Do we need more time for the breakout to start or should we go ahead and you guys are good to go. Okay, so, um, this is my colleague Julianne Miller, an RN, and has an extensive background and wound care work for several years as a home nurse doing wound care in the home setting. That was after she had time in the hospital as a floor nurse. We found Julie and has been with our wound clinic now for four years, four years. Just phenomenal wound nurse. All of our nurses are great. And so she agreed to be involved with the breakout session we're wearing our masks, because we're like literally like three feet apart. You know, and so if you have a hard time hearing. I'll just speak a little louder. I know sometimes it's more challenging we don't get the lip. I understand that. So, um, so I'm going to have Julie step aside for a second then I'll kind of start a little bit and then we'll kind of go back and forth here. Readjust the camera here. And since she's now over six feet away I can take that off here. So great here so my understanding is that the majority of people in the breakout session now are provider. That's right. Nurse. You know there's practitioner PA. But maybe even if some of the physical therapists join us all are welcome here. That's great. So, um, thanks for joining us on this session here. We're not doing a PowerPoint so well, you know, it's kind of like flying, you know, flying like live TV, like live TV. So behind me. Should be able to see this I'm going to bring it in a little closer here. I don't know if you can read that if you can't I'll just point it out to you. We're going to kind of do a mixing of, you know, major categories of what you see for wounds between Venus arterial diabetic pressure and surgical and really how to just be globally think about, you know, what's going on with that wound, you know, to a degree, but, you know, I like to think in broad categories, you know, and based on my assessment do I think a wound is too wet or too dry or too swollen or too painful or combinations of any parts of these as it relates back to these wounds. It really helps us figure out, you know what to do with the wound. So with that, I'm going to kind of turn the camera back to Julie, because we do have set up here. Different wound products. So first off, right off the bat, we are not promoting any particular brand, but it's almost impossible for some things to not be discussed. It's kind of like just the broad thing of like, hey, you know, all right, you know, Coke or Pepsi, you know, they're sodas we get that, you know, or you got your Nikes or your, your other tennis shoes but some things come with a brand name, but we're not promoting. It's just what we have, and we can always talk in the generic. Because not everyone's going to have the same brand. It's very well described that you're staying within the same category that there's very little that says that one brand is better than another, just like, you know, I'll be honest, you know, there's really not much difference between Coke and Pepsi, in my opinion. Alright, so bringing this down and bring this over to Julie. Hi. Okay, so I don't know if you can see some of our products here on the table we just brought some products out. And, you know, we like if we were talking Venus ulcer and we're going to look to see is the wound, you know, too wet or too dry. We use either a two layer wrap or a three layer wrap so again, these are just a zinc product it's a wrap to provide compression for like Venus ulcers, and it's a two layer wrap so this is a calamine, this is a zinc product. And then over top of that we will use coban, which is just a rubber, you know, I'm sure all of you know what coban is. That's the basic, but if we're going to see you know the wind is very wet and draining a lot. And we're going to need to put something in between the layers. So we have a whole bunch of different things you can use, you know, just a simple surgical pad. You can use these hydro fiber pads which hold like about 10 times their weight in some sort of fluid. This is another product. I don't whatever you have in your clinic you put this literally in between the wraps over top of the wound. And in a perfect world, you can leave that wrap on for a week. If it's still draining you may have to change the wrap twice a week. Okay, what's the advantage of these type of contained pads versus an ABV pad. So an abdominal pad will hold, you know, some drainage, this is going to hold. So you can literally take a glass of water and pour it in here, and it's just like diaper technology like you would use for, you know, changing a diaper on a baby, and it's going to pull the drainage away, whereas an abdominal pad or a surgical pad might keep all that drainage on top of the pad which will then excoriate the skin, so this is going to pull it away. So it locks it in so the skin's not feeling the wetness anymore like like a wet gauze pad. Yes. And, you know, for the most part, these will work on most of the wounds, we have still found that even this isn't enough. And when that happens, we have literally gotten baby diapers and put them on wounds to pull the fluid away. She brings up a really great point in at the height of pandemic when we're scrambling. You know, we're only seeing some of our Unaboot patients once every three weeks. And they're saying gosh I'm draining and I'm like well, you're not infected. But, you know, you're going to have to probably get over to the Walmart and get some diaper technology because, like Julie said, even those lock fluid. This is why kids don't get, you