Host: Dot Weir, RN, CWON, CWS | Guest: Maria Goddard, MD, CWS, MAPWCA
Dot Weir: Welcome to the SAWC Difference Makers Podcast, where breakthroughs meet the bedside. I'm your host, Dot Weir. Let's dive into today's conversation. Well, thank you for joining us, everyone. It's nice to be back with you, and I'm really excited today to be joined by a colleague that I've been on different committees and boards and things with. So it was really exciting that she agreed to come on and chat with us today, Dr Maria Goddard. I always like to let my guests introduce themselves. Maria has done so much groundbreaking work, in my opinion, and I want her to tell you first about, let's tell us about your background, Dr Goddard, and how you got into the kind of practice that you're in.
Maria Goddard: Hi, Dot. Thanks so much for having me on. I'm really excited to have this conversation with you because, as you said,, we spend lots of time on people with boards and getting to know each other is so important. So everyone has a really great wound origin story if you ask them. My training is actually in burn surgery, and I did 2 burn fellowships in Kansas City and also in Memphis. And I was brought into the mobile wound care world, which was really interesting to me. And because, of course, we take care of wounds in the inpatient burn space, but there are so many people who have the inability to get to clinics on a consistent basis. When I decided to go into medicine, I originally wanted to do orthopedics. What I really loved about orthopedics was getting people back to their lives—maintaining form and function and quality of life. Burn care has led me into wound care, which fulfills all of those things that I love and getting to know patients on that intimate basis like we did in the burn unit.
Dot Weir: As many times as I've been around you, I don't think I really had ever registered that, because I've known you more in your mobile practice, that you had a history in the burn world. So that's like a primary referral center for burns.
Maria Goddard: I worked in 2 academic ABA-verified burn centers. It was very busy. It was fantastic training and mentoring, so taking care of people really on the worst day of their lives. That's what really drives my wound care ethos and the way I practice as well, because the family and the caregivers are just as big a part of the team as the clinicians themselves. So taking people from coming in with severe burns and having them rehabilitated to discharge and then having them come back and visit you on the burn unit after they've been sent home and recovered was really quite rewarding. And they do that for years after.
Dot Weir: Oh my goodness. What was just going through my mind when I think about burns is that I can't imagine there are many things more painful than that. So I imagine you have become exquisitely good at recognizing pain and managing pain because I'm afraid that in our wound care world, especially with the pressure in the outpatient setting as far as opioids and finding medications and things that will manage people's pain, that you have sort of a sixth sense about that with your folks at home. Can you talk a little bit about that? That wasn't on my list, but that's just what struck me because, again, burns are just something to me that would be so painful. Has that helped you in your wound care management of people with pain?
Maria Goddard: It absolutely has. And it's not just the physical pain, it's the psychological pain as well. There was a recent report that came out from the Phoenix Society, which is the Burn Survivor Journal and their group, and it talked about how years after burn survivors talk about the pain of going through dressing changes and their terror about going into that tank room where they have dressing changes, and it's something that stays with them for years afterward. So you're correct. In fact, I saw a patient yesterday who just made a slight movement when I was doing something and I wasn't looking at their face and I said, "You're not comfortable right now." I came around to face them, and they said, "How did you know?" People exhibit pain not just by saying, "Ouch." It's by recoiling. It's by the way they shift their body. That's why, when we talk about debridement, the word itself sounds scary. You're using a sharp tool to remove dead tissue. So having a conversation with patients and empowering them to say, "If this isn't comfortable, please speak up. I can stop. I can do something different. I can use topical options to help with your pain." The other thing, too, from the psychological aspect, because I think about the burn survivors talking about going into that tank room, if there is a patient who is showing me a lot of anxiety, I'm in their home and I never want their home to become a space where they don't feel safe. And that's home, whether it's a nursing home or an independent living space. And if there's something like a sharp debridement that's extensive that needs to be done, if there's another room we can go into, I will ask to use that room, or I will refer them to an outpatient setting so that their home is always a safe space where they're not associating being uncomfortable with being in their home.
