Innovations in Wound Care: Advancements in Wound Care: Burns & Biofilms, Part 1

Wound Care Wednesday in July focuses on the care and treatment of burn wounds, including the importance of removing biofilms. Join Dr Jonathan Johnson and esteemed guest speaker Dr Maria Goddard for this week’s conversation on best practices, case studies, and clinical practice pearls related to wound care.

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Dr Jonathan Johnson: Hello Wound Care World! This is Dr Johnson, otherwise known as Dr Wounds. I am a wound care board-certified wound surgeon, and this is another episode of Wound Care Wednesday.

We are super excited and cannot wait to have a great discussion with our expert panelists today. We always look at our different topics of wound care to focus on what is engaging for our colleagues, educational for our patients, but we also want to make sure that it's fun and exciting. So, grab your coffee, grab your glass of wine, grab your water, and let's get started.

So today, we have an excellent expert in the wound care field who I have known for many years. She is above and beyond a great practitioner, a great educator, and understands the complexity of wound care but also has the compassion to make sure her patients understand her, and she gives the best care as she can.

So, without further ado, I would like to bring on our distinguished guest on this Wound Care Wednesday here at HMP, Dr Maria Goddard. Dr Goddard, how are you?

Dr Maria Goddard: I'm doing great, Dr Johnson. Thank you so much for that wonderful introduction. I'm really excited to be here and to share with everyone my expertise and to hopefully alleviate some fears that people have about particular wound care topics, especially burns.

Dr Jonathan Johnson: Great, great, great. Well, Dr Goddard, we understand that obviously wound care is a special field, and we love working with our patients, we love working with our colleagues. Tell us a little bit about where you're located, how you practice wound care, and tell us a little bit about your day-to-day interaction with patients.

Dr Maria Goddard: Sure, absolutely. I think one of the really fun things about being in wound care is that we've all sort of come to it from different directions and different backgrounds, which really makes it a rich and diverse field, not only for ourselves but also our patients. We've got that multidisciplinary care built in. So I actually practice in the Midwest. I'm in the beautiful sunflower state of Kansas, where I've been for 10 years. My background, how I got into wound care is I started out with burn surgery training, and so I spent many years in the burn unit. And so I have now had the pleasure of practicing in care settings across the continuum, and really that has allowed me to see the differences in care.

So I'm currently a mobile wound care clinician, so I take the wound care clinic to the patient. And that's really enjoyable. Patients really enjoy it because they don't have to worry about transportation. They're in a comfortable setting. It removes some of the day-to-day apprehension of what's going to happen, and I really love practicing that way. And I love to see that more and more of care is moving that way as well.

Dr Jonathan Johnson: Awesome, awesome. I really think that understanding how to treat patients where they are, whether that's in their home, whether that's in long-term care, assisted living, independent living, the hospital, even the wound care center. It's really important. So, I definitely applaud you for your professional accolades as well as your compassion for patients.

So, Dr Goddard, let's talk a little bit about a few awesome topics. Now, it is July, as we all know, it's the summertime, whether you're vacationing, whether you are going to a bonfire—I'm from Colorado, so bonfires happen very frequently—whether you're going to an event that has fireworks, we want to make sure we are cautious to mitigate against burns. Burns to the skin in the summertime can happen very frequently. So as wound care experts, Dr Goddard, what are some of the concepts that you want to make sure your patients understand? And how can you make sure that they have quality tips to prevent burns wherever they are this summer?

Dr Maria Goddard: Absolutely. Dr Johnson, I will say that summer is probably a burn surgeon's least favorite time of the year just because the volume is so high. And the first thing—but it's also our favorite because we get to take care of people really when they need it the most. So, the first thing is really simple that everyone has to think of, whether you have diabetes, all of us from the youngest child to the oldest adult. The first thing we need to think about is the sun.

Sun protection. We really need to protect our skin, make sure that people of all ethnicities are recognizing the importance of wearing sunscreen. Because you can have a really bad sunburn that could end up being not just a superficial, but it could be superficial partial-thickness, or if you lay out for a longer time, it could progress even to a deeper burn. And so the first thing is: Protect yourself from the sun. That's something that we all need to do. Wear your hats, wear appropriate clothing, minimize your time outside. We want that vitamin D, but you do not want that burn on top of that.

