us today, and this presentation is Wound Care and Referral Protocol, and the session is sponsored by the New England Region Opioid Response Network. And I'm Kathy Whalen, Technology Transfer Specialist working for the New England Region ORN. The ORN is funded through a grant by the Substance Abuse and Mental Health Services Administration, and our grant prime is the American Academy of Addiction Psychiatry. We provide technical assistance to individuals, groups, and organizations in the form of education and training regarding opioid and stimulant use disorder, and we cover the areas of prevention, treatment, recovery, and harm reduction. Next slide, please. This is provided at no cost, as it's covered through the SAMHSA grant. Our organization covers the entire United States and the U.S. territories, and we're broken up into regions, who all have technology transfer specialists who can assist you with a request. And the next slide. 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We also really appreciate if you do the survey, because it helps the ORN to maintain the funding it needs to continue offering free trainings and allows us to see how we can improve our services. The recording will be uploaded to the account in about three to five days, so if you don't see it right away, just check back. And we're fortunate to have Jason Beinart as our presenter, and I'll now pass this over to him. Can you guys hear me well? Excellent. So, my name's Jason Beinart. I'm a wound care nurse. That's pretty much how I love to identify myself with everybody. The truth is I have been working with people who use drugs probably for the past, whenever COVID happened, 2019, and I have a weird penchant for wound care, so a nonprofit group in Maryland heard that I enjoy doing wounds with people that use drugs. They worked as a harm reduction group in a syringe program, and they started seeing new wounds in a fairly rural area. They didn't know what it was, and all those folks are in recovery. And they had fairly recent experience with the drug supply, but something had changed. So COVID and my experience happened to usher me into this weird new world of xylosine and a whole new situation for a really delicate population that was kind of suffering. But my background is I started as a nurse later in life. I have a completely separate degree, decided to become a nurse because I wanted to help people, and I was tired of working for corporate America. So I started working for Hopkins, which is just like working for corporate America. But I started in the ICU, got into wound care early, and worked at a Hopkins wound center, then ran a wound center at another hospital, worked in the cath lab. It's a really varied background. But all of those things kind of became like an amalgam to make this a little bit better experience for me and able to sit here today and talk to you guys. So the goals of the training differentiate between healthy wounds and wounds that require some help. We're going to talk about basic wound care, and we're going to talk about like wound care kits. And this is all in the context of kind of street-based care, care when you're not within a clinic setting. A lot of this does pertain to clinics, but in the reality, it's really what you can carry in a backpack or, you know, like a bag or whatever. And we're going to talk about harm reduction strategies, and we're really going to talk about these throughout the whole presentation. Again, this is just the weirdness of the world. I was doing what I was doing in Maryland, and little did I know, this study was going on at Columbia University with a pretty awesome nurse practitioner. Her name was Kelly Bryant. She now works for the National League of Nursing. She was the director of admissions for the School of Nursing at Columbia, and she left her house one day and saw people doing wound care that weren't nurses, that weren't—they didn't align themselves with any kind of harm reduction organization. They were just participants taking care of participants. And she was like, you know, I'm going to do this, and I'm going to do that, and I'm going so she decided to see if there's any money involved and try to see what the heck is going on in the population. So she took all of her nurse practitioner students, which I think she got her hand slapped for later on down the line, but she said, who wants to go work with people in the community? You know, the few that raised their hand, she took them out, and basically, they were just asking people about wounds, if they participated, they gave them a $10 gift card and a wound care kit. This is it. Obviously, you could tell this was happening in winter, everybody's masked up, so this is the beginning of COVID, mid-COVID-ish. Kelly contacted me sometime after this to participate. They had some hospital nurses that did wound care, but they weren't really getting what the situation was. But of all, almost 600 people, 20, 25% said they had one or more wounds, and this was just directly from response. These are just asking people if they had wounds. They weren't really doing full body assessments to see if they were telling the truth or if they had more than one. They're just taking reported information. Most of the folks had used, they said heroin. This is the one part I think the study was a little naive. It's really, at this point, heroin wasn't in New York City. I think the folks were saying they were using heroin. It was an opioid of some sort, most likely fentanyl, and the stimulants, majority were crack cocaine, and most folks were drinking as well. This is the breakdown of where people reported wounds. The majority of them on the arms and legs, very few in the groin, the stomach. There was a few on the head. From what I gather and the little bit of information I saw about this study, it was a lot of picking on the face and scalp, which is another one of the fantastic side effects of stimulant abuse. I had a participant yesterday. I still do this in the street in Baltimore City. I had a participant yesterday. She brought me a little jar of parasites. It was just little flakes of skin. But in these moments, these moments where someone trusts you as a care provider, as a nurse, enough to show you a little jar full of skin flakes because no one else believes her that she has parasites, and the reality is she's just picking from her crack abuse. It's how you handle yourself in those delicate moments that matters the most. I have researchers on the truck I go out in. What I do now is a Hopkins-based program. It's research-based, but they hired a peer, someone with lived experience and myself, to go out and provide wound care and harm reduction. We're trying to change it a little bit as far as pulling away from the research because all of our researchers were like, you don't have bugs. There's no parasites that look like that. I just pulled her away and be like, they don't believe you. It's not really a question of whether you have parasites. It's how we can help you get yourself better. It's those delicate dances you do with words. I would never tell her she's lying or wrong, but the reality is it's just little pieces of skin she's picking off. That's that delicate nature of dealing with this population. Every word matters. You think it doesn't, but it absolutely does. The way this program is really broken down, we're going to go through the basics of a little bit of anatomy and physiology, just a little bit. We're going to cover skin and the protective mechanisms and really what is skin in and of itself, a refresher for some of us. I want to talk a little bit about needles. There's no slides about this, but this is something really important to remember. Then we're going to get into the wound part. The wound part is my absolute favorite. I don't see if people are raising hands. If anybody just wants to interrupt me if there's a question, whatever way you guys deem more appropriately. I see it, Jason. I'll let you know. Okay. Thank you very much. When we're looking at skin, there's a million different layers. Dermatologists break this down even more. But for general anatomy and physiology, right out of the gate, there's three layers of skin. The epidermis, as you see, this is just a little cube of somebody's meat. It's very thin. Epidermis is the outside layer right down to the very – it's right below the outside layer. Your dermis has all the chunky stuff you want. The majority of your hair follicles, nerve endings, blood supply. Then when you get down to the hypodermis, more blood supply, the hair follicle blood supply kind of roots itself in there. The base layer of your sweat and oil glands, your fat, the fatty tissue is underneath all of that. Most times you're seeing through the dermis. A lot of times you really don't see – we think it's a deep wound, but the reality is you really don't see fatty tissue. The majority of times when you see these kind of chronic wounds for people that use drugs, you're only seeing most of the dermis. When you see an acute wound, someone gets stabbed or a gunshot wound, you can see – you absolutely see hypodermis in those. You see fatty globules and stuff kind of oozing out in some areas if it's a big enough area. So this was a good refresher for me. I forgot about half of these and I deal with this every single day. Skin is probably – and I'm biased, but it's probably one of the most important organs. I mean it's the largest. Obviously it covers your whole body, but it does – I guess it's close to the liver. The liver does a lot of stuff, unsung hero too. But the skin itself protects you from environmental factors, hot and cold. It protects you from thermal issues like sun