So, without ado, I don't want to waste everybody's evening, I appreciate everybody for showing up tonight. I'm sorry my camera's weird. We had a death in the family and I'm currently at my mother's house in her weird computer room with a weird lighting. So normally I'd be a little different visually, but my name is Jason Biener. I'm a consultant for the ORN, the Opioid Resource Network, and we'll get into that in a minute with the slides. I currently, I work for Johns Hopkins Bloomberg School of Public Health as a senior research nurse, I think is my title, but basically I'm in the back of an RV in Baltimore City doing wound care for folks with substance use issues, like literally low, no barrier. I only need a first name. And it's with little medical oversight. It's just my experience. Prior to working for them, I've been doing that for a year, year and a half. Prior to that, I also worked for a nonprofit, a recovery community organization. Everybody was in recovery, but me, in rural Maryland. That was kind of on the water, the mouth of the Chesapeake Bay, the starting point. And with a huge opioid problem, think West Virginia, but in Maryland, it was the same setup. A couple of pill mill doctors, an hour away from Philadelphia, people go up to Kensington. They won't cross over the Susquehanna River for whatever reason, the river stops drug use crossing. But everybody in the county went up to Philly, Philly has xylosine, xylosine was unheard of. We knew what the word was, but we didn't know it was in the drug supply. And we started drug checking. We started finding it. And I was kind of alone during COVID. So the four years that I was there, I figured out how to heal these stupid wounds in a very frugal way, and how to use, because I was the only nurse working at this organization, how to use simple resources to kind of pull it all together. During that time, I got some attention, and that's where Hopkins found me. But luckily, so did Kelly Bryant, the nurse that put together the project that the wound care portion you're seeing. She was part of this, pulled me into it, and we kind of developed the program I'm about to share. When I share, I can't see anybody. So if anybody has any questions, this is a small group. Please just speak up. Just say, Jason, I have a question. Don't feel bad interrupting. I'm not a picky person. This is about sharing what participants have had. The main purpose of this is what was put together for really non-medical staff. And it's a way to introduce you to like wound first aid, changing the term from wound care to first aid is actually kind of important. We found that out legally, that first aid is something anyone can provide. Wound care is somewhat more explicit for advanced things. Even with my wound care certification, they are, my board of nursing is like, you can only do like minimal dressings, put on like gauze and, you know, a gauze pad and roll it up. It has to be exactly per label. So we figured out that providing first aid for these folks, what you would do for a child that skins their knee, you know, a nurse can put on a bandaid, you know, as a nurse working in the public health sector, we do a lot of stuff that's kind of off label. I'm sure everyone on this call does. You're with limited means. You do the best you can do. You don't let someone hurt or need. So that's my background. I have critical care and emergency care and all kinds of other stuff as a nurse, but all of it kind of combines to why I'm here today. So this is the little blurb. You got it last time if you were part of Fernando's presentation. The ORN is a SAMHSA funded, I'm not going to read it out to you, but it's a SAMHSA funded project. It covers the country. The ORN is a really good organization to utilize because it's free. It's free for everybody. It's covered with federal money and it's all kinds of support. It's just not, you know, wound care or for SSPs. It's anything dealing with the opioid epidemic and that also includes stimulant use. They're starting to bundle that together, which is really important. We all know that it kind of goes hand in hand. The community I was in, there was probably pound for pound, the same amount of meth use as opioids. But this is a technical assistance that can help out with a lot of stuff. That's the blurb. We don't have to talk about it or we don't continue on with it. Anyone can request it. You just go to the opioid response network. There's a little submit a request. I just heard one today put in for grief, like after someone passes, like how to cope with end of life, with substance use issues, with family. So it covers everything. And if they don't have it, they can find somebody. There's the website. There's the email and the phone number. So the goals of this training, it's really, I already kind of went over it, differentiate between healthy wounds and wounds that require treatment. It's kind of like, ooh, that's gross or ooh, that looks okay. Demonstrate basic wound care using a wound care kit. We don't go into, we go into specifics, but I'm not a brand name nurse. I'm a frugal nurse. I believe in having ownership of our finances and stuff. It's not infinite. We need to really be a good steward of resources. So yeah, I'm a cheap wound care nurse. And then discuss harm reduction strategies to reduce the risk of wounds. So this is where it started. Columbia University, that nurse I was talking about, she's a nurse practitioner. They kind of came around and said that there's a lot of people with wounds and like, well, how many people? They didn't know. So they literally got together a table, some nurse practitioner students. Kelly was the director of admissions for the nurse practitioners. And she had a big heart for substance use in our community. So they kind of, this was a criteria. Who did drugs? They gave him a $10 gift card and a simple wound care kit. And they really didn't think anybody would show up. She was using the nurse practitioner students to do the wound assessment. So it kind of benefited everybody. It was like a synergistic deal. And they use like motivational interviewing and stuff like that. And like some of the brief negotiated interview stuff to really navigate people to get medical treatment. And this is it. I've done more of these presentations where people like, I know exactly where that is. Apparently Burger King is behind us, apparently. But they did 591 people and 23% had one or more wounds. And this is what people were sharing. I have a weird feeling that this is kind of low, just based on self-reporting. It wasn't based on evaluation of the body. This is what people said they had. And if they wanted to share, they would show it. And you see the heroin and stimulant use is really close to each other. And that's kind of the same, whether it be crack and cocaine or methamphetamine. This is just a breakdown of where the wounds were found. This kind of screams to the xylosine thing. If you look at the percents, hands and arms, that's where we think most folks have wounds and legs. Not so much the back of the leg, but the trunk area, not so much at all. The head, not so much, and the neck and face area, not so much, genitals, not so much either. This is very indicative of xylosine. They didn't know xylosine was in the area. At this point, the New York crew didn't really know much about it. And to this day, even, it varies wildly in New York City from block to block, the drug supply. And that's through drug checking and everything. When we first came out with this, we decided to start really simple. We simplified the idea of what skin is. Skin has multiple layers. The outside is the epidermis. The dermis is a middle layer with all the chunky stuff. And the hypodermis is where you got to go down for the blood vessels and the fat. Your sweat glands and that kind of stuff are all kind of bundled in there. That's the base of your hair follicles and everything else. If you think about the wounds you've seen, they're either an abscess or cellulitis. An abscess is an infected pocket inside of those layers. A cellulitis is infection in between the cells, and we'll show pictures later. And then xylosine is really unique. To this day, they don't know why xylosine wounds occur, but if you look at this picture, xylosine wounds go all the way through, but they end abruptly. This area, if you put this into a wound bed that someone had a wound from xylosine, it could almost square out the edges. Any medical staff on here, if you've ever seen burn debridement, where they go right up to the edge of where the burn tissue is and they cut out a straight line, it's like cutting a pie out. We started seeing some of the hospitals in Baltimore doing these debridements, but they were saying these wounds are infected. And those debridements aren't done on infected wounds. You would see a much more beveled or a different kind of wound base. This kind of led to some recent doctors admitting that they may have gotten it wrong in Philadelphia, but that was street-level folks. We recognized that immediately, nurses taking care of people in the street, these wounds look different. And we'll show them later on. So when you think about skin, there's tons of purposes. And I say this all the time. It's not just a bag to hold all of our crap in. And that is it, though. That's part of it. It does all of that, but there's more to it, like regulation of temperature and moisture through evaporative cooling, through sweating, getting rid of moisture, profusely sweating. A lot of our issues we see with folks, like seeing somebody sweating heavily can be indicative of a heart attack. It can be indicative of a withdrawal or a fever. There's a lot of things