Wound Care Expert, Karen Zulkowski

[00:00] Michelle: Karen Zulkowski is the GOAT of wound care nursing. Her professional journey began with earning a BSN in 1972 and culminated with a Doctorate in Nursing Science. Throughout her career, she's held various roles, including business owner, associate nursing professor, and wound course instructor. Karen has also served on the National Pressure Injury Advisory Board and the World Council of Enterostomal Therapists. Her extensive research and publications in peer reviewed articles, both nationally and internationally, reflect her commitment to advancing wound care. Karen's primary focus is always on the patient, and she aims to improve patient care by bridging the gap between wound care research and clinical practice. In our discussion, she highlighted the knowledge gaps in wound care, the evolving landscape, and the exciting advancements in technology. Karen says wound care nursing is not for everyone. It requires a special dedication, and I would encourage those interested in this field to listen to her insights.
In the five minute snippet: Aloha! Well, good morning, Karen. Welcome to the podcast.

[01:41] Karen: Thank you for having me. It's an honor to be here.

[01:45] Michelle: Thank you so much, Karen. It's an honor for me to have you here. You were recommended by your friend and mine, Karen Gray-Leach. And a few months ago, I had put out my all points bulletin that I was wanting to talk to a wound nurse and Karen recommended you very highly. Basically, she said you are the GOAT of all wound care nurses. So I knew you came really highly recommended, and I've been eager to talk to you.

[02:20] Karen: Well, Karen's been a good friend for a lot of years, had a lot of lunches together.

[02:27] Michelle: That's great. Yeah, Karen and I worked together back in the day at the same institution and always just such a pleasure to be around Karen. So that's awesome. Well, so you are here today to talk about wound nursing, and I don't know very much about wound nursing. I'm going to get that out of the way right now. NICU and pediatrics, of course we saw wounds, but nothing like adult wounds. Kids, of course, heal very quickly. And we're going to talk about one of the interventions that we used back in the day for wounds and see if that's something that is still used. And then in my NICU years, we did have wounds, very specific wounds on our infants, especially our low birth weight infants. We had them on ventilators for a long time on high flow nasal cannula and those babies had wounds under their noses, their septums, their mouths, and then, of course, their perineal area. We had a lot of babies that had drug exposure, and they were, they were withdrawing from drug exposure and having lots of liquid stools. And so their bottoms were very excoriated. And then we had some extravasation wounds from IV's that had gone bad. So we had some. And we did work with our wound team there at the hospital. They were amazing. But that's just my experience with wounds. And I know that I'm going to get schooled today on all types. So let's just start. What's your story? How did you get into wound care? What was the pull for you?

[04:24] Karen: Well, I started out after I got my master's degree, and I wanted to do something very different. So I started a company, and I did low air-loss beds for people in their homes that were at high risk or had a wound. And it was a real learning experience for me because I had to fight Medicare to get it reimbursed. And from there, I decided to go back and get my doctorate and specialized in pressure injury, pretty much. And I originally looked at people newly admitted to a nursing home who had a pressure injury and what were their risk factors very specifically. And from there, I just kind of kept going. It was interesting. My students in Montana used to ask me how I got to be internationally known from Montana. And it was just like hard work, doing publications, doing research. I was very lucky in my career that I got to not only do the research, but I also did litigation cases for all over the country for different attorneys. And yet I still could do hands on wound care, which really was my favorite. I love interacting with the patients. So I started doing a lot of work for Mountain Pacific Quality Health, where we took Wyoming and Alaska from being 49th and 50th, according to Medicare, in wounds. And we made them one and two. And it took a lot of repeat going back, doing hands on, watching them do it. The problem we encountered was once we got facilities really good, their staff got poached, and we kind of had to start over. But it takes a special person to like wound care. You can't be grossed out by it. There's so many different kinds of wounds, and it's not the wound on the patient, it's the patient with the wound. So what I liked about wounds was the challenge of figuring out what we could do to make the patient more receptive to healing. In other words, what deficiencies did they have? Was it nutritional? Was it mobility? Was it moisture? What do we need to address? Obviously, we can't change age, but how can we improve the patient? And then how do we treat the wound and wounds is such a broad subject. We know that your skin is very acidic, and your wound needs to be acidic before it's going to heal. So one of the things that we look at is bringing the wound into the healing environment. So this isn't as easy as slapping a dressing on and saying, one dressing is going to work for everyone. You need to pick a dressing that works with the patient, and you need to change that dressing frequently. Wound Vacs made a huge difference in wound care. They're great for really deep wounds. One of the biggest problems is having physicians recognize when to take them off so that the wound doesn't become too dried out. There's always new products coming out, and it's the willingness to try new products that is really important. What you talked about with the pediatric patients with the pressure is actually recognized as pressure injuries, and it happens in adults as well as children. Feeding tubes also can cause it. Oxygen tubing on the back of the ear or in the back of the head. And so it's looking at all those areas and then actually trying to do some prevention before it occurs, rather than playing catch up. After you have a wound in people with them on their lower legs, you know, we're not going to heal them if we don't get circulation there. So either they're arterial or venous or a combination of both. And so it's not a matter of just going in and saying, okay, we're going to slap a dressing on. It's working with a team to find out what's the underlying cause. Oftentimes we have to work with the orthopedic surgeons. They go on and replace the knee, but they don't look at the circulation status, and then we end up having some issues, or I. I've had physicians that didn't put a wound vac on correctly and caused all kinds of problems when we went to take it off. So it's working with all the providers. Interestingly enough, some of my research has been in looking at nurses knowledge. Nurses generally have a c level of knowledge. Nurses aides have a d level, and physicians have a d level. Physicians can understand the pathophysiology, but they don't understand treatment and prevention at all. We found in the new, working with the New Jersey Hospital association that just providing education. We never taught to the test, and we would retest every time we did a program, but just working on providing knowledge and making people aware, we could take those nurses from a c level to an a level and really make a difference in development of pressure injuries in their facilities. So that was a big deal. We did that for quite a number of years. Dr. Barbara Piper and I actually have a pressure ulcer knowledge test that's been used around the world and translated into multiple languages. And it's looking at prevention, treatment and dressings and to see what, you know, where people's deficiencies are.

