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Polymeric Membrane Dressings for Topical Wound Management of Patients With Infected Wounds in a Challenging Environment: A Protocol With 3 Case Examples
Abstract
Patients with acute wounds often delay seeking medical assistance until an incapacitating infection has developed. When such patients come for help at a remote Christian clinic in northern Ghana, West Africa, the goals of care are to resolve and prevent a return of infection, decrease pain, enable an immediate return to normal activities, and facilitate healing. Because the local protocol of care, Edinburgh University Solution of Lime (EUSOL)-soaked gauze, did not meet these goals, the author tried using a variety of donated wound dressing regimens.Ultimately, polymeric membrane dressings (PMDs) were observed to meet patient care needs while also reducing clinic staff time and resources, and a PMD protocol of care was developed. Three (3) representative patients who presented with acute wounds and infection are described: a 20-year-old man with a hand abscess, a 16-year-old boy with a malleolus wound, and an approximately 20-year-old woman with an injection abscess, all otherwise relatively healthy, albeit undernourished. All 3 patients received oral antibiotics, their wounds were initially cleansed and debrided, and an appropriate configuration of either regular or silver-containing PMDs was applied to all exposed wound surfaces. Dressing changes were scheduled based upon the personalized plan of care. In all 3 patients, the pain-relieving properties of PMDs allowed resumption of activities within 1 day of initiating treatment, the dressings’ continuous wound cleansing system kept the wounds clean and free of infection despite the challenging environment, and the wounds healed steadily. Managing infected acute wounds with PMDs through complete wound closure was time efficient for clinic staff and met all 4 major patient goals of care. Randomized, controlled studies to compare wound and quality of life outcomes in patients whose infected wounds are managed with PMDs compared with those whose wounds are managed with other advanced dressings are warranted.
Key Points
• The author describes wound care experiences in a rural clinic in a remote area of northern Ghana.
• Because obtaining care for an acute or chronic wound often is delayed until the wound becomes very painful or impairs function, wounds frequently are infected on presentation to the clinic.
• To illustrate the effectiveness of the protocol of care developed to facilitate healing and early return to a fully functional status, the author presents 3 case reports of patients whose infected wounds healed with oral antibiotics and the use of polymeric membrane dressings.
Introduction
Acute wounds that initially are not managed appropriately often become infected, particularly in areas with warm climates and unsanitary living conditions.1–3 A cross-sectional epidemiological study1 of 2 impoverished areas in the tropics (N = 6917) found the most common cause (51.61%) of a chronic wound was a mismanaged acute traumatic wound. In this author’s experience, patients suffering from infected acute wounds who are accustomed to being healthy are often reluctant to modify their activities of daily living to accommodate optimal wound healing conditions. Clinicians treating patients with infected acute wounds in a real-world setting may find it difficult to meet the conflicting goals of patients whose main priority of returning to work causes them to engage in activities that can delay wound healing or even exacerbate their injury.
At the rural Christian clinic in a remote area of northern Ghana, West Africa where the author worked for 5 years, the challenge was to meet patient goals by restoring functional quality of life while using minimal clinic resources. These patients often are subsistence farmers or laborers whose families would go hungry if they were unable to continue working. The environment in this area of Ghana is harsh: after an approximately 4-month rainy season, the remaining 8 months are mostly void of even dew, and when the arid Harmattan follows the rains, thick dust hangs in the air and permeates every crevice. In the humid hot season before the return of the rains, nightly low temperatures remain well over 80˚ F (27˚ C), with daily highs often soaring beyond 120˚ F (50˚ C). These year-round, incubator-like conditions contribute to a high rate of infections.4
Patients with acute wounds in this setting are in many ways similar to farm workers in developed countries; both groups often delay seeking medical assistance until they are unable to work.5,6 Using a questionnaire, measurements of housing density and water quality, and skin examination of 1114 household members in 254 randomly selected households in 2 villages in Tanzania, Gibbs6 found 80% of individuals with lacerations or puncture wounds on the lower legs did not seek treatment. Thierry and Snipes5 reviewed 393 open-ended injury narratives from a database of face-to-face interviews by trained bilingual interviewers that included a nationally representative sampling of farmworkers (the National Agricultural Workers Survey) and compared the narratives with demographic surveys from the National Institute of Occupational Safety and Health’s supplemental injury module for hired crop workers using qualitative (grounded theory) and quantitative (descriptive discriminant analysis) research methods. Farm workers in the United States based their decision to seek medical treatment for an injury almost entirely upon whether they could continue working. In neither study was economic status of the injured person a major influence in the decision to seek medical assistance.