that we utilize that we don't really think about, but we all do it as part of our training, it kind of gets embedded. The physical and chemical damage, xylosine is chemical damage to the skin itself, but it also is physical damage. You're puncturing the skin with injection drug use. When we circumvent these things, when we try to change any of this, we add too much heat, you burn. Too much cold, you burn. When we're injecting through these skins, the fail-safe mechanisms are broken. When we're injecting a drug that can cause wounds, again, the fail-safe mechanism of protection is broken because we're overriding it. The germs, again, injection drug use, the destroying bacteria and germs on the surface, this is something that comes into play with wound care. We think of colonization for a wound bed. We think of heavily colonized or infected, but we're starting to look at our natural biomes a little bit more. The bacteria we carry with us every day, the viruses we have on our skin actually help protect us from invasive species of bacteria. We basically have a civil war that's going on all the time on our surface. We have germs that live there and germs that are coming in and saying that we belong here and they're constantly fighting. The germs that live there are really important for our body to continue on. The absorbing fluids and chemicals, sun is one of those. We absorb a lot through the skin. Medications can be absorbed through the skin. Special formulations of fentanyl, just the transdermal patches. I know I'm digging into some controversial stuff. Recently, an officer was supposedly exposed to fentanyl in, I believe it was California. They needed to be reversed. They called 911 for themselves and reversed it. We've shown time and time again that the contact with fentanyl doesn't produce that kind of result. Unfortunately, the anxiety and the panic attack that does ensue is real. That person did require some assistance, but it might not have been the same that they thought they needed. That's my personal side to that. I'm a big advocate for teaching that kind of stuff. And then touch. We feel things. Vibrations. You can feel textures, different temperatures, all that stuff. It's all in our skin. It all interplays with different parts of our skin. Hair, nerves, all those things interplay. That's the value of skin in and of itself. And overall, it works pretty good. As humans, we've lived on the planet for a long time. It's when we circumvent the protective mechanisms. And they're not hard to break. It's not like breaking into an iPhone. It's literally like you puncture the skin with something sharp. So most of our participants are doing this on a daily basis. And it's really important to remember that they're really breaking their failsafe mechanism of our protective barrier to the skin daily. So you can't talk about wounds. A lot of people think this should come later. When I first got my certification for wound care, this was actually one of the things that beat into our heads. And Kelly understood as well. So that's why it's up front. Understanding how wounds heal is really, really important. You have to have all four of these things happen for wounds to heal. And the EMTs on here understand part of this right off the top, the hemostasis. So think of like bleeding. Cut yourself if you're bleeding real bad. To form a clot, you actually need to have oxygen come in contact with blood. That's the initial formation of a clot because it starts a clotting cascade. There's a whole bunch of chemicals, interleukins, and all these fancy terms. But it's really air hits part of our blood and triggers this whole cascade of events. And we need to help it by holding pressure or the body slowly forms a clot. Jokingly, all bleeding stops eventually. Whether you bleed out or you form a clot, all bleeding does stop. But we seek to get a hemostasis from a clot. So if you think about cutting yourself, people say hold pressure. That's helping the clot form, the platelets aggregate, pull together, and stop the bleeding. When that happens, there's a fancy chemical called interleukin-6. Sounds like IL-6 is what you usually see it as. But it's an inflammatory marker. That's one of the trigger mechanisms of healing. So right after the clot's formed, think of it as like checkboxes. So oxygen and the clot or the clotting factors, the thrombin, all that stuff, triggered. Okay, so that's happening. Once the clot's formed and you're not really bleeding, the next phase happens. And that's inflammatory. So the other chemical, the next checkbox comes up. We need to bring the right white blood cells to the wound area. And you do that through inflammation. The inflammatory phase is actually necessary. Everybody thinks of it as a byproduct, but it's actually part of the healing process. When the skin becomes inflamed, it brings more red blood cells to the area, hence the redness. It gets hot. It causes things to expand, allowing more cellular material to pass through the vessel walls, our veins and stuff. Things shift a little bit. And then the white blood cells, the march of the white blood cells, it starts off with one type of cell and moves down the line to the big ones, the macrophages. But what happens during this phase is it's cleaning the wound. It's going there. The white blood cells are doing... Each one does a different thing. And ultimately, the idea is to remove the debris from broken cells, the things we can't see, to remove bacteria, to gobble them up, eat them up, because bacteria can't be there as we heal. They kind of slow healing down. And to help provide the necessary elements for healing, like the extra oxygen from the inflammation. Unfortunately, if we have an infected wound, we sit in this inflammation area because the body is still feeding it white blood cells. Our white blood cells are the fighting factors. That's what, you know, kills bacteria. And I know this seems simple, but when we think about this later on, the wound and the dressing supplies will actually make better sense. And this is where we get into weird territory that a lot of people have different words for. So proliferative, this is where the wound's healing from the base up. All wounds heal from the bottom up and skin cells migrate across the wound. They figured it out probably in the 20 aughts. And then research came out in like 2011 showing that, like, skin cells actually migrate. And the word moist will be used later on, if that bothers you guys, I'm sorry. But you need moisture for wound healing because skin cells need to travel through a moist wound bed. And this is where people say, oh, it's healed. This is healed because it looks better than it did. It's not red and juicy. It's got, like, that pink area. It's a lot of collagen that lines up. It's what we would call a scar. And the scar over time changes. So as a wound nurse, we never say that it's healed. Every patient's come in all the time. This is healed. Look, it's healed up. And we always say that it's closed. And a closed wound isn't healed because it needs to go through the maturation and remodeling phase. What happens is that initial scar, when your wounds heal, if you have a big wound and it heals, you can see this flaky skin that keeps coming off over the wound bed. I'm sure we've seen it in our participants. I see it all the time. That flaky skin is the initial closure of the wound. That flakes off, that dyes new stuff underneath, new collagen, new flexible, like a little bit more collagen, a little bit more regular skin cells. And over time, some of these big wounds take a year to be completely healed. I know that's like splitting hairs with folks because in that, you know, that first month after the proliferative phase and you get that scar, everybody thinks it's done. But these wounds, these big ones especially, are really... They're complicated inside. The body aims to get the skin closed immediately because it is protective. So a lot of times that closure is just scar. So it's like putting a plastic tarp over a hole in your house or your roof. That's not the roof. It doesn't provide all the same benefits. It only provides, you know, some rain or wind from getting in. Over time, those collagen fibers, initially, they line up really rigid next to each other, and that's a hard scar. Over time, they become more flexible and more like fence-like, if you think how fences are interlocked, like the chains go around. That this is what you're looking for. You want that flexibility because initially, if something hits that new scar, especially in the big wounds, it can break open. And it breaks almost like you would break styrofoam. It's kind of weird-looking. So that first six to eight months, that wound that's freshly closed is really delicate. With some of our Black folks, you can see this healing process a little better than our non-pigmented group. The pigmentation in African-American skin, that melanin creeps in, and as it comes in, that's part of the last phase of healing. So when you're starting to see that, it looks like a swirl. When you start seeing the pigment come back, that's a really healthy wound. And sometimes it might not ever come back, and that doesn't mean it's unhealthy. It just means as that pigment comes in, that skin is getting to be as good as it'll ever be. But one thing to remember is once you have a wound, that skin integrity is really about 80 to 85% of what it would have been if there was no wound. So you never get back to 100% integrity. You get close, and this is really evident, and I hate to throw examples like this, but our burn patients, people that get really, really serious burns, that skin is so delicate that sometimes people have to keep