Innovative Wound Care

[fisherdvm]

Thanks, vladimir, mild is a relative term. Didn't expect him to get hog wild about it though, as if I stepped on his toe. The bad one that is.

We all can get a little touchy at time, right?

 

[fisherdvm]

So here is my vote for innovative wound care product:

1. Water - always available, and prechlorinated (from the tap)
2. Sterile saline (Equate spray bottle $2 a can)
3. White petrolateum (sterile if possible)
4. Mucopuricin (bactroban ointment) or Altabax cream (great for MRSA)
5. Hydrogen peroxide (debatable, but I think evidence supports it)
6. Superglue (the medical grade if possible, the OTC if only small cuts - and no risk of wound injury from heat)

Hopefully DocVikingo and TSM will make their own list.

 

[fisherdvm]

Here are the thumb down products:

1. Bacitracin and Neosporin ointment - high risk of allergic contact dermatitis, which will fool doctors to think it is infected.
2. Topical steroid ointment or cream - can promote bacterial growth.
3. Any products with benadryl as a topical - due to risk of contact allergic dermatitis - like caladryl.
4. Dermagraft human skin substitute - why pay big money, if you can use your own skin.
5. Regranex - I've not used it, and have done fine. Cost is exorbitant at $700 a tube.

 

[TSandM]

My complaint is not the science, it is the application in less than ideal wounds. One has to look at the reason why a wound is not healing, and not simply relying on several thousand dollars worth of expensive drugs, or "artificial human skin".

This is absolutely right. The first thing to do with a non-healing wound is try to figure out WHY it isn't healing. Sometimes there's a foreign body trapped in it. Sometimes there's too high a bacterial load. Sometimes there isn't enough circulation. Sometimes the patient has an underlying metabolic probem that hasn't been diagnosed (eg. diabetes). Sometimes the patient is noncompliant with good wound care.

But I really don't think Arctic Diver's intention in starting this thread was to discuss the optimal treatment of an open wound to the bottom of his foot. I think he wanted to get some bright ideas from folks on how to manage a wound in circumstances (like wilderness medicine) where ideal treatment may not be readily available.

People can be quite creative; I worked an ER shift about ten years ago when a young man came in who had been climbing Mount Rainier. Not far from the summit, his crampon slipped and lacerated the front of his shin. It was a major wound, about 6 inches long. They were a LONG way from any medical care, so one of his companions sutured the wound neatly, using dental floss, which is fairly sterile nylon. They actually did a really nice job!

 

[ArcticDiver]

Not touchy at all. Nor would I characterize correcting your context as going "hog wild". If you want others to give you a break on your language you must not figuratively put words in their mouths. I was, and am, just seeking to keep the thread on focus. Of course, from one perspective any trauma that occurs to someone else is "mild". After all it is a lot easier to get concerned about one's own blood than someone else's.

As has been pointed out several times this thread was not started to provide a forum for pontification. It was started to ask for other people's ideas. Some will be worth thinking about and others will be better ignored. For example: Duct tape or super glue are good for closing a wound but lousy for covering one such as what I suffered.

By the way the idea of suturing with dental floss is taught in some wilderness medicine classes. Also, such courses teach when not to close a wound. For the curious there are several good field medicine texts. Some are oriented to wilderness environment and others are oriented more to remote areas like would be encountrered in the Amazon. They provide some good insights.


An additional comment:
Lots of attention has been given to how to treat the wound. From my perspective I can not overemphasze the need for and pain involved in making sure the wound area was clean and free of any debris. My body type is not designed to be able to pull a foot around so I can see the bottom of the toe. But a person cannot expect a wound to heal correctly if it is not properly and thoroughly cleaned. So, it was time to grit the teeth and go for it.

 

[fisherdvm]

Sorry, Arcticdiver, things always sounds harsh when you don't have facial expression to add to it. Like I said to Halemano, and vice versa, we always don't mean what we sound. It is harder to know who we are communicating to... But it sounds like you are at least a military medic, RN, physician assistant, or a very experienced wilderness expert.

I think we often overlook simple old fashioned remedies in wound healing, and the circle will come right back again.