During negotiations among Ghanaian clinic nurses and patients to create realistic treatment plans for acute wound patients, patients and caregivers consistently agreed upon 4 primary goals: establishing a clean wound bed and keeping it clean, decreasing persistent wound pain, facilitating the immediate resumption of normal activities, and promoting quick healing.
The Setting. Very few health care professionals choose to work in remote areas of western Africa, including persons interested in wound care. Patients at the clinic in which the author volunteered benefited from the collaboration of 2 BSN Ghana State Registered Nurses (SRNs) who were committed to improving wound management in this harsh setting: a Ghanaian with decades of tropical wound management experience and the author, an American with extensive formal continuing education training in wound care. The wound protocols described in this study were refined by these 2 health care professionals over the years they worked together.
The clinic gained a reputation for success in wound care, frequently serving patients with wounds who traveled from distant areas. These patients often stayed with distant relatives in villages closer to the clinic than their homes, allowing them to walk only 1 to 10 miles to reach the clinic for their dressing changes. On a typical day, the author, sometimes with an assistant, would dress wounds for as many as 20 patients before seeing the medical patients, who came to the clinic with illnesses such as malaria, dysentery, and pneumonia. This high volume of patients (~600/year) with a wide variety of acute and chronic wounds allowed the author to quickly discover what was successful (and what was not) in this environment.
Wound infections are an especially common complication in warm unsanitary environments such as the one surrounding the clinic.1,4 Keeping wounds clean was extremely challenging in this setting. The clinic staff had very limited resources in terms of both supplies and personnel. However, a wide variety of advanced dressings and basic wound care supplies are donated to the clinic, primarily by individuals in the US. As such, cost, marketing, reimbursement, and formulary listings had no bearing on advanced wound dressing evaluations. The author trialed supplies, methodically using them as she had learned in her wound management course. She had some initial success with closing wounds using copious quantities of triple antibiotic ointment and gauze. However, this method of wound management was slow and painful, and the patients were unable to resume their usual work activities for weeks.
Most of the other donated advanced wound products did not perform as well in keeping wounds clean as the local standard of care preferred by the author’s Ghanaian colleague (Edinburgh University Solution of Lime [EUSOL] soaked gauze) with one exception. Through trial and error, various configurations of polymeric membrane dressings (PMDs) (PolyMem®, Ferris Mfg. Corp, Fort Worth, TX), consistently were found to keep wounds far cleaner than any of the many other available products. Also, while EUSOL prevents infection, it is cytotoxic, which slows healing.2 When PMDs were used, a healthy deep pink wound bed with granulation buds along the edges often was established by the next daily dressing change. Wounds closed much more quickly with PMDs than with either EUSOL or thick antibiotic ointment, and patients found PMDs so comfortable they could usually return to work and to their usual roles in their families during treatment. In contrast with other modern dressing choices, infection did not regain a foothold in the wound bed after initial cleaning/debriding.
The author subsequently learned her positive experience when comparing PMDs with the other dressings was not unique; a distinction between PMDs and other advanced dressings has been reported in more than 30 studies7–40 and numerous conference poster presentations (see Table 1A, 1B, 1C, 1D, 1E, 1F, 1G, 1H, 1I, 1J, and 1K for an annotated list of references and Table 2 for a breakdown of posters by topic).
