Your methodology for wound care debridement

[NP 2 DPM]

Drs,

Wanted to know if any of you still use mechanical debridement (wet to dry) or do prefer the enzymatic debridement process for decubitus ulcer patients?

Today as i was working on a patient with a decubitus ulcer on the lower lumbar, i witnessed that some Podiatrists are still using went to dry mechanical debridement ? This method is growing out of use in wound care nursing because of the mechanical trauma. Is this still taught in Podiatry?

Just curious.

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[dtrack22]

This method is growing out of use in wound care nursing because of the mechanical trauma.

I'm not sure what this sentence even means

 

[ExperiencedDPM]

I believe wet to dry went out of vogue for a good reason. It's not that it's painful vs a blade. It's that it's very non selective and can be "ripping off" good skin, bad skin, epithelial cells, etc.

I believe it's use should be very limited since there are much better choices with evidence and literature to support those mehods.

Please don't get me started on those who still use Betadine on open wounds (I'm not talking about mummified wounds that you are waiting to demarcate).

Learn to respect wound care nurses. They understand what works and what's obsolete.

 

[heybrother]

I've inherited some sick patients with a pile of worthless debridement notes and no discussion of the actual cause of the ulceration. A lot of these notes contained references to all sorts of fancy products and preparations and not much detail about minor technicalities, like blood flow. Debridement is important, but I'm all about the intervention.

 

[ExperiencedDPM]

I've inherited some sick patients with a pile of worthless debridement notes and no discussion of the actual cause of the ulceration. A lot of these notes contained references to all sorts of fancy products and preparations and not much detail about minor technicalities, like blood flow. Debridement is important, but I'm all about the intervention.

There's an old saying "it's not what you put on a wound, it's what you take off a wound". The fancy and expensive crap isn't important. It's debridement and off loading. But there are outdated methods.

 

[AttackNME]

Drs,

Wanted to know if any of you still use mechanical debridement (wet to dry) or do prefer the enzymatic debridement process for decubitus ulcer patients?

Today as i was working on a patient with a decubitus ulcer on the lower lumbar, i witnessed that some Podiatrists are still using went to dry mechanical debridement ? This method is growing out of use in wound care nursing because of the mechanical trauma. Is this still taught in Podiatry?

Just curious.

Agree with AnkleBreaker's comments. Also.. are you saying your podiatry attendings are treating sacral wounds? Is that what you mean by lower lumbar? Anyway, the way I see decubitus wounds (either sacral or heel) is that it occurs in patients whom are really sick, most likely they are hospitalized and bedridden, or just have such horrible disease that they will likely die soon. For such patients, the goal is more palliative/hospice than closure/rehab, meaning we just want them to remain clean by removing bioburden since closure and rehab to independent living is likely not possible. Since santyl costs $50 a tube and not everyone has the same insurance, it would be torture to not only frustrate the patient and family to thinking that they can possibly heal this wound and potentially have to pay for a topical medication that isn't going to buy them the result they want. In that case, it is reasonable to go with wet to dry, or any cheap topical with the goal of treating just the bioburden in mind. The plastic surgeons, rehab docs and nurses that I've worked with prefer medihoney for such wounds, it's cheap, and accomplishes a little bit of debridement, but wet-to-dry isn't unreasonable.

 

[NP 2 DPM]

I'm not sure what this sentence even means

There are various forms of mechanical debridement -- which is the physical removal of wound debris by irrigation or hydrotherapy with a whirlpool bath or ultrasound mist, which i usually order , which is also used by other practitioners such as the gerontologist. I prefer to use the mist, which is delivered perpendicular to the wound and can be applied in grid pattern.

Wet to dry dressings -- a specific kind of dressing that is used for mechanical debridement, sticks to the tissue and removes the necrotic layer of tissue with it during change. This modality is not preferred in wound care nursing because they can disrupt newly regenerated tissue. Preference now is on Wet to moist dressings.