And then you also mentioned some really key things that we see in the summer. Fourth of July may have passed, but still fireworks and bonfires are an ongoing concern. And so you want to make sure that you're keeping potential sources of flame away from your home or buildings or things that are flammable. And If you do sustain a burn, let's talk about what are some more important first aid tips that you can do at the scene. Because a burn is something that we're all going to sustain. I've burnt myself just this weekend while cooking. So, it's something that we're all used to.

And so the first thing I want everyone to think about is cooling the area. And you don't want to do that with ice or with really cold water, you want that to be at room temperature. Because if you cool it too quickly, you'll actually cause some skin damage. And so that's my first thing. Really irrigate well with room temperature water.

Dr Jonathan Johnson: Awesome. Great. So number 1, assess the area, make sure that we don't see any issues with the area. Remove any foreign bodies. Very, very important.

Now, Dr Goddard, let me take a step back because you said something that was very important, and I think our audience really needs to understand. Tell us the difference between a first-degree burn and a second-degree burn, because you said superficial partial thickness. Help us understand what those words mean a little bit.

Dr Maria Goddard: Sure, absolutely. So, we've changed the naming of the burn system to be more accurate about the depth of the injury. So, the former first-degree burn is superficial, so that's just in the very top layers of the skin. Those should heal on their own. That's your usual type of sunburn.

And the key with those is that they are extremely painful, because you're just getting that top layer of skin where you still have your nerve endings active and exposed and firing. So that's your former first degree, now called superficial.

Second degree has now been divided into 2 categories. So, you have your superficial partial thickness and then your deep dermal. And that just gives us a breakdown of going even further into the layers of the skin.

And then we have your former third-degree burn, which is full thickness. So that's through all of the layers, and that is the type of wound that is going to need some sort of intervention to remove that top layer of non-viable burnt tissue and is going to need some type of assistance with covering.

We have fourth degree as well, where you have bone or muscle or deeper structures exposed, and those definitely have to go to a specialist in a burn center or a plastic surgeon.

Well, let me circle back to those 2 categories of former second degree or those superficial partial and deep dermal. The reason why we did that is because there are 3 zones with the burn. So, a burn is a constantly evolving wound. The first time that you see it, it looks one way, but then depending on different factors, how deep it was, how warm the source was, then it will start to evolve. And so, right in the center of the wound, you have this zone of coagulation. So that area is not going to change. It is at its deepest depth.

Right on the outside of that, you have your zone of stasis, which could go either way. It could improve—if you give people enough fluid, if you get the right interventions in place. And then you have this outer ring, which is red and called the zone of hyperemia, and so it's more inflamed. And so that area will often heal. You want to make sure that you're not confusing the zone of hyperemia with infection. So that's something I want to caution people about.

So in that first 24 to 48 hours, if you see that kind of inflamed area—for patients with darker-pigmented skin, it may not be red, it may have a darker pigmentation to their unburned skin. And so you want to make sure that you're not confusing that with infection and that you're monitoring burn injuries really well in that first 72 hours especially.

Dr Jonathan Johnson: Got it. That is a perfect breakdown of the different types of burns and the classifications that we typically see. So, what I tend to tell my patients specifically is that if you come in and you see blistering on the skin, you're looking at a more advanced burn. So you're looking at a secondary burn as soon as you see that blistering, any fluid. So you want to make sure you're interacting with your wound care provider. It's very, very important to really initially treat that wound as aggressively as possible so it doesn't start to transition—as Dr Goddard is saying, burns are always evolving—it doesn't transition to a more infectious or a more progressive burn wound. So it's very, very important.

Now, Dr Goddard, for our patients that are listening, and I hope they are, tell us a little bit about what coagulation means. You know, we have the different zones of the burn. Help us understand what coagulation means, and what do we need to focus on when we're thinking about that specifically?

Dr Maria Goddard: Sure, so coagulation essentially means that the proteins are completely destroyed in that area, and proteins are the building blocks in the foundation of our healing and our tissue. And so in that area, they have lost their ability to come back together, and they're destroyed.

Dr Jonathan Johnson: Got it, perfect. So now, team and our audience out there, we've discussed our burns. We've looked at the different classification of burns. We've also discussed the first-line treatment of burns. So, it's that Saturday night, you have your food on the grill. You have your hot dog or your hamburger or your, any type of food that you're eating. And unfortunately, you fall, you trip, and you burn your arm on the grill or you burn your arm in the bonfire or, unfortunately, you have an electrical burn, all right?

