Sometimes It Just Has to Be Done!

Wound debridement is essential for appropriate wound bed preparation and healing.¹ Admittedly, there are several methods of debridement — mechanical, autolytic, enzymatic, and biologic (use of maggot therapy) — but sharp debridement is considered the “gold standard” for removing necrotic material from the wound bed and periwound area. Unfortunately, sharp debridement is not performed as often or as well as it should be in the wound center setting. I cannot tell you how many times a new patient has been referred to our wound center because the patient’s wound is “not healing.” Upon examination, the wound is found to be covered with necrotic tissue and debris or is significantly infected. The “failure to heal” is the result of a failure to adequately and appropriately debride the wound.

Even if the practitioner realizes sharp debridement is necessary for the wound to heal, other roadblocks arise. Usually, surgeons are consulted, leaving them to decide whether the patient should go to the operating room for the procedure. The delay of seeing the surgeon, being admitted to the hospital, getting on the operative schedule, and having the procedure can significantly impede the patient’s treatment. Many times, especially in the face of a significant infection, the wound is worsening with each passing minute. There is no question that there are debridement procedures that need to be done in the operating room, but many times debridement can be performed safely in the wound care center, which would save time and money. The major concerns about doing sharp debridement in the wound center seem to fall into 4 categories: control of pain, control of bleeding, lack of sterility, and confidence in doing the procedure.^2-4 Although recent evidence shows these should not be an impediment to performing sharp debridement in the wound center,³ it appears that the overriding reason for not doing it is the provider’s insecurity in their ability to carry out appropriate, safe sharp debridement.⁴ Even though there is no question that many practitioners caring for wound care patients have had no formal surgical training that would include sharp debridement techniques, as a surgeon I do not feel that lack of previous training should let one off the hook from providing appropriate wound care. The technical ability to perform sharp debridement is a skill that can be learned like any other: the operator must understand the basics of using surgical instruments, the pathophysiology of wound healing, and the goals that are to be accomplished. If you do not possess these skills and are not willing to learn them, then treating wound care patients might not be your calling.  

This happens more frequently than you might think. In fact, I know of a story of a nonsurgically trained physician who began working in a busy wound center. After being “trained” in how to manage wounds, the practitioner went to work, but several months later, it was noted that the new practitioner’s patients were not healing as well as others in the center. A review of the situation revealed that the practitioner was rarely conducting appropriate sharp debridement out of fear of using a scalpel or even a pair of scissors to remove necrotic tissue in and around the  wounds. Despite additional training and encouragement, it just was not working. The practitioner realized the right choice was to leave wound care and return to previous medical practice. The practitioner and the patients did better because of the decision! It is unfortunate that the practitioner who had a heart for treating patients with wounds did not have a heart to learn and to apply the essential skills to properly treat them. 

We are obligated as physicians and providers to provide the best care possible, and when treating wounds, that includes appropriate sharp debridement. If this is not in your skillset, I encourage you to acquire it so that you can provide all aspects of quality wound care to your patients.

“Many a wound ‘requires cold steel, not the folly of a physician.’” 
— Sir William Osler, Father of American Surger