[10:27] Michelle: Yeah, that's so interesting that, you know, the levels that you said about knowledge and it's 100% true. I'll say in my case, before we had wound nurses, the nurses on the unit, the bedside, we were just trying to figure out what worked best for the patient. I'm talking, this is back in the 1980s and 1990s, before the advent of all these multiple different products that we have now out on the market. And we were just kind of flying by the seat of our pants. We didn't have a wound nurse. We didn't have that deeper knowledge, and mistakes were made, certainly. Who suffers when mistakes are made? The patient. Right? And I did see in your bio, and I thought that was very interesting as well, is that you said, "my overriding goal is to bring wound care research to the bedside. After examining nurse and physician knowledge of wound care. I know there are major deficits," and you just pointed that out today. As nurses, first of all, we have to have a deeper understanding of wound care. We can't always rely on our wound care teams. I think the more education that they can do with bedside nurses is just going to help everybody. But how do we communicate what we know, what we need to our providers who have very little understanding of what products are out there or how to use them? How do we communicate that?

[12:19] Karen: Well, I used to do sessions, education sessions with the physicians, and, you know, one of their go-to's is just do a wet-to-dry, which actually takes 40% more time to heal, has a much higher infection rate, it's totally ineffective, pulls out the good tissue with the bad, and most of them don't learn anything about it in their training. So it's actually being assertive enough, I guess, to stand up in front of them and say, you don't know anything. I used to use all kinds of tricks to get their attention. Like, if you're still using wet-to-dry, I'm going to find you in the parking lot and beat you up. They would go up to their colleagues, and they're like, you missed the lecture and you're going to get beat up in the parking lot.

[13:08] Michelle: I love that approach.

[13:10] Karen: It woke them up to, hey, maybe she's really serious, you know, maybe we need to pay attention. A couple doctors I stood up to when I would go in and do fill in wound care, there was one that kept wanting a wet-to-dry and I would go in and do something else. And I finally wrote in the progress notes, if you get. I hope you have deep pockets, because if you get sued, you don't have a leg to stand on. And I will not provide substandard care. And he called me up, livid. And I'm like, no, you need to learn. You know, don't you try to tell me you know more about it than I do, because I know more than you. So if you want me to come do an education session, I'll be happy to. He didn't speak to me again, which was okay, too, because if I would have provided care that I knew was wrong, I would have been liable.

[14:00] Michelle: Yeah.

[14:02] Karen: And I was on the National Pressure Ulcer Advisory panel at the time. I was on the World Council of Enterostomal Therapists, International Council. It's like I have this knowledge, and if I do it wrong, it's on me. So the other thing is educating the patient on what you're doing. Some patients are very reluctant to have you do much. So when they had a wound on their backside or their feet, I would take pictures and show it to them, and I would sit with them and explain exactly what I was going to do and why I was going to do it. And that made a big difference, too. It made a big difference in the nurses being willing to work with me. It also made a big difference when I went in and did a lot of programs with the Mountain Pacific Quality Health. My first presentation was identifying who was going to be doing wounds and then making rounds with them. And we would go in oftentimes in the morning, and of course, the patient had been incontinent of stool, and they'd be like, oh, I'll go get the aide. And my thing was, no, you'll go get the stuff, and I will clean this patient up. When I am too good to clean somebody's butt, I need to get out of nursing. I don't care if I have a doctorate. I'm a nurse, and that's my job. And when I'm doing it, I can look at the skin. I also worked with the aides in teaching them about why they were doing things, why keeping track of what patients was eating was so important, giving them tools to communicate any redness or anything they saw on their patients with the nurses, because they're usually the ones that'll see a problem first. And I did a video for AHRQ on how to do a head-to-toe skin assessment still on YouTube. That was a lot of, a lot of fun, but it took an entire day for eleven minutes because people don't realize that you're exactly what, all you're looking for is you're doing it. You know, it's not just looking at wounds, it's looking for excoriation, it's looking for moles. Anything unusual going on in the person that maybe they haven't talked about. So there's a lot more to wound care than just walking in and putting a dressing on.