Tell us what is our first line of treatment, Dr Goddard. What are we thinking about as far as our treatments? What do we need to do if it is more progressive than a first- or second-degree burn? How do we move from there? How do we treat those?

Dr Maria Goddard: Absolutely. And so the first thing that you want to do is, of course, like we mentioned, stop the burning. So that's putting out the flame. If there's an actual flame. Cooling the area with that water that is not too cold, and removing any debris, as you mentioned.

I also want to cautious our listeners that full-thickness burns, so the burns that are at those deepest depth and will need you to see a specialist, actually are not painful because the nerve endings have also been destroyed in that zone. So, lack of pain is actually a warning sign to you that you need to seek deeper care. And so, you can start off in an emergency room or urgent care if it is a small area of your body that is burnt.

If an important area like your hand, your face, your feet, those are areas where you really want to make sure that you're going to an emergency room right away, because those are vital structures. There's not much wiggle room for preserving them, and so you want to be really aggressive about getting them taken care of.

If you are at home and it's a smaller area, covering with a bandage is always wonderful because now you've broken that barrier to infection. And the most common complication with a burn injury is infection at the local skin site.

Dr Jonathan Johnson: Mm-hmm.

Dr Maria Goddard: And so, you want to make sure it's covered.

I'm sure all of you have a tube of some sort of burn cream that we've had for a long time.

Dr Jonathan Johnson: Right.

Dr Maria Goddard: But I want to caution people about that as well. It's really great in the beginning because it's antimicrobial, but we've had some studies recently in the last few years where you don't want to use that for an extended period of time, because it can actually slow down re-epithelialization or the wound healing and can form sort of a thick pseudo-eschar or top layer over the burn and can actually make it progress to third degree. So you really want to be using that for a short period of time before you're seeking care from a clinician.

Dr Jonathan Johnson: Great points, great points. So, what Dr Goddard spoke about there is very, very important, and let me re-emphasize some important concepts that you really need to make sure you understand specifically, if you're at home, if you're out, if you're anywhere where you do sustain a burn on a specific anatomical location. Remember, burns to the face, burns to the hands, burns to the feet, and burns to the genitalia area, you need to seek out the resource of a burn center.

If you cannot find a burn center, an ER obviously will suffice, but you really want to make sure you're under the care of an expert burn surgeon, like Dr Goddard in her training. You want to make sure that you are being seen because those are critical areas, and we can talk in extensive detail about some of the adverse effects of burns, contractures, scarring, mobility problems, et cetera, but we don't want any of those to set in. So, very important to remember that point.

The other concept before we move on to our next awesome topic is the types of burns, right? I mentioned electrical burns. There are types of burns that we need to make sure we understand how to treat and recognize as being a major issue. So, Dr Goddard, there's a bunch of different ways, unfortunately, that you can be burned. Back in high school and middle school, those burns were different, obviously, more psychological, if you didn't get that homecoming or prom date or whatever. But now, we need to think about the different type of physical burn. So, tell us a little bit about those, there's a couple categories.

Dr Maria Goddard: Sure, absolutely. And so the type that people most commonly think of would be flame burns. So that would be you're in a house fire, your stove catches on fire, and you have contact with an actual flame.

You mentioned electrical, so that is if you are struck by lightning. And the challenge with electrical burns are that they travel under the surface of the skin, and so you can't see the damage externally and that's why it's important that you seek emergency care, even if you didn't lose consciousness or any of those other factors, you need to be evaluated and monitored for a period of time, because that burn has occurred on the inside, that's where the damage is, and we want to make sure that we're protecting your kidneys, because your muscles can break down, and that can lead to some really severe complications affecting your heart and other organs.

Then we also have our chemical burns, and those could be from acids or alkali. People always think that acids are going to be the worst burn, and they get a really bad reputation, but alkali burns end up being the worst. So again, making sure that you're washing that area really well. If it gets into your eyes, seeking emergency care immediately. Really making sure that, because you may not think of that as a burn per se because it's a substance and a chemical, but those can cause some severe injuries as well, especially the alkali burns, like I said.

