Larval therapy from the patient’s perspective

Objective: to describe the perception of the patient undergoing larval therapy. Method: qualitative, exploratory-descriptive study, using oral history as a data collection technique and methodological framework, in the form of oral life history. Six patients with difficult-to-heal wounds participated in the study, followed by the dressing committee of a teaching hospital in Natal, Rio Grande do Norte, undergoing larval therapy. Results: the testimonies of the patients/collaborators point to various values, such as belief, fear, acceptance, improvement of the wound and pain. They revealed that there is no major objection and that clarification regarding the treatment instituted proved to be important in the acceptance decision. Conclusion: the feelings expressed by the patients, such as improvement of the wound, reduction of pain and odor, optimization of the healing process, emergence of sparks of hope regarding the return to their life, among others, translate the benefits of Larval Therapy (LT). Despite the seizure caused by the animal’s movement over the affected area and the disgust it causes to some professionals and people, LT was considered wonderful, especially for its effectiveness in cleaning the wound without the need for new invasive procedures such as cutting and surgical debridement.


INTRODUCTION
Caring for patients with skin wounds, especially chronic wounds, is challenging, complex, comprehensive and requires skill, scientific knowledge, holistic vision and multi-professional work 1 .
For several patients, the wound can have meanings far beyond the physical order, it is often an imperfection, it generates restrictions, such as limitation of movement, difficulties in the development of work activities, leisure and mobility, fears, social isolation, pain and odor that interferes in daily life, resulting in social and emotional imbalances 1-3 . In this sense, it is necessary to consider, in therapeutic planning, the patient's perception of his wound, difficulties in healing, possibilities of treatment, time to solve the problem and not only the choice of dressing and coverage.
The market has a range of products of different sizes, models and composition for the purpose of maintaining the microclimate, removing debris, protecting granulation tissue, among others 4,5 .
The present study deals with one of the therapeutic possibilities that brings together numerous benefits and prepares the wound bed to receive one of these coverings, which is Larval Therapy (LT), also known as: maggot therapy, larval therapy, biotherapy or bio-surgery [6][7][8][9] . It is a therapeutic, artificial myiasis, induced and controlled by a team of professionals that monitors the entire process, from the capture of the fly in the wild, to the application and removal of the larvae in the injured person [7][8][9] .
Despite being a technique known worldwide by the scientific community and presenting effective results, in Brazil its use is restricted to guinea pigs, except for the work developed at Hospital Universitário Onofre Lopes (HUOL), which in 2012 started the first applications of the larva in humans for the treatment of wounds that are difficult to heal, pioneering the use of the species Chrysomya megacephala (Calliphoridae) [13][14][15] .
The treated cases showed an effective response to LT and the advantages identified were: exuberant granulation tissue, release of enzymes with antimicrobial properties, speed in the process of digestion of necrosis, selectivity, speed in tissue repair, easy handling both in the hospitalized patient and at home and ambulatory 13,14 .

OBJECTIVE
Describe the perception of patients with difficult-toheal wounds undergoing LT.

METHOD
It is a qualitative, exploratory and descriptive research, using oral history as a method of data collection and methodological framework, in the form of oral life history.
According to Meihy16, this modality means a set of life experiences of a person, narrated by them, in which the perception is much more subjective than objective.
Assuming that each person has a history, with its particularities and uniqueness, the oral life history addresses the guiding questions of this study and also justifies the choice of methods, procedures and techniques according to the specificities of the proposed scientific investigation.
The research was carried out at HUOL, located in the city of Natal, state of Rio Grande do Norte, Brazil.

Hospital care institution belonging to the Federal University
Universidade do Rio Grande do Norte (UFRN). The choice for the aforementioned scenario is due to the fact that it is considered, in Brazil, the first and only one to use LT for the treatment of wounds in human beings 13,14 . Six collaborators were interviewed. Among the 11 selected, 3 died before the study started, 1 did not accept to participate and 1 had to interrupt the interviews due to worsening health conditions. When they were invited to participate in the research, they were presented with the proposal, received clarifications about its scientific character, justification, objectives, expected results, as well as the relevance of their contributions. At the end of the interviews, the reports were submitted to transcription, which is the process of recreating the speeches of the employees, transforming them into literary reports, which were subsequently checked and approved by them, in accordance with the proposed methodology.
To record the reactions, postures and expressions of the collaborators, a field diary was used, in which the "vital tone" was recorded, which corresponds to a phrase or word that synthesizes the narrative 16 .
In order to guarantee the anonymity of the collaborators, together with them, fictitious names were chosen, represented by songbirds belonging to the Brazilian fauna, by the free association of the text of Santos that deals with the communication of birds 17 .
In the interpretative approach chosen, we tried to describe each experience respecting the way it was experienced, from the collaborator's perspective.