going back, and they're kind of stuck in that proliferative remodeling phase because the scars, they get really tight, and they need to be cut back open and stuff. And to me, that's a really good example of how delicate skin can be. So this is, in a nutshell, what we look at and how wound care looks at these kinds of wounds. And this is kind of safe for folks to think about. So we're gonna start in the middle with granulation. That is a healthy wound bed. That, it looks like, everything's compared to food. For me, some people say that granulation looks like ground beef, fresh, bright red ground beef. Other, for me, I think it really looks like the rind on a watermelon that you haven't eaten all the way down, but you're close to the rind. You get that white, or that red, pinkish stuff. That's what it looks like to me. It has a tendency to be shiny. It's very moist looking. If you were to touch it with a gloved finger, it might be a little tacky, not really sticky, but the tissue might stick to you a little bit. And that is, you're getting more meat healing in at this point. That's the deeper tissue. That's the bottom layers of skin healing up. You need to have that beefy red before the skin can migrate across. And if you move to the left, epithelial, big word. I like to call it baby skin. That picture is hard to really see it, but the pink around the top, the white and pink is epithelium. On the granulation picture, that island, that little round circle, that's also epithelium. And those have a tendency to be very delicate. Those are baby skin cells. Your body has produced new surface cells that have migrated to the area. They stick together. They're kind of pre-programmed through chemical. The wound bed and the edges actually speak to each other in a wound, which I don't know the language, but they've proven that one will release a chemical, the other releases a chemical, and it kind of tells these cells where to go. And this is part of healing. Epithelium is necessary for healing. Sometimes it gets like a white waxy area on top of it that can be wiped away. That's just dead skin cells. It's part of the natural course of healing. A lot of times people see that, think it's something worse, but it's really just like a waxy cheesy substance that wipes away. That's what that white is on that epithelial picture. But that is brand new skin. We can damage that by over scrubbing. I always tell people if a participant or like a family member were to take their fingernails, you could reopen that whole wound. That little island can be scraped away. The edges can be changed on the epithelial picture. So we need to be delicate with it. The hardest part for a lot of folks to understand is the term slough. It really comes out of nowhere in medicine. It's a weird word. It means a lot of things and it makes a lot of people cringe. It is a dead layer of proteins and of kind of tissue, but it's not necessarily bad. It can be yellow, brown, it can be soft and slimy. It can be adherent or non-adherent, meaning that some of it can be wiped away. Sometimes it's stuck. Your body does release a chemical, a protease that will slowly remove it. To heal, it needs to be gone. And if you look at the right leading edge of that wound, the body's doing a really darn good job of getting it away. You see, it's almost a straight line and it's healing that way. That wound in a wound center would be debrided depending on who you're talking to, same word. One's a British pronunciation. But we would scrape it off, we'd cut it off or we'd use chemicals or we use some sort of product that would eat it away, dissolve it a little bit. And we'll talk about one of those types of debridement later on. But for our purposes and the purposes of wound care, mechanical debridement is what we would do with that. And that's nothing more than a washcloth. It's a fancy term for soap, water and a clean washcloth. To get that off. You don't need to get it all off at the same time. The body will work with you. And then necrotic. This is a picture of a heel. It wasn't my choice in necrotic, but it really did show it up close. Necrosis just means dead. I think most people understand that. This is just dead tissue. This person got this probably from having a heel stuck on a bed or bad footwear or something along those lines. Xylosine wounds produce necrosis. They produce a very specific area of death. When you see the purple bruise from a xylosine wound, it's already dead. You can't stop it from killing it. It's already there and I'll show you pictures. And this needs to be removed. This acts like a cork and there's ways of doing it. Like I said before, we'll talk about debridement methods, but mechanical works with this. You kind of rehydrate this for xylosine wounds. For other wounds, you'd leave it alone. This is stable on a heel. I just tell them to go see a wound center. But if it's a drug related wound and they refuse to go to the hospital, you can help them out with some tricks later on. So the factors that delay wound healing, some of these are really common. Other ones, medications and steroids. I use this, I point this out for everybody. This was actually a big issue. We had a participant that was, he bought drugs on the street, like prescription drugs, and his wound was getting worse. It wasn't getting better. And on assessment, I'm like, he said, I bought antibiotics and that's common. You can buy them in a lot of places, like on the street, along with their drugs. And some of the bodegas, some of the small, the community, the rural community had a somewhat large population of undocumented farm workers. And there was some small mom and pop shops that try to fulfill the needs of the community. And some of them sold antibiotics and they would sell it to the Arab participants. He was buying them from somebody else. They were actually chemotherapy meds. So don't underestimate the power of a dealer saying, yes, it's antibiotics, because they're not. And the wound healing parts, like advanced aids. These are common sense. Smoking closes the blood vessels. Nicotine is a vasoconstrictor. Some surgeons won't do any procedures if you have nicotinoborne, especially orthopedics and skin grafts. And we can take that with a, that's important to remember that skin grafts will fail if the person's smoking cigarettes. So these are all things, poor diet, our meth users. When I know meth was in a certain encampment or around folks, I would always ask them point blank, when's the last time, I would joke, when's the last time you sat down? Some people said a couple of days ago and they were being serious. But when they would laugh or I'd start that interactive conversation, I'm like, well, really, when's the last time you slept? When's the last time you ate? So these stimulant drugs are super potent at keeping you up and making you not hungry. So all of those things are super important for the healing process. Getting the wrong or delayed wound care can really screw things up. The wound care we're gonna talk about, the first aid, you really can't go wrong on it. And we'll go into that in a little bit. And that's the wrong wound dressing. The wrong wound dressing is really bad on certain types of wounds, not the ones we really encounter. And most people will discontinue the dressing because they are sentient beings and they know it hurts if there was a problem. Your comorbidities play heavily into this. Kidney disease, diabetes slows down, whatever. History of infection, when you have your folks with your MRSA infections, big issues with that. Historically, those folks have a tendency to end up with more abscesses, more infected wounds, and run a much higher risk of cellulitis as well as endocarditis. In our community, the advanced age, there were certain ones I really was adamant about keeping on here, advanced age. That was a big bugger because we have people in their late 60s that were still shooting up. Once they get an abscess or they would get some sort of skin issue, it was much more complicated because usually with advanced age comes comorbidities. As a harm reductionist, we fixed the sharing of needles. We made them profoundly available to everybody, but you still find folks with track marks. You still find folks reusing because they can't get to us or couldn't find us. So all of these things kind of play into the bigger purpose of wound healing. So I always tell folks, when we cover this, please think about when you get that little persistent, really painful infection in your fingernail, the one that's right up against the nail. That's a bugger. It hurts. It comes out of nowhere. Like you clipped your nails wrong or you were doing something stupid with your hand or you let your hands dry out. All of a sudden it gets hot. It gets swollen. You swear there's something in it. You can't touch anything. It's bright red. Like it might actually start sweating. I'm sorry that the slides didn't line up correctly. Pus drainage, you squeeze it and that little pinpoint of pus comes out and all of a sudden it feels better. All of that is a wound infection. You have a little infection in the corner of your nail bed. Chronically, the bottom one said the skin becomes hard and thick. Some of these folks with these chronic wounds that are lingering in the public regularly have really hard and thick skin. For the EMTs, it looks like vascular issues. It almost looked like bark, but this can come from chronic damage to the lymphatic system and changes almost like elephantiasis, like that kind of thing, where you see folks that need to go in for a special compression therapy. They can get that real hard, chunky skin also. All I'm covering here is sepsis. So for our non-medical