And then, of course, we have contact. So contact with a hot surface. And we're actually seeing quite a bit of this in the summer with the pavement and people walking barefoot. So, you're at the pool with your kids having a great day thinking that you're cooling down, but if you're walking barefoot, if it's 100 degrees outside, the ground is many times hotter than that. And it only takes a few seconds for a superficial burn to occur and not much longer for that to quickly progress to a third-degree burn. So you really want to make sure that you're being cautious, especially in the summertime, earth temperatures will cause a contact injury with your feet. Or if you fall, we've seen some people have fallen and maybe stayed on there for a period of time, getting injuries on other parts of the body as well.

Dr Jonathan Johnson: Great points. Great points. So, we've identified the fact we have a burn. Unfortunately, we've been involved in a burn episode. Let's talk a little bit about medical treatments, and then we'll transition to our other topic for the podcast. We want to make sure we're looking at water-based treatments, which is very important. Let's focus on making sure that our patients are hydrated. We need to have an increased amount of fluids, whether that's drinking, if you're in an ER or a medical advanced setting, you want to make sure you're having your IV. You want to make sure that you're regulating the patient's pain and anxiety, because obviously with burns, you're going to see pain, but the anxiousness of any pending physical deformity to that anatomical location after can be a major issue.

So sometimes psychology can be involved, counseling can be involved. Again, Dr Goddard is well versed being trained in a burn center and currently working with burn patients. So she understands that it's not just the physical and clinical side. You need to also work on the sociologic side as well to make sure the patient understands that we're there for them.

So, burn creams, burn ointments, we discussed that. Having adequate dressings, and also remember tetanus shots, right? Dr Goddard, can you tell us any additional treatments or any additional management concepts that we need to focus on?

Dr Maria Goddard: You really hit on a lot of the highlights. I will just add nutrition, especially if you have a larger burn. Burns behave differently to other wounds in that they increase your baseline metabolic rate. They're inflammatory. And so, especially if you have a larger burn, you need to make sure that you're keeping up with that cell turnover and making sure you're getting your good protein and high-protein diet.

We're talking about things like your eggs, meat, cheese, if you're a vegetarian, finding an appropriate alternative source, but really hitting that nutrition is important because things are really revved up with the burn.

Dr Jonathan Johnson: Great points. Great points. So, treat the whole body. I think the summary here is, number 1, identify quickly. Number 2, seek medical attention. Number 3, make sure that your treatment is all-encompassed, right? Not just physical. Mental, make sure you have your protein bills, make sure you're hydrating effectively. And, most importantly, understand that where you are burned is just as important as how quickly you seek medical attention. And then there are also types of burns that we need to be cognizant of that can have more adverse effects internally that we may not be able to see with a naked eye.

So, with that being said, let's think about some of the adverse products or issues that a burn will keep on the skin site after a burn, right? So the superficial skin is burned, and now we have a wound in place. One of the major issues with wounds is, as we know, chronic inflammation. And with chronic inflammation, there is a cause of chronic inflammation.

So now we're looking at our second topic for the podcast, biofilm, bioburdened devitalized tissue. However you want to call it, our main goal as wound care practitioners is removing this layer as effectively as possible to help the wound progress through the 4 stages of wound healing.

So, being a wound care expert and a burn expert and seeing patients in multiple places of service, Dr Goddard, help us understand a little bit more about what biofilm is and what causes it.

Dr Maria Goddard: Biofilm is such an innocent-sounding word, right?

Dr Jonathan Johnson: <Laughs> It is.

Dr Maria Goddard: It's a film that you can see through. I think of it as a bio wall, because it really, it's the bacteria, they go into the planktonic stage, which is in their native form, and then they start to communicate with each other and form a net over that broken skin, no matter the cause of the wound.

A lot of the early biofilm work actually started with dentistry and the teeth having a biofilm over them as well. And so, when you have a wound that you see that really shiny appearance to, shiny may be good for new things like electronics but not for wounds. That's your biofilm. It's actually, you can't see it with the naked eye, but that shiny appearance is a really good indicator that it's lurking there.

Dr Jonathan Johnson: Got it, great points, great points. So, I like the analogy of the tooth issues because my dad, being a dentist, he couldn't get me into dentistry, but I do understand the concept of removing the biofilm as frequently as possible, because it can re-accumulate if you're not removing the devitalized tissue, right? So that's brushing your teeth in the morning, hopefully we all do. And then brushing your teeth obviously before you go to bed.

