BOOK REVIEW
Dr. Athula Withanage’s latest book on ‘Wound Care and Management’, the only book ever published in Sri Lanka on wound care management so far gives an insight into modern concepts of wound care, and up to date account of wound management. It will help every medical student, Junior doctor, nurse practitioner, wound care specialist at various levels of education.
The author believes that it will be a handy book to have a copy of this book in all the wound care departments in hospitals as it contains essential information without burdening the medical student and all healthcare practitioners. The information in this book will also help to have a unified and consistent approach in treating wounds, which will open doors to local research.
Wound care and management
‘Wound Care and Management’ comprises 17 chapters. It encompasses Principles of wound care; Normal wound healing; Factors affecting wound healing; Different types of wounds and ulcers; Wound assessment; Wound infection and its management; Modern concepts of wound healing; Management of painful wounds; Basic concepts of a wound dressing. How to choose an appropriate wound dressing; Advanced wound dressing technique; Wound closure; New biological methods available for promoting wound healing; Selection of wound dressing for chronic ulcers; Standard precautions in wound care and Economic usage of dressings and affordability.
The author endorses not to cause harm to a healing wound and to the peri-wound skin in treating a wound, but to adopt a holistic approach to wound management by paying attention to a patient’s overall condition and social background.
Dr. Withanage wishes to update his manuscript in the future with the assistance of his colleagues in the medical field incorporating modern research and developments. He expects to receive any suggestions for improvement of future editions of the book. Anyone who wishes to contact the author may do so by writing to him at: althulawithanage@hotmail.co.uk.
Healing process
Healing of a wound means the replacement of dead tissues in the body. It is a mechanism through which the body repairs and restores the damaged tissue; it is a complex interaction of physical, chemical, and cellular events and helps the patient to maintain a quality of life.
Dr. Withanage believes that it is essential to understand the healing process especially at its various stages, if the wounds are to be assessed appropriately and to have planned management of a wound. The author discusses the vital elements in selecting the correct dressing for every stage of wound healing.
The old concept of encouraging the ‘drying up’ method with scab formation is discouraged; instead, the modern concept of novel methods by retaining appropriate moisture in a wound is encouraged. A process of natural healing achieves by maintaining a warm, moist and nontoxic environment, the aim of which would be not to harm the peri-wound tissues by using safe, simple, cost-effective, non-irritant, non-allergenic dressings and treatments. In wound dressing traumatising of new tissue is discouraged in changing of dressings.
Moist wound healing
Zoologist George Winter introduced the modern concept of ‘moist wound healing’ in 1962. In a study published in the Nature Magazine, he demonstrated that epithelialisation (successful wound closure) occurred twice as faster in most wounds compared with wounds that were kept dry (with a large dry scab). George Winter suggested that moist wound healing may not be appropriate for some wounds as a necrotic digit (dead tissue) in diabetes.
Treatment of wounds is a multimillion-dollar industry. New dressing techniques are mushrooming daily. The latest technology comes up in the form of various gels, maggots’ therapy (Larva farms), vacuum suction therapy, all of which are costly. If a doctor does not use the basics, then it boils down to ‘taking the patient for a ride’ by him, because it is impossible to apply any sophisticated methods to any wound, states the author.
Choosing a wound dressing needs to be carried out based on common wound characteristics. The modern concept of wound healing is by keeping the dressings appropriately moisture retentive. The author advises how important it is to determine whether the wound is acute, chronic or at what stage of healing, and the level of exudate (the fluid that seeps out of blood vessels or an organ). Even ‘washing of a wound with cold water delays the healing process!’
The days of slapping in Betadine to any wound is over and must end, suggests the author because it is cruel, painful and burns to no end. “The usage of Betadine alone for any stage of wound healing has been overused and misused.” The usage of Betadine causes a delay in the healing of a wound with considerable pain to the patient. The author observes that he experienced bilateral varicose ulcers being dressed on a patient for two years with Betadine soaked gauze, yet the wound did not heal, and the patient required narcotic analgesia. Later, by substituting the dressing to hydrocolloid gel the pain subsided and varicose veins surgery was performed; the wound healed within six weeks.