I work closely with Podiatrists as well as Internists when seeing my patients at the Med Surg floor and while new grad IM residents are using wet to moist dressing changes for removal necrotic tissue, i still see some surgical podiatrists use wet to dry. Wanted to know if the wet to dry technique is taught in podiatry school as an old technique ?

Wound Dressings and Comparative Effectiveness Data

Wet-to-Dry Dressings Do Not Provide Moist Wound Healing

 

[NP 2 DPM]

Agree with AnkleBreaker's comments. Also.. are you saying your podiatry attendings are treating sacral wounds? Is that what you mean by lower lumbar? Anyway, the way I see decubitus wounds (either sacral or heel) is that it occurs in patients whom are really sick, most likely they are hospitalized and bedridden, or just have such horrible disease that they will likely die soon. For such patients, the goal is more palliative/hospice than closure/rehab, meaning we just want them to remain clean by removing bioburden since closure and rehab to independent living is likely not possible. Since santyl costs $50 a tube and not everyone has the same insurance, it would be torture to not only frustrate the patient and family to thinking that they can possibly heal this wound and potentially have to pay for a topical medication that isn't going to buy them the result they want. In that case, it is reasonable to go with wet to dry, or any cheap topical with the goal of treating just the bioburden in mind. The plastic surgeons, rehab docs and nurses that I've worked with prefer medihoney for such wounds, it's cheap, and accomplishes a little bit of debridement, but wet-to-dry isn't unreasonable.

Im a hospitalist Nurse practitioner at Jefferson Hospital System. I work in the Medical Surgical as well as rotate in Pediatrics and Emergency Medicine. I see all kinds of wound care patients ranging from diabetic foot ulcerations , to decubitus ulcers on the lower lumbar (mostly skilled nursing home patients who have not been turned adequately), to occiput ulcerations in comatose patients et al. Do i see podiatrists dealing with decubitus ulcerations in the lower lumbar? of course i do. In fact Jefferson's Vascular and chronic wound care satellites are directed and operated by Podiatrists , Wound care Nurse Practitioners, Physician Assistants. My experience with working with all kinds of practitioners ? I always refer patients with ulcerations to wound care nursing (because of the excellent level of care and skill of wound care nurses), but of all the specialities in medicine out there -- ive come to see that Podiatrists are exceptionally above par in wound care as well. I have seen podiatrists care for decubitus ulceration on the lower lumbar with various stages of tunneling. Said patient also had significant diabetic neuropathy and ulceration that had dug deep into the connective tissue and exposed the calcaneus.

The patient was admitted as a diabetic foot patient, but the physicians in the ED had failed to identify the tunelling on the lower lumbar. The podiatric surgeon who rounds at Jefferson's Vascular wound care center had identified the issue and treated it in conjunction. It was like an art watching and observing him pack the wound, and the intricate detail in removing old dressings and applying new dressings.

 

[NP 2 DPM]

There's an old saying "it's not what you put on a wound, it's what you take off a wound". The fancy and expensive crap isn't important. It's debridement and off loading. But there are outdated methods.

Agreed. And in my opinion mechanical debridement vis-a-vis wet to dry dressing on a patient with peripheral vascular disease is an issue. I prefer the wet to moist methodology.

 

[NP 2 DPM]

I think wound care nurses have a major role in large hospital institutions where there are just too many wounds to be handled. In my residency training wound care nursing was relied on when the wound in question was surgically stable from the surgical service point of view. The surgical team would check on wounds less frequently from that point on unless reconsulted by the wound care team. Wound care nurses were amazing when it came to changing wound vacs and documenting wound quality in their notes with exceptional charting and entering pictures into the EMR.

Any new wounds admitted to the floor involving deep probing to fascia or bone should be referred to a surgeon immediately in my opinion. Be it general surgery, vascular surgery, or podiatry depending on anatomy involved.

I do not understand how a podiatrist can legally treat a sacral wound anywhere in the USA.