So, going back to the basic biochemical or the biologic aspect of biofilm, we know it's a community of bacteria, and sometimes that biofilm can also include fungi. So, it's not going to be one type of bacteria, if you agree with me, Dr Goddard, here. It's typically going to be a multifactorial component of bacteria that's producing this bioburden and this biofilm. It's invisible to the naked eye. So, when you remove the dressing, it's not like it's something that's staring you in the face and waving at you like some of those old school cartoons, right? You need to understand that it's there because within 24 to 48 hours, this biofilm will re-accumulate.

Now, the problem with the biofilm is that it continues to induce chronic inflammation, which obviously prolongs wound healing, right? Our chronic wounds typically have about 90% of biofilm that is preventing the wound from transitioning through those beautiful 4 stages of wound healing.

So, Dr Goddard, you see a patient, you're seeing a patient in one of your home health venues, and you remove the dressing, you see biofilm, tell me a little bit about your treatment regimen.

Dr Maria Goddard: Sure, absolutely. And as you alluded to, essentially every wound has biofilm, right? As soon as you've walked away, that community of organisms, they start talking and they get to work right away. And so, I always assume that there is a biofilm present, because 99% of the time, there usually is. And so the first thing, and again, I will go back to dentistry, is the importance of wound cleansing. You know, when you brush your teeth, you don't go really gently. You really have those bristles going at a certain speed. And the function of that is to remove that biofilm. I always want to make sure that the people I'm working with, whether that's the nursing staff, other clinicians, that they understand that the first step to good wound care is good wound hygiene.

And so, we don't want to hurt our patients. Of course we don't want to cause more pain, and we want to make sure that patients are pre-medicated as much as possible when we're going to do treatments. But we have to make sure that we're using an antimicrobial cleanser if possible, and then really using some good mechanical debridement. So that's just scrubbing the wound itself. And that will start to break up that layer of biofilm as the first step. So cleansing is the first step to getting to where you need to be.

Dr Jonathan Johnson: Perfect. So again, just to reiterate the concept, if we remove our dressing, we see an increase amount of biofilm and bioburden and sometimes devitalized tissue, we need to remove it some way. And what we don't want to do as providers is just remove the dressing, wipe it down gently, and then replace the dressing, because you're not helping the wound progress through the 4 stages of wound healing, right? So when we discuss aggressively removing the biofilm, I like to call it massaging the wound bed to remove the devitalized tissue.

So, we're using an instrument that can help remove that. And every single wound we see, I know from a practitioner standpoint, most folks agree, there needs to be some type of removal of the bioburden. So, bleeding is a good thing, right? Because wound healing needs to have blood flow and oxygen. So removing that type layer of biofilm with a little bit of bleeding and exudate is okay. That's what we want to focus on. And we want to be aggressive initially because remember, it can re-accumulate between 24 and 48 hours. So removing that is very important.

Now, couple questions, Dr Goddard. Number 1, what is the difference? Because I get these questions sometimes from some of my patients. What is the difference between bioburden and slough? How are they different?

Dr Maria Goddard: So slough is a description of tissue type. So we have granulation tissue, which is the wonderful, healthy tissue that's normally red or pink that we like to see, but not too red. Slough is that kind of pale yellow tissue that we see in the wound bed. And it's an indicator of bio-burden, nonviable devitalized tissue that needs to be removed from the wound bed in some way. Whether that's from sharp debridement or enzymatic debridement or biologic, but that needs to be removed from the wound bed because that's a tissue type as opposed to a descriptor of bioburden.

Dr Jonathan Johnson: Correct. Take a brush, remove some of that devitalized tissue as much as you can, it's really, really important. Now, the other question I typically get, and if you have had experience with other questions about biofilm or about initial wound care treatment, is: Why don't antibiotics work? Why can't we just remove the dressing, prescribed PO or IV antibiotics, and assume the wound will continue to improve? What's up with that?

Dr Maria Goddard: And that's why I call it a bio wall instead of a film, because it has really locked itself off. The bacteria have formed and fungi have formed their community and they've walled themselves off, and so the infection starts out locally in the wound bed itself, and so oral antibiotics might not necessarily get to where it is.

The other challenge that I also see, Dr Johnson, is the way that we try to identify the organisms in a wound bed. There's still a lot of people who are doing wound swabs, and given that we've described that there's that wall that biofilm over, if you swab just the surface of a wound, that's not going to give you a true indicator of the community of organisms that's really contributing to your wound infection.

