Restricted Access?

How many times have you seen a sign that says “Do Not Enter” or “Trespassers Will Be Shot”? A modern twist on the latter notice now informs us that “Trespassers Will Be Shot and Due to The Cost of Ammunition, There Will Not Be a Warning Shot!”   There are times in wound care that it seems access has been restricted to common sense and one’s ability to learn. A recent news story pointed this out, not only to the wound care community but the entire television viewing world. A 4–year-old boy went with his family to vacation at the beach in California. During the stay, the child cut his knee on a rock. Within a few days, the wound became red and swollen. The parents took the boy to an urgent care facility where they were told he had a “Staph infection” and was given antibiotics.   After 2-3 weeks, the wound had not healed. In fact, the area of the wound was turning black. The mother asked the doctor about draining the wound, but he advised against it. Despite this advice, the mother “squeezed” the wound and out came a small black object. She put the foreign body in a small bowl with some water, and a small snail emerged from the object, which turned out to be its shell. The wound has now healed, and it is presumed that a snail egg got into the wound when the boy fell, and then hatched.¹   This is an unusual story, but does point out several issues we as wound care professionals face every day. The treatment of any acute wound should involve cleaning of the wound. This usually involves sharp debridement or, perhaps, irrigation by one of several methods² to remove any foreign body that might be present in the wound. This must be done no matter when the wound is first seen. I have seen some interesting objects in wounds through the years, all of which were overlooked at the initial evaluation.   The use of antibiotics with acute wounds depends on the location of the wound and the wounding object. I would think most would agree that every wound does not need to be treated with antibiotics. Unfortunately, I cannot remember a patient referred to our wound center with an acute or chronic wound that has not had numerous courses of antibiotics and, many times, is only referred because the antibiotics failed to heal the wound!   It has been well-documented that, especially in the treatment of chronic wounds, antibiotics must be restricted “to infected wounds and infection must be determined on clinical grounds and not microbiology results (swab cultures) due to the universal colonization of such wounds.”³ Even with good evidence-based recommendations like this, a large study has shown that over a 1-year period, 66% of patients with chronic wounds received antibiotics.⁴ Of the group that received antibiotics, only 12.3% of the patients had a diagnosis of a “wound infection.” This was not influenced by the number of diabetics in the group; just 2.4% of the patients were diabetics.   Another issue is the recommendation that the red, swollen wound not be “drained.” If a traumatic wound has not healed in 7-10 days, I would suggest there is a reason for it—the most likely of which being the presence of a foreign body. This is even true of wounds that heal, then breakdown weeks, months, or even years later. It has been amazing the kinds of foreign bodies I have removed from wounds that are not healing, or ones that seem to have healed and then broken down: bits of cloth, pieces of wood and metal, sewing needles, sutures, surgically implanted devices, surgical devices that were not implanted, rocks, dirt, just about anything you can imagine getting under the skin. Until these foreign bodies are removed, the wounds will not heal.⁵ For this reason, any acute wound that is not healing should be aggressively explored and debrided.   We need ready access to all the knowledge we can accumulate, as well as common sense, if we are to provide the best care possible for our patients. I hope you can remove the “No Trespassing” signs from the storehouse of your knowledge of evidence-based wound care. Ammunition is expensive, you know.