Mode of action. A prospective crossover study7 and case series8,10,12 have shown PMDs continuously cleanse wounds. Overviews, literature reviews, and case series18,19,32,34,35 support that PMDs release a nontoxic surfactant cleanser41 to break the chemical bounds between the wound bed and adhering slough, dirt, or other substances that may impair healing. As shown in case series and reviews,15,19,32,35,36,38 the hydrophilic (water-loving) components of PMDs (the substrate and glycerol, a bacteriostatic simple sugar) pull nutrient-filled, enzyme-rich fluid from the body into the wound bed, enhancing both healing and autolytic debridement. A case series,8 a literature review,35 and a randomized, controlled trial (RCT)13 found the loosened undesirable substances are drawn into the superabsorbent and substrate of the PMD along with excess fluid. Manual cleansing or rinsing can increase pain, and may slow healing by cooling, or can even damage fragile new granulation tissue.42-44 The literature shows these common interventions are rarely necessary when PMDs are used.8,13,18,31,34,35 Because PMDs are nonadherent, reviews and case reports8,12,14,18,31,36 show the dressing change process is quick and easy.
Pain. Several RCTs and numerous clinical reviews and best practice documents10,11,14,15,18,21–24,27,29–31,33–35 support that PMDs relieve pain (see Table 1A, 1B, 1C, 1D, 1E, 1F, 1G, 1H, 1I, 1J, and 1K). The relief of persistent wound pain provided by PMDs goes beyond that obtained by simple occlusion; an RCT24 in 72 rats comparing PMDs with other dressings show PMDs placed on either intact skin or on wounded areas of the body subdue and focus the nociceptor response, as measured by a significant (P <0.05) decrease in spinal cord Fos expression at Laminae I through VI, inclusive, a significantly (P <0.05) smaller area of spread of inflammatory cells at the wounding site, and significantly (P <0.0001) decreased withdrawal latency. In humans, this ability of PMDs to subdue and focus the nociceptor response, as demonstrated in 2 RCTs10,22 and literature reviews and case series,14,23,30,34 explains the observed decrease in secondary inflammation and resultant decrease in pain, bruising, and edema. Patients with acute and chronic wounds treated at author’s clinic usually experienced such dramatic decreased pain and inflammation when PMDs were initiated their normal activities, such as walking and farming, could be resumed as soon as they stepped out of the clinic.
Also, case series30,32,34 have shown this decreased secondary inflammation can help increase circulation, which facilitates healing. When wounds were managed with PMDs in the clinic in Ghana, granulation buds usually were observed at the first dressing change.
Additional benefits. Unlike conventional foam dressings, in reviews and case series15,19,32,35,36 PMDs have been shown to be appropriate for use over structures that must be protected from desiccation, such as tendon and bone, as well as in heavily exudating wounds. This is because in addition to directly introducing glycerol onto all wound surfaces, the hydrophylic components of PMDs pull fluid from the body and redistribute it to dry areas of the wound bed while absorbing exudate from areas that are overly moist, as shown in reviews and case series.19,30,31,36,38 Reviews and case series8,19,35,36,38 also have found that because of this ability to optimize wound moisture and continuous wound cleansing, PMDs are indicated for use on every wound type at every stage of healing.
The combination of keeping the wounds clean, decreasing pain, and brisk healing impressed the entire clinic staff so much that the author solicited donations of PMDs directly from the manufacturer, who provided enough PMDs for the clinic to use PMDs on virtually all patients with wounds.
Clinic use. Using PMDs on hundreds of patients with wounds for more than 16 months demonstrated to the author and clinic staff that these dressings were able to meet or exceed all of the expectations of the clinic’s patients with wounds while decreasing the clinician time required for appropriate wound management. Using PMDs also resulted in a decrease in supplies needed for wound care, partly because when PMDs were used, wounds rarely needed to be rinsed during dressing changes.