know, diaper rash anymore because, you know, it's not like a wet piece of cloth on their skin and locks it in. So, we had to be creative at the early part of the pandemic, or people don't have good resources. They're without insurance so you want to think about those alternatives. So he's talked about, go ahead. There's just a question about the name of the absorbent pad if you could share that. Yeah, absolutely. We have Opti-Locks, we have dry masses. You know, here. So here's one. And it depends on, you know, your company that you order supplies, they'll have things called extra dry. You know, but this is kind of what we use here. And those would go underneath or over top of the very first layer of whatever wrap you're using. So we also use a three layer wrap which is your cotton, and then your ace wrap, and then the coban. And, you know, that's for an extensive wound where we need more than two layers. So you would put your cotton wrap on and then use whatever absorbing dressing over top of that layer, and then continue on with your layering. In addition to layering, the skin is really important. So the surrounding skin, if it starts to break down, you can use any kind of ointment. You know, like your zinc based products. So any kind of skin prep or barrier cream can always go around a wound where the drainage is breaking down the skin. So this is the three layer wrap system. So, can you take another minute and discuss maybe what you put around the outer part of the wound to keep that moisture from worsening of that maceration. So what are some of those. Yeah, those go to's. Yeah, we see a lot of maceration here and you can use something as simple as a Kevlon spray like you would use for ostomy patients. They come in little pads. It's called skin prep you can surround all the maceration with that. You can use that with any wound. We always use this when we put a wound back on some sort of a skin prep around the skin to prevent the wound from breaking down. If you're not using something adherent like a wound that you can use a cream. And a cream would be something like calmoseptin or a triad we use triad all the time. And our hospital has that it's it's you can use it on bottoms you can use it around venous ulcers diabetic ulcers it's just a really thick white cream. And the nice thing about this one is it's got a little bit of soothing for pain is called dimethicone I think. And, you know, this is really good. And other things that like diabetic wounds or arterial wounds beta dine if you know some of these wounds are necrotic but maybe one portion of its greening. We use beta dine for the same type of thing to dry out the wound and prevent maceration and those are just common steps. Patients can get those at home, even. Yeah, we always do a thorough wound assessment with the surrounding skin before we pick a product. So, um, we've talked about venous wounds, we're going to kind of switch into arterial there gets to be some overlap. I'm going to just briefly kind of show the camera what I've been pulling out of here this is our wound cart. And every room has this. And you can pull a drawer open here it's, you know, stocked with, you know, gobs of things here that they have the tape the measuring stuff, you know, silver nitrate sticks, you know other drawers. Different gauzes and measuring sticks and specimen containers, and then a lot of our ointments and stuff here, like she was just showing you. So I wanted to kind of just briefly show you that because, you know, we're a full time wound center. And so we have to have that in every room, we recognize that, you know, many clinics will not. I worked for 18 years in a vascular surgery office. And, of course, we would see patients before and after operations, some of them of course had the leg wounds. We barely did boots, we didn't have all the nurses trained so that was always a challenge. And most doctors were just using the what to dry God so we didn't have all these things. You're not that you have to have all of it, but, you know, you probably want to kind of pick and choose but you know there's a great variety of things that are about out there. So, why don't we talk a little bit about the arterial wounds and Julie what do you think, do you think arterial wounds tend to be too wide or too dry. Mostly dryer for arterial. The biggest challenge with arterial is the pain. They're very painful. Yeah, we don't put compression on that because of the flow. So how can we help with that, that pain component. So, sometimes we do have the patients use like pain that we can give them a prescription for it we're this clinic, we don't particularly prescribe pain medication. We let the primaries do that and a lot of arterial wounds are looking at your neuro pain meds like gabapentin or Lyrica. Most of them are on something like that position control and dressings are key. The ointments that go around the wounds the beta dynes keeping them dry, trying to keep them from getting infected are what helps the pain the most. Yeah, I have to say that Some books you may read say oh well, you know, venous wounds, you know, may be painful but I think the ischemic arterial ones are really kind of will show itself. You know, like I talked about in the previous slideshow, you know, getting that assessment quickly. You really convinced that you're on the right path, finding your vascular circulation specialist. And sometimes you have to have also a threshold of the patient need to be in the hospital. It really depends on how much tissue loss is there. If it's kind of accelerating or out of control. So