radiation, heat from fire, that kind of stuff, ice when it's up against your skin. It's a protective layer for that. You have your whole biome, which is your bacteria that's unique to you. It's almost like a fingerprint. Your biome helps protect you from invasive bacteria and viruses and fungus. And that takes up residence on your skin very happily. It is a physical barrier to germs getting in, hence why we have to wash our hands so frequently. That's why hand hygiene is so important. I learned this in Boy Scouts and I really want to share this. My scout leader is long gone. He was an old man when I met him and that was forever ago. But he had this rule. If it was wet and not yours, don't touch it. And that is the only caveat, the only carve out for this is like you can touch it if you have gloves on. So if it's wet and not yours, don't touch it unless you have gloves on. Keep that in mind. A lot of wound care, you'll see people do it barehanded. There's a lot of risk inherent with that for the person and for you. A lot of times we're not in a situation where we have clean, fresh water when we're doing street-based care. So carrying around like a plastic bag to throw your extra gloves in. I always have, I'm a party pooper. I always have like one or two pair of gloves folded on themselves in my pocket just about at all times. And also through the washer. So you always remember to take them out of your pants. But always keep your hands gloved. But a lot of this stuff happens with the skin. When we have a break in it, the opposite occurs. You cut parts of your finger, you burn them. You can't feel vibration and pressure. If you have chronic burns or chronic sunburn, your skin can get thicker. You may not absorb things through the skin. There's a lot of things that the opposite occurs when we really damage it. And we take it for granted. Like our skin is really abused all the time. We're not healthy. We don't treat it well. Just being outside is detrimental. And when we think of our participants we're taking care of, they don't have the opportunity for perfect hygiene, whatever that might be, or good nutrition, all the things necessary to keep your skin up and running and healthy. So everything we do, every single wound you have in a normal setting, regular setting, like this is the way things should occur. They happen in four different phases. Think about cutting yourself with a piece of paper or you get a little cut on your arm. First thing that happens, you break the skin. You break down into the blood vessels. Blood hits the air. The minute blood hits air, the clotting cascade occurs. The clotting cascade probably has a billion different layers to it. It's all fancy. But the reality is air hits some of the chemicals in your blood. It immediately starts to clot. Stops the bleeding at the cork. It's nature's cork. Right after that, once the bleeding gets stopped, the inflammation occurs. A lot of people think inflammation is a bad thing. But inflammation is actually necessary for healing. It has to be there. And I say that because inflammation helps bring, if you think about your white blood cells as kind of like, you know, going to a party. The first white blood cells are typically the neutrophils. The neutrophils that show up tell the next group it's time to come on. That all happens through the inflammatory, the chemical markers that occur with inflammation. Each one of those white blood cells has a job. Each one of the white blood cells has a time to show up. And it all happens because of inflammation. Wounds that stall or get delayed are stuck in the inflammatory phase. Something delays them. Something trips them up. One of the inflammatory markers hangs on longer. And there's a million reasons for it. But they get stuck between phase two and three. Phase three is proliferative. This is a fancy, fancy term for stuff's just healing. You have granulation tissue, which is the healthy tissue starting to form from the bottom of the wound up. The edges start coming in. You're starting to get these things called fibroblasts. Fibroblasts are part of the healing portion of new cells and whatnot. A lot of times, this is where our participants will say, without a shadow of a doubt, I'm going to leave it uncovered because they think it's closed. In wound care, we never say, oh, this is healed. We say it's closed or covered. And that skin layer on the top is temporary. When a wound first closes and covers over, that skin is going to be shed probably within a day or two. A lot of times when these wounds are healing, you'll see people come up to you with a quarter sized wound on their arm. It's now covered over. They think it's healed. And it's super dry looking. And that dry cap comes off. And it's like pink and healthy again and fleshy. And then that will pop off. This is all part of the healing process and necessary. Those skin cells that are covering over those new epithelium aren't meant to be permanent. During this phase, you can really destroy a wound. People think it's closed, it's healed, whatever they want to call it. And they bump into something. That new skin just rips apart. This is why we like to keep things, at least if the participant will play well with us, we like to keep it covered during this phase. The fourth phase is when you start getting your scar. You start getting a keloid formation. All of these things happen in the maturation remodeling. During the third phase, between the third and fourth, you get your collagen. Collagen is part of that scar that builds up. Collagen should be loosely linked to each other, almost like a chain link fence. With scarring, collagen lines up like soldiers. Over time, those soldiers start to form that chain link kind of fence. But unfortunately, at this time, you have that really hard scarring and whatnot. For large wounds, and this usually blows some people's minds, for large wounds, once they're covered, you have another six to eight months of healing that needs to occur. During that time, it's really important to maintain people's nutrition. This is best case scenario. Maintain their nutrition, maintain their skin, like the suppleness. My wife hates the word moist and supple, and they're used in wound care so much. You have to maintain their suppleness by keeping them moisturized, keeping the skin hydrated, kind of protecting it. It's a really delicate leather at this point. You don't want to scratch it. You don't want to mar it up. And these are things that are really hard to do with the population we take care of. This is kind of a pot shot whether or not the wounds will stay closed. If I had a dollar for every time someone said, oh, my wounds are closed, they pull up their pants leg, you have this new baby skin covering it. And in a week or two, something happened, and their legs swelled up and all that skin ripped apart. And everybody thinks it's a setback. Your participant will feel like, oh, I'm back to square one. You're really not. You know, you can heal. You can heal again. It's really controlling the underlying issues, making sure their skin is supple, making sure that they have lotion or even Vaseline. Vaseline is cheap and easy, and it's one of the best moisturizers out there. So again, we're still going through some of the A&P, but now we're getting a little bit more into wound care. I want to cover the easy ones first. I'm going to leave the toughest one for last. So I'm going to start on the left side. Epithelial tissue is new skin cells. It's a healthy pink tissue. I just took a picture of a wound yesterday that got me and the participants so excited because she went from having a wound probably about, I don't know, three inches wide yesterday. It was about an inch and a half and had all this new baby skin in the middle of it, and she could see it. She felt the last time I saw her calf was twice the size. It should be. She refused to go to get any kind of medical care. It was a lot to bring her to see me, and then she showed up yesterday. She's like, this is crazy. Look at all this new skin. But that is super fragile. You could take your fingernail and scratch it off. It's loosely bound to the wound surface. In that picture there, it's the whitish pink stuff around the edges, not the center. The granulation tissue, I wish this was a better picture. Kelly put the photos into this presentation. Granulation tissue looks like ground beef, or if you've ever eaten a watermelon down to the rind, but you left a little bit of the red still on it. You don't want to get into the rind too much. You left that red layer. It looks like that. It should be beefy red, healthy red. It's a vibrant, vibrant Valentine's Day red. That's new tissue that just lacks an outer layer of new epithelial. That it's all healing. There's so much good things when you see one of the healthy red beefy. Not to be confused with a maroonish beefy red which is usually a sign of infection or a stalled wound and healing um also on this granulation photo you see that little pink island that's an epithelial island um that means that the wound is super healthy everything's doing exactly what it should be and you actually have healing occurring within the past see I got into wound care in like 2010 within the past it was before I left that so like 2017 between 2010 2017 they really figured out a lot about chemical messengers in the wound bed the edge of the wound and the base are actually two separate things that communicate to each other with chemical messengers in the wound bed I'm not going to get into like metalloproteases all the complicated what they are but they communicate with each other skin cells migrate across the the epi or the granulation tissue and they