[16:25] Michelle: Yeah, absolutely. And, you know, I really like that you touched on our partners and making it a multidisciplinary approach, like, first of all, involving the patient, right? Educating the patient, the family. Those are some of our strongest partners that we can have. And also the nurses aides, they are in the rooms probably much more than the nurses are, and they might have more contact, more intimate contact with the patient, doing a back rub or whatever it is, changing the chux. And so for them to be educated as well and be able to report to the nurse what they're seeing, that can only help the situation. 

[17:17] Karen: And now I don't want you to think that every single wound can be healed because they can't. We have palliative care patients, and so oftentimes with that, it's working with the family to understand that we're not going to heal this wound because they think it should be. But as asking the patient, what's the biggest problem they have with their wound? Is it odor? Is it pain? Is it, you know, are they afraid to have their family come in because they think they might smell? I'll use the same dressing products, but I'm using them for a very different reason because I want to keep the person comfortable and it's teaching the family why I'm doing it. I had one patient, and I had been going through the nursing home as part of a training thing, and she was obviously end of life. And she had a very large wound on her heel. And normally we don't debride a heel ulcer. And her daughter happened to be there. Her daughter lived in Alaska and I was in Montana, so it took her days to get there. Basically, and asked me if I could come in and check the patient. And I went in on my own time and kept checking her. And the nurses told us that the heel was causing her so much pain. So my friend Dr. Elizabeth Aiello happened to be visiting me, and she came with me and the two of us debrided the heel, opened it up and then put manuka honey dressing on it, calcium alginate dressing on it. Within a day, the pain was gone. It wasn't that that was ever going to heal. It was that I needed to treat her pain. And when I knew it was bad enough, I called her daughter and asked her to come. And she got there a couple days before, which was what she wanted. It was also calling the physician and saying, here's what I'm doing. Here's why I'm doing it. And it was kind of funny because when she was coming back, he's like, okay, he called me up, Karen, now tell me again why then he wanted to learn because he needed to talk to the family. But I had already talked to the family, so they pretty much knew. But, you know, it's working with the team to make sure everybody's on the same page. Working with the staff, working with the doctor, working with the family, and most of all, working with the patient.

[19:40] Michelle: Yeah. I love that. I really love your approach. And towards the end of my career, we started using manuka honey pretty regularly on some neonatal wounds with really good results. We started first using it on extravasation wounds, and it healed them very, very quickly. Do you get pushback from, you know, your circle as far as nurses, physicians in certain interventions that you employed?

[20:19] Karen: Not too much. The nurses are grateful for any help, and so is the patient. I think it's the physicians that are the hardest to educate the patients. When my friend went to work for Derma Sciences when they first started out, she sent me a bunch of samples to try and said, look, give us your honest feedback. Well, I found that using calcium alginate dries wounds out. It's seaweed. But when you added the manuka honey to it, it just managed the exudate as the honey melts, basically. And it's very good at debridement. It's very good at getting the wound to the correct pH. So I found more pushback from the staff who was like, you're using honey? Really? Then the patient who was like, oh, my God. I wanted something natural. This is wonderful. Can I take some home for the, you know, the visiting nurse to use? And so it was interesting. It took it a long time to become mainstream, but I was very impressed with the abilities, not only on wounds, but burns and stuff, too. Now, it's not something that I do start to finish, and I use the calcium alginate on some, the hydrocolloid on other things, you know, and it's very soothing. But then oftentimes, I would transition to some of the newer products, the cellular matrix and things to finish the skin healing.

[21:47] Michelle: Yeah. Well, what do you do when. So, you know, you're the wound nurse, you're the GOAT. You know, you've got all the knowledge. And what do you do when you get stuck? Like, has that happened to you? Have you just said, I don't know how we can manage this wound? How does that happen?

[22:09] Karen: It does happen. There's been a few wounds that I didn't know what they were. And what I do is send the information in a picture to all my friends and ask for help to other wound nurses. Yeah, I'm not perfect, and I know that. And sometimes you do get stuck. I mean, we had one that was a reaction to an immunization. It's a very rare wound. It happens occasionally. It's the microcirculation becomes necrotic, and they end up with a hole. It can happen after any immunization. But it was so unusual that that one I sent out, and actually, the nurse that identified that asked me to come in and look at it, she and I wrote an article about it because it just wasn't something that was out there. So, yes, I do ask my friends for help.

[23:00] Michelle: I love that. I love that you have that network that you can do that. That's very cool.

[23:06] Karen: Well, isn't that what nursing's about, having networks?

[23:09] Michelle: Yes. And it's about, you know, we have egos, right? We all have egos. And it's about kind of setting that aside and saying, you know, as knowledgeable as I am about this, I, like you said, I'm not perfect. I don't know everything, and it's okay, and I can ask for help instead of just kind of muddling your way through it and causing yourself a lot of anxiety and maybe making a mistake.

