On Wetting Wounds
Physicians often recommend to their patients with fresh surgical wounds that they not get in the pool for a couple of weeks and not soak the wound in a tub for prolonged periods. However, when I ask my colleagues why they offer this recommendation, they usually can’t explain it. Or, at least, the explanations I receive are not consistent.
For example, some will say that the chlorine is harmful to healing tissues. While that is true, chlorinated water – even in a pool – is relatively dilute. Pure chlorine is certainly toxic and deadly, but the dilute chlorine in pool water is only threatening to bacteria. It is also paradoxical that those who claim that chlorinated water is so harmful to wounds that they don’t want their patients in pools or tubs that they often seem to have no problem in using Dakin’s solution to treat open wounds.
Dakin’s solution – first used in World War I – is sodium hypochlorite (i.e., bleach). Surgeons have been using it for over a century to treat open wounds, especially burns. It has excellent antibacterial properties, killing bacteria from a wide variety of species. However, there is also old and new evidence that it may be harmful for healing tissues, although this effect may not reach the level of clinical significance. I’m not trying to denigrate Dakin’s solution – although I do have questions as to whether it really accomplishes anything, given that we don’t have any prospective controlled clinical trials on Dakin’s to guide our use.
My point is that, if it’s OK to throw bleach into a raw open wound, why is it not OK for tap water or pool water to touch a primarily closed surgical wound?
Other caveats against soaking a wound include the potential to contaminate the wound with organisms that are growing in the water. Now, of course, the chlorine in pool water is there to reduce the bacterial burden in the pool. I suspect that the concentration of organisms growing on any one human being’s skin is higher than that of pool water (except, of course, those humans who just stepped out of a shower). So I fail to understand how a relatively aseptic swimming pool could contaminate a surgically closed wound to any significant degree. (If we’re talking about swimming in a smelly waterhole or swamp, of course, that would be a different story.)
What is also inconsistent is the fact that standard treatment for an anal wound — such as that following an incision and drainage of a perianal abscess — is to soak the wound for 20 minutes or so several times a day in a Sitz bath. If it’s OK to soak this heavily contaminated open wound in tub water, why is it not OK to soak a primarily closed clean surgical wound in tub or pool water?
There are likely millions of animals on the surface of the planet that currently have open wounds. They treat their wound by licking them. Their wounds heal just fine. And they heal without any wound packing, antiseptics, ointments, or dressings. I contend that a shower, a bath, or getting into a pool are simply more civilized forms of licking. It would be a paradigm shift in medicine for us to ensure that a healing wound be the cleanest part of the body (because it’s being washed) rather than the dirtiest.
The Difference Between Infection and Colonization
The concept of infection is as fundamental a concept as you can get in medicine. Everyone seems to have a general idea of its nature, and everyone knows that antibiotics and antivirals play a key role in treating infection. The related concept, colonization, is also generally understood along with the understanding that antibiotics and antivirals don’t play a role in the management of colonization.
Despite its fundamental nature, I am constantly amazed at how poorly the concept seems to be taught: most students and residents are unable to provide a satisfactory definition that can consistently distinguishes the two. When I ask a student or resident to define the difference between infection and colonization, they often respond that infection is when there are more than 100,000 organisms per gram of tissue. (Actually, they sometimes get the “more than” wrong and flip it to “less than”, but I know what they mean.) Unfortunately, this is a definition that is often used arbitrarily in research studies because the counts can be quantified. But it doesn’t really define the presence of an infection. I can usually poke a huge hole in their definition by reminding them that the human colon (large intestine) has about 100,000,000,000 (that’s right: one hundred billion) bacteria per gram of stool, so does that mean that every human has an infected colon? Obviously not, because it’s not making us sick and we don’t need treatment for it (unless some actual disease — like colitis or diverticulitis — erupts).
Failing on that definition, they fall on the concept that infection occurs when bacteria aren’t where they’re supposed to be. While this is closer to the truth, I defeat this argument fairly easily; I ask, “Who decides where bacteria are supposed to be?” No one seems sure as to who that arbiter could be.