have a place they're supposed to be a lot of people think wounds heal from the edges in it's really a joint effort um most wounds and you'll see this in a lot of wounds you start paying attention to um once they start healing they the body likes to heal things in the round so that big leg wound you see on that granulation photo will start to become more and more round as it heals and eventually just kind of seals itself up um all wounds heal like that if you stare at them long enough you'll see it we're gonna skip the next one slough and go for the one that's super duper easy is in the chronic necrosis means death that black skin in the center is rock hard it is completely dead in that wound we don't know how dead it is we don't know how deep it goes that's a heel it could go down to the bone we don't really know so it's hard to say what's happening underneath of there there's some telltale clues you have some some healthy skin it I guess it like what would that be like seven or eight o'clock little pinkish skin it looks like that's just a cap of dead tissue but without removing that entirely we wouldn't know and we would never do this on the street we would never do this in a real situation you basically leave dead tissue on heels as long as it's stable some of the the bad situations you may see at this point if you push on that gently typically they don't hurt but if you push on it and putt comes out or goo comes out or it feels soft and fluctuant meaning that there's something underneath the surface that that's something that your participant will need you know care sooner than later for that you have an effective process going on you have like a wet necrotic layer bacteria loves necrotic tissue it's basically what it thrives on it's dead protein if that were to get wet it would be a great host for a lot of different types of anaerobic anaerobic bacteria underneath those where you really got to worry about your anaerobes getting in there and and wreaking havoc especially on a foot because you have different bacteria on your feet so now we're going to talk about slough slough is one of the biggest things most people get confused with our participants will all say your wounds infected this is a good picture of it it is that yellowy brownish ruddy looking slimy there's adherence slough and non adhered slough it's just dead tissue it's a product of inflammation it occurs in in most wounds large wounds you'll see it it's not necessarily a bad thing typically it means the wound might be able to be managed a little bit better but it's not typically a bad thing wound healing doesn't occur where it's adhered and stuck there but our body actually produces chemicals that help cleave it meaning it it helps it be removed from the body slowly when the wound bed is completely covered in slough that's when you know wound care would have to step in in a facility or a location and do a little bit of debridement and there's different ways of doing that I'm washing with a simple washcloth I'll cover this later soap and water and a clean washcloth is considered mechanical debridement that would work like I just want to scrub it right now looking at it um and wash it like you're washing a two-year-old you don't want to scrub the skin off them they got the thin skin but the two-year-old gets into some messy stuff so you wash it gently but enough to get some of that crud off um the body like I said does it naturally there are times where you may need a little boost from like unnatural ways of doing it but the reality is you'll see this on your wounds it's not necessarily the end-all be-all infection does like that tissue but when you see it first it doesn't mean the wounds infected let's keep that in mind because slough will pop back in a lot of times and it usually makes our participants super super nervous so this is something that over time you'll start to recognize as people taking care of people that are in the worst of cases for themselves a lot of these really aren't an option a lot of these happen naturally outside of their control there's some things as harm reductionist or care providers working in a harm reduction setting can help augment there's some ways to work within the system and you know within Maryland our syringe program if we give out food which isn't allowed but if we say it's for wound care and it has a high protein count we have nutritional bags we give out with it's last time I counted one of our bags had 48 grams of protein in it and they were simple things like a shelf-stable yogurt like a tuna can with crackers like a soft granola bar because we have to think about our friends without teeth a protein shake that actually we tried a couple different ones that actually tasted okay that people like and that's how we got around it so there's ways to work within your system whatever that might be getting some nutritious foods out but anyway um these things that delay wound healing nutrition is a huge one and that's why I kind of sit on it because that's something that we might be augment sharing and reusing needles it happens even if people have you know a thousand new needles sitting in front of them they're still going to reach for the simplest thing in a time of desperation and that might be someone else's needle it might be reusing their own needle this is an education point this is something we can push home is like hey we have so many new needles please every time you hit the skin use a new needle and on to that always remember our syringes people are injecting with were never intended to go into veins for those of you that know and those that might not you know when you with gauges of needles the lower the number the thicker the wall and the thicker the the bigger the needle itself the bigger the barrel the center of the the actual metal part when you're using a lot of these insulin syringes and again they're meant for insulin to go right into the you know the outer layers of skin just into that sub cue area when you're using these you're using like a 29 gauge or a 30 gauge they're super tiny the center of that hole is super tiny to make that hole tiny and comfortable for insulin injections they thin the metal down they coat the outside of insulin syringes with a hydro hydrophilic coating and it's kind of not marked on the syringes it's it's a comfort injection needle it's sometimes it's called something about comfort or easy injection the reality is it's meant to be wet and it becomes slippery so it doesn't get hung up on the skin or hurt all of these things combined do nothing to the breakability of these needles if you drop one of these syringes it just snaps off if someone bumps their arm while they're injecting it just snaps off inside the body so we really need to be mindful these syringes were never intended to be put into veins your your best vascular access folks are people that are career injection drug users they use the worst tools to get into their veins every single day that being said soiled skin what we're talking about with this soiled skin isn't so much like just generalized dirt or unwashedness it took me a while to realize you don't need to wash every wound you don't need to wash every every bit of skin doesn't need to be scrubbed down you're removing your own biome your own protective barrier this is really about soiled skin as in a stool and urine we had a gentleman sitting in his tent he didn't leave for almost three weeks he said he couldn't walk I wasn't sure what the whole ramifications were but he never left the tent he would just soil on himself and he just put more blankets on top of him the fire department had to get him out and lift him out and like firefighters were getting sick and stuff and they said it was awful but he had wounds all over and that's just from the pH differences in urine and feces um so that would be soiled skin advanced age that fella was also almost 62 as as you get older collagen changes in your skin skin becomes a little less stretchy a little bit more less supple if you will age really plays a havoc when you get to be I think they said now 45 and 65 are big changes for the body the human body and 65 things really do change a little bit more with the skin smoking smoking does a lot of negative things to the body we're really concerned with what we're doing with blood vessels nicotine is a vasoconstrictor it means it clamps down decreasing oxygen flow to wound beds decreasing healthy blood flow to wound beds really makes it complicated to heal because that's where all your nutrients come from comorbidities your heart kidney problems everybody's got comorbidities again with your aged population back to the gentleman in a tent he had a lot of other comorbidities that he was in denial of like he had arthritis he had a bunch of other stuff that he was kind of pushing down and not really talking about it took him three three or four weeks to get resituated and to be able to come back but he got discharged back to the kind of tent village he lives in the wrong wound dressing this isn't so much as you're gonna choose the wrong thing because by the end of this the mantra you're gonna remember is pretty simple the wrong wound dressing is putting something on that makes something super wet and leaving on for too long or even using newspaper on a wound i've had to cut off newspaper from people's legs before that they've used as compression and the actual ink was impregnated into their skin it almost acted like a cast which actually helped with the swelling but it did nothing for the the damage to the skin um that's really what i'm hitting at with the wrong wound dressing not doing anything for your wounds is terrible attempting