[23:40] Karen: You know, when I was a baby nurse, many years ago, I can't tell you how much I learned from my aides. My nurse's aides taught me so much about patient care. And, you know, it's not just being a nurse and I'm superior, and people that think they know it all are doomed to failure. You know, it's and it's not just treating the wound, it's the other things, too. It's the nutritional support. It's having the right support surface, which is really difficult because nurses don't learn anything about that. And there's really not a lot of research about what to pick. But you need to make sure you have a surface. If you need a bariatric bed, regular bed is going to do more damage. It's understanding that 60 minutes in transportation on a hard surface or 60 minutes combined with a hard surface in the emergency room and operating room can lead to pressure injury. So all, you know, it might not be anything the staff is doing wrong. It might be factors that happened to the patient before it came to them. So one of the things I highly recommend is when you have a hospital or facility acquired wound, is doing a root cause analysis. Was the problem some equipment we couldn't get? You know, or was our equipment outdated? Was it products we couldn't get? So was it a supply issue? Was it something that happened along the way? In other words, the transportation time? Was it that we weren't turning this patient like we should have been, or that we didn't use the proper cream? What happened along the way to this person and taking it not as a punitive thing, but as a learning experience to say, here's where we can intervene the next time and make a difference. And I think too often people see it as, oh, you know, they're going to find me at fault. It's never one thing or one person that did it. It's usually a whole combination of factors that came together and caused an issue.

[25:58] Michelle: Yeah, no, you're absolutely right. You know, thinking back to the IHI, you know, 'To Err Is Human' right? And all the things that happen to create that swiss cheese effect where you know these things, just like you said, it's multiple things, it's not one thing. And, you know, RCAs, I love them. I have gained so much knowledge from root cause analysis, you know, inspections or whatever you want to call them, but, and I think the overriding feeling, like you pointed out, is one of blame, which we absolutely need to make sure that is not entering the equation at all. Like, this is so that we can see what steps we missed. And I was reading the other day about a patient that had fallen at home and was down for a while before she was found and then admitted to the hospital and a few days later got like a deep tissue injury, right, started showing itself and how those things can be attributed to being a hospital acquired injury. But without, yeah, without closer inspection. You know, we need to find exactly what was her situation before she even got to us.

[27:36] Karen: And it's sometimes really hard to tell if it's a bruise or a deep tissue injury because they look very similar to start with. I used to use. So one time I was traveling and my husband went out and was playing on the four wheeler with a friend, and he rolled it and had this huge bruise all over his backside. So I took, I said, if you were going to do something stupid, I'm going to use it. So I took a picture and I would often show it and say, is this a bruise or a deep tissue injury? And show them side by side and show how hard it is to be able to tell the difference, you know, so you want to always a deep tissue injury with turning and, you know, prevention until you're proved otherwise. I had a patient one time, we were doing the audit of all the patients in the hospital, and she was 21, and she'd been in a car accident with her boyfriend, and she had hit her head and she broke her leg. Now, they kept her for a couple days to make sure she didn't really have a head injury. She could move. Her boyfriend was killed in the accident, and she was very depressed. She didn't move. And when we did the audit, she had a stage one pressure injury. Nobody checked to see if she was moving because they knew she could move. So it's the little things like that that sometimes trip us up.

[29:09] Michelle: Yeah, absolutely. And, you know, we can only find those things by observing, by questioning. That's how we're going to find those things. We, we have to stop assuming and just really investigate, right?

[29:28] Karen: We do. Because I can walk doesn't mean I am walking. For example, for a long time, my father in law could roll himself around in the bed, but he couldn't get up and walk. And that's the difference between mobility and activity.

[29:45] Michelle: Yeah, absolutely. And my mom is 83. Wait, 84. She just had a birthday. And, you know, I'm, I'm seeing that I, you know, obviously I grew up with her and eight kids. She was super active, you know, always running around. And then, and then all her kids are grown and what does she do? She opens a daycare, right? So it's like, wow, you didn't get enough of your kid fix. Now you need a daycare? And then she did the daycare for 14 years. And I saw her running around for 14 more years, right? And then she retired in her late sixties, and then it was like no activity and now she's 84 and she has very limited mobility. You know, she could probably do more than she thinks she can do, but she doesn't, and it's a big factor. So, yeah. You have to take all that into account.

[30:50] Karen: You have to take the family and the social support into account also.

[30:53] Michelle: Yeah.

[30:54] Karen: Who's moving out and getting food? How far is it to your doctor, your dentist? And we found people in Montana thought they had it available. If it was a hundred miles away. We had to start asking, how far is it?

[31:09] Michelle: Yeah, no, for sure. Those rural areas.

[31:12] Karen: And there's rural areas in a lot of states.

[31:15] Michelle: Oh, my gosh. I live in a rural area. I'm right smack dab in the middle of California. So, yeah, you know, northern California, very populous southern California, but where I live, it's, it's very rural.

[31:29] Karen: And I know a lot of hope you're not being impacted by all those wildfires. Those are nasty.