folks on here, that is a really serious body infection and it causes systemic inflammation in the body. It has a negative feedback loop. Once it starts, it's hard to stop. It affects all your major organs. The inflammatory markers that we talked about in wound healing creep into the blood. The bacteria burden becomes too high inside the blood, triggering all these, they call them cytokines, triggering all these cytokines to start spinning around and your body becomes inflamed, starts making clots everywhere, starts doing all kinds of crazy stuff. This is the one life-threatening thing. This is the one thing that we need to keep in mind when we're seeing folks is ruling out sepsis. The EMTs and paramedic folks that you guys have your SERS criteria may understand that. Emergency room, that's what we look for is SERS criteria. It's the inflammatory response syndrome that goes along with sepsis, kind of right before it. I think they used to call it cold sepsis back in the day. I've been a nurse for like 15 years and I remember learning about cold sepsis, but I think they changed it to SERS criteria. But it's all of these. Fever over 101, really fast breathing, super fast heartbeat, nausea, vomiting, diarrhea, the shivering chills when you see it, you know it. But unfortunately with our opiate use folks, these look like withdrawal. And this comes from, you really need to have a good conversation with folks you know are using and that you got to establish that trust bond really fast. For me, I usually go through this. I said, so I need you to understand that this is not withdrawal. This is, you need to be able to differentiate your own body telling you like you need more opiates or you have these symptoms from an infection. Typically, it doesn't matter how many opiates you do, you'll still have them. And most people learn about sepsis the hard way, that way. They try to over medicate thinking that they're just not well. And then next thing you know, they're getting a ride from 911 to the hospital, getting a PICC line. Sepsis can play a whole bunch of, can also play problems later on down the line with bacteria can, loves heart valves. Heart valves don't have a blood supply. So as it gets pumped through, bacteria will stick to it because there's no white blood cells to kind of like usher it away. And then all of a sudden you end up with growth on a heart valve and that's called endocarditis. Again, that can be life-threatening because the bacteria can break off and travel to the lungs of the brain or various other places. You get a, yeah, it's a mess. Hey Jason, I just wanted to jump in, especially for the folks on the call that are like not in EMS, specifically if you are concerned or like have, sepsis is like literally life-threatening and can kill someone. And like the sooner that it's captured and even if it's, hey, let's, you know, call 911, get EMS to look at you. Like, you know, people can refuse care if they want to, but like sepsis can like save lives if it's caught and if it's too late and that can be for any one thing, even if it's beyond just like wound care. In EMS, we do a lot of work around trying to capture this earlier, but it like literally people can die if it goes too far down the road. Like it's, there's not much that we can do. So I just want to like emphasize that. No, and that's, no, and you're an EMT, correct? Like, this is important. These are the life-threatening things that like our participants deal with on a daily and understanding how to differentiate between these is the earlier the intervention, people hate me. I very rarely called 911, but when I did, it was because my assessment did not correlate with what they were telling me. And what I was seeing were early signs of sepsis. And in one case, the person, yeah, it turned out to benefit them that EMTs came. The person needed to go to the hospital immediately. So this is the one true wound care emergency. There's other ones that come close, but this is the one that when you see these signs and symptoms, I wish everybody understood, you know, I wish everybody was trained in this in like your general first aid or whatever class they teach you about in high school and stuff. Because sepsis can happen to anybody also. It doesn't necessarily need to be, Courtney was very right about saying that. I get pigeonholed because I'm a wound care nurse. I think everything's about wounds. We got plenty of folks when I was in the ICU, that's where people would go to try to break the inflammatory process with antibiotics, fluids. A lot of folks that don't get that magic window die and they die of a bloodstream infection. And that's why hospitals, when you go and, you know, they say, oh, you have a bloodstream infection. This is really serious. They're not kidding. A lot of folks, a lot of medical folks don't really emphasize how important it is to why it's so important to recognize these symptoms. So I just wanted to like jump in on like just, and, you know, a lot of, you know, thinking of the mix of these things, you know, something that Jason, I welcome you to correct me if I'm wrong of like, you know, if they're hot, they're experiencing chills, diarrhea, sleepiness, whatnot, like the breathing fast and a fast heartbeat, like even like after a couple minutes of rest, if that's not, like that can be like, hey, it's more than just not feeling well. You're still, your pulse is super high. You're breathing super fast. Like that's your body trying to compensate and not doing the right thing. So those are like some things where it's like, it's not just you're dehydrated or whatnot, but can be possibly helpful to have the person kind of chill for a little bit and then be like, hey, let's actually call, let's call someone to check you out. And that's, those are actually, it's funny, Stephanie. Those are the two, the rapid breathing and heartbeat are ones that I usually don't see with drugs. And those are the ones that I usually hone in on the first, like first, right out of the bat. I get someone comfortable when I'm called to see them. If I catch that, like that kind of panting or that rapid shallow breathing, I'll sit with them for a little bit, let them know me, who I am. The whole time I'm checking their breathing and I'm checking their pulse or I'm talking to them. I have tricks like when I say, oh, let me see the wound on your arm. I'll hold their wrist and check their pulse so they don't know I'm checking it because some people getting anxious when you do. Yeah, those are the two I always hone in on because the rest really do look like withdrawal. And then the shivering and the chills and like the, it's a cold feeling that's not so much ice cold. It's a weird, sticky, moist, cold. Yeah, those are the easy ones to hone in on. You can continue now, thank you. Yep, I don't know why this didn't line up correctly. I'm sorry. The types of drainage. The first word is cirrus. That just means clear, watery. That's the first picture on the top left. It just looks like a wet spot. It can have a little bit of color to it, but that would be considered cirrus. Cirrus sanguinus, I skipped over sanguinus on purpose. Cirrus sanguinus is kind of a pinkish color right below it. And then sanguinus is just blood. Sanguine is red, it's a fancy term for just bloody drainage. And then when you look at the pus, when you get down to the pus part, pus can come in a lot of different colors. The yellow, green, brown, it can also be a weird minty blue-green that's indicative of one type of bacteria, but it can definitely be minty blue-green. It has a unique smell too. But this is when they say, look at the drainage, this is kind of what you're looking for. Most times, most healthy wounds will be the cirrus and the cirrus sanguinus. If the dressing's been on too long, it might be sanguinus. It looked like the one with just the clear and the bloody mix, the pinkish, but it's been on for a while. Real sanguinus is if someone cut themselves and they have blood and clot in there. And pus is pus. It runs, it's gooey. Sometimes it's cheesy too, so it takes on different forms. I still don't know where Kelly got this picture of the heart. I'm gonna skip over it since this is more for in-person, but drainage-wise, that would be sanguinus, the red with the clottiness to it, the bloodiness. The one on the right, the one that looks like melting lemon meringue, obviously, that's pus. That's one of the grossest pictures of pus I've seen. And then the middle one gets people hung up and this isn't this isn't meant to hang people up but that one that could be serious. The wound behind it's making it look pink. That's really kind of a straw clear color if you look at the drop it's not quite as pink but we're splitting hairs on it. The pus is the one to take home because that's one of the most impressive pus pictures I've seen. This is one of my favorite pus pictures though because it's on an infant's limb and this doesn't I like the fact that it's not just drug abuse that they're showing this because you need to see it in different forms. And one of the more complicated parts of this is differentiating between pus and slug. When we first did this presentation and talking about it there was really no like I assume people know because it looks different but most people never see either or rarely see one of the other. So pus is really just made up of excess dead bacteria, living bacteria, dead white blood cells and other substances inside the body. It can be brown, green, yellow, tan and it usually can be wiped away easily. There is a cheesy type of pus. It comes out looking kind of like cottage cheese or even a little bit more thick. That kind of pus is directly because the