I may occasionally get the response that infection is defined by the presence of erythema (redness), warmth, pain, and swelling. These, of course, are the clinical signs we commonly use to detect the presence of infection. “However,” I’ll ask the student, “are these signs specific for infection, or do they really represent the body’s inflammatory response to infection?” They, of course, have to concede that the latter concept is more accurate. Then I ask if a patient with a poor to absent immune system — say the Boy in the Bubble — could ever get an infection, given that they would never demonstrate such symptoms. This generally stumps them.
At that point, I explain the nature of the integument. Once they understand that we have a water-tight barrier wrapping us and keeping our interstitium shielded from the outside world, they can then understand the fundamental difference: colonization is the presence of organisms on our surfaces, while infection is the presence of organisms in tissue. Then I can go on and explore the different management approaches to the two conditions.
Here’s a paradigm shift in medicine: let’s focus on making the fundamental biologic processes that govern health and disease easily defined and easily understood.
On Unrealistic Expectations
It is often difficult to convey to families of critically ill and injured patients what they need to expect. The human part of me wants to reassure them that “everything will be all right.” Yet, in this era of lawsuit bonanzas, such statements can be professional suicide. Once you give them that reassurance, if anything less than “all right” occurs, the family will think we must have done something wrong. Recriminations and potential litigation can easily develop from that point forward.
Consequently, I’ve moved away from providing reassurance or even encouraging hope. I don’t actually need to give them hope; they’re going to hope for the best anyway, with or without my encouragement. I’m going to hope, too. If I weren’t hopeful for a successful outcome for my patient, why would I even try?
Unrealistic expectations among the public were revealed in a noteworthy article that appeared in 1996 in the New England Journal of Medicine. The authors reviewed an entire year’s worth of medical television shows (ER, Chicago Hope, Rescue 911) looking for episodes of cardiopulmonary resuscitations. Among their findings were that 65% of the cardiac arrests in these scripted shows occurred in children, teenagers, or young adults. Of course, this is completely backwards from the real-life experience, in which the overwhelming proportion of cardiac arrests occur in people who have sick hearts — that is, mostly older people.
More importantly, 75% of the patients survived the immediate arrest, and 67% appeared to have survived to hospital discharge — within an hour (including commercials) at that. While the survival rates of in-hospital cardiac arrest vary by the type of clinical report in the literature, all are well under 30%, and most average no better than 5% for the more common elderly hospitalized patient who suffers an arrest. And, of course, the usual hospitalization typically lasts for several weeks or even months, and such patients are not usually too functional when they leave the hospital.
Just as patients fail to understand the reality of their health situation, given the erroneous portrayals usually see in the media, caregivers often fail to realize the degree of ignorance patients and families have about what to expect. Clear, patient, calm, and thorough explanations to help them understand the situation and potential outcomes is key.
We can’t keep them in the dark. We have to explain what we know and what we’re thinking. We may even have to be brutally honest to paint the realistic picture of the experiences we commonly see. They are actually depending upon us to convey that knowledge and experience to them. Sometimes it’s a paradigm shift to explain medicine in simple terms that put patients and their families in our shoes, seeing the uncertainties just as we see them. We must help them see the situation through our eyes.
Understanding circulatory and non-circulatory shock
I find it best to think of the circulation as a fuel delivery system and shock as what happens when the energy supply dries up. Your car certainly has a fuel delivery system: gasolene is pumped from the tank to the cylinders where it undergoes combustion in the presence of oxygen. If the gas tank is empty, or the pump is broken, or there is no oxygen, or the spark plugs aren’t firing, the engine will not run.
Water is a fuel for plants that use it in combination with carbon dioxide for photosynthesis. Thus, in arid environments, a water irrigation system is a fuel delivery system. The categories of shock that humans can experience may be best understood using this analogy:
- Hypovolemic shock: Low water tank level. If there is insufficient water to deliver to all the plants, plant growth and/or life is impaired.
- Cardiogenic shock: Pump failure. If the pump fails so that water is not delivered to the plants, it produces the same result as not having enough water.
- Neurogenic “shock.”: Bigger pipes. In neurogenic shock, blood vessels dilate because the sympathetic nervous system is impaired. This larger pipe diameter does not actually reduce fuel delivery. Yes, the driving pressure in the system is lower, but the resistance to flow is less due to the larger diameter. Hence, the flow of fluid is usually normal.
- Septic shock: Poisoning. The irrigation system is working just fine. In fact, it’s working better than normal. However, the plants are still dying. The only conclusion the farmer can draw is that some pest or poison is killing his plants. He would not conclude that there’s a problem with the irrigation system.