you have to kind of keep all those elements in mind. We probably have maybe 15% of our patients are arterial. Different when I was in the vascular world, they're all arterial or some venous. That's because it was already specialized so The other main category we see are the diabetic foot ulcers. We have two podiatrists who come to our wound clinic. Each week on different days. And Julie sees a lot of the diabetic foot ulcer patients with them. Do you want to discuss, you know, some of the elements of wound care for the diabetic foot ulcer. Sure. So when they first come, of course, we always want to know what their blood sugars are because high blood sugars can affect your diabetic wounds. For the most part, they're usually high. Sometimes it's because they have an infection and the infection has made it high, but most of the time it's poor nutritional status. We do ask them to get on some sort of a diabetic program, whether it's with their primary or an endocrinologist, we do touch on that. As far as the wound. These ones also can be very painful. Most of the time they're on the heel or the toe. They always involve mobility. And that's always a problem because offloading is key. You have to have offloading off of these wounds. So whether if they can have a cast on a TCC, we do a lot of those here. However, you know, a patient, usually, you know, if they have got a right foot wound and they drive with the right foot, then of course they can't drive anymore. So sometimes it's a challenge. We, like Dr. Halloran said, have a couple of podiatrists here. They are wonderful as far as figuring out and giving, you know, the very first visit a script to go to our other sister facilities to get either a shoe or a surgical shoe or a cam boot. We've got the nice owl and crow boots, which also are great for offloading. And pre-fold boots, just whatever they need so that there's no pressure on the wound. Most of the, and this kind of overlaps with pressure wounds, but most patients, for some reason, it's not second nature to understand that, you know, if a shoe is rubbing, don't wear the shoe anymore. You kind of have to do teach them that. So as far as wounds, we, same thing, if it's got slough in the wound, then the wounds are debrided. We may have to use a debriding agent, like metahoney or Chantal over, you know, we might put some sort of an alginate if there's drainage on these wounds over top of that agent and we teach them how to do daily dressings. They come back usually weekly. These wounds are hard to heal and hopefully they don't get infected. So I was going to take a minute and show some of the debriding instruments that we use. I guess I'll bring that up. And obviously, scalpel's key. You can get disposable scalpels. We actually, since our wound clinic is physically attached to facilities of the hospital, we use actual scalpel handles, which can go back to get autoclave process with disposable blades. It just clicks on, and then it's got a little guard. But again, some places will have disposables. Another key instrument is the ubiquitous curette, sometimes referred to by our patients as the torture micro ice cream scoop here. But it does a nice job. It's a go-to. My podiatry colleagues have introduced me to what's called the tissue nipper. And this is really great for some of that callous skin. You can just kind of get right up to the edge there. And if you're careful, you can avoid some bleeding. And not uncommon is also the same. Yeah. Anyway, I was going to show a nail clipper, but you all kind of know about that. We're pretty quick to make sure that the nails are addressed, even if that's not the main problem, because we try to want to prevent problems to boot. We're going to move into pressure ulcers, and then quickly on some surgicals. And we'll have a few minutes for some chats. Pressure ulcers. So we see a lot of pressure ulcers here. Mostly your coccyx area, the ischial bones, the trochanter bones. We have a lot of paraplegic, quadriplegic. They come in by stretcher. They may live in a home. They might live at their own home. They might live in a facility. These wounds can get pretty bad. We always focus on protein with them right off the beginning. We rule out infection, of course. You'll see a lot of necrotic tissue in these bones, a lot of slough, or I'm sorry, wounds. And then same thing with offloading. We immediately will address what chair they sit in at home, what bed they have, and then make a referral for a low air loss bed for them. And then we can also order wheelchairs and wheelchair cushions. All of that is addressed the very first visit before we even can decide the wound care. And at that point, we have to get the wound clean and then figure out a product. Products mostly for these wounds, we start out with probably like an Aquacel Silver or any kind of silver ribbon product that will help with drainage. And then your secondary dressings, of course, we like to use a foam product if we can, something that stays in place. It's always usually changed daily. If there's not a lot of drainage for some of the wounds that maybe are not so bad, we could go every other day. And once the wound is clean and granulated, then we have a lot of collagen-based products that we use for pretty much all of our wounds, but pressure ulcers a lot once we get it clean. Great, yeah, so I think the main pressure ulcer that's seen in the foot and ankle world is gonna be that calcaneal heel ulcer. And what do we do if we have that dry black eschar that's just kind of locked on there and doesn't have any bad smell or drainage? Yeah, not