Article originally featured on WoundSource
I can hear it now: "Alton! Don't forget to wash your hands." That's the voice of my grandmother I hear anytime I needed to wash my hands after using the lavatory, before and after treating patients, and before eating. However, I also have the voice of my residency director in my head issuing a similar reminder. I recall one of the very first emergency room consults I had as an intern and excitedly calling her about the patient presentation. I specifically told her the wound is very pungent and malodorous. She quickly replied, with over 30 years of wound care experience, "Alton, did you wash the wound?" and that was when it hit me. I told her, "No, I did not wash the wound." She responded, "Well, call me back when you wash it; then we can better assess if it's truly infection or not." It was at this very moment I learned the very first step of wound care. This step is known as "Please Wash Your Wound!" and it is equally important for both health care providers and patients to understand the basic steps for cleaning a wound.
Proper Wound Washing
Reflecting on my wound care training and experience from the last five years, there is typically one recurring motif I have learned, which is that there are two types of patients: individuals who are compliant with dressing change instructions and those who are not compliant. Then, I realized that there are two types of health care providers: those who have specific dressing change instructions for their patients and those who do not. However, one thing that has to be consistent with both the patient and the patient's wound care specialist is what to do when the dressing is removed. That critical step is learning how to cleanse a wound properly before application of a fresh dressing. Just as in early childhood we had to learn how to wash our hands properly, there is also a proper way of washing a wound.
Many of the wound care product companies sell various wound cleansers that are marketed as the best on the market because they can eliminate or significantly decrease the wound's bioburden. I address these products later in this blog post, and they do serve a purpose, but there is a cliché saying that you have to know how to walk before you can crawl. So, before I ever order my patient those rather pricey wound cleansing products, I typically educate the patient or their caretaker on how to wash a wound.
There are hundreds of published research articles that support the claims that mechanical handwashing with soap and water significantly reduces the amount of bacteria on our hands. This is why I inform the patient that, no matter how extensive the bioburden of their wound is, they should wash their wounds with sterile water and fragrance-free antibacterial soap (i.e., Dial Gold Antibacterial Soap) using mechanical circumferential motions. Patients should be instructed to lather the soap on a 4 × 4 gauze pad to gently cleanse the wound using circumferential motion for approximately 20 to 30 seconds. The patient should then be instructed to gently rinse the soap off the wound with sterile water and pat dry. Although these steps may seem simple, they are actually not common practice within our wound care community. Many wound care facilities or home wound care providers simply douse a wound with a diluted hydrochloric acid solution and then pat dry without actually ever performing a mechanical cleanse to the wound surface.
Conclusion
Now that I have stepped off my soapbox (pun intended), I do agree that industry wound cleansing products have a role in wound care, but I think they should be a second- or third-line choice after traditional antibacterial soap and water applied using mechanical circumferential motions. These wound cleansing agents are more costly to the patient, and they should be used for wounds with more complicated healing processes. I refer to this approach as wound cleansing stewardship: knowing when to use which wound cleansing products based on the response to treatment, just like knowing when to use different dressing types based on the clinical assessment of the wound.
I also think that using these wound cleansing agents allows for an increase in compliance for our patients because of the ease of use. Just as when we are on the hospital wards in a rush, it is much quicker to go to the alcohol-based hand sanitizer than to wash your hands when you are in a hurry to see the next patient. So, something is better than nothing in these scenarios. In closing, I hope my grandmother's and residency director's voice is now ingrained in your head: "PLEASE WASH YOUR WOUNDS WITH ANTIBACTERIAL SOAP, STERILE WATER, and CIRCUMFERENTIAL MOTIONS!" You may actually notice a difference in the response to treatment.
About the Author
Alton R. Johnson Jr., DPM is currently an American College of Foot and Ankle Surgeons Podiatric Medicine and Surgery Clinical Research Fellow at the Penn Presbyterian Medical Center in Philadelphia, Pennsylvania. After graduating podiatric medical school in 2016, Dr. Johnson went on to complete a three-year Podiatric Medicine & Surgery Residency (PMSR+RRA) at Aventura Hospital and Medical Center in Aventura, FL. Dr. Johnson is currently a PRESENT Podiatric Residency Education Summit Faculty Member. His research emphasis has been focused on gerontology, tropical and international medicine, regenerative medicine, diabetic limb salvage techniques, and rare dermatological and bone pathologies.
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