Highlights from Published Independent Studies
In response to successful use of PMDs on a variety of wound types, physicians Kim et al10 performed 3 prospective studies comparing PMDs with petrolatum gauze dressings: 1 with 15 rabbits (using contralateral sides) followed by 2 RCTs with human patients who had either second-degree burns (n = 44) or split-thickness skin graft donor sites (n = 28). The researchers found wounds in all 3 studies closed significantly faster with PMDs (P <0.05 for epithelization in the animal study and P <0.01 for healing time in both human patient groups). Both of the clinical trials with human patients demonstrated significantly decreased pain (P <0.01) and improved patient comfort (P <0.01) scores with PMDs.
Yastrub,13 a nurse practitioner, conducted a RCT comparing PMDs with conventional moist dressings (antibiotic ointment and gauze) on 44 Stage II pressure ulcer patients in a long-term care facility.13 Using the Pressure Ulcer Scale for Healing (PUSH) tool, the author found significantly improved healing scores (P <0.001) in the PMD group.
In a historical cohort comparison trial, Weissman et al30 compared PMDs to previous usual practice (an antibiotic plus steroid ointment) on patients with facial burns in Israel. Patients whose burns were managed with PMDs reepithelialized more quickly (6.5 days versus 8.5 days) and experienced less wound site pain (average 2.6 versus 4.7 on a scale of 0–10), as well as a complete lack of dressing change pain. No manual cleansing was needed at dressing changes when PMDs were used, a benefit of using PMDs that saved nurse time and dramatically decreased overall costs. The researchers also observed that typically facial burn patients suffer additional damage due to secondary (neurogenic) inflammation, but when PMDs were used on patients with facial burns, the area of inflammation did not extend beyond the actual area of the burn.30
A case series32 of 6 consecutive patients was conducted with a focus on the wound cleansing ability of PMDs in patients with diabetic foot ulcers complicated by both deep abscesses and osteomyelitis. The silver rope configuration of PMDs was inserted into the deep cavities, with adjunct topical oxygen therapy provided during twice a week dressing changes. Despite poorly controlled diabetes (HbA1c >9 throughout treatment) in 2 patients and significant arterial insufficiency (ankle-brachial indices of 0.57 and 0.61) in at least 2 patients, the wounds of all 6 patients healed completely and did not recur. The authors concluded surgical interventions can be safely replaced by the continuous wound cleansing actions of PMDs in at least some patients who have both deep diabetic foot ulcer abscesses and osteomyelitis.
The use of PMDs was evaluated in a prospective case series31 of 20 consecutive patients with head and neck cancer, including patient reported pain-, sleep-, and free-text diaries, as well as objective measures and subjective reports from nursing staff. Compared with the facility’s standard treatment for radiation-induced skin damage (topical aqueous cream for initial burns with the addition of paraffin gauze when moist desquamation occurs), the use of PMDs decreased both moist and dry skin desquamation and decreased the sensation of burning for all 20 study patients, indicating PMDs were able to balance moisture and decrease inflammation. PMDs were easy for nursing staff to adapt to meet the patients’ individual needs. When PMDs were used, patients reported a cooling sensation on the skin, dramatically decreased pain in the radiation affected area, decreased dressing change pain, increased comfort, and increased sleep; nurses confirmed these findings and documented improved skin healing. Family members performed many of the dressing changes, and manual cleansing was eliminated for all but 6 of the patients by week 3. The facility changed its protocol for radiation-induced skin reactions as a result of this study, replacing the previous treatment method with PMDs.
The results of these studies are congruent with the current author’s experiences with PMDs. The purpose of reporting these cases is to provide examples of how the Ghanaian clinic’s PMD wound management protocol met the needs of patients with infected acute wounds in a challenging environment.
Protocol
The clinic’s usual PMD wound management protocol (see Figure 1)was followed for at least 900 patients (dozens with infected acute wounds), including the 3 example patients presented. After initial cleansing and/or debriding, PMD cavity filler (with or without silver, depending upon dressing availability and the patient’s perceived immune status) was inserted into any undermined areas, and then standard PMDs (with or without silver) were applied to the exposed surfaces of each wound and over any cavity filler. PMDs were changed daily at first, with intervals increasing up to a week as exudate levels diminished. Initial daily dressing changes were important because often the wound produces a large amount of exudate for the first few days of PMD use.18,19,35 As granulation tissue increased and the wounds became cleaner, exudate levels decreased so the patient could make less frequent clinic visits without jeopardizing healing. The optimal time for the patient to return to the clinic was easier to anticipate with experience.