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The patient was admitted due to diabetic foot ulceration, i suppose it is well within the podiatrist's scope of practice to treat additional disorders , in this case a tunelling wound in the lower lumbar. I don't know the scope of practice in your state, but in Pennsylvania and New Jersey, they do allow concurrent medical treatment if it is related to a podiatric diagnosis. I've some friends who are podiatrists who run Virtua's Health System's wound care satellites as well. They regularly come into rehab and skilled nursing as well as hospital floor to observe the wound care management.

 

[NatCh]

The patient was admitted due to diabetic foot ulceration, i suppose it is well within the podiatrist's scope of practice to treat additional disorders , in this case a tunelling wound in the lower lumbar.

My head just exploded.

 

[NP 2 DPM]

My head just exploded.

Why the surprise? It is well within the scope of practice.

 

[Weirdy]

Why the surprise? It is well within the scope of practice.

Try that in my state you'd be looking at lawsuits at the very best.

Lower lumbar is quite a stretch for physical scope of practice for a podiatrist.

 

[NatCh]

Lawsuits, disciplinary action by the state medical board, loss of hospital privileges...

 

[NP 2 DPM]

Try that in my state you'd be looking at lawsuits at the very best.

Lower lumbar is quite a stretch for physical scope of practice for a podiatrist.

What state do you in live in? Not all states are as liberal in podiatric medical scope of practice, one for example is NY!

I medically manage corporeal wound care cases as do my PA colleagues , and to say that a Podiatric Surgeon would have any less capability in managing a wound care on the lower lumber is preposterous. Considering in that anecdotal reference, it was the attending Podiatric Surgeon who identified the tunneling lower lumbar ulcer, which the ED staff had failed to see!

This is one of the reasons why there needs to be increased Podiatric Medicine scope of practice in the country and to have a uniformed aperture.

This is coming from an NP!

 

[NP 2 DPM]

Lawsuits, disciplinary action by the state medical board, loss of hospital privileges...

Maybe in your state? Where i practice, the head of the wound care center is an attending Podiatric Surgeon. The NPs, PAs and IM docs are managed by him.

Im referring to the Pennsylvania - New Jersey region, by the way.

 

[Weirdy]

What state do you in live in? Not all states are as liberal in podiatric medical scope of practice, one for example is NY!

I medically manage corporeal wound care cases as do my PA colleagues , and to say that a Podiatric Surgeon would have any less capability in managing a wound care on the lower lumber is preposterous. Considering in that anecdotal reference, it was the attending Podiatric Surgeon who identified the tunneling lower lumbar ulcer, which the ED staff had failed to see!

This is one of the reasons why there needs to be increased Podiatric Medicine scope of practice in the country and to have a uniformed aperture.

This is coming from an NP!

Down South.
I understand scope of practice varies by state.
It was just a bit eye opening that something that far up from the foot could be medically managed by a podiatrist in a different state.
Literally unheard of where I'm from.

 

[NatCh]

I'm in Oregon. I think I'd make the front page of the local newspaper (not in a good way) if I took a scalpel to a sacrum.

P.S., I know we were talking about lower lumbar but there's less alliteration than scalpel-sacrum.

 

[NP 2 DPM]

Down South.
I understand scope of practice varies by state.
It was just a bit eye opening that something that far up from the foot could be medically managed by a podiatrist in a different state.
Literally unheard of where I'm from.

When you get clinical experience to rotate in a large regional hospital in the north (i will recommend you try to do your elective rotations at Temple, Inspira, Virtua, Jefferson, Hahnemann), you will see how in depth the surgical care and rounding wound care you do as a Podiatrist. I tend to get into disagreements with MDs in regards to wound care practices, mostly from residents and hard headed attendings who really fail to see EBP on wound care therapeutic modules. But whenever i work with podiatrists, i always heed their input as well as learn a lot from them in how they do wound care , even the way they apply the packings (lol). Its like an art with them, ever so delicate and intricate. They do not rush (from the ones i work with). A league on their own in this area of medicine (wound care / ulcer care).

 

[NP 2 DPM]

I'm in Oregon. I think I'd make the front page of the local newspaper (not in a good way) if I took a scalpel to a sacrum.

P.S., I know we were talking about lower lumbar but there's less alliteration than scalpel-sacrum.