Moist wound healing
Dr Athula Withanage adopted the latest method of moist wound healing to treat a female patient of 88 years of age, when the patient was suffering immensely and completely bedridden, ostracised by her own family and was in an Older People’s Home. He described the wound as completely ‘hopeless‘ and it emanated a nasty odour. These facts, probably made her family members ostracise her and did not even bother to visit her in the Older People’s Home! The patient needed both psychological healing as much as wound management. Dr Athula Withanage undertook to treat her free of charge, under their family trust – Piyaseeli Withanage Charitable Trust.
Piyaseeli Withanage is a Family Trust established by Withanage family members to transfer merit to their deceased parents and his late brother, Bandula Withanage. During the treatment, the only person who visited the hospital to see her condition was only the Director of the older people’s home. Finally, upon the patient’s full recovery, the Director of the Older Peoples’ home contacted a relative in the USA, which made her son visit her in Sri Lanka and accompany his mother to the USA for good.
Types of dressing
Semi-Permeable film dressings allow the wounds to breathe and give access to water vapour and air. With such dressings, patients could have a shower without contaminating the wound. Absorbent dressings on a wound are recommended where slight ooze of blood or uninfected exudate is expected.
Hydrocolloids are the modern dressings developed since George Winter’s concept of modern wound care for lightly secreting wounds. Hydrogels are always applied with a gel retaining as a secondary dressing. It can absorb a substantial amount of fluid via hydrogen bonding.
Medical grade honey is prepared after a filtration process of impurities, gamma radiated and produced under sterile hygienic conditions. It is a potent antibacterial agent, thus can be used in infected wounds. It has to be undiluted to retain its antibacterial property. It needs to be used moderately on oozing wounds because excessive exudate dilutes the honey. In the case of diabetics, it can be used with blood sugar monitoring.
Vac Therapy is a method of sealed surface wound suction using a suction pump. Vac Therapy uses when exudate is so excessive and cannot be handled by any other method of dressing.
Maggots or Medi-flys are sterile larvae hatched from eggs laid by laboratory-reared flies. Maggots produce powerful proteolytic enzymes that break down slough and necrotic tissues, and many maggots ingest bacteria. Maggots are known as the world’s ‘smallest surgeons‘ among medics.
Older people over the age of 65 with 70% of leg ulcers suffer due to venous disease. The author advises it is vital to explain to patients about the development of venous hypertension, and to advise and encourage them to wear support stockings, and also to raise legs when sedentary.
Dr Athula Withanage is a basic surgical trainer for doctors from all over the world. He has been training young doctors for over 25 years as a Faculty Member for Royal College of Surgeons in England and Welsh Institute of Minimal Access Therapy WIMAT in Cardiff. He is also an Honorary Clinical Tutor for Cardiff University. Presently he is attached to the Kotelawela Defence University as a Clinical Supervisor, Educational Supervisor and Examiner. On completion of his 50 years of Service to the Public & National Health Service (UK) and 25 years of Surgical Skill Training at the Royal Society of Surgeons (UK), the book authored by him on ‘Wound Care and Management’ has just been released.
Dr Athula Withanage is a versatile character whose part-time hobby is writing books to relax after a tiresome day in the operating theatre. He has published several novels, in Sinhala and English. His medical thriller, ‘Within a Capsule’, discusses the limited time factor when a surgeon has to grapple with brain surgery. The text is written as fiction but with a mixture of murder, romance, bribery, and medical ethics surrounding some of the ‘unorthodox‘ experiments on human beings. Although, ‘Within a Capsule’, creates inspiration, yet it deals with a serious vital medical opinion to examine whether the human brain could be made to survive death on ‘near-death’ patients.
Picture credit: Dr. Athula Withanage