[31:35] Michelle: We are not right here. Well, actually, I'll say the Sequoias that are just to the east of us, we've had some fires burning actually, for a few months now, and. But they're starting to get a handle on some of the ones in northern California. So, it's been a better fire season. Well, I saw that you were an associate professor for a couple of decades. Do you think nursing schools provide enough education for a good foundation of wound care?

[32:10] Karen: No. In the studies we did, we found there was not enough. For so long, it was assumed that all wounds are treated the same. And it's important to understand that I have a heart condition or I have liver failure or I have renal issues. How does that also impact my skin? So my thing with my students was always started when I had the sophomores and was doing pathophysiology. I'd make them look at a system, but then tell me the impact on every other system in the body because, you know, if I have kidney problems, how does that affect my breathing or my heart or my skin or my whatever? So I think it's really important for nursing schools to really integrate everything. It's a lot to take in, and nursing isn't easy, honestly. After I graduated and I had worked for a year, I went back and reread my pathophysiology book, and it made a lot more sense because I had seen it firsthand and I could really begin to then integrate it. So that's a learning challenge, but it's something we need to work with. I taught undergraduate research. I also taught doctoral evidence based practice that they were very motivated. The undergraduates could see no rhyme or reason for it, you know, so the point is to them, how do you know you're doing the best care? How are you going to defend yourself on your care if you don't read these journal articles? And you need to know not all journal articles are good. What do you need to look for in the journal? It drives me nuts when people say, oh, I researched it on the Internet. No, this proved to be effective. No, research never proves anything. It may indicate because I can pick a sample to make anything look good if I know enough. So, yeah, it's teaching students to be educated consumers as well as knowledgeable on holistic care.

[34:27] Michelle: I love that. I love how you said undergrads. Nursing research is boring. And my brother is a nurse researcher and he's the director of research at our institution here. So many similarities. Talking with you and talking with him. He obviously really gets it because he's done the research and it's more than just googling something, right?

[34:58] Karen: It is, definitely.

[35:00] Michelle: Yeah. That's so cool. I love it. And you know, again, going back to your quote about you want to bring research, wound care research to the bedside. Yeah, that's what we need, right?

[35:15] Karen: Well, we need nurses to understand it's not magic, it's not scary.

[35:20] Michelle: Yeah.

[35:20] Karen: It's, you know, it's logical and it's looking at the wound, the depth, the amount of exudate, the colors, it doesn't matter what kind of wound that is. And then looking at what could possibly be causing this wound and then how can we get it to heal? I mean, we had some people when I was doing, I would do fill in at the hospital, but we had a couple people that it took two of us 2 hours to get the wound vacuum right. Because of the complexity of the wound, you know, I don't expect a staff nurse to come in and handle that, but I do expect the staff nurse to understand why we're doing it the way we're doing it. And, you know, what to watch for if it's not working right.

[36:06] Michelle: Yeah. And that's not too much to expect. Like we at the bedside, we need to know why we're doing what we're doing, what is behind it. 

[36:19] Karen: And report if we see that it's not working or report that there's a complication or, you know, know what to do if the dressing falls off and it's, you know, three in the morning, nobody's going to come up and redo it. So what do you do?

[36:33] Michelle: Yeah, because those situations happen all the time.

[36:37] Karen: Yeah, they do.

[36:39] Michelle: Well, compare some of the technologies that you used, you know, decades ago to things that are being used today. And just some of the differences.

[36:49] Karen: Well, the differences. We've come a long way in our understanding of the pathophysiology of wounds and understanding the different exudates, the different causes of wounds, that kidney failure can lead to a wound, for example, or cancer or, you know, any. Any incision that doesn't heal properly can become infected. What do we do? How do we treat it? When I started out, pretty much, you put a wet to dry or you put a gauze dressing on it and left it alone. Yes, it was. Some of my early wounds as a young baby nurse were wound dehiscence with. We had one lady that had, and I'll never forget her, her large intestine developed a fistula to her aorta, and they went in and tried to fix it, but we had all this drainage, and it was horrible. And eventually she died from it because they never could get it corrected. But it was doing this huge incision and trying to make her comfortable and giving her pain medication ahead of time because that's sometimes very important. So, you know, even before then, in the fifties, they used milk of magnesia or maalox on wounds to dry them out. Well, now we know we don't want to dry them out. That's not going to help. So maggots in wound care, people get so grossed out. But, you know, medical maggots aren't going to turn into flies. They really do kill necrotic tissue. Even if people get grossed out of. It's keeping up with what's new. Wound care vacs, like I said, really changed deep wound care and made a big difference. They help some incisions that are in hard to heal areas to help them heal any of the newer dressings that have come out in education, really calling attention to wound care and prevention. Prevention is really important and understanding how everything goes together in it. You know, their oxygen levels are low, their skin's not getting the oxygen either, things like that.

[39:12] Michelle: Yeah, it's really a holistic approach. And as you were speaking earlier, talking about, you know, kidney failure affecting the skin and how you are imparting those things on your students, it's like we are. We're one person and we are not all compartmentalized. It's. Everything affects something else. And I think when you put it that way, it's really easy to understand.