something is much better than nothing um even if someone washes it once a week that's great that's better than than not washing it at all uh trying to cover it with something simple is much better than and not covering it all i've already covered the the nutrition and this bottom this bottom block is near and dear to me because this was my very first hang up with a non-healing wound that didn't make sense um in that rural community and what was happening was somebody was selling chemo they feel like oral chemo um as antibiotics and it's not so much chemo as much as immune modulator but it's still in the chemo kind of category and their wounds were actually getting worse to the point where i was nervous of amputation they refused and finally one day they're like i'm like are you taking anything at like any herbal supplements anything and she looked at me she's like i do take these antibiotics i bought you know on the street but they come in a foil pack and i it was it was it was completely the reason the wound wasn't healing um within like three or four days of not taking them everything changed she didn't have diarrhea anymore her wounds started healing um so always keep in mind during that conversation that we have wound care is a very intimate thing we use our eyes we use our ears we use our nose to figure things out but you also use your mind and your heart when you're talking to people and i never thought i'd be that cheesy kind of hippie nurse but i it really is super important because the stuff we lean on when we're in a clinic setting is we lean on epic or whatever kind of um emr you have and you know that's your database you need to lean back onto your mind and your heart because the person is not going to share this information with you up front and sometimes you got to think about what you said last time you got to build that rapport and that relationship with that person and um it's kind of medicine the way i assume it used to be back in the day when doctors made house calls so we're now going to start talking about infections and this is this is one of those things where every participant that comes to you is going to say this is infected i need antibiotics this is infected i need antibiotic soap and oral antibiotics i need ivy antibiotics i want everyone to think about those terrible little infections you get if you clip your fingernail wrong um it's in the corner of your nail your finger gets super hot it gets really painful out of the blue um you may actually start sweating on that side your little perspiration on this side where it's swollen and eventually you get the courage to squeeze it and a little pinpoint of pus shows up at the edge of your fingernail everything i just described is everything that's here those are all symptoms of a wound infection and if we can remember that it doesn't need to be a massive like amputation bearing event an infection is simply your body's um battle if you will over the bacteria or foreign body or whatever kind of um invader you have in that area uh swelling pain redness around the wound your body swells up that inflammation is trying to go back into that healing state whatever the insult was happen inflammation occurs bringing all those white blood cells whatever it is isn't going away so you can't move to the next phase of wound healing so you bring more white blood cells inflammation occurs you bring more healthy red blood when things become inflamed they become swollen the swelling is really because it's allowing more red blood cells to the area to bring more oxygen what occurs is in that little pocket whatever happens in that little corner of your fingernail is a mystery to me but the results are some little bit of pinpoint drainage it may have a little bit of an odor usually it doesn't and that's usually because of the bacteria but pus is really just a bunch of liquid is dead back or yeah it's dead bacterial cell parts um it's part of uh your dead white blood cells that you know gave it their all and are no longer in existence um the the bottom one the skin becoming hard and thick if you continue having an infection there between the inflammation stages and the healing stage your skin starts to thicken up a little bit you'll see this on people that work with their hands a lot you'll see this really rough skin on the corners um other nails then let's go over to the leg wounds these folks have swelling legs that leak a lot through that process the swelling and and decreased swelling skin changes and it becomes really hard and thick chronic infections chronic burns will do this if you keep getting burned in the same area people keep getting sunburned in the same locations their skin changes where it burns real bad and i skipped over the increase in the amount of drainage this is one thing that whether you're a nurse you're a peer um you're just a passerby on the street like these are things that you don't need to be a medical professional to really really hone in on if you're giving if you work at a syringe program you're giving out bandages to somebody and they come in once a week and they get two packs of bandages then all of a sudden the next time they come in they're like i need i need three packs and i'll see you on thursday because this is my wounds really draining a lot that is a really good indicator that you want to kind of give that person to the next level of care whether you're a peer you want to give that person off to like a nurse or a nurse practitioner if you're lucky enough to have them working in your organization um if you have doctors handy just have them swing by um you know start that conversation with like you know like increase in drainage what happens is bacteria in the skin and that inflammation stage the body's fighting something that's swelling the pain all that stuff you don't even need to ask about those when things drain more something is causing it and with most of these large open wounds an increase in drainage i would bet my paycheck is um as is the beginnings of an infection or you're already depending on how uh honest or how well the person describes that you're already in the middle of an infection um so this is one of those things that you don't need to be medically trained when someone says i need more dressings because it's leaking a lot that's when you start reaching out to your resources that's when you start thinking about where can we go next and you can't talk about infection without really talking about sepsis um sepsis is a medical term it really what sepsis is is an inflammatory state inside the body where it's a negative feedback loop um inflammation causes more released chemicals cause more inflammation cause more chemicals and eventually your body become it lives in this inflamed state and starts shutting down um the icu i worked in we were the medical intensive care unit we handled all septic patients and all respiratory failure um sepsis leads the respiratory phase so we got all the kind of the sickest folks in the hospital were coming to us sepsis is nothing to laugh at it moves extremely fast um we did find my last job we found one guy that was kind of they don't use the terminology anymore like pre-septic or cold septic um there's old-fashioned medical terms but it really was he had fever he was breathing super fast he talked about feeling faint and passing out so the icu nurse in me sprung because that's typically a sign of low blood pressure that dizziness and fainting that's not drug related um these folks are troopers these folks have been doing this for a while they know when something's drug related or not they know with the chemicals they're putting inside their body so having that building back on that rapport part is super important but what lay people can do that aren't you know don't have a stethoscope that aren't feeling pulses if you see someone panting um if you touch them and they're really hot to the touch and they're they have chills or rigors they're shaking so hard or they actually feel cool um damp and clammy you don't even need to think about the heartbeat these are typically signs of a pretty serious infection going on they need help um when they start getting into the nausea vomiting diarrhea that's all stuff that could be dope related or opioid related a lot of the symptoms for a serious infection replicate when someone's going through withdrawal so this goes back to the rapport um people know me right early because i say the same things like signs of really serious infection nausea vomiting diarrhea fever chills um etc that's not drug related tell me about the last time you were in withdrawal do you know how that felt people it's a visceral feeling for folks they go right back to it then they'll start talking ad nauseum about it then you ask them do you remember last time you were sick most folks you know you don't really recall how sick you were and stuff some people do but you need to get it through that it's not that dope sick it's a different sickness um and as soon as i say it all the time the folks they're very used to me saying it and the dizziest fainting part is the one that like i that's a medical emergency about to occur um because that's a drop in their blood pressure uh most people get dizzy and faint because they don't have blood supply to the head um the blood pressure isn't enough to keep the body upright and stable so all of these we this is something that we can't stress serious this is the medical emergency when it comes to dealing with folks in the street um most folks when you find them like this are not sitting up talking to you one of their friends is bringing you to see them um that's how i found that fellow someone said you know