For anyone who watched television in the 90s, the phrase “The More You Know” likely drums up memories of a bright yellow star shooting across the night sky, big purple letters, and celebrities offering helpful information about current social issues. A side-effect of our emphasis on knowledge is that when a patient enters your care, they come with the expectation that you will know “more,” if not “all” about the complaint. It can be tempting to jump into that persona, to go along with “seeming to know everything” at that moment, and fill in the gaps later. But what if admitting how little you know opened up a new window toward better wound care outcomes?
Physicians obtain their knowledge from many sources: medical school, clinical rotations, patient experiences, literature, and conferences.
Staying current is essential to providing patients with the care they deserve. But it takes time. And when new protocols or pharma solutions are presented, a physician will want to know more before changing known and successful programs. There is a risk that sticking for too long with what is known to be successful can cause us to miss something new, but it is essential to incorporate new learnings and challenge our comfort level with the care we provide.
In recently published trial results, I, along with my colleagues report on How Little We Know About Bacteria in Chronic Wounds, and the challenge to increase the accuracy by which bacteria is detected in wounds. By acknowledging we need to know more, we step outside the use of Clinical Signs and Symptoms (CSS) standards to detect infection in a wound and guide decisions regarding treatment.
There are many challenges with this approach, to use a three-step process to determine if the use of fluorescent light could help increase the accuracy of bacterial detection in chronic wounds. By starting with CSS, using fluorescent light technology and concluding with a biopsy to confirm the diagnosis, we were able to see the variance between what their professional opinion might have been on initial analysis and the reality of the wound.
In the first round of trials nearly 20 percent of the wounds that were originally determined not to be infected turned out to have significant amounts of bacteria present. Based on the photos from the fluorescent camera, many of the professionals participating in the trial were able to adjust treatment recommendations to better suit the patients’ needs and described feeling more confident they were making the right decisions.
The knowledge in the treatment room extends beyond what the physician knows. It is an illustration of the importance of a multi-disciplinary approach to wound care and treatment. It turns out, it is not The More YOU Know, it’s The More WE Know together.
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Correction: In a recent article entitled "Madness Among Us" the article should have reported a recommendation to wait 4-6 days to perform wound closure, not to do the change of dressing. AAWC regrets the error.
It is ironic that in a post designed to warn readers that we may not know as much as we believe we know, the author confesses to persuading clinicians to treat "wound infections" based solely on the amounts of bacteria present, even when there were no clinical signs or symptoms of infection. This is an example of making a decision based upon a lack of understanding of what an infection is. Killing off potentially helpful (and clearly not harmful) microbes may make clinicians feel "more confident," and is certainly billable, but it is not patient-centered or evidence-based care. We need to acknowledge that when it comes to the human microbiome, we truly know very, very little. We DO know that some microbes communicate our immune system via the dendritic cells to promote health.(1) And, we know that microbes in our patients' guts accelerate skin wound healing by stimulating the production of oxytocin, leading to recruitment of T cells.(1) We also know that the number of bacteria in a wound is a poor predictor of healing - what is important is what those bacteria are doing.(2-5) We also know that some bacteria aid in wound desloughing(6), and contaminated wounds seem to heal more quickly than extremely clean wounds.(7) Therefore, it should be no surprise that using antibiotic ointment on wounds does not improve healing,(6-9) and, using antiseptics in wounds actually increases infection rates.( 10-14) Indeed, we DO need to embrace a spirit of humility when it comes to what we know about wounds in general, and wound infections in specific. Meanwhile, I suggest we adopt an evidence-based approach to managing wound infections, which begins with defining them accurately. In 1860, Louis Pasteur said, ”The germ is nothing. It is the terrain in which it is found that is everything.” What he meant is that the interaction between the microbes and the patient are what determines whether or not there is an infection. Infection is, “when microorganisms cause host tissue destruction.”