[39:41] Karen: I used to teach my diabetic patients to put a mirror on their bathroom floor and look at their feet because oftentimes a large wound in their foot is the only way we find their diabetic, and they can't feel it, so. And as teaching nurses, I used to give out little pocket mirrors because I didn't want to bend over all the time and try to look under somebody's heel, and they couldn't get their leg up in the air. And you can see the heels that way, and it's a great way to find any, you know, any redness or open areas that's going on on the heel. So, you know, it's some little tricks to help people.

[40:17] Michelle: Hey, whatever hacks we can get, we're happy to get them, right?

[40:23] Karen: My back wouldn't take crawling on the floor looking up at people.

[40:26] Michelle: No. Heck, no. Well, you were talking about the medical maggots. And, you know, it takes me back to the 1980s. We had one summer where we had a lot of kids, I was working in pediatrics, and we had a lot of lawnmower injuries with kids. It was really bizarre, you know, kids running around on their grass as the parent was mowing the lawn and, like, falling down and the lawnmower taking off a few fingers. And it was really, like I said, it was just really quite bizarre. It seemed like it was a couple summers in a row that this was happening, and we had a lot of kids that were having the ends of their fingers reattached. And, of course, with that came the possibility of infection. Some of those incisions got infected, but a lot of blood congestion, a lot of venous congestion to that area. And we started using medical leeches.

[41:29] Karen: Yes. And they worked very well.

[41:31] Michelle: Very successfully, right? Very successfully, yeah. And, you know, I don't even know if there was any research on it at the time. There had to have been, you know, but we weren't reading it. But we were, you know, taking in these leeches and applying them to the wounds. And the parents, of course, were freaking out, you know, you're not using that on my child.

[41:55] Karen: Yeah.

[41:56] Michelle: And once we explained, like, the pathophysiology behind it, and they agreed to it, you know, much improved. But it just, you know, it just goes to show that some of those new things that are being used, we only come across them because somebody has researched that, right? They've done the work, they've done the research, and they've seen the improvements. And so that's another reason why we need to continue doing research, not just in this area, but in every area.

[42:30] Karen: On some of the research from internationally, it's very interesting, too, because often they have different products or different needs. So it's not just looking in this country, it's looking, you know, around the world. What's going on? Any of the international wound journals or advances in skin and wound care here, or ostomy wound, anything that's a peer reviewed journal is what you want to use as your authority. I still do reviews for multiple journals, and, you know, very rarely does an article come in and go through the process and be published. It goes back for revisions multiple times to clarify something or ask for more information. So it's a grueling process for the author, but it makes for really high quality articles. My dogs are pounding on the door to get my attention because I pen them in the living room now they're playing with a toy.

[43:39] Michelle: I love it. I love the roosters in the background, too.

[43:42] Karen: Oh, yeah, they're everywhere.

[43:43] Michelle: It's so cool. Well, okay, so talking about research and all that, there are quite a few certifications, or, I'm sorry, professional organizations for wound care. So there's the association for the Advancement of Wound Care, or the AAWC, the American Board of Wound Management, the ABWM, the Wound Healing Society, the National pressure Injury Advisory panel, which you were a member of, and the World Council of Intrastomal Therapists. Are there any that I missed? And I will definitely put those links in the show notes for anybody that wants to find those.

[44:28] Karen: Yes, they're all excellent wound organizations. AHRQ, you know, at the federal level, has some publications that are really good resources as well. So.

[44:42] Michelle: Cool.

[44:43] Karen: And then association is another one. I don't know if you mentioned that you have to take a certification test.

[44:51] Michelle: Okay. And I did see some certification. So the wound care certified through National alliance of Wound Care and Ostomy. Certified Wound Care nurse. There's a Certified Wound Ostomy nurse and Certified Wound Ostomy Continence nurse. Yeah. There are so many certified wound specialists. 

[45:12] Karen: And it's just, you know, people have put a lot of time and effort into getting advanced education to be able to take those certifications. It's just wanting to be the best in your profession, and you have to really like wounds. Once you get students over being afraid of them, they get much more interested in it.

[45:33] Michelle: And I'm glad I asked you that question about nursing students, because I was thinking back to my schooling, and I can't remember a thing about maybe the wet-to-dry dressing because it was the early eighties, you know. And I worked on a surgical floor as a nurse's aide as I was going through school. And so we had lots of, you know, surgical wounds, and we didn't have any of those, you know, quote, newfangled products that are out there today. You know, we just made do with whatever we had, and it wasn't optimal and it wasn't comfortable for the patient.

[46:16] Karen: But somehow they survived in spite of us.

[46:19] Michelle: Right? I know.

[46:20] Karen: I find if I, you know, when I would be doing fill in at the hospital and we had students on the floor, I would take them in with me and have them help me do Wound Vac. And they were so scared at first, and then, you know, when I'd have them come back the next time and do it, they were like, oh, let me do it, let me do it, let me do it. And they got over their fear of it. And I think that's what it takes. You know, it's not just being a wound nurse, but it's being a mentor to everyone out there and helping them get over their fear of making the wrong decision. Well, if you put a dressing on and it's not working in five to seven days, you don't see improvement. Switch. You know, use something else. It's not like you can have a handbook and say you have a stage three pressure injury and this is the dressing that'll cure it. No. And, you know, as that wound heals, you're going to try something completely. You know, you're going to progress your dressings accordingly. So it's getting people over, oh, my God, what if I make a wrong decision?