someone who's not doing well will you please come look at him um typically when that occurs something bad is happening. The guy that wouldn't leave his tent, one of his campmates, is the one that came and got me. You take that very serious. For every three or four you go on, there might be one that the person overreacted, but the reality is folks are in that protective mechanism, and they're in the heightened state of safety. They need to feel safe, and they're aware of all the bad things that can occur. When they're asking for help, it's probably super bad. Now we're getting into the fun part. I always like this slide, because this is the other side of the game, because now we're getting into the wound stuff. When addressing, I always tell people, look at the dressing when you take it off of somebody. It might be makeshift. It could be a t-shirt. It could be an ABD pad. It could be gauze, whatever. Glance at it. I need you to look at it. It's gross. It's like looking at a baby's diaper. You're like, ah, this is gross. The reality is that's going to tell you a little bit about what's happening in the wound. Depending on how long it's been there, it might have an odor to it. It doesn't necessarily mean the wound smells bad. It means the dressing smells bad. All of our dressings are made predominantly from cotton, or a cotton derivative in some form. Something super absorptive, cotton. It might be a synthetic package that holds it, or a weird polymer kind of thing. But the reality is cotton is the most absorbent thing we have. It's easy. It's cheap. Gauze is made from cotton. When our body fluid sits in that long enough, the body fluid breaks down. One of the main constituents in drainage is protein. When protein breaks down, it turns into ammonia. Ammonia will start to degrade cotton. Between all the funk that's coming out of that person's leg wound, the cotton degrading and decomposing, it smells horrible. People are like, my wound smells bad. I always tell folks, I sit on the floor right next to them on the ground. I'm like, let me be the judge of that. Do you mind if I take off your dressing? Do you mind if I touch you? I always ask permission. Do you mind if I take off the dressing? If it's stuck, will you take it off? I'll look at the drainage and I'll put it in a plastic bag and tie it immediately. Nine times out of 10, that eliminates the odor. After you gently wash the wound, even just with a wet piece of gauze, the odor's gone. It's because it's on the dressing. So keep that in mind. With drainage, you have different types. These are a little bit medical term. There's no easy way to describe these other than like cirrus, it's clear. It kind of looks like snot on this picture. It's kind of gross. It looks like someone spit on it. Sanguinous, sanguine, red, that's your blood. You might see clots in it. I think that's what the dark spot's supposed to be on there. Cirrus sanguinous, obviously it's a mix of the top two. And that's where you get that bottom left one. And pus. Pus can be a lot of different colors. One of my favorite colors wasn't put on here. It's blue. There's this bluish green color that's pretty amazing. When you see one type of bacteria makes it, it'll turn the whole wound this minty green color and the goop that comes out of it will be this minty green color. It's pretty cool. But these are the types of drainage and you'll probably see, we're not going to see them fresh enough to be like, oh, that's just cirrus drainage. If something sits on a body long enough, it gets that ruddy, dirty color anyway. It's a mix between the top right and the bottom left and a lot of stuff in the middle. This is just to be understanding. After you clean a wound, if you see fluid dripping out of it, that's cirrus. If you see that pinkish fluid, if you wipe it up with gauze, it's pinkish. It's cirrus sanguinous. That means there's some red blood cells mixed in. There's some oozing of red blood cells. If it's sanguinous, I've never heard a doctor be like, oh, that's a sanguinous wound. That's usually a fresh wound. If you see red, like bright red bloody, that's an acute wound. Someone got stabbed or they have like a piece of wood sticking out of their leg somewhere. Yeah, these are all different things to be aware of, but this is what you're going to see on your drainage. Normally if I was teaching this, I usually ask the class, Kelly, I don't know where she found the heart. I still think it's CG. I think it's like AI created, but that would be considered sanguinous. There's a clot there, like I said. It's bloody. The one on the right looks like loose lemon meringue. I don't know where she found this photo. It is the grossest bit of pus I've seen in a while. It just looks like lemon meringue that just didn't set up right. I stumped the doctor. He thought he knew what he was saying on this middle one. Um, everybody wants to say a serious sanguinous. It's actually, it's on a red background. It's serious that this is actually a yellow colored liquid because there was other pictures that went into this, um, this slide set that she grabbed these from. And it's just this yellowy clear liquid, but it's sitting on top of that pink. So there's a little bit of misconception. It's always fun to stump a doc when they think they know it all. Um, I hope no one's in the room right now. That's like that, but everyone knows someone that is. Um, so back to that, that slough picture, it's a little bit closer and this is where a lot of people get confused. That's why we made a slide about it. This is why I talk a little bit more than other slides about it. Um, past is made up. It's at liquid dead bacteria, different cells. Your body is processing whatever bad stuff is happening. It may or may not have an odor. It may or may not wipe off easy. Um, typically it's runny. The one caveat to that is sometimes pus can be wacky or cheesy, and that's a really horrible relationship to food. But there is, there are some types of infection and effective process that when you wipe it and leave the wacky sheen or like a kind of a gross cheesy, it's like you took cheese curds and mushed them. Um, and basically what that is, is a super, it's a super dry pus. Usually those occur around, uh, oil glands, um, sebaceous glands, that kind of stuff. Um, just know that pus doesn't necessarily need to be runny. It can be kind of gelatinous or goopy as well. And back to slough. So slough is that, that stuff about impeding wound healing. Um, it needs to be removed. And that doesn't mean by you, the body does a good job of it. Um, I wouldn't mess around with the wound that's there. I would, I try to wash it if I had the ability to, um, it's usually an off white color and it's more of that yellowy Brown. I didn't know what color, how to describe that color perfectly, but it's that color. That's a great example of slough. And sometimes it looks like a jello. You might wipe a wound and all of a sudden it looks like the edge of the wounds coming up and you just keep wiping away from that edge and all of a sudden it just rolls and it's kind of gelatinous. Um, kind of like the, the, I guess the, the gelatin that can form on a gravy skin when you put gravy into the refrigerator and you can pull it away from the edge. Um, most times these are really, these are pretty well attached unless the body's processing it to come off. When it's gelatinous like that, you can just roll it away from the edge. Um, and this is why I always talk about wound washing is this slide. So a lot of us, myself included, um, as we're asked to put together a wound care kit and there's always like five little pink bullets or four little pink bullets of sterile saline or, or sterile water, whatever, cause they're convenient. Um, that's 20 cc's of water. That's like a big, large bore, a syringe full of water. It's not a lot at all. If we think we're washing a wound or anyone's really washing a wound by squirting one of those at it, we're all kidding ourselves. The only people that makes, the only people that that feels better for is the person that's squirting it. Cause you feel accomplished. You're like, I emptied out two of these little bullets on this wound and it must be clean. Um, your best bang for the buck is using little pieces of woven gauze, the stringy kind of gauze, using those, wetting those and actually wiping the wound bed with them does so much more for the wound than just squirting these little bullets at it. As I was giving these trainings across, you know, most of the U S I would get people to raise their hands. Most people give out those little saline bullets. Most people squirt them at the wound. And no one ever thought that that doesn't clean. The wound is the size of your calf. That is, that's given a whale a tic tac. It's not going to change the scent of their breath. It's a joke, but using the gauze to clean is really good. You don't necessarily need soap unless you have the ability to use soap. Um, non-antibacterial soap, regular soap is great. Um, if we're in a bougie world, dove liquid soap, the, the, uh, the hypoallergenic one, um, it's, they used to be dove free or something and they changed it. There's a mild scent to it now, but it's supposedly it's still hypoallergenic, which scented materials that things shouldn't have a scent. Um, I always tell people don't use your bath and body soaps to, to wash wounds unless that's all you got. Um, a wash, like a washcloth and water is fine if you don't have soap. And we always have to remember to rinse our soap off. A lot of groups will give off those little, those little pills that turn into towels. Those are great. They take a lot of water to open up though. So you're going to use like half