At their initial clinic visit, all patients with wounds also routinely received oral pain medications (usually over-the-counter dosages of a nonsteroidal anti-inflammatory), vitamins, extensive nutritional teaching, prayer, and antibiotics as appropriate in addition to direct topical wound care. Although many of the patients suffered from chronic protein deficits, it was not possible for this small clinic to provide nutritional supplements in this setting. Due to the need for all of these patients to continue working during treatment, PMDs often were covered with porous protective outer materials such as bedsheet strips or, occasionally, stretch gauze. The bedsheet strips could provide nonelastic compression.
The patients described here were chosen as representatives of the larger group because on the first day of their wound management each had provided written informed consent for their images and data to be used by the author, allowing the data to be prospective, and because their photographic and written documentation was relatively complete. All 3 patients were young and comparatively healthy other than their debilitating infected acute wounds (patients 2 and 3 showed some protein malnutrition, as was typical for individuals of low social status in this culture). None of the example patients sought treatment beyond self-care for their wounds until pain from severe infection motivated them to request care.
Example Patients
Patient 1. An approximately 30-year-old, otherwise healthy man punctured his hand with a stick. Because it was not extremely painful at the time, he did not stop to wash the wound. Two (2) weeks later, a painful abscess had developed. He came to the clinic when the pain became unbearable (10 on a 0 – 10 scale) (see Figure 2a).
His pain was so excruciating it was difficult for him to allow caregivers to touch his hand. Lancing the abscess released a large quantity of yellow and brown fluid. After thoroughly flushing the cavity with normal saline to remove clots of exudate, iodoform gauze (NuGauze, Johnson and Johnson, Princeton, NJ) packing strips were inserted into the undermined area. The dorsum of the hand then was covered with gauze and wrapped with stretch gauze. Ceftriaxone (2 g) was given intramuscularly (IM), and the patient went home with 5 days of oral cephalexin (500 mg, twice daily) and oral ibuprofen+caffeine to be taken as needed for pain. Because he reported having felt feverish, the patient also was presumptively treated for malaria, which was endemic in the area.
Dressings were changed daily by the author. The skin over the central wound area had been stretched so much by the pressure from the abscess it was not viable. This skin was left to demarcate and separated on its own at the first dressing change, leaving a 5 cm x 6 cm x 1 cm deep malodorous open wound with ~2 cm of undermining in all directions. By the second dressing change (day 3), it was clear the use of iodoform gauze packing strips in the large cavity wound could not provide satisfactory results for this patient. Despite antibiotics and pain medications, the extreme persistent wound pain prevented sleep, the quantity of purulent malodorous exudate indicated the infection was not resolving, and the undermining was expanding (see Figure 2b).
Treatment was changed to PMDs on day 3. Layers of silver PMD cavity filler were laid flat in the large area of undermining between the skin and the exposed muscle. Silver PMD cavity filler was used due to the risk of infection spreading up the tendons and down into the bones of the hand. Silver PMDs pull microbes into contact with silver locked into the dressings, making them safer than other silver dressings.37,39 The flexibility of PMDs was advantageous in this mobile area of the body. The patient was encouraged to move his hand to avoid contractures. One day later (day 4), the decreased pain and inflammation provided by the PMDs allowed the man to grip his hoe so he could farm again. A standard (not silver) PMD was used as the secondary dressing, and stretch gauze was used to protect the dressings from dirt. Dressings were changed daily.