Unfortunately, in modern medicine, there is a great deal of confusion over the latter two versions of shock. Physicians often read the low blood pressure in neurogenic shock and assume that it must be fixed. While providing more intravenous volume may help ensure adequate blood flow to tissue, the use of vasoconstrictors does not. Similarly, in septic shock, it is difficult to understand how overcoming a compensatory vasodilatory response with vasoconstriction can change the fundamental problem of inadequate oxygen consumption by the cellular machinery. There needs to be a paradigm shift in medicine’s understanding and management of the various physiologic shock states.
Quality vs. Volume
For certain procedures or conditions, it appears that high-volume centers usually provide better quality than low-volume facilities. This finding is behind the concept of Centers of Excellence for everything from cancer to weight reduction. However, there is an interesting inconsistency when applying such concepts to Trauma Centers.
I was more than a little confused about 10 years ago when the American College of Surgeons amended the requirements for Level I Trauma Center designation to include a volume requirement. That is, unless a trauma center admitted a specific minimum number of trauma patients, they would not be designated as a Level I Trauma Center. Currently, the requirement stands at “a total of 240 admissions with an ISS [Injury Severity Score] >15 or an average of 35 patients with an ISS>15 for the ‘core’ trauma surgeons on the trauma call panel.” Because a high volume of severely injured patients is generally more likely to insure that the resources are available in such a facility to deal effectively with those patients, this seems, on the surface, to be an entirely reasonable requirement.
There is serious inconsistency, however, in requiring a minimum patient volume for trauma centers. And that is that another requirement for Level I Trauma Centers is that they must have an active trauma prevention program consisting of “prevention activities that center on priorities based on local data.”
Given these two requirements for Level I Trauma Center designation, it is apparent that such trauma centers must have a trauma prevention program in place — they just have to make sure that it is not very effective.
Obviously, the problem is that volume is being used as a stand-in for quality. This approach has been easier for health care in general because quality is very difficult to measure. Given the various pre-existing conditions and uncontrolled degrees of disease and injury, it has been difficult to compare outcomes on a case-by-case basis. However, through the use of statistical standardization tools present in the National Surgical Quality Improvement Program (NSQIP) and the Trauma Quality Improvement Program (TQIP) developed by the American College of Surgeons, it is likely to be increasingly possible to grade quality performers for designation purposes. The paradigm shift in medicine will be to seek appropriate indicators other than volume to determine high-quality centers. Such a move will promote a migration to effective health care through active prevention.
Bullets and Bugs
Physicians should consider the bacterial load when dosing their antibiotics.
The inoculum effect is a phenomenon that has been described for many different antibiotics and how they affect several different organisms. A general observation is that a higher concentration of organisms requires a higher concentration of antibiotic to achieve the same degree of bacterial killing. Simplistically, it would make sense that the more organisms there are to kill, the more antibiotic molecules are needed to do so. If 1,ooo soldiers invade your land, your supply of 1,000,000 should be adequate defense. However, if 100,000,000 soldiers invade, you’re going to need more bullets. However, the mechanisms for the inoculum effect appears to be complex, depending upon the number of antibiotic molecules necessary to kill a single organism, the various resistance mechanisms employed by bacteria, the quantity of inactivating enzymes produced by the organisms, the growth cycle characteristics of the organisms, and so forth. Regardless of the mechanism, it appears that in most cases, a higher concentration of bacteria — that is, a greater number of bacteria in any given volume of fluid or tissue — will decrease the effectiveness of antibiotics.
Unfortunately, the implications of this phenomenon have not yet translated into clinical practice, even though it was first recognized in 1945. For one thing, the actual concentration of bacteria in the infected tissue is usually unknown. Such a determination is not a part of standard clinical practice. While most laboratories can perform a quantitative bacterial culture, clinicians rarely ask for it to be done.