a bottle of water to open it. If you're giving out bottles of water for wound care, just be mindful that it takes a lot of water to open those compressed towels. They're like little pill towels. There's a picture later on of them. So the next, the next confusing mark for wound care is the difference between an abscess and cellulitis. So we're going to talk about them. Um, an abscess is just a collection of pus. Think an acorn underneath the skin full of pus. A lot of times it happens at injection sites. Sometimes it doesn't. Um, they're kind of a pain in the behind to figure out what caused that abscess in that location. They usually start as a little red bump that's underneath the skin that might be tender. Abscesses take time to form. Abscesses just don't blow up in a day. An abscess is actually the body processing something isn't right and you see it's in that top two layers of skin. It's not deep. Abscesses are really superficial. The idea with an abscess is to get it open. It's a, abscess is really a glorified pimple if you will. Um, the body processes the abscess and tries to push it out on its own. That lump will start becoming more superficial coming to the surface. Um, the World Health Organization rates giving antibiotics on the same level as warm, moist compresses. As a wound care nurse that cannot prescribe, a warm, moist compress is usually easier to provide for my patients than finding a nurse practitioner or someone that will give them antibiotics for abscesses. If going about the warm, moist compress, it's 15 to 20 minutes on. It makes sure it's not too hot. Um, and take it off. If the person is housed or sitting in a like a community setting with a house, I tell people to put a warm, moist compress on and then take it off during the commercial breaks of a television show. And that's just so they don't burn themselves. Um, it works by causing more inflammation in the area and it, uh, brings red blood cells swelling and the moisture from the moist part of the compress actually softens the skin in the center. Um, much like a pimple, little whitehead, the center will thin out. It's the thinnest point between the pus pocket and the outside world and the body will eject it. Um, the idea when they open that that's key in treating these and that's the opening and draining of it is actually what puts it on par with antibiotics. Antibiotics will treat it inside the body and sometimes not allow it to rupture when it's open and draining out. Um, we always just tell people the drainage that comes out can be infective. You might be able to spread infection throughout your body, like once like in your skin. Um, so like throw those dressings into a plastic bag, throw them away in the trash can, wash your hands really well and try to keep the area draining. That means don't let it dry out to air. If it dries out to air and it reseals and you need warm, moist compresses to keep it open. We've never had issues with this in the population that was treating in the population I'm seeing in Baltimore city. Um, keeping a, people have a way to find warm, moist compresses somehow and they work. Um, in my time in the five years working in the rural community, you could count on one hand the amount of times I would say someone needs to go get antibiotics. Um, and I would always err on, I'd be cautious with that recommendation because a lot of people, when I say, look, I'm really, I need you to go, you know, go to urgent care, go to patient first, um, whatever your urgent care is or the hospital, you might need some antibiotics. They'll say, sure. Then I would come back the next day and they won't be where they were. And I assume they made it to the hospital when in reality they would be hiding from me because they'd be embarrassed that they didn't go. So I know you guys have community health. You guys have health in the truck with NPs that are there with you. Use them, use that relationship building, um, momentum you have with your participants. And you know, if you're a prescriber that prescribes for abscesses, please like communicate well, make sure your patients are getting it. A lot of times people have 50, that's where the warm moist compress is. Like people were cool about it cause they felt like they could take care of their own, their, their own healthcare. Um, and then I always tell folks, if you're spreading more, if your redness around it grows more than an inch an hour, you need to immediately seek care cause that's an infection that's spreading to a cellulitis. And we'll talk about that in a minute. Here's the minute. Um, this picture looked better on the computer screen regularly for whatever reason, as many times as this thing has been put into a PowerPoint, it's kind of washed out. You can see better, better delineation with this, but cellulitis abscess sits in them top layers. Cellulitis is full skin infection. Um, one of my buddies was on an infectious disease, uh, cellulitis consult team at Hopkins and they found that a lot of doctors will over diagnose cellulitis. Um, there's another type of skin infection. That's the outer layers of skin that looks a little bit like this, but the edges are different. The edges to a wound tell you a lot. It's not for this group to know, but it does tell you a lot. One infection, topical infection, the other cellulitis deep down. Cellulitis is a medical emergency that requires hospitalization and IV antibiotics. Um, everything that's red is not cellulitic. If both legs are red, typically not cellulitis, that's typically a vascular issue, but a lot of docs will, will diagnose because it's red. Then when the patient's sitting up with their legs up, all of a sudden the swelling goes down, the redness goes down. The minute they stand back up, redness comes back, the legs start leaking and they're bright red again, but true cellulitis, that infective process can spread to the body very fast. It can spread to septic. That's why this is something that it requires IV antibiotics and treatment. Um, it's not our place as, as, as a nurse or, or, um, uh, peers to make these diagnoses when it's red, hot and swollen. That's when you bring it, you bring it up the chain, you show it to somebody else. You make sure someone else is laying eyes on it. That's smarter than you are or more skilled than you are. And I say that within the biggest part possible. Um, we need to recognize where our place is in this care pyramid. And we all work as a team. We move as one, we work as one, and we relate to each other as one. Um, this could save this person's life. Getting early intervention doesn't necessarily happen on legs. Cellulitis can happen on any part of the body. It can be extremely hard to the air to, uh, harden, uh, skin in the area that's red. Um, it's extremely painful typically, and can cause a lot of like, uh, damage. It takes a long time to heal post cellulitis. So this person may get out of the hospital and still need pretty advanced follow-up for their wound care. All of the skin typically has a tendency to die where it was infected. Um, it usually takes like a good week or so of IV antibiotics. A lot of people with true cellulitis may end up in the ICU or a PCU for this. Um, and it can be a, it can be kind of quite a bugger for the person to make it through. So this is something we do see. We don't see it quite as much as, um, we used to. And I think it might be what's in the drug supply a little bit, but, uh, we don't, well, I don't quite see it as much as I used to in my time in those five years, there were very distinct cases in two different houses of cellulitis. I'm not quite sure why. I think there was environmental factors like cleanliness that may play into this. And they were sex workers. They had, um, say latest on their leg and they refused to stop working. Um, because that was their main source of income, uh, for their habit and eventually pain and feeling just like dog crap was what sent them to the hospital. Um, and they, they remained, they kept their legs, everything else. They've stayed in the hospital. The one girl stayed in for two weeks, uh, trying to get under control, but this is, we can't, you can take a horse or whatever. You can't make them drink as medical staff professionals or team players with folks that use drugs. We can't force anyone to do anything. There's a lot of burnout in this, this field because of that. You tell Mr. Jones that Mr. Jones, if you don't do something about your arm, you're going to lose it. The only time you can force someone to do something is when they're unconscious. That's when a medical emergency becomes your emergency too. So we can't force anyone to do anything for themselves. And I had a very good friend that I buried two weeks ago that, um, I was in the wall street journal and I chose him to be the patient. Uh, he, he admitted he wanted to, and he was really close to me. He ended up losing one hand, both legs due to xylosine. And when he passed away, he was at home with his mom and his rib cage was exposed on the left side. The only thing, only limb he had was his right hand. Burying him was tough. And I knew it was coming. Like I knew, I, you knew it's going to happen. So burnout happens. You can't force people to take care of themselves. You can only provide that care, love, and understanding of where they are at that moment and be there when they need it, be ready for it. Some other fun things you might see. And this slide is really important to me because as I came to Baltimore city, we learned that healthcare suck. We have two major teaching institutions in the city of Baltimore, Hopkins and university of Maryland. And I'm going on record as saying this, we have two of the greatest soft