fluid has been reabsorbed most times into the body. Some types of wounds can give you really disgusting smelling pus. It's a cheesy waxy substance that if you ever smell it you know it immediately. So slough is that byproduct like we said before of healing. It's that tissue that is yellow. It's the kind of stuff that looks like it's stuck to it. Sometimes it is, sometimes it's not. It needs to be removed. The body tries to do it on its own. You can see the healing edges of that wound. The body's already doing it. Sometimes it needs help. It can be a yellow color and that's when it's moist. It can darken up quite dark when it's dry and almost be like a hard rocky type material but in the end it's still slough. It's complicated but it's part of the healing process. It's kind of what would be making up the scab if a scab could cover a wound that size. It's the byproduct of a lot of things not happening correctly but not in a bad way. If you just run water on it it's not going to come off. You have to wipe with a little bit of vigor to break the bond. It's a protein bond that connects it to the surface. You have to wipe vigorously to have it come off. It does come off with soap and water if you're rubbing with a washcloth. I tend not to linger on this because you'll see with the xylosine wounds they're slightly different. The wounds that we're seeing with most of our participants, you see slough and more chronic wounds, ones that have been around for a little bit. A lot of times I just refer folks when they're real big, that would get referred to a wound center unless they refuse to. Then I would take care of it. The S is right in the middle there. Abscesses. An abscess, like I said before, is a collection of pus in that middle area. They can form from a couple different things. It's an irritant of some sort and the body's reaction to it. Initially it's a hardened area. A lot of times they appear like a walnut-sized area that's really hard and rigid and hot. All those infective processes are in place in that local area. Our body's trying to fight it. It can be really painful as they start to get reabsorbed into the body. If they don't open and drain or the person doesn't get antibiotics, the body will start to absorb the fluid inside and condense it. That just turns out to be a hard nodule that's no longer painful. The World Health Organization states it is equally important to have it open and draining or antibiotics. When I was in the rural community, I was solo nurse and we don't prescribe. We went the old-fashioned way, the way that traditional folks in the wilderness did it. Warm, moist compress. It works wonders. It causes more inflammation. The warmth does. The moisture softens that top layer of skin and the body's trying to push it out. We always tell people let it drain naturally. Don't squeeze it. Everyone's going to squeeze it. The risk for squeezing it is there's a protective bag around that. After the abscess forms and the infected pocket is there, there's this weird paper-like bag that the body forms. I don't know what the real material is, but it's containing that infective process. If you squeeze it, you can rupture that down into subcutaneous tissue. Then you're in for a cellulitis. We always tell folks soften up that outside. I have participants tell me they use clean syringes to perforate where the head would be. If you think of a whitehead, you want that area to open up and drain. Once it's open, typically tell your participants the drainage that comes out can be infected. It doesn't necessarily mean it is, but it can be. The dressings as well because that is an infective process inside of your body. Keep it clean. Throw it away in a plastic bag. Keep it away from the rest of the folks in your community. I've seen MRSA and other type abscess infections spread rapidly inside of unhoused folks and encampments because they weren't keeping their dressings cleansed. They weren't wiping their hands off with an antiseptic wipe. This is the one time where cleaning is super important, teaching the best habits for cleaning. That's just soap and water, hand sanitizer, benzalkonium chloride wipes, BZK wipes, that kind of stuff. You can keep these open and draining with moisture. The same compress used to open it. As long as the hole is open and draining, you don't need antibiotics. My trigger marker for antibiotics with this is if the redness is spreading rapidly. If it's open and draining and it doesn't start to look better in probably three to five days, antibiotics might bump it out of that inflammatory process and let the body go. I ended up getting someone's wound goo on my beard. When I had a beard, it went to my face. Ended up with a huge abscess along my jaw line. I went to urgent care. We opened and drained it. She's like, do you want antibiotics? It's the first time a nurse practitioner asked me if I wanted them. We went the route without them. Everything healed up beautifully. No scars, nothing. The pocket took a time to heal. That paper material gets reabsorbed into the body. It was lumpy for a minute, but it went away. The EMTs on here understand this. Redness is really complicated, especially on lower extremities. That redness that's really profound. It's hot. The whole skin is. This is an intracellular. This is that infection inside the skin. It's in the skin. It's not like a pocket, like an abscess is. A lot of times these are staph infections. It can be other bacteria. These can lead to sepsis. Left untreated, when people come into the emergency room, this is a free ride for a night's stay there when you have sepsis. Keep your legs up. They usually give you IV antibiotics. Bank is a choice because it's broad spectrum and covers a lot of stuff that typically is cellulitic. You can see it in other parts of the body. It's that redness. It's got an orange peel look to it. When you see it at an angle, the skin looks orange peeled and puckered a little bit. This can go into tissues, deeper into the body. It's just not the surface. Most times abscesses, they can travel as well, but for the majority of times, the abscess for our population doesn't tunnel really far. It's close to the surface. Cellulitis can be one of those things. This is something I lose sleep over when I know someone refuses to go to the emergency room and refuses medical care. This is something that when I go back to work, I check back in on them. A lot of times I tell them, if I were you or you were my family member, I wouldn't give you an option, but because you're not, I'm going to check back in tomorrow. This kind of infective process is, to me, is one of those kind of emergency things because this leads to sepsis or can lead to sepsis. Just because you have it doesn't mean you're going to have sepsis. This is just one of those uh-oh moments. You can't treat this on your own. I had a bunch of gals that were sex workers and they refused because that was their way to make money. They refused to get off their legs. Two of them lived in the same house. Two of those had the same type of infection. I believe it was from sharing needles, trying to go into the legs. They kept their legs covered in yoga pants. It really wasn't an issue for business, if you will, but they would only shoot up in their legs. All of a sudden, one came down with cellulitis and the next thing you know, the other one does. You usually see it in one leg. You may see it in both. It's not typical in both limbs. It's an effective process in one. These gals both had it, both right leg. I literally lost sleep over it because they were bullheaded. A lot of times, what gets them to the hospital is when they start showing signs of that early sepsis, that fever, the chills. Chills get you really big on this and so does the pain from the inflammation. The body's inflamed all over the limb. That's the inflammatory process that triggers the all-body inflammatory process. Sorry, Jason. For the cellulite, for again, people who are not maybe medically trained, sometimes what can also be helpful, especially if something's affecting one limb or the other but not both, you can be like, let me see both of your feet and compare the two. If there's weird swelling in one, not in the other, that can be a sign that something's going on. Then also, specifically cellulitis, because we see it in older folks all the time, people that have diabetes can be at increased risk. There's other things that can cause these type of emergencies need to seek urgent care beyond just if someone injects drugs. Sorry. That's kind of the caveat. It's a beautiful caveat because you've never seen this. We're moving into the other wounds that you may see, not necessarily will, but you may. Diabetic foot ulcers is number one. People with diabetes lose feeling in their feet. The sugar in the blood changes the way their nerves work. It's called neuropathy. It's a fancy term, but the actual glucose level changes the proteins and denatures the proteins in the nerves. It's kind of crazy. They lose feeling in their feet, so they might get wounds on their feet. These wounds oftentimes are affected. You have a lot of glucose in the blood, which is sugar. Sugar is how you grow most bacteria. People with uncontrolled diabetes, and that's a thing that other people can have. It's just not injection drug use. There's other times, other things going on. You might see wounds similar to this. You might see it on the heel. You could see it on the toes. I just saw one the other day that the guy, I'm like, you're walking funny. What's going on? He's like, I got something bothering me. We took his sock off. He had a giant infected big toe, and he didn't even know it. Was that an injection drug wound? No, but