The Development of the Available Technology Dressing for Wound Management in Low-Resource Settings

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Linda L Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, and Richard Benskin share background and key findings from their original research paper, "Development of the Available Technology Dressing: An Evidence-Based, Sustainable Solution for Wound Management in Low-Resource Settings." Read the full paper here. 

Transcript:

Linda L Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, WOCNF:

Hi, I'm Dr. Linda Benskin. I'm a PhD nurse, a wound specialist, researcher and educator. I mostly do secondary research. And what that means is that I evaluate and distill the best evidence on a wound topic into a conference presentation or an article or an educational booklet for use by practitioners, practicing physicians, and nurses who may or may not be wound specialists. I also continue to conduct case studies. That's mostly done remotely via email or WhatsApp or that sort of thing, and that's worldwide. People tend to send me their most difficult cases. And then, of course, I do the studies that are described in this article, which culminated in our randomized control trial of the available technology dressing, or ATD, which my husband and I developed together.

This is my husband, Richard Benskin. We've been married for 46 years, and we are true partners in pretty much everything we do. When we travel to developing countries, he is the driver, the mechanic, the diplomat, the IT guy, the bodyguard, the chief cook, and bottle washer, quite literally. He's very inventive and good at improvisation, which was helpful in developing this dressing technique. And when I write, I generally do the basic initial writing, and then he is the thesaurus, the editor, and the master of succinct.

This was basically a summary of the research leading up to that randomized controlled trial, and then a really brief summary of the trial itself. We'll write future papers that describe the trial in more detail. So, we described the initial research, which was case studies to try and find what worked among the modern dressings in remote and conflict areas of tropical areas of developing countries. And then we did a couple of literature reviews. I did a qualitative study that led to a quantitative study of usual practice. And then we did the randomized control trial of the available technology dressing, which took place in collaboration with a wonderful team that we put together of researchers at the University of West Indies in Jamaica.

Richard Benskin:

Well, in a single word, need. It's kind of been a journey. Twenty-five years ago, we moved to Ghana, West Africa, to help operate a Christian clinic. Prior to that, we'd done a number of short-term medical trips in which we realized that wound care issues were a big problem in that environment. So Linda took a basic wound care course. Prior to that, she was a pediatric nurse and a general nurse, but we knew that needed to be honed up a bit.

So upon moving to Ghana, we hadn't been there for more than a month or so when a messenger came to us from the king of a tribe of about 2 million people where we live. A friend of the king was in trouble and needed wound care assistance. So we packed up some gear and headed over to the place where he was. And he had dramatic tunneling wounds that ran almost circumferentially from knee to ankle, and his family was conspiring to haul him off to have an amputation. But his religious beliefs were such that he would rather die than have an amputation, so he's getting ready to starve himself to death.

But we did basic clean wound care, cleaned it up, used what we had readily available at the time, which was a lot of triple antibiotic ointment and gauze, did moist wound healing, and it didn't take long before it started looking a lot better, but it took an incredible number of supplies, and we knew and even the gentlemen realized that this was not really sustainable in that environment. So that led us to begin the search for something that would be sustainable in those kinds of environments that was using materials that were already in place, either in the villages or natural materials that could be found in the community. So that's basically how it got started. And here we are.

Linda L Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, WOCNF:

Yes, we've actually had quite a few surprises along the way, beginning with just being at the clinic. As it turned out, my Ghanaian colleague was known throughout the area as being a wound expert, and he was just using EUSOL, which is essentially very similar to Dakin’s, and gauze and just doing wet-to-wet dressings and getting really slow healing, but that was better than what anybody else was doing, which was the wounds were just getting worse.

And when I looked around through the clinic and rummaged around in the cupboards and stuff, I found that there were a lot of donated modern dressing supplies, and I couldn't understand why he wasn't using them. And so I set about to use that short course that I had taken in wound care and show him how much better modern dressings would work. And I was immediately proven wrong.

So we were seeing 10 to 20, sometimes as many as 30, wound patients every morning early before we saw our usual medical patients. And so there were plenty of patients to manage. And he'd clean them up with his EUSOL and gauze and then hand them off to me. And I'd put on whatever modern dressing was the most appropriate—if it was a dry wound, something wet; if it was a wet wound, something that would absorb—just like I'd been taught, and the results were just horrible. And I just was really surprised at how badly modern wound dressings worked in that setting. I got virtually no healing and almost instantaneously got bacterial and mixed fungal infection in these wounds.

And then the next dressing that I was trying turned out to be the polymeric membrane dressings, and they were just, it was just a night and day difference. They performed dramatically better. They kept the wounds clean, they kept them appropriately moist and healing to where I had granulation tissues sometimes in just one day, and so with that dramatic surprising difference, I wrote to the company and asked them to donate a large amount of probably very expensive dressings to this clinic they'd never heard of in their lives, and they sent a big box of the dressings, and that's how I got started doing the case studies.

Then the next big surprise was, eventually, we decided that I needed to get the credentials to be well-recognized by governments in developing countries. So I went to get my PhD and as part of that work, I did 2 literature reviews, one on usual practice, and found out that there's basically no description at all of usual practice in tropical developing countries. And then the other one was what improvised dressings could be used. And we were really expecting it to turn out to be, you know, something like a particular leaf, banana leaves came up in the study and everything, but it turned out that the most successful improvised dressings were using food grade plastic, plastic wrap in particular. And that was a big surprise.

And then the third big surprise was when we were performing our randomized control trial in Jamaica, we expected our available technology dressing to outperform wet-to-moist gauze. We were doing a really good job of keeping the wounds wet with saline soap gauze, but the available technology dressing just wiped the floor with that. They did so much better than we anticipated. They didn't outperform the polymeric membrane dressing, which was our positive control, but compared to usual practice for sickle cell leg ulcers worldwide, they performed very, very well.

Richard Benskin:

As she mentioned, the trial that we did was on sickle cell leg ulcers, which are an incredibly challenging wound, painful, a lot of our patients had had them for multiple decades. But we'd like to see further trials with other wound types and in other environments. We've talked to people that work in the prison and jail systems who have patients with chronic wounds who are later dismissed into the community and are either resistant to hospitals and formal care or don't have those resources. We think trials for patients that are living on the streets or in Appalachia, the Texas Valley, other places where resources are limited, we'd like to see these trialed on diabetic foot ulcers and various other chronic wound types. From what we've seen, we're very optimistic that this could be a sea change for people in those sorts of situations.