Dr Jonathan Johnson: Great point, great point. So, I think with the biofilm conversation, I think we can summarize this by number 1, understanding that wounds will have biofilm, bioburden, and devitalized tissue within 24 to 48 hours. We will constantly see that. So our job from a practitioner standpoint is to make sure we remove that.

Now, there's different methods to remove that. You can brush away the devitalized tissue, biofilm, and bioburden, sharp debridement is key, enzymatic debridement is key, but there needs to be some way to clear that bioburden because remember, bleeding and oxygen from a wound care standpoint is always going to be our friend. So we want to focus on that because remember, you're not going to see it from a naked eye.

So Dr Goddard, I'm really interested in learning a little bit more about you. Help me understand what got you so passionate about wound care.

Dr Maria Goddard: So again, I started out wanting to be in orthopedics. And why I really like that specialty is that you could take an individual from having an injury and you could return their quality of life, get them active and moving again. And through my burn surgery training, I realized that burn and wound care gives you that same outcome, and I really love connecting with the patients we spend as wound care specialists.

We spend more time with our patients than a lot of other specialties because we're seeing them sometimes bi-weekly, if we're doing a negative pressure change, we're seeing them once so week, maybe every other week. And so that relationship that forms between the clinician and the person that you're taking care of and their family, I really love that about wound care.

It takes care of people from head to toe, inside out. And I think that's what makes wound care really special and why I love it so much.

Dr Jonathan Johnson: 100%. Passion is key. And you can definitely hear it in Dr Goddard's voice all the time. Now, one last question before I let you go. Tell me about a great clinical experience or a not-so-great clinical experience and how you were able to overcome that.

Dr Maria Goddard: How about we use a clinical experience that started out not-so-great but progressed into a great clinical situation?

Dr Jonathan Johnson: I love it. I love it. Let me hear it. Let me hear it.

Dr Maria Goddard: So, our patients who have wounds tend to get a stigma attached to them that they are quote unquote non-compliant. And if anyone knows me even a little bit, you know that that is my least favorite word. Compliance indicates that for some reason the individual didn't do what you told them to do. But there are so many factors at play, and that's why adherence is now the term that you want to use, because you don't know people's circumstances once they walk out of your door.

You don't know if they weren't able to get the medication you ordered, if they've lost their insurance, if they have to choose between feeding their family and getting their medicine. And so, sometimes our patients who have had chronic wounds for months, years, will come in with their walls up. And that's totally understandable.

And so, I have had a patient who had chronic lower extremity venostasis wounds, and it was challenging for them because it changed their entire quality of life. They were stuck in their room in long-term care. They didn't want to go out because of the draining. They kept to themselves, they didn't go out for meals and things like that.

And so, we started working week after week, addressing that biofilm, explaining why we wanted to have compression on, showing them what things were like with compression/without compression, choosing a compression that was comfortable to them. So, listening to their feedback, they had had things on before that were too tight.

And so as we went on, that person then became their own advocate. They made sure that when I came to the building, they showed me that their compression was going from the base of their toes, all the way up there like as it should. And they took control of that. And once the wounds got better, they were able to, they left their room more often, they started going to activities. And so wound care is not just about healing a hole. It's about taking care of an entire person, and so that started out as a challenging situation but was really rewarding at the end because we got that person back out and engaged in life and improving. Not only their pain but also their quality of life.

Dr Jonathan Johnson: Awesome. So that wraps up our Wound Care Wednesday topics for this Wednesday. Remember, if you have burns, treat them effectively, treat them quickly, and seek medical attention as quickly as you can. And remember to focus on removing the devitalized tissue from the wound, whether that's biofilm, bioburden, devitalized tissue, it all means the same.

We want to thank Dr Maria Goddard for joining us today, Dr Goddard.

Dr Maria Goddard: Thank you so much, Dr Johnson. This was fantastic, and I hope our audience learned as much as they could about burns and biofilm.

Dr Jonathan Johnson: Awesome, we appreciate you coming on. We'd also like to specially thank our sponsor, ExtremityCare. It's important to make sure that we prep the wound bed so that it's clean, clear, and ready for any treatment measurements that we need going forward.

Again, this is Dr Jonathan Johnson, also known as Dr Wounds, and I am extremely excited to be here today for another Wound Care Wednesday, signing off until next Wednesday.