tissue clinics, the greatest public health teaching institution, but Baltimore city health is terrible and it shouldn't be. So what I'm learning is I'm seeing less xylosine wounds. So many more diabetic foot ulcers are not so much arterial wounds yet. And venous ulcers on a population that feels disenfranchised from the medical system, the older African-American population that just doesn't want to mess with Hopkins or university of Maryland. It was a big eye opener for me. I'm helping people with venous issues, uh, seek out care that, you know, that's appropriate for them. I'm treating people with like partial, uh, like transmetatarsal amputations where their prosthesis in their shoe doesn't fit right. And it's rubbing and has been, they had last time they got prosthetic was, you know, like 20 years ago. So they're hanging on by a thread to something that's, they should have gotten a new one, like every two years, you know, had their foot measure for it. So all of these things play into this. We're going to see this. I think I, I was slapped in the face with it because um, of the, the massive amount of resources and the disconnection of a community from it. Um, so this is really important. Know that every hole in the body isn't from drugs or infection. Uh, diabetics can't feel the bottom of their feet. That's typically from bad footwear. Sometimes your feet change from a lack of feeling neuropathy can sometimes change your feet to hammer toes and the bones change a little bit. Your feet don't, your footwear doesn't fit. Um, that's a mess that can lead to serious infections or foot loss. Arterial ulcers. It's when the blood flow, the healthy blood, the oxygenated blood doesn't get to the toes that can mimic frostbite that can also mimic hitting an artery injecting xylosine with fentanyl can cause those same kind of dead toes. And then the venous ulcer, I've seen more mixed venous wounds with xylosine wounds in people's legs than I could shake my fist at. Um, venous ulcers have a tendency to be from shooting up in the legs, at least in this population and damaging the valves. Age related venous changes also occur in every human being. Those nursing students are on this line. You're going to get swollen legs. Trust me from standing on the floors. It happens. I made fun. I dated nursing students when I was originally in college and I'd laugh at them because they were in compression stockings. The best thing I ever purchased was professionally fitted compression stockings for me where I worked in the ICU. It was a godsend for swollen legs. That's just our veins take a beating. Staying on those hard floors with shoes that may or may not be the best shoes for doing the job we're doing. Eventually the veins take, you know, take a beating. Our friends that inject drugs damage the valves, the one way valves that sit in our legs and swelling occurs. You'll see folks with swollen feet, swollen ankles, that kind of stuff. I'm mixing xylosine on top of it. They'll get a wound there. And next thing you know you have this wet xylosine wound and they don't go together. So that came from my skill with like, you know, almost eight years of wound care, working at a wound center, understanding things can be mixed, but you'll see these there. I'm not expecting anyone to diagnose these. Just know that venous issues are all over our community. So, um, when my friend passed away, his name was Nate. When he died, I realized all of the pictures of people that I use are dead. Every single person is gone now. Um, and it happened in two years. So this young lady is gone as well. Um, this is the same woman's foot. There's about a week and a half difference between the pictures on, um, the left side to the right side. These are xylosine wounds. The green and the red arrow on our first picture on our left, those are pointing to two different presentations of xylosine wounds. The green is pointing to a center that's blanched out, meaning there's no blood flow to it. Um, and a red ring around it. They have a tendency to be a little bit more round. Initially, the red arrow is pointing to the other type of presentation. That one is pointing to this blotchy. It almost looks like, I forget the name of it now. It's escaping me, but like children have those birthmarks. It kind of looks like that. Irregular borders, um, circular in some way, shape or form, but very irregular. And the difference is the outer layer that the arrow is pointing directly to the center of that milky center. It's actually a blister. The very top of the epidermis blisters up with xylosine wounds. The, um, the, um, the golden arrow is pointing to something very unique. That is a non-injection site wound. And I'm sure you're going to say, how do you know it's a non-injection site? Because I was treating arm wounds for this woman. Um, because the health department was taking care of her not so well. It was a nurse that used to treat people with a cigarette hanging out of her mouth. She's retired. Um, and they weren't using the dressings properly. They were using dressings that are meant for very clean wounds. Um, and her wounds were not, and they were, they weren't doing so well in our arms. And she asked me if she, cause they hurt really bad. I don't care if people use drugs in front of me. Um, I'm a different kind of nurse in that sense. So I watched her shoot up on her foot. She hit the vein each time I watched that purple spot appear and never had a needle in it where the golden arrow is pointing to. Um, we've learned over time, if it's purple, it's already dead. Um, that is death from the, from whatever's causing xylosine wounds. There's a, there's some prevailing thoughts and some research coming out. And I would be a terrible research nurse if I shared what the research is showing, but it's pretty technical why these wounds appear. Um, it's, it was way out of my pay scale, why they feel the wounds happen. Um, it's complicated. I don't fully understand, but just know that it's not something as superficial as xylosines, uh, a vasoactive drug. It's way beyond that. These wounds that initially start are not infected. The drug is causing something inside the body to create these wounds. They don't necessarily need to be an injection sites. They don't necessarily have to be in the same limb, which is even crazier. Um, traditionally they don't form in the face or the body. The body only forms if you inject in that site. Uh, we had a young lady that was injecting in her breast and breast. Isn't that, um, it doesn't have the greatest blood flow. Uh, she had, she had somewhat larger breasts and that's a lot of fat tissue and xylosine was just melting it away. It would run out of her body. Um, she kept thinking the blue veins that she was looking at. She was getting, like she was hitting a vein and she wasn't, it was terrible. And when I left that job to come down to Hopkins, um, she had probably a quarter of one breast left on her body. Um, and I'm not kidding. I never took pictures just because I was in shock and all I have no problems taking pictures of people's wounds if they give me permission. But every time I saw them, I was in complete shock and all, um, it was, it was the craziest thing to just know that xylosine wounds don't truth. They don't necessarily happen in the trunk unless it's an injection site, breast stomach, that kind of thing. Um, they can, they, they can become infected over time, but traditionally not so much. And the treatment, this is so stupid. Keep it covered and keep it moist. So that's the mantra. I need you to remember as non, if there's any peers on this or anybody, you're not going to do wrong by just putting a little Vaseline on a bandage and covering it. That is safe for all wounds, all wounds. You're never going to hurt by keeping it covered and moist underneath of a scab that our body's creating a scab is just the body's own dressing underneath of that. It's, it's moist. It's gooey, gross, slimy stuff, but it's moist. It's keeping the wound bed moist. Keep it covered. Keep it moist. Keep an eye on it for changes. A lot of people enjoy injecting into the xylosine wound itself. When they inject into the center of these wounds or along the edges, when they pull back, it looked like blood. It's really inflammation mixed with fluid. So it's inflammatory. Um, edema basically. Uh, it's not quite as dark as blood. It definitely has red blood cells in it. You have wound kind of drainage in it and it looks to someone that's really desperate about getting high. It looks like they're in a vein. It's really similar to skin popping and it creates more xylosine wounds. I can tell you probably nine out of 10 times you show me a wound. I can tell you people are still injecting into it just based on the healthiness or unhealthiness on the right hand side. That's about a week and a half later. You see all the wounds somewhat look alike. They heal this in the same trajectory. The dry crusty skin on the green arrow underneath it is just like the red arrow on the wound that appeared without an injection site. Same thing. And you notice there's new xylosine wounds on her ankle. Um, this young lady passed away because she was buying drugs from someone that went to the VA. He got his drugs cut off at the VA cause they found out he was selling his Xanax. He started buying from a biker gang. The biker gang said they were real, but they weren't. Um, they looked real. They passed the real test for me too. I sent them out to get tested. Um, it was fluber mazelam, which is an experimental, uh, Benzo, and about enough xylosine to kill a horse. So when she was injecting these, she would inject a couple Xanax bars and she just never woke up. Um, whenever