On day 5 (the second dressing change with PMDs), the patient laughed and joked with the clinic staff about his previous pain, which was now a 0 on the 0 – 10 scale. The silver PMD cavity filler painlessly pulled the purulent malodorous exudate from the wound bed, even in the deepest areas of undermining (see Figure 2c). Within a week, the silver PMD cavity filler, when removed, was saturated with serous exudate only, indicating the infection was resolved. At that point, rather than using cavity filler, an extra-thick PMD (without silver) was placed over the entire open wound on the dorsum of the hand, and a pressure dressing was applied to allow the undermining to seal shut. Subsequent dressing changes consisted of replacing the PMD, then wrapping the hand to keep the dressing clean as the patient farmed. Dressing changes decreased from daily to twice a week when the cavity filler was no longer used. The PMDs continued to keep the wound bed clean without any rinsing at dressing changes. Granulation tissue formed rapidly. The patient remained virtually pain-free with full range of motion. At 4 weeks, a standard thickness, 2.5 cm x 2.5 cm bordered cloth adhesive PMD was used to dress the now small, superficial wound (see Figure 2d). The patient was dismissed from the clinic <6 weeks after the use of PMDs on his wound was initiated.
Patient 2. A 16-year-old, mildly protein-malnourished boy (nutrition status determined by midarm circumference measurement) cut the area of his medial malleolus while hoeing. He applied local leaves to the wound, which burned the tissue as they decomposed and may have contributed to his malodorous infection. He reported through a series of interpreters (his dialect was not spoken beyond his remote village) that his pain level was so high it completely prevented him from being able to farm. Because he needed to be able to farm again to help support his family, his wound management needed to diminish his persistent wound pain and to dress the wound in a way that would not inhibit his ankle movement. Ceftriaxone (1 g) IM and oral amoxycillin provided for 7 days diminished the wound odor and purulent drainage, but initial sharp debridement and wound cleansing was incomplete because of concern the boy’s tendons, visible through a thin layer of muscle tissue, could be damaged by aggressive debridement techniques (see Figure 3a).
The avascular ankle wound measured 7 cm x 5 cm x 0.8 cm deep with 30% adherent yellow slough and moderate serosanguineous drainage when standard PMDs were initiated. Three (3) thin pieces of PMD cavity filler were cut to fit into the deep grooves between the visible tendons. The entire wound area then was covered with an improvised extra-thick dressing made of a PMD cavity filler covered with a standard-thickness PMD (at the time this boy was being cared for at the clinic, the clinic had a temporary shortage of extra-thick PMDs) (see Figure 3b). Due to the distance the boy had to travel to get to the clinic (more than 30 miles), the plan of care was for every-other-day dressing changes with extra-thick PMDs to absorb the wound exudate. However, flooding of local rivers led to his erratic clinic attendance. The wound developed thick green adherent slough when he was unable to come for dressing changes. This was managed with cleansing using a cotton-tipped applicator and rinsing with saline to remove the loose dirt and slough before applying a fresh extra-thick PMD. Otherwise, dressing changes consisted of removing the saturated PMD and applying a new one, then wrapping the ankle area with a bedsheet strip bandage or stretch gauze to protect it from dirt during farming. Saline rinses were added when visible dirt from farming found its way under the dressings.
By day 3, the wound bed was already much cleaner with noticeably decreased size and depth at the first dressing change. On the second dressing change (day 7, because flooding prevented the boy from coming to the clinic sooner) the wound was 0.5 cm deep and the wound filler was no longer needed. At this second dressing change, through a series of interpreters the boy stated he had been completely pain free, even during farming. Oral antibiotics were restarted because it was anticipated that sporadic flooding would continue to prevent him from attending the clinic regularly. Granulation tissue filled in the wound bed steadily. After 4 weeks of PMDs, despite erratic clinic attendance and soaking the wound in muddy water for prolonged periods of time, the wound was 94% smaller, measuring 4.9 cm x 3.4 cm x 0.1 cm deep (see Figure 3c).
Patient 3. A relatively healthy young woman (uncertain of her age but probably ~20 years old based upon her appearance, her memory of historical events, and her circumstances in life) presented with a large injection abscess on her left buttock. Injection abscesses are a common complication of medical care provided by uneducated itinerant pharmaceutical sellers. These entrepreneurial individuals travel from village to village with a box containing a jumble of tablets, capsules, tonics, and injectables strapped to the back of a bicycle. They are often illiterate and rarely have sanitary equipment.