It is not clear what the clinical response should be to a higher bacterial concentration. Should we throw more bullets into the fray? That is, would a higher dose of antibiotics be necessary? In some cases, this could be the solution. In the era when many of our more popular antibiotics — such as the aminoglycosides — had a significant dose-related toxicity, such a solution was unfeasible. However, now with our large number of safer antibiotics, it is not such a farfetched possibility. In other cases, higher antibiotic doses may not work, as in those situations where the concentration of bacteria affects their growth phase, thereby inactivating those antibiotics dependent on a particular growth phase. In such situations, a switch to a different antibiotic class would likely be appropriate or. potentially, debridement of the infected tissue to thin their numbers and give our side a fighting chance. The paradigm shift in medicine would take advantage of these observations and improve clinical practice.
Dictation vs. Templates
Medicine is moving into the electronic information age. Slowly, perhaps glacial, but moving there nonetheless. Unfortunately, there needs to be a major paradigm shift in medicine for this move to be truly effective, but we do not appear to be getting there in the near future. Instead, we are using electronic medical records to mimic what we have been doing for decades on paper. Toward that end, however, there are some methods that are better than others.
Clinical notes are a key part of medical records. Physician notes serve to assess the patient’s condition and progress, summarize the pertinent findings of various examinations, and outline the treatments planned for the patient’s condition(s). Nursing notes document the patient’s subjective and objective findings, verify treatments provided, and note the time at which medications were administered.
Several tools have been developed to facilitate the documentation process. Dictation and transcription have been present for decades, and have been used primarily by physicians for their notation of history and physical examinations, operations, consultations, discharge summaries, and even progress notes. There tends to be some standard formatting in these notes, primarily following the “S-O-A-P” (for Subjective – Objective – Assessment – Plan) However, beyond that, there is little consistency in the notes. More importantly, the dictated notes often leave out information because it may slip the dictating physician’s mind.
Electronic medical records often have tools to provide a significant improvement over dictated records. Theses include the use of templates for the various types of notes that must be generated. Among the improvements templates provide are :
- standardized formatting of notes, making it easier (and quicker) for users to find specific pieces of information,
- prompts for data entry, improving the likelihood that required elements are entered in the not for billing, medicolegal, or regulatory purposes,
- the opportunity to carry unchanged information forward from previous notes, charting by exception those items that have changed,
- an improved ability to extract and compile information through electronic parsing from many notes and many patients, enabling improved capabilities for research and performance improvement purposes.
Templates also provide a distinct advantage to the physician over dictations: speed. A well-constructed template can be completed within minutes or even seconds, depending on its complexity and the physician’s familiarity. Dictation can also be performed quickly by speed-talkers. However, it then must go to transcription and then be returned to the physician for review. To save time, many physicians practice the unsafe act of signing without reading. Those who play it safe do read and edit their transcriptions, but must then wait again for the corrections to be made for the final saved version to be available.
On the other hand, once the template is completed in a few key strokes, it’s done. While there is often a significant investment of time in developing the template, the overall time savings for the remainder of a career is substantial.
Bacteria Can’t Read Calendars
Physicians should stop a course of antibiotics once the infection has cleared, instead of using an arbitrary number of days.
I am constantly amazed at the standard practice of giving antibiotics for a predetermined number of days. We often prescribe a 7-day course or a 10-day course or a 14-day course. Sometimes, it’s just a 3-day course. Whatever it is, it seems that it has to be a relatively standard football score; an 8-day course simply won’t do.
Over the years, I’ve tried to find out where these numbers come from. The best I can determine is that it comes from the process of antibiotic approval by the Food and Drug Administration. A prospective controlled study must be done to compare a new drug for a particular infection with a drug that already has FDA approval. However, instead of comparing which drug cures patients faster or more effectively, cure rates are sought after a predetermined number of days of treatment. I suspect that is because it would be almost impossible for the pharmaceutical company to determine study costs with an uncertain duration of treatment. So when the study is completed and the drug is approved, its publication becomes the reference for physicians to use.
Unfortunately, the duration of treatment — that predefined and arbitrary number of days — is taken to be gospel, and physicians start using for their patient management, even though it was cooked up by some bean-counter in the pharmaceutical company.
We have data to suggest a better way. In a study analyzing 11 prospective controlled trials of antibiotic alternatives for the treatment of intra-abdominal infections, Dr. Harlan Stone demonstrated that the inflammatory signs (fever, elevated white blood cell count, presence of immature neutrophils) often used to identify the presence of an infection can also be used to identify its eradication.
It is amazing to realize that it would be a paradigm shift in medicine for doctors to act like doctors and not obey the therapeutic recommendations of accountants.
