By Michael Miller DO, FACOS, FAPWCA
RAMBLINGS OF AN ITINERANT WOUND CARE GUY, PT. 9
One of the most obvious things about being a health care professional is that our goal is to help people get better. The concepts of an ill patient saying to me, "Dr. Miller, I don't want to get better or worse, can you do something to keep me in this condition?" Seems ludicrous and more, improbable. I could not imagine any health care professional being successful if patients remained in the exact same condition weeks after treatment. As I have said in previous blogs, I recognize that while there are many variations on the definition of "better", I think it's safe to say that "better" means improved in some way, shape, or form.
I prefer to keep my wound care simplistic. To my mind, there are three things a wound can do: get better, worse, or stay the same. As a health care professional and wound care specialist, at least one of these three is clearly at odds with my Hippocratic oath and thus untenable. The last of the three may occur but only rarely can I imagine it as a treatment goal and certainly not in the wound care arena. And so, getting a wound to improve is the clear, unmitigated, definitive goal of treatment. If you are not in complete agreement with all of the above, then stop reading now because what follows will make no sense to you. My goal in writing this blog has always been to take on issues and concepts and try to offer simple, lucid, logical arguments to support the point(s) that I want you, the reader, to consider and adopt.
At this point, I want to advise you that I will be digressing from my usual diatribes on political and social issues and take on a definitive wound care issue, namely the use of Dakin's solution in wound care. I must confess to you that my rationale for doing so is that I have recently seen a spate of wound care cases from some very prestigious and nationally recognized facilities in my area whose treatments consisted solely of daily to twice a day Dakin's wet-to-dry dressing changes as the only treatment for the patients whose wounds have not only persisted, but worsened over a period of months with clear documentation of these findings! I will not attempt to impress you with the descriptions of the results of these treatments on these patients whose overall appearance morbidly causes me to describe them as human Swiss cheese. On the "attagirl" side, I work with an extraordinarily skilled, knowledgeable, and compassionate home health care nurse who is now forbidden from contacting the largest and most prestigious burn care center in my area even to update them on their patient's care, for telling them (after receiving yet another patient being treated with Dakin's solution) that their care was substandard, unethical and "primitive".
Recognizing that there is a huge amount of controversy concerning what things define efficacy, and recognizing that science is in a constant state of flux (presumably in the positive, beneficial direction), then the support for any treatment can be divided into three basic categories:
(1) What is logical?; (2) What is based on experience ?; and (3) What is scientifically proven? If you are aware of another category, please let me know.
Let's take on the logical first. Dr. George Roedeheaver's statement regarding "Never put anything into a wound you would not put into your own eye" has always been one of the most basic and fundamental tenets of my wound care practice. Recognizing that due to evolution, our eyes have become the most significant source of sensory input and hence are unquestionably in need of constant protection, one need not be Albert Einstein to recognize that putting stuff into your eye that makes it hurt is a bad idea. The consideration of benefit versus detriment has led me to add my own corollary namely "Wound care products should be edible". I am not saying they should be palatable nor am I encouraging you to supplement your diet with huge mouthfuls of calcium alginate or the latest honey-based products (which taste nothing like my favorite SUE BEE honey). It just makes simple, logical sense that if you suffer no toxic effects when putting something in your mouth (or in your eye), then that product has the highest likelihood of not being detrimental. I believe I can safely assume that none of you has any interest in ingesting any amount of Dakin's solution.
One concept that is overlooked by zealous Dakinites is that for any given wound, at a given time and place with a given treatment, some wounds will heal. We are all aware that merely attending to a wound using simple means improves healing outcomes compared to doing absolutely nothing. Most wound care practitioners also fail to realize (time for the tongue in cheek statement) that for better or worse, there are a multitude of companies whose goal is to make a profit and to do so, they must identify, manufacture, and sell products that are potentially beneficial and have the highest benefit to risk ratio. Products that help heal wounds not only get produced, but also get duplicated in various forms. Can any of you name all of the companies that not just produce, but also the names of all the incarnations of calcium alginates, foams, collagens, and negative pressure systems? And yet there is only a single company producing Dakin's solution. If indeed this product unquestionably helps wounds to heal then why has there been no effort by reputable companies to not only produce Dakin's solution, but perhaps combine it with one of their own unique offerings? It is clearly easy and inexpensive to produce and so the potential for enormous profit should be self-evident. Has Convatec never considered creating Daki-Derm? Will Derma Sciences push the envelope by proudly announcing the introduction of Medi-Daki-Honey? Looking at Dakin's solution through the most "profit-colored" glasses unquestionably shows that in the eyes of the wound care and general chemical manufacturing audience, interest in its sale seems to fall well below having Two Live Crew perform at an AARP convention. If Dakin's solution works so well, why does just a single company manufacture it?