RESULTS
In this space, the life history of each collaborator will be presented, including the sociodemographic characteristics and particularities of their life trajectories, which runs through the period before the illness, the treatment with LT until the present day. The narratives revealed "vital tones" that made it possible to understand concrete phenomena from the collaborator's experience.

Characterization of collaborators
The sociodemographic characteristics of the collaborators

The experience of being cared for before falling ill
When asked about their life before becoming ill, the answers that emerged refer to the onset of the disease, especially "diabetes" and the advent of the wound. Little was said about being healthy.
Before diabetes I was a guy who lived well, worked day and night and felt nothing, until an injury appeared under my foot, then I started to suffer. (Azulão) In fact my life was very peaceful, until that simple scratch on the side of my foot appeared, that took time to heal, then a friend asked about my rates, went to the doctor, did the tests and knew I had diabetes. (Galo de Campina) Before I discovered diabetes, I had a normal life, I did everything, after I found out I started to rule some things, take out of my life, but I continued to insist, I played with diabetes, I played, I played and she ended up with me, she beat me (Fim Fim) I have lived with the disease since 77, when I had a venous thrombosis in my leg, so I was hospitalized for almost 30 days and my leg was very swollen, which I had to lose. (Coleirinha) I was 5 to 6 years old when my mother took me to a hospital and found out that I had type I diabetes. I actually lived with this disease, even today. (Trinca Ferro)

Living with a wound that is difficult to heal
The presence of the wound was mainly represented by conflicts, fear, anguish, shame, hopelessness and overcoming, in which the history of the wound converges to the life story itself.
Living with the wound is sometimes despair, I look desperate thinking about something, but it is very difficult. (Fim Fim) The difficulties of having a wound were great, they were great, because it was the whole foot and I had to mobilize it all, but I've came to suffer the most when the treatment was over. I suffered a lot, very much, I thought I would not escape. (Azulão) Living with the wound, whether or not it is complicated, I am very afraid of hitting, I cannot step on it, I now walk with crutches so as not to put my foot on the floor, because I am afraid, and I cannot wear any shoes. (Galo de Campina) Living with the wound is terrible, I don't know what it's like to wash myself under the shower, because I can't get wet, I haven't put on a skirt for more than two years, I don't do anything anymore, I stopped doing hydrogymnastics because of those legs of mine, and even walking was difficult, it bothered me, it burned like pepper, dear. Ah! And I feel ashamed, we feel ashamed. (Coleirinha) For me, living with the wound is like living in a dream, just taking care of it, nothing happens to it. (Trinca Ferro)

Initial impressions of larval therapy
When asked what were their first impressions about LT, the responses presented reinforce data already described in the literature. In their statements, the desire for improvement and cure was predominant in the acceptance of LT 6 .
As I wanted to get well, I was asked and I accepted, that was my impression. The nurse spoke to me, said it was an experience that was already being in the United States, and my first impression was as follows, if it is to improve my life, I accept it. I accepted and I did well. (Azulão) My first impression was: oh, that crap on me! To be honest, at first I didn't like it, but we do everything to get well, so I did it, put it in, twice and I don't regret it, I would put it back if necessary. (Coleirinha) It cleaned, right, the larvae cleaned everything and was not aggressive. When they put the larvae and then took it off, after two days everything was red, it took all those dead tissues, ate everything, it was very good, I didn't think it was bad, if it had been bad I would say. (Coleirinha) I believe that for those who can bear it is worth it, they do the cleaning indeed. (Sabiá)

Síntese das narrativas (tom vital)
After a thorough reading of the narrated stories, the "vital tone" corresponding to the phrase or word that will serve as an epigraph for reading the interviews was chosen 16 , that could be grouped and interpreted, intending to understand the collaborators' life stories.
Sabiá's vital tone: But I believe that for those who can bear it, it's worth it, they do the cleaning indeed.
When he realized that his wound did not evolve with conventional treatments, he did not hesitate to accept treatment with LT. However, he could not endure the feeling of bubbling that the larva caused. He said in his report that he believes it is a viable alternative, given that the short space of action supported resulted in an improvement in the condition of the wound.

