das magazin / 4 May

    The “Cinderellas of healthcare”

    An Interview with Christina Lindholm.

    Education and training
    1. Registered Nurse, PhD in Medicine (Dermatology & Surgery), Senior Professor at Sophiahemmet University, Wound Consultant to the Karolinska University Hospital and Dalen Geriatric hospital.
    2. Member of the Executive Board of European Pressure Ulcer Advisory Panel (EPUAP)
    3. Editor in Chief of the Swedish Wound Journal “Sår”
    4. Council member (and first president) of the Swedish Association of Tissue Viabilty Nurses (SSiS)
    5. Member of the EWMA Council from 1994-2008
    Practical experiance50 years

    It’s exactly one book, containing more than 300 photos and illustrations and more than 700 references, that is being used in all nursing education and woundeducation in Sweden. Its author: Christina Lindholm. Born during the Second World War, she is holding the first professorial chair in clinical nursing in Sweden. The Registered Nurse with a PhD in Medicine (Dermatology & Surgery) has published more than 70 scientific papers and 10 scientific reports on wound management– next to her book “Sår”. We asked the passionate health care expert about her motivation and about the achievements she is most proud of.

    You played a crucial role in the development of multidisciplinary wound management organisations in the Balcans and the Baltic States. Why is an interdisciplinary approach needed to manage wounds?

    The value of interdisciplinary work concerning patients with chronic wounds became apparent when working as Director of Research in Caring Sciences at Uppsala University hospital. The availability of highly specialised staff like vascular surgeons, dermatologists, clinical physiologists, occupational therapists, lymphedema therapists as well a sparticularly well educated nurses (atwo-year wound education which we franchised from Cardiff University) qualified me to lead the project of founding an interdisciplinary wound clinic at the hospital. And I was so proud to see this clinic flourish! Solid data on all wounds in the county backed up the plans and structure. Yet, unfortunately, this center was recently closed, following the trend in Sweden to move health care out into primary care.

    What would you describe as breakthrough moments in your professional life?

    Quite early in my career I recognized a huge group of patients withhard-to-heal wounds, who we later came to call the “cinderellas of health care”. Very little was published about chronic wounds back then. During my work as a nurse in a surgical ward, I witnessed an experiment which hooked me to the wonders of wound healing: A patient with a giant leg ulcer was the first one in our country to be injected intravenously with a dye, “Fast Green”. The plan was to remove all dead tissue which did not become green by radical debridement performed by surgeons. The patient healed miraculously! This was my first understanding of the importance of debridement. However, the method was never used again, since the green color remained for a long time. The most important finding in my PhD studies and in later studies was the dramatic decrease in quality of life in patients with leg ulcers. The studies on pain in this patient group changed the traditional beliefs that venous leg ulcers were not painful and I believe those studies to be the most important achievements of my entire scientific career, since they raised awareness about the importance of pain relief for a big group of “forgotten” patients. Another breakthrough was the detection of MMPs in chronic wounds, where our research group in Malmö was the first one to publish this finding. The consequences with development of a targeted treatment with the purpose of eliminating some deleterious MMPs from wounds has opened up the possibility to heal many “non-healing ulcers”. Another breakthrough in my understanding of retardation of wound healing was the science behind biofilm formation. An excellent scientific paper by Kalan and Griffith appeared in 2018, describing the role of fungi in wounds, which gave me the final understanding of how important it is to debride the wound biofilm.

    You have received several scientific awards. Which achievement are you most proud of?

    I am most happy about the important steps forward we have all taken in the care of patients with hard-to-healwounds. Since early childhood I was interested in science, my best Christmas gift ever was a small microscope, through which I could look at hidden creatures and botanical miracles in nature. Following my passion and curiosity, and after having performed a number of studies, I decided to develop academically. My PhD-thesis in Dermatology and Surgery at Lund University in 1993 contained five papers on patients with leg ulcers. I was actually one of the very first nurses in Sweden to get a PhD in medicine. My professorial chair is my final working position in life - combining academic and clinical work: educating and supervising. The focus of my research group was – hardly surprising – wounds, epidemiology, treatment, microbiology, hospital hygiene.

    Besides wound microbiology, your scientific interest focuses on the prevalence and incidence of pressure ulcers. Why is this indication of particular interest for you?

    During my early time being one of the founders of the European Pressure Ulcer Advisory Panel, I noticed that there was no data available on the prevalence of pressure ulcers. Thus, I initiated studies according to the EPUAP protocol, that have been on-going on a national level until last year. Unfortunately, we saw very little changes in the prevalence overall these years, even though the awareness of the problem had been raised. One of the most successful longitudinal studies which I performed together with the management and all staff at a geriatric hospital resulted in a dramatic drop of both prevalence and incidence. The magic bullet was raised level of knowledge, recognition of the problem, and the setup of a very strict care bundle including e.g. risk and skin assessment with in two hours after arrival at the hospital, arginine-enriched nutrition formula, strict turning schedules, etc. The result of this project is one of my greatest prides. The engagement by the chief doctor and all staff has been particularly impressive, as for two years we have measured the results every month. Everyone was so proud of the performance. In general, I feel profoundly grateful for all colleagues, researchers, staff and to the patients who so generously have shared their experiences with me.

    What does healthcare staff need to consider or what needs to be done to heal those kind of wounds?

    The concept of moist wound healing was introduced in the early 80`s, and is still valid. In recent years there has been a break-through for regular wound debridement, motivated by biofilm, new knowledge about fungi and the deleterious effects of dead tissue in the wounds. The development of an almost painless monofilament debridement method is one of the great inventions in modern wound management. So the debridement circle, starting at the brusque story about the green man, has now been completed by modern technology.