that was a wound that I'm like, look, we're going to need to do something to keep your limbs attached to you because it's easy to move to the bone. Cellulitis is another one of those things with diabetic folks. Because of the high glucose in the blood, they're always at risk for other kinds. They're opportunistic infections. Again, love to grow in glucose. You do see it tons with your diabetic folks. Arterial ulcers look very similar to xylosine wounds. They're black, they're dead. That comes from the artery not providing oxygenated blood to the toes. You see it a lot on toes. Sometimes you see it around the ankle area, but it's where your vessels start to narrow. They become hardened just like in your heart. They get a lining that's like a calcification, and that calcification makes it less likely for healthy blood or makes it like a lot harder for healthy blood to get to the base of it to heal and to provide oxygen to tissue, and it slowly dies. These are extremely painful wounds. And then your venous ulcers, bad veins, chronic injecting into the leg can damage your lymphatic system, which is kind of your body's drainage system, as well as the veins. Veins in and of themselves, think of them as plumbing. Those are tubes with one-way valves. Your arteries actually have lining that's muscular, that helps pump and to change the blood pressure inside your body. But veins are kind of the dumb version of that. They don't have the smooth muscle lining that other ones do, and they have one-way valves. When those valves go bad, the leg swells. They can go bad for a variety of reasons. One of them is injection drug use because you're sticking a syringe, like a 28-gauge piece of metal through the valve that will no longer work. Leakiness happens. The fluid backs up. You end up with this ruddy color. It's kind of rusty or darkened on pigmented skin. It's like a darkened pigment you can see around the wound that just comes from blood slowly leaking into the tissue. It's called, it's staining. And you see that they have a tendency to be very wet. Sometimes these can be mistaken for regular drug wounds. A lot of our younger male population that work in factories or warehouses, Amazon's got a bunch of folks with venous ulcers that are injection drug users because they stand on their feet for 12-hour shifts and don't really sit down. Their legs swell naturally and everything backs up. I treated a bunch of young men because Amazon just came to our community where I was with venous ulcers because of chronic injection drug use. Typically, you would go to a wound center to treat this. Again, those guys were refusing any of that treatment. This is the fun part. This gal that shared her feet is no longer with us. I was there when she was injecting into the wounds. I can validate this almost like a notary would validate a photo. These are what early wounds look like. If you look at the picture, the green and red arrows are pointing to the two different presentations of xylosine wounds that I have seen over the past four years. The green one is pointing to what we assume xylosine does to tissue. It clamps it down. It makes no blood go to the area. That one is a blister. The green arrows point to a blister on the left that is closed still. The red ring is around a very white area. The white area would be skin normally. That's been devoid of blood flow. It's super white, pale white. Same thing happens on heavily pigmented skin. It becomes pale white, almost ghostly. The red arrow is pointing to the other type of formulation of xylosine wounds. This was one day post-injection. I did see her inject. I was there. These appeared within 10 minutes of injecting, which was the first time I ever in my life saw this. It dawned on me I need to record this. The golden rod colored arrow is actually pointing to a non-injection wound. Something interesting about xylosine is that it doesn't necessarily have to be in an injection site. This gal was notorious for getting them all over her body, not just in the limb that she was injecting in. They can develop super quick or they can take some time. This is an either-or situation. They can become infected. These are not based on an effective process. This is a chemical process killing the tissue. Initially, these wounds are actually super sterile. When the skin's intact, there's no bacteria in there. When the blister skin wipes off, it runs the risk of bacterial exposure. In my four years, cellulitis and infected process were not an issue. It did happen, but it wasn't as common as one would think it is. That could be why the wounds actually occur. Research is still pending as to why the wounds actually happen. The reality is the treatment for these wounds is super simple. Earlier the intervention, just like sepsis, the earlier you get to it, the quicker things turn out for the better. Keeping it covered and moist. This is where we get into the word moist a lot. The idea with this is the purple area is dead. The stuff in the center of both of those wounds, the purple and white, is just dead tissue. The damage is done already. Keeping the outer layer covered and moist, when that blister breaks open, you're allowing that center tissue, which would be called necrotic tissue like we covered, to remain moist. The necrotic tissue can't be there as things heal. We're jump-starting the healing process and cutting off the length of time. I've had participants have wounds for seven months and not do anything about it. They open up, they become rock hard, and they just leave them there. Keeping that moist allows the edges to start healing and the base to start its process. Eventually, keeping it covered and moist allows that necrotic tissue to come off naturally. Observe it. Just keep an eye on it. These participants, if you're in an SSP situation or an outreach situation, always check up with them. Again, not typically infected, but always check in. This gives you an opportunity to continue that conversation with folks you might not be conversing with. The left picture, for reference, is one day after injection. I was driving away saying, oh crap, I need to go back. The picture to the right is five days after injection. That's what these wounds, arrows pointing to the same wounds. There's new wounds on her foot. She continues to inject in those areas, but you see that they all heal the same way. The center dries out. She didn't do any wound care. This was her choice. These were not infected. I don't know if we included, we didn't include the picture. I have a picture of them healed. They heal up beautifully. She didn't do it right, but they end up with scars. These are the left side, early wounds. You see there's three of them visible. That red one is not infected. I want this picture to be shown as that. It's the body's inflammatory response to that necrotic tissue being there. The body doesn't want it there. It knows it can't heal. It's a cork that it needs to blow. It needs to pop out. The infected process is trying to pop it out. It's trying to get it out. On the right side, this is uncontrolled xylosine wounds. The participant continued to inject. This is a hospital photo, obviously. He continued to inject into the edges, which is unknown. People feel they don't. Fernando probably covered it. One of his theories is that because the xylosine is vasoactive, the veins clamp down. I've had folks tell me there's nothing else on their body. I point out veins. They're like, no. They just continue injecting into the edge. The dark tissue on there is necrotic mixed with a little bit of dead stuff. It's the scab with the necrotic tissue. It's funny. The first time I was showing this picture, if they had done proper treatment, this person did nothing to themselves. They had done the kind of treatment we had figured out, keeping it covered and moist. I'd bet a paycheck I could start healing this in less than a month to get them at least halfway closed if they were doing it. he went into the hospital, got surgical debridement, they knock you out, they cut all the dead stuff off. And unfortunately, a lot of times in hospitals, they discharge you or the patient leaves AMA because they're not meeting their opioid needs. This doesn't happen overnight. These are chronic users with high needs. And a lot of times hospitals will give you like one Percocet, you know, every Q6 to keep you there. And it's not enough to cover the opioid. So they're smuggling bags into the hospital and stuff, or they get kicked out, or they just leave because there is a withdrawal syndrome from xylosine withdrawal. So these next couple slides, it's crazy. Kelly interviewed me for a while. I have ADHD. I'm all over the place. Never asked me for a presentation to be organized. So she recognized that like a good educator should. And we talked for a couple hours, and this is what came out. This is, she picked my brain about what we do. So we assess the wound. Is it healthy? Does it look healthy based on the stuff we talked about? Is there slough or pus? What type of tissue? Is it necrotic or, you know, really healthy granulating? Is the wound dry? Is it wet? Is it dripping moisture? Is it like dripping out as you're talking, they're making little droplets? Or is it moist? Does it look a little tacky and, you know, just slightly moist? Are there holes and tunnels along the edges? These are things that you don't need to be trained to look at. A hole is a hole. A tunnel is a tunnel. If you see a hole and it goes into the wound edge, that's considered a tunnel. And are the edges really deep? Those are all indicative of things. And some of these answers, if you say yes to those, you need a higher level of care. It's, you know, it's not