Everything Old Is New Again

This past weekend I was invited to be part of a group of wound care practitioners from the United States, Europe, Australia, and South Africa to design a manuscript to assist health care practitioners from around the world treat hard-to-heal wounds. At the meeting, cases were presented, and treatments were discussed, and it dawned on me that everything we were discussing was information that had been discussed many times before. It seems that no matter where in the world one treats wounds, the problems are the same and solving old problems is a major issue. As one who has had the privilege to teach and write about wound treatment in Sub-Saharan Africa, for me, the old topics became new again.

In the meeting, cleaning the extremity and wound was discussed; the group agreed that the use of soap and water was an acceptable option for wound cleansing. On the topic, I brought up my experience of treating wounds in Africa, which included ensuring there was a source of clean water before recommending soap and water for wound cleansing. To my surprise, the health care practitioner from Canada had encountered the same problem. She said there are areas in rural Canada that have never had clean water and still need to boil all water used. From our discussions, it seems the old problems are still new, even for countries that are not considered to have low resources.

Another discussion topic focused on debridement, including the importance of sharp debridement in managing hard-to-heal wounds. A fellow panelist said their patients could rarely receive sharp debridement despite how badly the wound may need it. Per the individual in the meeting, the surgeons in their area generally would not perform sharp wound debridement because of the lack of reimbursement for the treatment; however, those same individuals did not seem to have reservations toward performing an amputation. This information was both amazing and disturbing for a number of reasons, but adequate sharp wound debridement also can be difficult to secure in the United States, though sharp debridement is considered the gold standard for removing necrotic material from the wound bed.¹ In a study presented in poster format several years ago, we found 57% of health care practitioners surveyed were not performing sharp debridement in the wound center because of the fear of bleeding.¹ The second most frequent problem found was that practitioners had little confidence in performing the procedure.² No one had reported avoiding sharp debridement because of the lack of reimbursement. From this topic, the old problem of adequate and timely sharp debridement is still new.

One of the most obvious examples of the old being new is in the choice of wound dressings. As most know, despite the availability of many modern dressings designed to treat the wound microenvironment and support healing, the most frequently chosen dressing is still the wet-to-dry gauze dressing. This is despite copious amounts of older and newer literature showing the inferiority of gauze wet-to-dry dressings that often do more harm than good for the healing wound.^3,4

Encountering the above challenges in clinical practice are doing a disservice to advancing our knowledge of wound management and implementing more evidence-based standards. From the above recurrent discussion topics, it may be time for us to change our tactics on approaching these problems. Would it not be more beneficial if we spent that time for discussion on learning the most recent information on the treatment and study of wounds? Perhaps if we focus on the new evidence to guide practice, rather than the old, we can avoid the recurring topic of everything old becomes new again.

Terry Treadwell, MD, FACS
Editor-in-Chief, Wounds
woundseditor@hmpglobal.com