Dot Weir: That is fabulous. One of my memories from nursing school, the one time that I really almost slid down a wall onto the floor was when I went through a burn center and I was in the Hubbard tank room and it was humid and the person was in agony. I mean, you could hear them. So gosh, hats off to that. I'm blessed to work with my husband and our outpatient center is mostly lower extremity. And he always says to the patient, "I'm looking at your foot or your leg or whatever he's working on. She's going to watch your face, so you need to let her know if I'm hurting you." Patients just take it sometimes and you can look at their face and see that you're hurting them. So I just think that's a huge message for all of us in wound care that we have to manage the pain. And if the patient says it hurts, you got to stop what you're doing. People come in and say, "Oh, I went to someplace and they just scraped me every week." And it's like their memory of wound care is that they were hurt every single week. Well, anyway, that was a tangent I didn't expect to get off on, but I just think that's so important for us in wound care that we manage the patient's pain. Okay, so you started in mobile care. How in the world did you get into it? Because you did it before it was cool.
Maria Goddard: I was fortunate enough to have a colleague who was interviewing with a mobile wound care company and I was getting ready to finish fellowship and I wasn't sure that I wanted to be driving in at 2 AM to see people. You're correct: it really wasn't cool or something that common when I started. That was back around 2015 or 2016. First of all, the residents in nursing homes start looking forward to these visits because they don't have to leave. When they're going out for appointments, it's a big production. It's a big production for the building as well: getting people organized, arranging transportation. So it's someone that they saw consistently, you build that relationship with them, and then you're delivering high-quality care at the bedside, which is something that can be a challenge. The other thing that I enjoy about mobile wound care is you're educating the masses because I would get CNAs and pull them into the room with me because they're the eyes, ears, and heart of all of our care settings. We really need to give them kudos because your resident might not love the nurse they have for that day and they only see the provider or clinician infrequently, but the CNA is the person who's giving them their bath, who's changing them, who has that time to bond with them, and they notice things before anyone else does. So I always make sure to bring them in the room when I can, show them skin changes that we're looking for. And then I ask them if I'm worried about someone, have you noticed anything different? Are they eating differently? Then they'll say, "Well, their family hasn't come in to see them for 2 weeks and they're more depressed." So that's what I love about the mobile world. It's like the old-school in-home house calls, but on a much higher clinical level because we have all of these tools available to us.
Dot Weir: What percentage of your practice is in long-term care? Do you also do assisted living?
Maria Goddard: I do.
Dot Weir: And what about somebody's private home?
Maria Goddard: It's mostly long-term care, a few people who are in assisted living settings, and then the smaller percentage is usually independent living. That is starting to change as mobile wound care is becoming more common and more readily available. The referral sources now are able to let people have the choice of going out to a wound care clinic or having someone come into their home. The acuity of health care—and I'm sure you've noticed this, Dot—across care settings has really changed. Someone I previously would have thought was definitely going to a skilled nursing facility sometimes is going to assisted living with home health or home with home health. So being able to have someone come to them who's able to give them that quality of care and wound care that they need and also support home health has become really, really important as that health care acuity has shifted to more complex patients being seen in locations that they wouldn't have been 5 or even 10 years ago.