rocket science. A lot of times in medicine, we make things way more complicated. And then is the surrounding skin thin and delicate? Is it missing? Does it look like it's, you know, shiny and has holes and wet around the wound? These are really important things to think about with the dressing that we'll get into. And then look at the drainage. This is the part that I warn people about. You don't judge a baby based on a dirty diaper. So you have to take this with a grain of salt. But does the drainage have a foul odor? All dressings will smell. Most participants with dressings don't change them frequently enough to really make that a great assessment. But if you put the dressing on a couple days, like two days later, you go back and it has a foul odor, that could be a sign when it's mixed with other signs that you have an infected process happening, especially if, is there a lot of it? If there's a change in drainage, the amount of liquid coming out of a wound, most times that's indicative of an infection. The body's irritated and it's trying to, it's inflamed and producing more moisture. And then what color? Goes back to the drainage question. This is really hinting at the pus comment. Is it white and cheesy or yellow and gooey, like wet meringue? And then you're coming up with the wound treatment. So this is really how you clean it. This is soap and water and a clean washcloth. If you're rich and your organization has a lot of money, you can do a wound wash, which is like one of the good ones is Vash, but it's like $17 for eight ounces. What kind of ointment? We're really thinking about keeping the wound moist. A&D ointment is a great option. Vaseline is another great option. If you see the person, I don't recommend honey for our own house folks because it does attract bugs. Ants love it. And we moved the whole encampment because the health department is giving honey out like it was their job. It has its place. That can be, it's slightly a chemical debreader. And then how do you secure the dressing? Are they, is it, is their skin wet or moist or around the wound? You don't want to tape anything to that because it looks like it hurts. Sometimes I love it. A sock, your random socks make great wound cozies. If you think how a beer cozy works in the can, you just cut the end off of a sock, slide it over the wound and it holds the dressing in place. In the colder months, these work wonders. And it also worked great to get rid of your socks from your missing sock bucket or however you keep them. And then what makes up a dressing? And this is, we're getting to the meat and potatoes of this. It seems simple. Think of a Band-Aid. That's a brand name, but think of a Band-Aid dressing. So you have an outer layer that makes sure everything stays in place. It could be waterproof. It could not be waterproof. It could be a whole bunch of things, plastic, fabric, you name it. The next one is your absorbent layer. In a Band-Aid, it's the white patch. The inside of the white patch would be considered the absorbent layer. In a Band-Aid, that white patch in the center also has a contact layer. It's a non-stick piece of fabric or material. In a Band-Aid, it's Telfa. That's the 3M's brand name, but it's a non-adherent wound layer. Note for folks in here, when you look at that non-adherent part of those pads that you can buy, they still adhere. They still stick to people. They're less likely to stick to people. It lessens the surface area that's actually in contact with the wound, but they still do stick. If you don't think because they have a non-stick layer on, you can just rip it off. These are the different types of dressings. You start from the left. You cleanse it. Soap and water, clean washcloth. I learned early on, you don't need to wash every wound. I didn't wash wounds for our unhoused folks unless they had visible soiling in it. That goes against all training, but it really does make sense because you're messing up with their biome. The contact layer part, we're going to start at the wound up, the base. You're looking at something like Xeroform, traditionally burn dressing. It's been around forever. It's sold. It's not been trademarked. There's no patent on it. A lot of companies make it. It's a sheet of linen. They call it fine gauze. It's really like a really, really cheap dish towel, very thinly woven fabric, impregnated with Vaseline and bismuth. In a lab, bismuth kills bacteria. In reality, they're not real sure it does. No one's going to spend the money to actually research it because everybody makes it and sells tons of it. Why would they have to get FDA approval to say it kills bacteria? In a lab, bismuth does. I came from a hospital that had a burn unit, so I was very familiar with using it. It is the quintessential burn dressing. It's usually the base for, I'd say, 99% of burn dressings, the contact layer. I gravitated to that to use Meta Honey, the medicinal-grade honey. You shouldn't use regular over-the-counter honey because that has not been radiated and filtered for fungal spores. Botulism lives in honey. That's why you should never feed raw honey to infants. It's the same thing. There are fungal spores and different bacteria that do live in the beehive. Medicinal-grade honey is a certain type. It's Manuka honey, and it's been irradiated and filtered. What that does is a high concentration. It gets pulled from the cells, the gradient from low to high, and fluid travels along that gradient. The honey is kind of a magnet for fluid in the body, so it creates a moist wound base. There are antibacterial properties inside the honey. That little tube there is about $7, and it's like an ounce and a half. If you've got the money, that's a good thing to use. If not, you can get away with the Xeroform alone. Dressing, the outer part, your absorbent layer, gauze, or ABD pad. My dressings were very simple. I was given carte blanche to order and use what I wanted. We came up with Xeroform, ABD pads, and Coban. Coban is a brand name, but it's self-adhering gauze. Some people know it as VetRap. My wife's worked with animals for 20 years, so Xylosine and VetRap were not new to her. But yeah, that's my dressing of choice for 99% of the wounds that I see. It's safe. You're not going to hurt them. You have a moist wound base with the Xeroform. Xeroform traditionally is nonstick because of the Vaseline. If it sticks, a little warm water rehydrates it, and whatever Vaseline's in there, it kind of mobilizes again to make it nonstick. The ABD pads, highly absorptive. They both come in 5x9 sizes, so I cut them down. Just got to be mindful, the abdominal pad's full of a cotton absorbent material, so when you cut it, you always hold it up because you'll just pour it up. And then your adherent layer. Folks that inject, I use Conform Roll gauze. People that inject in the wound margins. People that don't inject in the wound margins, I use Coban because it can stay. You can take it on and off one or two times. But this is simple wound care. These lists were put together at the University of Pittsburgh, and what they did is they just started looking at Amazon for the cost for non-profits, and all this will be available. Don't get lost in the sauce with this. These are ideal. If you got the money, this is what you spend. They came up with the other one, Street Medicine Supplies. This is kind of like they're cut and dry what's in their wound care packs. I don't like the non-adherent pad. I feel like it's a waste of money, but other than that, these are really good. I helped them come up with this, and somehow I made it into the presentation. This is kind of older, though, so the prices might be slightly different. This is where the moist comes in. If the wound is wet, this is kind of a go-to in the way you assess a wound really quick. If it's dry, add moisture. If it's wet, you need to give something to absorb it, so you maybe give them a couple more ABD pads. They might have to change it more frequently to get that drainage away from the skin. If the wound looks infected and is infected, you need to provide something that will kill bacteria. That comes in a lot of different ways, but most of them come from a referral to a medical care facility, like an urgent care or patient first, or maybe you have a doc on the team that can prescribe for you. And then the necrotic, the dead tissue needs to be removed. And that comes through. Metahoney is considered slightly like a chemical debreader. It's really not. The fluid does the breaking down, how it produces excess fluid in the wound bed, but it really, you can kind of consider it that way. There are chemical debreaders. There's really expensive drugs. They go to a hospital. The drug's called Santhal. It's made from, it's actually made from bacteria, and it's made from one of the toxins of a really bad bacteria, and they ferment it. And for whatever reason, it eats away the proteins. It's like $300 a tube, very, very not cost effective, but it works great. And then the wound care education portion. So this is the kind of stuff that's important. Always try to wash your hands when you're taking care of someone. I wear gloves, but I still try to do my hand hygiene stuff. That's because I'm a nurse, and they beat it into you, and you feel like a failure when you forget to use your hand sanitizer. Always try to wash the wound if possible. A lot of folks give out those little saline squirt, those little three or five cc saline bottles. You're really just giving a whale a tic-tac. They're just going to have fish breath still. Those little bottles don't really clean a wound. You might get away with squirting that into gauze and maybe using a little friction. But those little saline