OFF TOPIC: ah, nice state !

 

[AttackNME]

Its gonna get hairy once pods start debriding sacral wounds though, at what point would it be too deep for us to handle? Will we be some day manage sacral wounds primarily and consult gen surg to do a diverting colostomy for good candidates? who knows, it'll be great to have more docs that care about these wounds and can treat them well

 

[ExperiencedDPM]

Hold on, I'm confused. Are you saying that a DPM is packing a sacral wound? Can I please have the phone number of his malpractice carrier? A DPM may be in charge of the wound care center, but I assure you it is NOT legal in PA, NJ or any other state for a DPM to treat a sacral wound. And the line that it can be treated since it relates to the foot wound is complete nonsense. A DPM in Pennsylvania can treat soft tissue up to the knee as the function relates to the foot.

I did some of my training in Philly and there is no hospital less friendly to podiatry than Jefferson. Rothman Institiute is a MAJOR player at Jefferson and Rothman only employs NON surgical DPMs. I don't believe any DPM has ever performed a surgical case at Jefferson University Hospital. Jefferson has merged with some smaller hospitals that do have active podiatry programs. But Jefferson Univ Hosptial does not have a warm and fuzzy relationship with surgical DPMs.

Ain't NO DPM debriding sacral wounds in PA, NJ or anywhere legally. And I can assure you that no DPM at Jefferson Univ Hospital (no referring to the smaller satellites) is debriding a sacral ulcer.

 

[Adam Smasher]

I had a mentor once tell me that one of the things about wound care that makes it uninteresting is that there's nothing wrong you can do to a wound. Still, I have some feelings about some modalities mentioned above.

Wet-to-dry dressings: nice if you can't think of anything better to use. More than anything else, it seems to be a carry-over from vascular and plastic surgery where you are debriding a wound and want to check it the following day to see how it's granulating to see if it's ready for STSG vs amp. Convenient for fasciotomy wounds in compartment syndrome, though one might also consider VAC for any of these applications.

Betadine: it's commonly taught that betadine is toxic to granulation tissue. One of the presents lecturers made a convincing argument that this has only been demonstrated in vitro and that it's still ok to use betadine for wounds. I didn't routinely use this in residency just because if a patient getting IV antibiotics then topical antiseptics are pretty pointless. For outpatient I prefer...

Santyl: yes it's $300 a tube, and yes the manufacture says you have to lay it on really thick. Smith & Nephew has put out studies demonstrating that you still save money in the long run because wounds were closing faster and not getting infected or suffering other complications. Note that per manufacturer recommendations, YOU MUST DO A PRELIMINARY SHARP DEBRIDEMENT, because I have colleagues who just want to lay it on like it's panacea. Fun fact, santyl is the only drug in its class, which means Medicaid MUST cover it.

What I really like is good old fashioned piano felt, and when that doesn't work, total contact casting is a nice "nuclear option" for a chronic wound, even if it's time and labor-intensive.

 

[SportPOD]

Why wet to dry dressings? It's easy, but for who? Wet to dry dressings require it to be changed every 2-3 hours, if in a high humidity area possible an hour longer. Who is going to convince a nurse on the floor or a patient at home to change this?
Wet to dry dressings are not STANDARD of CARE at this point. Please use hydrogel or an ointment at this point since the point of wound healing is to keep a moist environment.
If all the other checkboxes have been filled for making sure that the wound is going to heal, then use a moist dressing to the wound.
Santyl is great if the insurance covers it. Debride the wound first to remove any necrotic tissue. If it is eschar, score it so that the santyl can get underneath.
If it's a plantar wound, use a TCC as Adam Smasher suggested, this is a gold standard, if patient is under 400 lbs you can use the EX cast which is quicker and lighter for the patient.
Iodine is good product to use when wanting to dry out the tissue. Do I use it on everything no!
Wound care is an art form but it is also mainly common sense. Figure out what is making the wound. Then fix that problem be it poor blood flow, nutrition, pressure, infection, etc.