Regarding the experiential consideration, truly experienced wound care specialists and others who have treated wounds for a long time will humorously and embarrassingly recall the use of heat lamps, sugar, milk of magnesia, and aggressive peri-bedsore massage with lotions with successful healing of many open wounds. As a teenage, nursing home orderly (well before the concepts of CNA or CMA were invented) working in a Bucks County, Pennsylvania long-term, indigent care facility in the 1970s, I have clear memories of performing these and other inconceivable treatments on my patients with equally clear memories of many wounds healed. As of this date, I have yet to encounter any of these "treatments" still being perpetrated on patients. And so the arguments of "I've always done it that way", or "I've used Dakin's for many years and it healed a lot of wounds no one else could", or the more common "We only use it for a little while to clean the wound", are essentially indefensible, pitiful excuses which in my mind identify the user as unscientific, uninspired, and unimaginative...in other words, a Wound Care Dabbler.
Lastly, we can talk about scientific evidence. One cannot truly count the number of research studies considered, initiated, and completed trying to identify why wounds fail to heal and what things help wounds heal. I think it is safe to say that within the continuum ranging from absolute, total product failure to the opposite end of total, unquestionable, universal product success, the results of testing the efficacy of all products fall somewhere in the middle. Moreover, that at any given time or place, their success moves a little bit in one direction or the other along this continuum. And so I offer the simplistic but irrefutable concept that regardless of the quality of the scientific research, everything and anything that could conceivably be put in a wound to promote healing will in fact at one time or another demonstrate wound healing (including Froot Loops). I always laugh when I hear of the wound care clinic manager who refuses to allow a pitiable wound care rep access to their precious staff to entice them with yet another silver product or negative pressure system without the rep producing voluminous and meaningless "White Papers", case studies done by "only people who we know and respect", or the always laughable request for the names of, "other major US Hospitals or Universities currently using your product exclusively who have medical staff's greater than 1000, who are at least level II trauma centers, have at least 15 active residency and/or fellowship programs, and have done over 10,000 successful cases with your product". These wound care equivalents of a bar bouncer will, at the same time purposefully avoid taking the same requested information if at first blush, it takes them out of their comfort zone and forces them to consider that there may be other potentially viable, and "better" alternatives. They bristle against information that forces them to recognize that regardless of the science, logic, and their experiences, that what they're doing is at best, questionable and at worst, detrimental. And so at the risk of rattling a few cages, bruising a few egos, and forcing you to conceive of what was previously inconceivable, I offer the following:
Using Google and Medline, I did what I consider a reasonably extensive search for all articles in which Dakin's solution is mentioned. Further, I looked for those that used the terms Dakin's solution and wound care together. There is a fairly extensive number of Internet articles regarding Dakin's solution. The overwhelming majority are either single case studies or "how to" sites. Interestingly, these "how to" sites rarely offered any scientific documentation or citations to support their recommendations and the overwhelming majority were written by laymen.
Nonetheless, I was able to find sites that appeared to have some scientific and historical basis that appeared uniform and consistent (recognizing that these may have gleaned information from each other and not from exclusive, independent sources).
With respect to Dakin's solution, the term "Full Strength" refers to the highest concentration of sodium hypochlorite tolerable to the skin, which is 0.50%. As a result, a solution containing sodium hypochlorite 0.50% is known in the industry as "Full Strength". Likewise, "Half Strength" contains sodium hypochlorite 0.25%, and "Quarter Strength" contains 0.125%. Shortly after its invention by Dr. Dakin for use as an antiseptic on battlefield wounds (recognizing that the other treatments available at that time included mercury, carbolic acid and bloodletting), experiments by Daufresne showed that below 0.45%, the solution is insufficiently active as a bacteriacide, while above 0.50%, it is irritating to the tissues, evidence that has never been definitively refuted. Recognizing that the skin's function is to protect the delicate internal environment from the harsh extra environment; need I say more regarding its effects on exposed tissue? The basis for its use in the earliest literature repeatedly identifies the need for "sterilization" of the wound; a concept that we can safely say is nonexistent. Recognizing that air, exposure to light, factors regarding the ingredients used, and longevity of the final solution all affect the concentration, the odds of your specific solution being in that .05% range between potentially beneficial and definitively detrimental is a fairly large gamble.
An exhaustive review of the literature provides little to no randomized studies (blinded or otherwise) demonstrating evidence of any ongoing and reproducible benefits. A recent study in 2011 from Turkey on Fournier's gangrene treatment suggested benefits of Dakin's when compared to povidone-iodine as the only two treatments offered. Even the sole manufacturer's website's most recent article cited that remotely suggested any benefit in wound healing (and in the home care setting only) was from 2004. The company's proffered literature review in support of other benefits of their product dates from 1997.
To those of you who would still consider the use of Dakin's solution for wound care, despite what I believe is overwhelming and irrefutable evidence of no appreciable benefit (and thus only risk), I respectfully request that you send me the address of your wound care clinic to be published in my blog so that evidence-based, patient care-centered, wound care clinicians in your area will know where their newest patients will be coming from. For those of you who also still use Unna boots to treat venous disease, repeatedly debride venous ulcers, swab culture wounds or slather your wounds with topical Gentamycin, you can expect CMS to want to chat with you in the near future regarding your cost/outcome ratio.
Until the next time we ramble together…
About The Author
Michael Miller DO, FACOS, FAPWCA is the Founder and Medical Director of The Wound Healing Centers of Indiana and IndyLymphedema, as well as a clinical consultant, teacher, inventor, and published author.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.