bottles make the provider feel better, but really don't clean the wound. Try to rinse it. Saline isn't necessary. Just try to rinse the wound out. Rinsing is the action of removing the debris. If the person has access to running water, tell them to get in the shower, rinse that part of their body last. If they can, hang it under the shower, let the water run down. If they have a detachable showerhead, hold it above the wound, let it run down. They don't need to spray into the wound. You don't need to be a hero. The movement of the water helps remove some of that dead tissue and continuously keep the wound bed clean. Don't wrap your Curlex tight. Curlex is that rolled gauze. Not all rolled gauze is built the same. There's conforming rolled gauze, which is stretchy. It's got an elasticity to it. You have your other gauze like Curlex, which is woven. It's actually fiber. It's actually like cotton strands, like you would think of regular gauze, but they make strips of it, like long rolls. You can make that too tight. If someone swells, that can cut into their leg. Just be mindful. You're not trying to crank their leg off. You're just trying to wrap it up nicely, so if they move, they can be mobile with what they're dressing on. Always review the signs and symptoms requiring medical treatment, like the not bleeding wound. Hopefully we don't see those, but when they start, they can be emergencies. We had one in the county I was in. It was something going on inside the vessel, and they injected, and they couldn't stop the bleeding. It was a type of pseudoaneurysm going on. That happened. That's real. That could happen. It's less likely to happen. It was way off my radar for a long time until then. Now I'm hypervigilant. Go over the signs, like Kodya said, go over the signs of sepsis, the fast heart rate, the fast breathing. There's bits missing from here. That's the rest of that line. The wound's not healing. You're getting worse. You'll be the best judge of that. A lot of people look at a wound and it looks the same, but when you start seeing that happy, healthy edge and that pink tissue coming in, point it out to your participants. I use photos. I try to take the same photo, same angle with their permission, and then I bring it back to them. I was like, here's your wound. Look at this. This is what it looked like before. Before it was a lot bigger. And then difficulty moving the limb. If they can't move their arm or limb or they start losing feeling in their fingers, the ability to move, they definitely need advanced medical care. That's when you call 911 and get them to urgent care. We found that when that started happening in our community, lidocaine and tetracaine were being added to the dope supply. And basically they were giving themselves anesthesia every time they missed or got into their body. They were doing a nerve block on themselves. Made me panic. I don't know what else it could have been. And then we figured it out with drug checking. But it's still a medical emergency. You got to get someone there. You don't want to make them lose their ability to feed themselves or dress themselves. Common sense stuff. If you can't move your limb, I can't help you anymore. We're only looking to apply dressings to keep them clean and to maintain folks. It's the simplest of dressings is what we're shooting for. This is the Jason do's and don'ts. This is really important to me as a wound care nurse and to pass on. You're taking care of a person, not a wound. Remember that. Privacy is super important with this. Maintain it at all times. Some people don't care. Other people care profoundly. Use your motivational interviewing techniques to get people to understand the gravity of the situation and get them to other places. Establish rapport. I do it immediately. I joke with people. I get to know them. I start learning about them. And during this time, I'm explaining everything I'm doing. I do the see one, do one, teach one mentality where I'll do it. I'll have them tell me. I'll have them do it. Then I'll have them teach me why they did what they did. Always like I said, nonstick doesn't always mean it doesn't stick. Removing the dressings can be painful. Let them lead. Let them dance with you. If it hurts, they may not come back. So moisten the dressing, talk to them, get to know them a little bit during this time and suggest maybe, hey, you take it off and don't use hydrogen peroxide or alcohol to clean wounds. These are things that have been around forever. And what happens is both of them kill new skin cells. Epithelial cells die. They dehydrate with alcohol and then hydrogen peroxide. The fizzing actually rips epithelium apart. It chews it up in bits and pieces. So this is somebody I used Dawn dish soap to clean. It's crazy. I don't recommend it. She wouldn't use regular soap. She was an oddball. But this is the process. This was probably, I don't know, six months of care. She never took an antibiotic and that's not as worse as the wound looks. These are ones that we decided to use. We used zero form ABD pad and roll gauze because she would inject into the wound for a while. And that's why the knuckles in the third picture are still open because she was continuously injecting. And then when she realized that she was kind of, you know, losing fingertips, she stopped. She used her other hand. So a lot of people want to know about debridement. We got a couple of minutes. Debridement. Don't worry about it. Just know that all of these happen sharp, autolytic, enzymatic, biological. That can happen on its own accidentally with maggots. But the reality is what we teach during this program is about mechanical debridement. Super fancy term, soap and water in a washcloth. We don't say, I like to tell people, wash it like you're washing a two-year-old. You don't want to scrub their skin off. But if they're dirty, you need to apply gentle pressure. If you're actually helping someone clean, teach them that and just watch them. The idea isn't to clean their wound. You don't want it to be crystal spotless after the first time they wash it. You want them to be comfortable washing their wound. And a lot of times we tell people, wash it with dressing changes if you can. If you can't, that's okay. Try to do it at least once a week if possible. And if not, we need to talk about it and find other ways maybe to get you to some place to clean. Like I've washed wounds before in Taco Bell bathrooms, which is not what I'm suggesting as an ORN representative right now. So again, this slide, it must be my computer, I apologize. Safer injection techniques. This is really the harm reduction point. The takeaway from all of this is that the red areas are no-go zones. You don't want to inject into these areas. You have really important vessels that are close to the surface and they line right up against arteries. The idea is not to inject into an artery, the idea is to inject into a vein. Yellow is the yield area. Try not to inject into these. Those veins are a bugger on the upper body. Just because they see them doesn't mean they can get them. Breast tissue and xylosine do not mix well. They're very complicated. And then with the lower extremities, the veins there can be a little tricky. They roll, they have a tendency to be a little bigger and you can damage them a little quicker. The green areas are the places to go and that's the safest areas. That's where you would normally get blood drawn. Don't use the palm of the hand. Someone asked about that. The back of the hand is easier. People have lost fingers shooting up into the palm of their hand and the bottoms of their feet. All of this goes along with the harm reduction portion. Always try to use people using a tourniquet. Pull back slightly when you're injecting to make sure you're actually in a vein and not in a vein. I want to see what happens. The timer just went off. And I'll hurry up on this. Always try to avoid the leg, groin, neck. People end up with terrible problems injecting into all of those. If you hit an artery, it can be life-threatening. If you can get someone to change from injection to stiffing and then rinsing their nose with a little saline, those little saline bullets are great for that. Xylosine has been less likely to show wounds in the sinuses if you snort it and flush afterwards. If you snort it and leave it in the nose, you end up with wounds in the nose. Always try to use your testing strips if your community makes them available. Testing strips at least let you know to go slow if xylosine is present. There's research showing that testing strips don't stop someone from using it, but it makes them more aware and safe. Always use drugs with somebody. Never use alone. That's an old line. I would tell people if they're using drugs in their motel room, let their neighbor know if they were friends. If not, call someone that they do trust that they can check in on a couple hours and make sure everybody's distributing naloxone the best they can. We're going to skip over this one since we already covered most of this. This one does have healthy little islets in there. That's why I enjoy this picture, but I don't want to take up your time, your evening anymore. References. There is an ORN evaluation survey. When you get this, they're going to ask you to do it. The reason they ask you to do it is so we can continue doing it. We only get better, and this has changed dramatically from the first time, the inception of it.

Jason Biener

Opioid Response Network

Johns Hopkins Bloomberg School of Public Health

wound care

substance use issues

Baltimore City

rural Maryland

infection signs

xylosine-induced wounds

wound care education

harm reduction

sepsis symptoms