The woman’s occupation as the driver in a fufu pounding operation (food preparation) required her to be able to move vigorously while sitting on a low stool. Due to cultural taboos, young women are not permitted to eat meat, eggs, or peanuts, and milk products were unavailable where she lived; this patient’s protein intake was quite limited. The skin covering the abscess was not viable and sloughed off, exposing an approximately 5-cm diameter, 2-cm deep cavity with a base of muscle tissue (see Figure 4a). After the wound was irrigated with saline to remove the foul exudate, 4 layers of standard PMD cavity filler were torn to fit and placed one on top of another to gently fill the entire undermined area. A standard PMD was placed over the wound bed and window-pane taped in place.
The young woman received oral antibiotics and ibuprofen (400 mg) as needed for her reported pain. Dressings were changed daily at first, with decreasing frequency as the cavity filled in and less exudate was produced. Because the surfactant from the PMDs continuously loosened wound debris and the superabsorbent pulled the contaminants and the excess exudate into and onto the dressings, no manual wound cleansing or even rinsing was required at dressing changes. The abscess granulated quickly and filled in; only 2 layers of PMD cavity filler were needed by treatment day 12 (see Figure 4b).
The patient walked several miles to and from the clinic for dressing changes during the entire course of her wound management. This young woman was able to return to her work on the day PMD wound management began with her pain controlled by pain medication and PMDs. The flexibility of the PMD cavity filler allowed her to sit and to move freely as her wound healed (see Figure 4c). The abscess closed completely in 8 weeks.
Discussion
The patient cases presented demonstrate how infected acute wounds successfully healed with antibiotics and PMDs without return of the infection. Most patients with wounds treated at the clinic, including all 3 of the example patients, walked many miles for dressing changes. Due to the decreased wound pain following application of PMDs, patients were able to resume their normal daily activities, including strenuous manual labor, by their second dressing change at the latest. The flexibility of the dressings and the substantial reduction of their wound pain and inflammation increased patient quality of life by allowing the patients to resume the usual roles in their families. Wound bed cleansing during dressings changes was necessary only when dirt or debris was able to migrate under the dressings during farming. Eliminating routine wound cleansing at dressing changes significantly decreased the staff time and supplies needed to care for these patients. These attributes have been repeatedly cited in the literature described herein.
Managing infected acute wounds with PMDs also allowed care providers to meet all identified patient goals: freedom from infection, quick healing, significant pain relief, and minimal inconvenience. The clinic also benefitted when PMDs were used because patients required far fewer clinic resources for complete wound closure.
Limitations
The author and the clinic staff successfully managed hundreds of wounds, ranging from minor tropical leg ulcers to life-threatening diabetic foot abscesses, with this PMD protocol. For the final 16 months of the author’s tenure at the clinic (after PMDs were donated in sufficient quantities to prevent serious shortages), it was rare for a wound to be managed with any other dressing type. However, due to time constraints, detailed documentation was gathered for only a small fraction of these patients, and many suffered from chronic rather than acute wounds. Therefore, no rigorous scientific study was performed, and only 3 patients with infected acute wounds are described here in detail. The external validity of this study is also limited by the unique location and observational nature of case studies.
Conclusion
Three (3) example cases illustrated how the use of PMDs met all goals of care for patients with infected acute wounds. The results seen in the Ghanaian clinic — specifically, the observations that PMDs clean wounds, keep them clean, decrease both dressing change and persistent wound pain, facilitate the immediate resumption of normal activities, and increase healing rates — have been documented in other studies. This suggests results observed may apply to patients in less challenging locales. RCTs to compare wound outcomes and quality of life of patients whose wounds are managed with PMDs compared with those whose wounds are managed with other advanced modalities are warranted.
Acknowledgment
The Church of Christ Mission Clinic is directed by Peter Bombande, who worked together with the author to create the wound management protocols from which these patients benefited.
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