Dot Weir: Oh, absolutely. Even my own wound center—it's a great place, but it's in a hospital, in an old nursing unit— so people have to park, they have to come in, they have to come up elevators and come down the hall to our patient rooms. That's a lot. That's hard. We have people who can bring them up in wheelchairs, but going back to especially the long-term care person, sometimes they have some dementia and you're taking them out of a place now that they have felt safe for a while with that caregiver, that special caregiver, that CNA they really know intimately. Then they're taken to a place where there's a bunch of strangers and maybe we hurt them. I mean, it's just such a perfect scenario for someone to go to them instead of them coming to us. What I was most recently involved with you on was my very first board of directors meeting for the Coalition for At-Risk Skin, or CARS, which is not a brand-new group. I mean, I remember when they first formed, this was years ago, and they were formed by Medline at the time. Of course, they've since broken off from that. I went to a breakfast or some meal presentation where Diane Krasner was there. I don't remember if Cathy was there or not, but it was fascinating how much I learned about skin care in that little meal meeting. So the Coalition for At-Risk Skin is not a new group. A lot of people may not have heard of it, but it's not a new group. It's been around for a while. So I was approached by Cathy Milne, who's the president right now and Diane Krasner, about joining the board of directors. There was almost a personal reason that I wanted to join because I'm not young anymore. I grew up in Florida and have been in the sun all my life, so I never really took super-great care of my skin. They sort of hooked me with some of the things that are coming up that they want to start working on with consensus statements and things. So I'm excited about being part of that group. I'll tell you what really hooked me. It was mostly about getting the word out about good care, good cleansers, and good moisturizing. That was the hook for me at that early meeting: how much moisturizer we're supposed to be using and that most of us don't use enough.
Maria Goddard: Yes. Two medicine cups twice a day.
Dot Weir: Twice a day. That's a lot of lotion.
Maria Goddard: It is.
Dot Weir: And as Cathy Milne has demonstrated on stages, and I know our audience can't see us, but getting your back moisturized is the biggest challenge. I think one of us needs to invent something great to do that, but it is so important. The other big hook for me was that they want to educate more about pH. So Dr Goddard is the chair of the education committee, if you will, of CARS. Tell us what you guys—and I say you guys because I wasn't part of it until last week—have already done and what's going to be happening in the future.
Maria Goddard: I'm really excited about CARS and having you on board with us, Dot. So I joined the organization, which, as you said, has been around for several years and started by putting out 21 consensus statements for the care of skin. Now, we tend to focus on wound etiology and we're not so prevention-focused when it comes to skin as an entire organ. So I love the global message of this group. It's not just for clinicians; it's for laypeople and supporters. We are working to put together education via our website and social media, and we have some upcoming webinars where we try to spread the word about moisturizers and how we can protect our skin. You're absolutely correct, Dot, growing up, being tan was an asset. You spent as much time in the sun as possible. We didn't realize how much damage was being done to the skin. We are really hoping to break things down and bring a wide community of people in. What I love about our board is that we are truly multidisciplinary. We have representation from dermatology, we have podiatrists, we have physicians, we have nurses, we have nurse practitioners, and we really want people to join as supporters. It's absolutely free if you go to our website and you will get all of the information as we start to release those infographics that you can hang in your facility, download, take with you to your doctor's appointments, have in your home. So I'm really, really looking forward to all of the new things that we're going to be bringing into the skin protection space, which we don't really have right now.
Dot Weir: I see that as something that's so easy to educate about in little snippets, and this goes back to that CNA that's helping that person shower and giving them the bath. My brain is exploding with things I want to say, but just educating them on how important it is after you've helped that resident shower or bathe that they do get their skin moisturized. In the bigger picture, facilities need to have a quality skin care line, that the first ingredient on their moisturizer should not be water because it's so easy to go the inexpensive route with that because it's a commodity. Every room gets some kind of skin care, but there are huge differences, and this is not to promote any one product. I think people just need to know what's in it. Again, I've got things that I'm going to need to learn, but especially the pH of products and what will help us keep the pH of our skin normal, as well as all the things done, especially in acute care, like all these CHG baths, for example, That was a very short part of our discussion the other night. I looked up CHG, and the pH is not necessarily the issue, but it's how it's changing the microbiome of the skin. Can you talk a little bit about that? That was interesting to me.
