It's the best. It's the best.

So please include those subjective matters and.

Also the converse when they're saying the pain is new or different or it's not so much new, there's new pain or it's getting worse.

Jump on it. Yeah, yeah. Respond to it.

Yeah. And so going back, finally, this is funny. How can we spend so much time.

But, you know, we're only scratching the surface.

Yeah.

And so then I meant that pun and now we're laughing. So we're starting to get to the end.

Yeah. So the other thing, really. So it made me think about other things on the body that I photograph and.

But also that I ask people, you know, if someone's got pitting edema, particularly these really advanced stages of chronic edema, lymphedema. I get them now to always take a photo of their. The dorsum of the foot, the front of the foot.

But also I get them to do the pitting tests and then photograph it.

Oh, see, I've not done that. That's really great.

And you know What? It's also a good education, teaching nurses.

So all our wound management colleagues out there who now are going to go and do your lymphoedema course, do that. It's a really powerful educational tool. It actually teaches them the value of assessing the swelling and it's very easy.

And so we mentioned earlier that we'd attended a conference recently and I just wanted to add on to this conversation.

It's so encouraging that so many of our wound colleagues, podiatry colleagues, are looking at and have registered and have done recently the lymphedema chronic edema courses, the accredited courses by the Australasian Lymphology Association. I know we've put a link in our previous show notes to the accredited courses, but we'll put it here as well and I dare say we'll do it again.

Again, because we feel it's that important and changing to your practice. You don't have to be an advanced clinician to go and do one of those courses.

But it's really great to hear that so many of our colleagues are doing those courses as well and I really feel as though that tide is changing and we're going to all be better wound clinicians for it. I had a lot of people asking me, well, you know, what does this. Does the stiffness in the garment mean?

And, well, what options do we have, apart from tubulars in aged care? Lots, absolutely lots. So I think it's great to watch this space.

Yeah. Well, how's that? I think we spoke more about measurement and photography than we talked about the meaning of life.

We did indeed. I think we did that very well. Well, so keep your questions coming and keep your feedback coming.

We would love to know what issues you have in this topic area and where we can talk about this more.

Yeah, I. I just think if we got another, you know, five monikers and. And five donners in the room, we'd all have different tips and tricks to share.

Yeah, that's a great point.

But the. But the main message is, if you're using a ruler, don't cover the wound. Yep.

Undeniably fantastic. We will.

Oh, but, yeah, and also finishing up and dual infidemicles.

On that note, we'll finish off this episode and we'll catch you in the next double figures where we hit. Double figures.

Yes.

Yeah. Fantastic. Thanks to a kid name.

Thanks, Donna.

Bye.

Bye.

We are so grateful to have this opportunity to share our learnings and challenges with you today. Hopefully it has inspired you to be more curious in your clinical practice and burrow down to issues that bug you.

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But what you do what I do Take around to cover you but would you do what I do?