hardly anything. We may paint it with Betadine, but I know families sometimes are like, wait, what, we don't do nothing? If it's stable, it's not mushy, not draining, and there's no redness, then yeah, we call it stable. You're right, because the healing's gonna take place underneath there. It's a balancing act and a timing act. And the things that Julie just mentioned, if it's not blank, blank, blank, leave it. What if it is draining, and if it does have some smell, and if there is some redness or increasing pain, then you're probably obligated to debride that heel eschar because you don't want to leave an undrained abscess that could potentially invade into the calcaneal bone. And so we have a threshold. If it's stable, leave it. If it's changing, address it. And so those are really key things for that pressure ulcer that you'll see in the ankle foot world. We're seeing them all over the body because we're a comprehensive wound clinic. So lastly, we got the surgical wounds. We see surgical wounds head to foot, front to back, and even in the foot. So what are some of the keys about the surgical wound that you would want to bring out? Yeah, so sometimes this can get a little scary because a surgical incision can come into the clinic and you can glance at it and it won't look bad. I had a patient yesterday that came in, it was reported, home care said the incision looks great, the family said it looks great, the patient said it looks great. Well, unfortunately during assessment, you are measuring and you're checking to see if anything is there's a depth. Well, I only checked the depth a little bit and the Q-tip went down the foot that long. So these can get kind of scary. This happened to be an amputation of a toe and it was mushy underneath there all the way about six centimeters. So anyway, a dry, perfect surgical incision, you keep it dry, clean and dry. Doctors might order a betadine paint daily and then dry gauze. Anything else, if it starts to get infected, then it's opened up sometimes right here in our clinic. At that point, we call it just filling the dead space. It's just lightly filling anything that's open with something like an alginate or even sometimes a plain packing. So I have a question. If someone's got a foot surgical wound, partly the hist, not a lot of necrotic tissue, they're gonna do some daily dressing changes, but their skin is really starting to kind of be sensitive and breaking down to tape. So what alternatives do we have to taping gauze and ABDs over things? Yeah, so we actually try to always not use any tape. Sometimes you can't get away from it, but we might do a Curlax wrap. We have this awesome, every size possible, it's called Spandagrip and you can get this on Amazon because patients love this and it's stretchy. We just got a new size that'll probably go over abdomen, but there's every size of this and it's wonderful. You can put it over your leg for a light compression. If you don't want any compression, then this, everybody knows what this is from hospitals. It's like spandex or spandage. And this one's not as firm as the, we call this 2B grip. So that's great for any wound to help keep it in place. Super. I was gonna look at our chat box for a second here. Well, several chats. Multi-layer dressings, is there a reason why you would choose zinc or calamine? Oh, that's such a good question because it comes up every week. Your thoughts? Zinc and calamine. So the calamine has calamine in it and it helps a lot of patients do complain of itching with these. And so in preparation to prevent that, we always put like an Aquaphor ointment on quite liberally on dry skin. But for those patients that have a lot of itching, the calamine, you're always gonna choose that one. Some people, the zinc starts to create the dermatitis. So then we have to be able to switch midstream also. So it's nice to have a couple options for your patients here. The next one's on Penn site care. We would only see that if there was breakdown any problem. However, I know a lot about it. I don't know if you do. But yeah, that would be a daily, sometimes twice a day, especially for a new one. Tell the patients anytime there's like a crust on there, you need to take a Q-tip, a little soap and water, wash around that, and then put a new split gauze every day, minimum. So you're talking like a zero form type gauze? No, we're talking like a split two by two. Okay, like a drain gauze. Four by four, yeah. Drainage sponge, yeah. Drainage sponge, okay. What about like an ointment, like a, aren't there some good ointments? Yeah, I mean, in the beginning, if it was broke down, you might use an antibiotic ointment, but not really. You just wanna keep it clean and dry. So what is the name of the wound product for surgical wounds? The wound product. I don't understand. Like if you're packing a surgical wound that de-hissed? Well, maybe. Well, maybe there was refractive, some of the alginates. Yeah, we use AquaCell silver or calcium alginate with silver. If you don't need silver, you can just use any alginate. It's just really nice. It lays in the bed of the wound. It turns to a gel with the drainage. And the next day or two days later, alginates are made to last a couple of days. So it will come out of the wound bed. It'll be nice and gelled and come out easily. So one more question, then we'll go back. Is there any role for Bactroban ointments? And oftentimes people already come to us and they've been on Bactroban for the last eight weeks. So we've kind of stopped it if it's been going on that long and there's no improvement. If