Maria Goddard: People forget that our body lives in a delicate balance of good bacteria, and I'm going to say not-so-good bacteria, because I don't want to say that they're harmful unless we change that balance. So we are so focused sometimes on cleansing and sanitizing that we don't realize that we can really disrupt that balance and get rid of the bacteria that we need to protect our skin barrier. pH is so important to that and it can change very easily. Patients and residents—and even I—sometimes want to pick the moisturizer sometimes that has the best fragrance, but then if you look at the ingredients, like you mentioned, you'll realize that there are a lot of alcohols in it that dry the skin, that really affect the balance of the chemicals that you need. So really using this education that we will be providing so that everyone can make better choices, whether you're at home or in the hospital. We also want to help organizations that are making purchases to realize that this might be a more expensive upfront cost, but if you can reduce injuries such as skin tears, pressure injuries, and bruises— things you might get tagged for by the state, for example, if you're in the long-term care world— skin prevention is really skin health. So making sure that you understand that the balance of that economically as well is really important to consider.
Dot Weir: Absolutely. I live in the wound world. I don't see a lot of intact skin. I do educate a lot, especially with lower-extremity wounds, because we do a lot of descaling, for example, on people with venous leg ulcers, and the importance of cleansing that skin well afterward, and then also the pH balance, learning about pH, and that's a piece of CARS that I really want to get involved with, and this is from a wound care standpoint, but there are so many bad things that happen in an alkaline environment, and that's why they call our skin the acid mantle, right? Yes. But even as you go down in the 5 layers of the epidermis, the pH starts to drop. So again, topically, our skin should be around 4 to 6, somewhere in that range. And as it inches up toward 7 and 8, then if you do get an open wound, then you have unhealthy skin surrounding that wound. There are so many exciting things that we're going to do. There are 2 groups of people I want to talk about as we talk about CARS, and one is: How do people join? How does the average clinician or someone's mother, how do they join? Because it is free—that's the important thing—and then they begin to receive any work product that comes out of the group. How do they join?
Maria Goddard: You go to our website, which we will provide to you, and you just join as a supporter, and we have the option for you to join as a clinician or health care provider or as a non–health care provider, and then information will be sent to you. You can go to our website for updates, but we will also email you educational materials and ongoing updates as we release our new infographics and educational material. We're also on social media for those of you who like that platform as well. We're on Instagram and also on Facebook. So we're really trying to reach a wide audience because, as I said, this is not just for clinicians. We really want the wider public to join us as supporters as well and give us their experiences and feedback and things that they're interested in learning as we continue to develop more education going forward.
Dot Weir: This is also a group of volunteers. For any industry people who may be listening to us today, industry gets approached for funding all the time by all kinds of organizations, but especially now, with CARS still in the gearing-up mode, the organization is looking for supporters and someone who becomes a supporter this year will be deemed a founding supporter. So I say to our industry friends who have an interest in something that can impact pH, can impact the moisturization of the skin, to please reach out to us so that they can hopefully become a founding supporter for us. Well, it has been such a pleasure chatting with you about this. My brain just starts to go when I talk to someone like you who is so involved and contributes so much. I'm the co-chair for the Symposium on Advanced Wound Care, and Dr Goddard is also on our planning committee. And your recommendations are always predictably very patient-focused, and so you're such a big contributor. The wound world is very lucky to have you. So anyway, any closing thoughts?
Maria Goddard: Thank you so much, Dot, for having me. As we continue in this wound care and skin care world, I just want everyone listening to remember that your contribution matters from our clinicians to our bedside nurses. Our wound care patients need us now more than ever as there are so many changes in health care. It can be discouraging, but if that little lady you took care of 3 months ago calls you to tell you that her leg wound is still closed and she's wearing her compression and she doesn't need to see you, and she's going back to church, it reminds you why we need to keep going. You really affect people's quality of life in ways that we don't even realize as wound care clinicians. I'm really, really glad that the wound care world found me.
Dot Weir: Yes, I am too. Well, thank you for joining us, everyone. I'm Dot Weir. This is Dr Maria Goddard, and we're happy that you joined us today. Goodbye. The SAWC Difference Makers Podcast is brought to you by the Symposium on Advanced Wound Care, one of the leading forums for advancing wound care education, research, and collaboration, and Wounds, the official journal of the SAWC.