Feelings about the larva in their wounds
During the interviews, the feelings reported by employees are common, among them: seething, itching, scratching, tingling and sometimes nothing. I felt the animals seething, they put them on, I came home and spent the night well, the other day already at night, it was what I felt seething; it was because they were evolving and having an effect. (Sabiá) I didn't feel anything because the foot was numb, if I tell you that I felt it's a lie, I didn't feel anything. Sometimes there were 200 or so bugs inside my foot, I didn't even know I had. (Fim Fim) When I was with the larvae in the wound, I felt that little seething, that from the second day on, but it didn't bother me at all, I felt it was good, because it didn't hurt anymore, it was just that delicious swirl. (Azulão) I felt like that tingling, but I didn't feel pain, I didn't feel anything anymore.

Changes that occurred after treatment with larval therapy
In the testimonies, the collaborators praise the improvement in the color of the wound bed, saying that it turned "red". For them, significant changes occurred during the treatment, and factors such as cleaning and pain improvement were reported, which may influence the process of expansion of LT among those with difficult to heal wounds and health professionals, since positive results encourage acceptance of the method.
While I was doing the treatment with the larvae, I got along well, I didn't feel pain anymore, I didn't feel "sucked" or anything, because before the foot looked like it was inside a fire pit, it was burning. The foot unpinned, the larvae ate all that rotten flesh, the wound was very red. (Azulão) I used larvae twice, from the first time when I took it I saw a difference, it was very dry, very red, everything was cool, but no new larvae were placed because they died, only on Wednesday did they come again, this time they were placed around of 80 larvae, when they took it off my foot on Friday, it was a blessing, I was discharged and went to the commission's clinic. I thought it was wonderful, a fantastic treatment! (Galo de Campina) Galo de Campina pointed out that the treatment with LT was very important and effective, in just two applications he felt the difference, although he felt very bad when he saw the larvae dead at the end of a session. He emphasized the speed of treatment and commented that he would do it again, in addition to recommending it to others.
Coleirinha's vital tone: And I feel ashamed, we feel ashamed.
Coleirinha reported having undergone numerous treatments before LT, over the years of the presence of the lesion, including the hyperbaric chamber, describing the limitations and the consequent social isolation. She reveals that, initially, she felt disgust when she was informed that the larvae would be placed on her body, but, as she wanted to be cured, she accepted. Despite not being diabetic, she felt no pain during the applications. She did not regret it and guarantees that, currently, she has seen progressive improvement, even managing to walk again.
Trinca Ferro's vital tone: For me, living with the wound is like a dream, just take care of it and nothing happens to it.
Apparently, Trinca Ferro calmly faced the difficulties and limitations imposed by type I diabetes and chronic renal failure (with dialysis treatment), in addition to a kidney transplant and thrombosis in one of the lower limbs. As for the treatment with LT, he asserts that he did not feel pain, only itching and seething that were bearable to the movements of the larva in the lesion bed. He stressed that he was instructed by the nursing team on autonomous care and that he is not walking due to the new injury, this time on the side of the foot. Studies confirm that the interaction between the professional and the patient is a significant factor, since the relationship maintained between both is fundamental for the patient's adherence to the treatment and consequently to the healing process 1,3,6 .

DISCUSSION
It is worth noting that the nurse, a professional who is directly involved in assisting the person with a wound, has a fundamental role in this process. It is their competence to assess the injured person and prescribe the most appropriate care, in addition to performing, guiding and supervising the nursing team in the execution of the dressing 3,4 .
It is believed that the qualitative approach based on oral history allowed the patients/collaborators of the study to express their life histories, difficulties, perceptions, fears and anxieties about the therapy. The researchers had to listen to such experiences with all the richness of details that the reports brought.
The study's limitation is characterized by the sample of six patients, however its relevance is confirmed by being the only one to deal with the perception of patients undergoing larval therapy in Brazil.

CONCLUSION
The feelings expressed by patients, such as improvement of the wound, reduction of pain and odor, optimization of the healing process, emergence of sparks of hope regarding the return to their life, among others, translate the benefits of LT.
Despite the seething caused by the animal's movement over the affected area and the disgust it causes to some professionals and people, LT was considered wonderful, especially for its effectiveness in cleaning the wound without the need for new invasive procedures such as cutting and surgical debridement.
It was unanimous that LT led collaborators to chances of keeping the member or part of it, with less limitations to carry out their daily activities, as well as increased belief in wound healing.
One of the major critical nodes was the discontinuity of treatment due to the lack of larvae, which confirmed the need for greater involvement of managers from all walks of life in order to undertake efforts to insert therapy within the scope of the public health system.
It is hoped that the apprehension of these narratives incites discussions, research among health professionals, particularly nurses, about the benefits of the technique, stimulating its insertion as an integrative practice in health units in order to promote a better quality of life for people with difficult to heal wounds.