On Drying Wet Wounds
It will be a true paradigm shift in medicine when clinicians fully understand the biology of open wounds and their physiologic management.
I’m often told by other health care workers that wounds must be kept moist to keep them from desiccating. When I challenge them to explain desiccation, I’m told that it means “drying out’ (which, of course I knew). However, I’m more interested about what is actually drying out. You see, I think that many clinicians believe that living cells in the exposed wound will dry up and die if left exposed, which is not accurate.
What is known is that cells in culture, such as epithelial cells, need moisture to survive. However, the cells in an open wound are not the same as isolated cells growing in culture. The cells in the wound have a blood supply providing them nutrients that diffuse through the salt-based interstitial fluid bathing all cells. In fact, the serous fluid that normally leaks off an open wound is the manifestation that the wound is perfused and is spontaneously moist. Hence, they are not in jeopardy of drying out unless their blood supply gets cut off.
Also, we know that open wounds that are otherwise left alone will dry out. However, what is drying out is a scab, or what we call an eschar. This consists primarily of coagulated protein from the 
plasma that has leaked to the wound surface.
It is interesting that one of the original studies that formed the basis for moist dressings on wounds was actually misinterpreted. Hinman and Maibach published a study in Nature in 1963 in which they compared open versus closed management of split thickness skin wounds in volunteer humans. The open wounds on one arm were simply left exposed while the others were covered with sterile polyethylene film. The covered wounds healed much faster, lea
ding them to conclude that the process of drying out impaired healing in the other wounds.
However, the histology presented in the report reveals another story. The epithelium had to regrow over a longer distance because of the presence of the scab in the open dried out wounds. Epithelial cells weren’t dying out from desiccation, but were actually trying to grow across the dermis to confluence. The scab actually prevented contracture that would otherwise occur to flatten out the wound and provide a short course for epithelial resurfacing.
So the problem isn’t that the living tissue will dry out and die. The problem is that scab formation — which occurs more readily when the wound is dry — delays wound healing. A more direct approach would be to prevent the scab by frequent cleansing. In cases where the scab has developed, it is best to remove the scab, which can be done by cutting it away (i.e., surgical debridement) or by using a true wet-to-dry dressing. These actions leave the wound healing processes of contraction and epithelial resurfacing unimpeded.
Wishing and Hoping
There is no benefit to prolonged courses of prophylactic antibiotics, and there are some serious things wrong with them.
It is standard practice to give antibiotics prior to a surgical operation, especially those with a suspected or certain risk of bacterial contamination. It has been demonstrated that doing so will reduce the risk of a subsequent wound infection. Timing, dosing, and antibiotic selection are all critical in optimizing the outcome.
The practice of giving antibiotics in this manner is called prophylaxis, because we expect it to prevent some of those infections. A critical concept behind prophylactic administration is that it is given to patients who currently have no evidence of an active infection.
What has also been demonstrated is that there is absolutely no benefit to a prolonged course of prophylactic antibiotics. The concept underlying the practice is that antibiotics should be in the tissue at the time bacteria land in the tissue as a result of the skin incision. Once bacteria are no longer landing in tissue, further antibiotic use will be futile as those bacteria that are surviving are in some microscopic area where the antibiotics cannot get to them, such as a fluid collection or a hematoma or a piece of suture material or debris.
Continuing to administer “prophylactic” antibiotics after the wound has been closed cannot reduce the risk of subsequent, but it can select out for resistant strains of bacteria. On a practical level, it becomes problematic to manage a patient who develops a fever and other signs of infection at 5 or 6 days following surgery while still receiving a putative prophylactic regimen. None of the available options are satisfactory:
- switching blindly to some other antibiotic(s) (difficult to choose appropriate without culture results),
- stopping antibiotics and reculturing (not optimal while the patient is becoming more ill), or
- continuing the current antibiotic regimen (not likely to work as the infection developed while on that regimen).
However, if the patient has been off “prophylactic” antibiotics when (and if) signs of infection develop,cultures could then be obtained and presumptive antimicrobials can be started with reasonable expectations that the offending organism(s) will be covered. This practice would reduce costs and deter the emergence of resistance without increasing the rate of surgical infections.
It would be a true paradigm shift in medicine to realize that knowing and doing works better than wishing and hoping.
Medicine out of the Box 