[47:21] Michelle: Yeah, I mean, that's the nursing process, right?

[47:25] Karen: Exactly.

[47:26] Michelle: It's like constantly evaluating and intervening and evaluating again. And I think that's great, you know, taking nurses, nursing students in with you to go through those procedures. And we do have fear. And, you know, I always maintained that if you have fear of something, you need to do that something repeatedly until that fear is gone.

[47:55] Karen: Right, right.

[47:57] Michelle: The natural inclination is to avoid when you're fearful of something, and that's not gonna help.

[48:06] Karen: If you have a mentor to come in and hold your hand, basically, you know, and I think that's why Mountain Pacific Quality healthcare, it worked so well when we went out to the facilities because we did. Actually, that's the first time I came to Hawaii, was I did lecturing on all the islands for them, but I did it in Montana, Wyoming, Alaska. I lectured all over the place for them in Wyoming and Alaska. I would go back three and four times a year, and it was showing and then hand holding and telling them how good they were doing and then talking about what they could do differently, or talking with them about any wounds that they had problems with or being an available resource they could call if they had questions. And that's what it took to make people feel very confident in their ability to do it. And that's the goal.

[48:58] Michelle: Yeah. Mentorship is so important. Do you think there are enough wound nurses?

[49:04] Karen: I think there's always a need for wound nurses. You know, you have to have them in home care, long term care, hospital care, all over. So you really need a lot of good wound nurses.

[49:18] Michelle: Yeah, I agree. And, you know, in our institution, when I started, we had one wound care nurse. I think that came along in the 1990s, and then by the time I left, many years later, I think we have three, so. And this is a, you know, this is a 800-bed hospital.

[49:40] Karen: Yeah. And you can't be everywhere at once. So if you get to see the patient twice a week, you're doing good. You know, and that's one of the reasons some of the modern dressings are good, too, is you can leave them on, you know, three to four days, and that's important. You know, while the dressing might cost more, the staff time and dressing change time is less. So you're actually not spending a fortune on dressings, because that's always been one of the administration, you know, concerns.

[50:16] Michelle: Oh, of course, yeah. Costs.

[50:19] Karen: That's everything. You want to make sure you get a the wound nurse on the materials committee so that they're there to help pick the bed products, to make sure that the dressings that you need are being, you know, that they're available. And oftentimes we overlook that that committee is really important.

[50:40] Michelle: Yeah, that's a really good piece of advice. Yeah. Okay. Well, as we get ready to close here, Karen, what piece of advice do you have for the nurse who is contemplating going into wound nursing?

[50:56] Karen: Don't be afraid. Go for it. Be holistic, include the family, and enjoy your profession.

[51:06] Michelle: I love it. Great advice. Okay, well, Karen recommended you as a guest on this podcast, so now I'm going to put that to you and see if there is someone that you recommend as a guest on this podcast.

[51:23] Karen: What kind of a person are you looking for?

[51:26] Michelle: Well, I know you know, a lot of people, and I put this out here so I really would like to talk to a nurse ethicist. And you don't have to tell me here. You can think about it.

[51:41] Karen: If you would like to talk to an oncology nurse who deals with life and death situations a lot, I would highly recommend Dr. Janine Brandt. She's the director of research, I'm blanking on the hospital in California. It's a big cancer hospital. I'll have to think about that one. But I can, you know, you can probably find her easily. She was president of the American Oncology Nurses association. I've known her for a very, very long time. I met her when I first came to Montana and we've been friends since then, so. And she's a very articulate person. So I highly would recommend her as a guest.

[52:26] Michelle: Okay, well, thank you. Awesome. And you can introduce us. That'd be great.

[52:31] Karen: Yeah, I will tell her.

[52:32] Michelle: Okay, so where can we find you? If our listeners want to reach out to you today, where can they find you?

[52:39] Karen: The best way to do it is my email drkarenz@aol.com or call me 406-671-2909.

[52:51] Michelle: Okay, I'll put those in the show notes. And yay for AOL. We're hanging in there, right?

[52:57] Karen: I know, right? Well, it just was too hard to ever change it. I had too many people in there.

[53:04] Michelle: Oh, my gosh, it's so funny today telling the young people my email address because depending how young they are, they go, huh, AOL, is that new? I go, no, no, it's not new.

[53:21] Karen: Hard to change.

[53:23] Michelle: I love it. I loved our conversation today. I knew when Karen Gray-Leach recommended you that you were going to be fabulous because anybody. Yeah, anybody that Karen recommends, I'm like all over it, so.

[53:38] Karen: And she's quite an artist.

[53:40] Michelle: Oh, my gosh. I know. I love her work. Yeah, I love her work. You know, I wanted to give your business a plug here for a second because it seems like I've talked to so many nurse entrepreneurs lately and I saw that you also are an entrepreneur. You are there in Hawaii and you have a business called Kenai Coffee. 