(15) Respectfully, Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA Independent Nurse Researcher and employee of Ferris Mfg. Corp. 1. Alverdy JC, Hyoju SK, Weigerinck M, Gilbert JA. The gut microbiome and the mechanism of surgical infection. BJS [Internet]. 2017 [cited 2019 Aug 21];104(2):e14–23. Available from: http://onlinelibrary.wiley.com/doi/abs/10.1002/bjs.10405 2. Hutchinson JJ, McGuckin M. Occlusive dressings: a microbiologic and clinical review. Am J Infect Control. 1990;18(4):257-268. 3. Hutchinson JJ, Lawrence JC. Wound infection under occlusive dressings. J Hosp Infect. 1991;17(2):83-94. 4. Tuttle MS. Association Between Microbial Bioburden and Healing Outcomes in Venous Leg Ulcers: A Review of the Evidence. Advances in Wound Care. 2014;4(1):1-11. doi:10.1089/wound.2014.0535. 5. Eaglstein WH. Effect of occlusive dressings on wound healing. Clin Dermatol. 1984;2(3):107-111. 6. Cho CY, Lo JS. Dressing the part. Dermatol Clin. 1998;16(1):25-47. 7. Beckett A, Tien H. What’s new in operative trauma surgery in the last 10 years. Curr Opin Crit Care. 2013;19(6):599-604. doi:10.1097/MCC.0000000000000033. 8. Norman G, Dumville JC, Mohapatra DP, Owens GL, Crosbie EJ. Antibiotics and antiseptics for surgical wounds healing by secondary intention. Cochrane Database Syst Rev. 2016;3:CD011712. doi:10.1002/14651858.CD011712.pub2. 9. Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H. Topical silver for preventing wound infection. Cochrane Database Syst Rev. 2010;(3):CD006478. doi:10.1002/14651858.CD006478.pub2 10. Fleming A. The action of chemical and physiological antiseptics in a septic wound. Br J Surg. 1919;7(25):99-129. doi:10.1002/bjs.1800072508 11. Rodeheaver G. Controversies in topical wound management. Wounds: A Compendium of clinical research and practice. 1989 Apr:19-27. 12. FLOW Investigators, Bhandari M, Jeray KJ, et al. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. N Engl J Med. 2015;373(27):2629-2641. doi:10.1056/NEJMoa1508502. 13. Owens BD, White DW, Wenke JC. Comparison of irrigation solutions and devices in a contaminated musculoskeletal wound survival model. J Bone Joint Surg Am. 2009;91(1):92-98. doi:10.2106/JBJS.G.01566. 14. Menton DN, Brown M. The effects of commercial wound cleansers on cutaneous wound healing in guinea pigs. Wounds. 1994;6(1):21-27. 15. Thomson PD, Smith DJ. What is infection? Am J Surg. 1994;167(1A):7S-10S; discussion 10S-11S. 1. Alverdy JC, Hyoju SK, Weigerinck M, Gilbert JA. The gut microbiome and the mechanism of surgical infection. BJS [Internet]. 2017 [cited 2019 Aug 21];104(2):e14–23. Available from: http://onlinelibrary.wiley.com/doi/abs/10.1002/bjs.10405 2. Hutchinson JJ, McGuckin M. Occlusive dressings: a microbiologic and clinical review. Am J Infect Control. 1990;18(4):257-268. 3. Hutchinson JJ, Lawrence JC. Wound infection under occlusive dressings. J Hosp Infect. 1991;17(2):83-94. 4. Tuttle MS. Association Between Microbial Bioburden and Healing Outcomes in Venous Leg Ulcers: A Review of the Evidence. Advances in Wound Care. 2014;4(1):1-11. doi:10.1089/wound.2014.0535. 5. Eaglstein WH. Effect of occlusive dressings on wound healing. Clin Dermatol. 1984;2(3):107-111. 6. Cho CY, Lo JS. Dressing the part. Dermatol Clin. 1998;16(1):25-47. 7. Beckett A, Tien H. What’s new in operative trauma surgery in the last 10 years. Curr Opin Crit Care. 2013;19(6):599-604. doi:10.1097/MCC.0000000000000033. 8. Norman G, Dumville JC, Mohapatra DP, Owens GL, Crosbie EJ. Antibiotics and antiseptics for surgical wounds healing by secondary intention. Cochrane Database Syst Rev. 2016;3:CD011712. doi:10.1002/14651858.CD011712.pub2. 9. Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H. Topical silver for preventing wound infection. Cochrane Database Syst Rev. 2010;(3):CD006478. doi:10.1002/14651858.CD006478.pub2 10. Fleming A. The action of chemical and physiological antiseptics in a septic wound. Br J Surg. 1919;7(25):99-129. doi:10.1002/bjs.1800072508 11. Rodeheaver G. Controversies in topical wound management. Wounds: A Compendium of clinical research and practice. 1989 Apr:19-27. 12. FLOW Investigators, Bhandari M, Jeray KJ, et al. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. N Engl J Med. 2015;373(27):2629-2641. doi:10.1056/NEJMoa1508502. 13. Owens BD, White DW, Wenke JC. Comparison of irrigation solutions and devices in a contaminated musculoskeletal wound survival model. J Bone Joint Surg Am. 2009;91(1):92-98. doi:10.2106/JBJS.G.01566. 14. Menton DN, Brown M. The effects of commercial wound cleansers on cutaneous wound healing in guinea pigs. Wounds. 1994;6(1):21-27. 15. Thomson PD, Smith DJ. What is infection? Am J Surg. 1994;167(1A):7S-10S; discussion 10S-11S.