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The latest advice on wound management

From telemedicine to tilapia, what technologies and techniques are advancing wound healing?

22 November 2019, at 11:54am

Georgie Hollis, founder of the Veterinary Wound Library, is passionate about wound management. She is an independent expert on healing and lectures across the UK and abroad in the small animal and equine fields. I asked Georgie about her thoughts on the latest advancements in veterinary wound care.

Can you see telemedicine being widely used in wound management?

Telemedicine from the Vet Wound Library point of view is vet-to-vet; we don’t do any client-to-vet. We provide a service where member vets and nurses are able to get help for a case when they have seen a patient and would like to know what to do. It’s very much a supportive role from start to finish.

Telemedicine sounds high tech, but it’s something that everybody is doing anyway – they’re using Google or ringing up the specialists informally. In that situation, it’s the people that dare to ask that get the answers. By providing a formal service, we standardise the help we give, but can also collate data that will help others in future.

Helping clinicians via telemedicine is just a relay to those who know the answers, and a means of giving people per-mission to ask. Our feedback tells us that through assisting with early decision making, we build their confidence and help reduce healing times and cost of care. At the end of the day, it’s about animal welfare and we want to do all we can to help everyone get the best possible outcome.

Is there any space for vet-to-client telemedicine in wound management cases?

I think it is inevitably going to happen to one extent or another. In terms of wound care, there is poor legislation on what can be used, so really anyone could set up an advisory service and recommend and supply products that may not meet VMD standards. This is particularly frustrating when cases require a multidisciplinary approach, where surgical repair is the most viable (and cost-effective) option, and where a whole range of factors and differential diagnoses may be responsible for persistent or chronic wounds.

In terms of client perceptions, it is unfortunate that many wounds can be costly to manage and Dr Facebook, home remedies, creams and potions may be used well before veterinary attention is sought. Confirmation bias tends to be an issue as many wounds will heal anyway; that’s why we developed the wound library – to support cases and capture the best practice outcomes to find out the most cost-effective routes to closure in the fastest time.

How can we prevent owners from trying to treat wounds themselves?

Sometimes people make up their own potions because they’ve read about it – that’s very much demonstrated with horse owners, who tend to share their favoured methods readily in the equine arena. We need to remind people that just because they invented it themselves, doesn’t mean it’s safe. I’ve often said that arsenic is natural, but is not something I want in my tea. Unfortunately, there is little to stop a company incorporating their favoured plant oils into a product and claiming natural benefits.

The VMD, which oversees the products used in this way, has its hands tied by its own rules. A CE mark (used to guarantee quality, safety and conformity) is used to validate wound products and medical devices for use in human healthcare. But in the veterinary sector, it isn’t required for wound dressings. So you can literally fill a tube with margarine and promote it as aiding healing by preventing moisture evaporation while soothing the area. Its components don’t need to be declared in full. This is something I find deeply troubling.

Remember the uproar of the images of rabbits being used to test cosmetics? Yet those who happily experiment with highly sensitising essential oils (tea tree oil, for one) faithfully believe it to aid healing. It comes down to marketing and regulation.

The case is similar with medical devices that claim to influence physiological function positively with anecdotal data. It’s almost unbelievable that something with a plug on the end can be used on our pets with little or no regular calibration tests, safety testing or service plans. Unfortunately, it’s not only clients who fall for these products that claim to achieve wonders. They are rife in the veterinary world.

What is the one common practice in managing wounds that you would change?

Use of chlorhexidine! There is huge variation in the concentration and use of chlorhexidine and other antiseptics. It seems that people often confuse Hibiscrub and Hibitane, using them interchangeably when they are intended for different purposes and at specific dilutions. Approximating measures of antiseptics should be the new taboo.

I’ve caused a bit of a stir recently after I found out that the manufacturers of Hibiscrub are adamant that Hibiscrub (4 percent) is intended for use neat. That doesn’t happen in veterinary practice. A lot of people mix 50:50 and although as long as the contact time is sufficient that may be OK, there is a significant risk of resistance to Hibiscrub at levels less than 3 percent. I believe that new guidance needs to be set up for veterinary use.