they've really been on nothing and it's really a kind of a slight surface breakdown, I'm okay with pretty much any of the over-the-counter antibacterials of a Neosporin or Bacitracin or triple antibiotic. I believe Bactroban is more prescription. So if people are looking to minimize their out-of-pocket costs, we may just go over-the-counter. So I think we're at this time stage where we'd want to wrap up the breakout session. Is that true, Lauren? No, I think that we're gonna stay here for any more questions. So since there seems to be some discussion, we can continue questions here. We're starting the next session at 1130 Central. So if you guys want to stick around and then once we get to the end of this, we'll have a little break before the next session starts. We have a couple other questions we missed. Well, we have handouts, a PowerPoint of the products. Not specifically, but... Where'd that one, the listing of all the different products go? So that's our company. We have a grouping, like products that we get through our company that we order for patients. And there's so many products that are under just the word alginate. You can get an unbelievable amount of things. So it's kind of hard to just say one product because the billing for an alginate is gonna be the same as it is for a Drymax or an OptiLock. So I'm gonna go ahead and show this a little closer and give you the website. And there is an email address, but this is a company called Advanced Tissue. They are not Michigan-based, we're in Ann Arbor. They list their address as Little Rock, Arkansas. Their website is www.a as in Apple, D as in David, V as in Victor, T as in Thomas, I and S.com. So A-D-V-T-I-S.com. And their email address is info at A-D-V-T-I-S.com. I think if you were to email them, what you may be able to do is just get this digitally or faxed over. And like Julie said, it lists the different categories with the different products and vendors, the different sizes. This is basically kind of our little wound Bible for our nursing staff when we're trying to figure out what to order and get delivered to patients. So every product pretty much that we've discussed today is in this. So it's not St. Joe Trinity. It's again, probably available if not already publicly on their website, they could share it with you because they probably like, hey, someone hears about us. What we like about it, it really does categorize things. And you'd be kind of surprised how many different adhesive foams there are. Of course, some of them are made by different companies. And so, but again, maybe it depends on what your particular center is already contracted for, but. It will also tell you right on here under your category that like these particular foams is they're for moderate to heavy drainage. And then these hydrocolloids are for low to moderate drainage. I mean, there's just so much out there that that is very helpful. I'm gonna go ahead and type in the email address just to let you guys know here. While you're doing that, I'm gonna, one of the questions is, do we have any experience with Metholex? Yeah, it's one of our favorite foam dressings because it's got a silicone border. The whole thing is silicone. That's also listed in our product list here. The thing with Metholex is you, insurance will pay for three a week. So, you put that product on, you really want it to last for a couple of days. We here, if we've got a wound that we can use the Metholex on, but maybe it drains a little bit more and gets the dressing a little more wet. And because it's silicone, if the silicone's right on the skin, of course you're gonna have that bandaid effect where it's gonna macerate. We will put like a dry gauze in between it, like maybe just a two by two, and that will take care of it. So, we might put a dab of Meta Honey, might put the two by two and a Metholex, and then that's good for three time a week dressing change. What's really nice is I don't know if you've heard of something called Excel Sap. It is the exact same thing as a Metholex, except for whatever reason, the insurance companies will pay for that one every day. So, if you did have a smaller wound or even a larger, cause it comes large, if you use what's called an Excel Sap, you can get the insurance to pay for that on a daily basis. But yeah, great question, we love that. Ah. IotaZorb, many insurances don't cover it, it's out of pocket. You don't really use much, do you? Yeah, we use just the Iota form packing. We don't use that a lot unless we have a wound that smells. So, in that case, we may, you might prescribe like a Dakin solution or acetic acid, and we pack the wound with a plain packing and use that instead. I wasn't aware of the insurance part of that. Another question was, when would you use the silver with the alginate? And again, the silver is to combat your microbes, your bacteria. So, if you've already addressed that through your debriding and prior treatment with either topical or systemic antimicrobials, and it's just a colonized, contaminated wound without active infection, then you can just go to calcium alginates, which will be cheaper. So, that's how we kind of address it there. So, it sounds like the other room is done. So, we're gonna go back to the main room now, but we can continue answering questions there if, just because I guess the other room is stuck in their breakout room until we're done. So, we'll go back to the main room if there are any more questions, we can answer them there. Okay.

nurse

Julianne Miller

wound care

venous wounds

arterial wounds

diabetic wounds

pressure wounds