[54:03] Karen: Yeah, our dog Kenai had autoimmune hemolytic anemia and so he had to take a lot of medication and had a shortened life. But he was always so happy and pleasant and loved everyone, so we wanted to name the farm after him. In fact, my friend Anna is here picking coffee today. We're doing our first picking.

[54:24] Michelle: Wow, that's so cool. Love it. Well, I put your link for your coffee place in the show notes too. Because I just think that's cool. Yeah. Well, okay, we're at the last five minutes of the show, and so, you know, I do what's called the five minute snippet, and it's just five minutes of fun. It's just some kind of off topic questions, but are you ready to play it?

[54:50] Karen: Sure.

[54:53] Okay. Convince me to live in hawaii.

[55:34] Karen: The climate, it's beautiful all year. The hardest part was getting used to not having snow at Christmas. But the friendship among people, the aloha spirit, is really wonderful.

[55:49] Michelle: I could not agree with that more. I've visited several times and I just love it. It's a magical place. And if you haven't been, you need to go, right?

[55:57] Karen: Right.

[55:58] Michelle: Okay. Would you rather be chronically underdressed or overdressed?

[56:04] Karen: Underdressed.

[56:06] Michelle: You live in Hawaii.

[56:08] Karen: I know. We wear shorts or, you know, we only need one season's worth of clothes for a guy getting dressed up as having a hawaiian shirt on. It's very casual.

[56:22] Michelle: Okay. Earlier we talked about mentors and the importance of mentors. Who is the one person you would like to have as a mentor?

[56:32] Karen: Well, the person that was my biggest mentor, there were two, Dr. Courtney Leiter and Dr. Elizabeth Aiello. And they're both very good friends of mine. Elizabeth's gotten me into all kinds of things to do. She's one of my very best friends, and so is Courtney. So I've known them for a very long time.

[56:53] Michelle: I'm sure they were very helpful. Oh, yeah. I'm sure their mentorship and their friendship means so much. Would you rather lounge by the pool or on the beach?

[57:04] Karen: Beach. Although I usually lounge on my lanai. The beach because it's very calming.

[57:12] Michelle: Yeah.

[57:12] Karen: We have the City of Refuge National park, and there's an area in the back that's a picnic area. And there's been a picnic, a community picnic for 30 years there on Wednesdays so every Wednesday I go down and just, you get your calm on.

[57:31] Michelle: I love it. If you could have coffee with two historical figures, who would they be?

[57:38] Karen: Do they have to be dead or can they be alive?

[57:40] Michelle: They can be alive.

[57:42] Karen: I would love to meet Michelle Obama. I think she's one of the classiest people, you know, around. In terms of other person, I don't know. I know so many people that it's hard, I guess. I would like to meet some of my favorite authors. There's a series by Matt Lincoln that is an adventure series that I really like. And my all time favorite author is Jenna de Leon, who writes the Misfortune series there. Like a whodunit book. But they are so funny. They laugh out loud. If I'm reading one at the airport, people like, move away from me because I think I'm crazy, because I'm laughing so hard.

[58:28] Michelle: Oh, my gosh. I love those. You're going to have to send me the link to that. Those are the best. Yes. Okay. A couple more questions. Sunrise or sunset?

[58:39] Karen: Sun. Well, I like them both. I like the feeling in the morning, I get up early six, even though I'm retired. But the golden hour of sunset and watching for the green flash is always beautiful here.

[58:51] Michelle: Yes. Oh, my gosh. I remember that. Yeah. The sunsets there are amazing. And, man, I'm just like you. I get up early and I love to see the sun come up, too. So it'd be hard to pick.

[59:03] Karen: It would. It is.

[59:05] Michelle: Okay, last question. So we're in your house and we see your favorite travel photo. Where was it taken and why is it your favorite?

[59:17] Karen: Any of Alaska? I absolutely loved Alaska. I think it's an absolutely beautiful state. So much to see and do. I made so many trips there, both summer and winter. People are like, oh, my gosh, winter is so terrible. But, you know, I was, I lived in Montana, so it wasn't that big of a deal. But I really liked Alaska.

[59:39] Michelle: I love Alaska as well. My husband and I went on our honeymoon cruise in Alaska and. Yeah, again, Alaska, Hawaii. Magical places, right? Things happen there that just don't happen everywhere. So I would have to agree. Yeah. Well, Karen, this has been so much fun and so informational, and I've just had a blast. And love hearing the sound of your pups and your cat and your chickens, and it's been a magical experience.

[01:00:13] Karen: My cats are angry that they can't get in the house and the dogs are angry they can't get out.

[01:00:19] Michelle: I love it. Oh, my gosh. Well, thank you so much for joining us today and for sharing.

[01:00:24] Karen: Well, thank you for having me. It was very fun.

[01:00:28] Michelle: All right, well, you take care. Have a great rest of your day.

[01:00:32] Karen: You also. Thank you.

[01:00:33] Michelle: Thank you.