Where could nurses be doing more in wound management?

Everywhere but surgery. Most of the tasks that are involved with wound management are best done by the vet nurse. We talk about “prepare, promote and protect” when we’re teaching. Prepare means getting the patient ready: admitting the patient, evaluating the wound, history taking, liaising with the client and preparing the wound so it is clean. That’s something nurses do really well. Good wound care is all about timing and having a vet nurse take responsibility for continuity of care and monitoring of the wound means that progress (or lack of it) can be acted upon quickly. In many of the wounds we assist with, we find that we are coaching through the phases of healing and once that wound gets to two weeks old and it’s granulating well, it is time to pass the case back to the surgeon for a decision on whether to close or continue with open wound management.

A large number of cases we see have been managed for many weeks, sometimes due to constraints on funding. Dressing it may be considered less costly than surgery. These are the cases we love to help early as we can often assist with decision making and nursing advice, helping clinicians to work well as a team and learn as they do. These cases that tend to be managed open for six weeks or more just to see how far the wound will close are the ones we find may have missed an opportunity to close earlier in the healing process.

Nurses are vital and really help the decision making: they help to choose the right wound dressings, enable continuity of care and play a huge role in education and encouraging client compliance to help avoid healing delay.

Do you have any advice for vets on how to get nurses more involved?

Nominate a wound nurse in the practice. If someone’s keen, whenever a wound case comes in, make sure they get a tap on the shoulder and they get to watch what happens. The nurses aren’t going to take the surgeon’s job away; they’re just going to make the outcomes a lot better.

What’s your opinion on manuka honey?

Ten years ago, I would ask if anybody used honey and one hand would go up. Now, everybody uses it and I’m trying to stop people using it on everything. Honey should only be used for the inflammatory stage of healing. It helps to clean the wound up and reduce bio-burn (bacteria and debris). Once the wound is granulating and it’s got a wound bed in it, the properties of honey can be detrimental because it’s quite acidic and has a high sugar content, which we’ve seen anecdotally can cause overgranulation. My tips are that it’s the yellow stuff for yellow wounds and clear for clean.

Do you have any recommendations for reducing antibiotic use in wound management?

Yes – wash it! We did about 200 audits as part of a wound course we ran from 2014 to 2018 and one of the key things that people didn’t do was wash wounds enough. They didn’t use enough volume and they didn’t use the right solution. People would use a small solution of chlorhexidine as opposed to a large volume of lavage. It’s volume of solution that’s really important. For every hour earlier you wash a wound, you reduce the bacterial load by half. If the owner can’t get to you for six hours, wash the wound with warm water under a shower if it’s safe to do so.

There have been several instances of tilapia fish skin being used for wound management in the press. What are your thoughts on that method?

Tilapia skin has been used quite widely now and is often seen as a miracle product on the internet. It has been used in the UK a fair bit too, and the press loves these cases. It is quite a pretty skin, after all. But I feel it can be used more for show than as a miracle cure. It is just a xenograft – a collagen-rich substitute for skin that will be tolerated for long enough for the healing process to occur beneath. It’s waterproof, of course – that is handy – but it really is a technique that has been used for decades in many other forms.

It is a biological dressing and not a substitute for functional skin that patients may be able to supply in abundance themselves. Tilapia does have its place but its properties are not so unique; in fact, I’ve often joked that sausage skins could be used in the same way, given a similar preparation process to make them sterile. Wound care is a fascinating area; you never know what is going to be on the market next!

Senior Editor at Veterinary Practice

Jennifer Parker, BSc, PgDip, MSc, is a science writer and editor. She studied zoology, endangered species re-covery and palaeoanthropology in the UK. Jennifer was Senior Editor of Veterinary Practice magazine for almost three years; she left the publication in October 2019 to move abroad and pursue a freelance writing career.

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