How about sterile maggots for wound debridement. In wound with poor venous return (like the toes), sterile leeches to provide venous drainage. They use it to reattach ears, fingers, etc after excidental amputation.

Next, how about hyperbaric chamber. I still think it is a total waste of money, in the hand of an incompetent wound care professional.

Next, how about getting a dermatologist involved. Not in primary wound care, but to give input on what complicating factors might be involved - pyoderma gangrenosum, necrobiosis lipoidica diabeticorum, sclerosing panniculitis, bullous pemphigoid - all common enough to see regularly in wound care - and often missed by non dermatologic physicians.

Next, failure to look at multiple microbial agents especially on the foot - dermatophytes (fungus), yeasts, staphylococcus, e coli, and especially - pseudomonas (from the excessive exudates and places to hide under the nails). This is where an old fashioned antibacterial agent like hydrogen peroxide mixed with iodine is just the perfect choice - but ignored by those who reads only one journal (that cites the cytotoxic effect of these agents), and not realizing the beneficial use during EARLY wound healing. You can not get granulation tissue till you control infection. And why worry about epithelization until you get granulation tissue. It bothers me to see someone having been on 4 or 5 courses of multiple antibiotic, because the doctor is simply treating the culture result.

And lastly, look at all the expensive novel wound care bandages which half of insurance companies do not cover..... I can't even keep track of them. But they are a new science in themselves. Hopefully we'll get a good wound care physician to give you input into it (I am not one).

 

[fisherdvm]

And then add some agents which I don't use, but others use on the foot with regularity:

1. Epsom salt - a dehydrating agent - probably beneficial in controlling the growth of yeast and fungus, by deriving them of their food source?

2. Vinegar - also discussed in the quoted article above - changing the pH so that yeast and bacteria grow less aggressively. Likely to impair epitheilization. But we have to get there first. So why worry about it?

3. Gentian violet - old fashioned, and used by older doctors. I'll bet it worked well when used in competent hands. I've never used it. It is antifungal and antibacterial.

4. Domboro soaks - a mild astringent and acidifying agent - kind of like vinegar, except better? Comes in small packages that you can mix on the trail. A soothing agent when used as a wet compress.

 

[fisherdvm]

On suturing wounds - Dental floss, fishing line, cotton thread. I'd prefer fishing lines, as it is monofilament and has no flavoring. A straight sewing needle will work. Even a small fish hook will work if you can get the sharp curve to unbend a little (they often break) and break the barb with a plier. I am not always sure if it is good to sew up a wound in the wilderness, especially if it is contaminated, and you can increase your risk of gangrene and infection.

One can use a plier, a forcep, or just your finger as the needle holder.

If you can keep it clean, secondary closure after granulation tissue occur is still a good idea once you've returned to civilization.

 

[Divingdoc112]

Wounds and diving...I am a board certified general surgeon and FAA medical examiner. I teach a course in offshore medicine for long distance cruisers and wilderness adventurers. Sea water is heavily contaminated with microorganisms, especially protazoans and bacteria. It is not anticeptic. Any wound should be cleaned and dressed with sterile gauze and an anticeptic ointment. The dressing should be occlusive and changed everyday. It should be kept dry. Contaminated or infected wounds may be packed with sterile saline moistened gauze and the wound changed daily, using the dried gauze to slowly debride (remove) dead tissue from the wound by pulling it away without moistening it. Staph infection is a constant danger in sea water contaminated wounds especially those involving punctures and lacerations from corals, boat bottoms and corroding underwater metals. Tetanus shots are a must and early systemic antibiotics advised for any wound with evidence of invasion (redness, increased pain and heat). Diving with an open wound is not advised. It invites trouble.

 

[fisherdvm]

Sea water is heavily contaminated with microorganisms, especially protazoans and bacteria.

Survival of enteric organisms in sea water is an interesting review of how dirty sea water is.

And yet it is kind of contradictory that many folks with skin diseases like psoriasis find sea water and the sun very healing to their skin disease.

It also perturbs me to see these folks sitting in fresh water community pools to let little fish nibble on their flesh... Disgusting - but so are maggots and leeches.

See the fish cleaning the wound: http://www.psoriasisfishcure.com/virtualtour/10.htm