she would ask me if these pictures are being used, I always told her, I would always use these photos with her memory and that she's helping other people not get these wounds. And it would always make her, her name's Amber, make her super tickled. Um, so that's why I always bring her name into this and show this. I have full consent to use these two by, by the folks. So these are early, you know, which ones are early. You see the white rings with the red, uh, outside and then the red center. And then the one on the right is looks horrible. And the reality is those can be healed. The body's already trying to heal those. This fella injects into his wound beds. He does skin popping how by the scars on the backs of his hands and up his arms. Um, he doesn't necessarily hit a vein. He just injects into the subcutaneous tissue. He's been injecting into the wound beds. A lot of hospitals will take this person into a surgical debridement, um, and send them back out. They're just sending them back out with giant open, clear platforms to keep injecting into. So that bounce back is pretty high. I'm keeping these wounds covered in moist. I would be like 90% confident. These would heal if we could convince him not to inject into them and maybe give him some tutelage on, um, proper injection sites. On the other side, that centerpiece, a lot of patients will call it a plug. That little red, the redness around that isn't necessarily from infection. The body's trying to push it out. Um, it is dead tissue that flush with the skin and is different than other types of dead tissue. Typically dead tissue happened from an injury or an infection or something along those lines of pressure ulcer. The edges are not connected and it makes it easier for the body to express it and start healing. The body's trying to heal and that's why it's turning red around it. Um, this was a young lady that all we did was cover that with a little Vaseline and a bandaid. Um, like three or four days later of doing that it popped off on its own and she healed up and then we kept the other ones covered in the same bandaid and everything healed up well. So this is kind of after Kelly spoke with me, this is what we do for wound care. Um, this is kind of like using your eyes, using your nose, um, and really using that communication process. Not going to dig in too deep into this, but you really just want to look at the wound to look at all this stuff we just discussed. Is it healthy? Is it granulation tissues, epithelial tissue, that kind of stuff. Um, is it wet, dry or moist? We want it to be moist. A lot of times we're going to see them super dry cause the participant doesn't keep them covered or you can see them super wet and they need some intervention as some way, shape or form where they need super absorptive dressings, like extra pads to be sent home with them or they need some sort of intervention like antibiotics. Looking at the edges that I really don't talk about this much cause I don't want to get lost in the weeds with this. The edges of wounds should look like an edge of a wound. If you imagine what an edge looks like, that's the way it should look like. If you see tunnels, holes, if you see little tracks leading up into the wound, those are signs that things aren't right and they need more advanced medical care. And for the, the wound itself, you want to pay attention to the skin around it. We don't want to be giving tape to somebody with really thin skin or skin that's seen a lot of damage. Um, you're going to create scarring, you're going to keep ripping the skin that goes for people in the hospital too. You don't want to, you know, you don't want to put really strong tape on an old person cause you're going to rip their skin. Um, just trying to reposition it. Um, is it wet? Is it raw? They've been keeping a dressing on it for the past three weeks and is all the skin denuded, meaning the outer layers are gone or they're macerated, they're wet and kind of dissolving. Um, we want to change our dressing. We'll think of something different to protect that. You want to, when you're taking their dressing off, look at the drainage, pay attention to what's on the dressing and also what's coming out of their body. Is there an odor when it comes out of the body? Um, is there a large amount of drainage on the dressing or dripping out? What color is it? We want to go back to that. Is it bleeding? Is it bloody? Is it, you know, pus filled, that kind of stuff. Um, and we're going to think about wound treatment and this is where we get into like, what are we going to do for you? Um, because this is for a varied audience. Some people, some places are well, uh, endowed with money. Other ones aren't quite so endowed. So we kind of put everything on here. Um, Bosh is a, a wound cleanser. That's quite costly. Um, the Columbia team was putting together this like, I think it was like $72 for their wound care kit, but they got a huge grant. They were putting together these like really bougie kits. Um, and big bottle of Bosh in it. Bosh is like $24 a bottle of like, I think it was like 16 ounce bottle. It was super expensive. What we found is most participants will empty it on the first time they change their dressing and not use it as a cleanser or soak gauze and clean with it. Um, so I can't recommend that, but in a wound clinic or mobile clinic, Bosh is an option. Um, especially when you have ties to a big, um, like teaching institution or teaching hospitals. Um, they may have it on on par with your supplies. You guys can order, uh, soap and water, really simple. Um, any soap, pink soap works fine. Like you just want something. If people are, have allergies and stuff, just be mindful that, um, ointments, it's a contact layer. What are we going to put on there? We're going to use honey. I don't like honey and I'll explain why later. Um, honey is a good choice if you're in a facility, in a detox facility, in a treatment facility, in a hospital, honey kind of runs the, the, kind of ruins itself when you get out into the field. Um, and the ointment is just an emollient. Um, they use it for diaper rash, Vaseline's cheap, dirty, and easy. It's so simple to use. Um, Bacitracin, Neosporin, Polysporin, those, they come in a little packets. People are allergic to that and can develop allergies. We put it in our wound care kit because people ask for it. And they're pretty insistent on using it. The reality is it's not going to do that much. It's not going to help as much for these larger wounds. And you do better with just something simple to add moisture, a moisture donator, like, um, like, like a Vaseline or Vaseline type dressing or oil impregnated dressing, those kinds of things. Um, what do you use? Does it need a lot of absorbency? Does it not? And how do we secure it? Are we going to use tape? Are we going to use, um, self-adhering gauze, like the co-band stuff or vet wrap or whatever they call it, where you guys are, or are you going to use a sock? Socks are great. I call them wound cozies. Um, everybody's got like a drawer full of socks that you're hopeful you're going to find a mate for and you don't, um, and they just keep growing. If you cut the end of a sock off one, that isn't like that, you haven't abused terribly. Um, they still have stretch to it. You roll them up and you put them on to like someone's limb, like a condom. Um, they, they can secure a dressing as good as, or better, especially in the winter when a little extra layer helps to keep people warm. Um, they work great. That's just a street-based care aside. Okay. So now when we're getting to the dressings, I want everybody to like picture in your mind, a Band-Aid that's a brand name. The Band-Aid like a million companies make things that look just like it, but really think about Band-Aid. Just that, that quintessential, weirdly peach flesh colors. Nobody's flesh looks like that. Um, dressing. It is an engineering Marvel for wound care. Dressings are all comprised of three layers. Every dressing. If you have a two layer dressing, you're not doing it right. Some people think just putting a piece of gauze on the outside of a wound, a piece of tape, that's not addressing at all. Um, there's studies and these are somewhat outdated, but bacteria can travel through. I think the last number was like 72 pieces of gauze stacked on top of itself in an hour. So the reality is we need to think dressings are always three layers. They can be more, but three layers. The outer layer is what secures it. We're going to start from the outside in. That on a Band-Aid, that would be the outside like that, that synthetic material they make or the plastic. Um, the plastic one can protect from dirt coming in. It has little holes in it that allows moisture to evaporate naturally. That's what those little holes, those little pores are for in the plastic Band-Aids. The fabric ones allow moisture to evaporate on its own. It's got sticky on the other side that secures it safely to the wound. It's not too sticky, but it's sticky. Um, the cheap Band-Aids, the ones you get, you know, like your, your facility may order because look, we can get three cases for the price of one case. Um, the adhesive on those is either crap or it's super strong. You can't peel it off. Um, like adhesive plays a really big part in a lot of wound care. Your middle layer in a Band-Aid is actually like a cottony layer. Um, if you think of that, that not, uh, not adherence stuff called Telfa, Telfa has this weird, shiny, plasticky layer on one side and it's got cotton behind it. That's kind of what a Band-Aid is. Band-Aids actually have a nonstick layer on that. It's called a contact layer. Behind it is the cotton behind that is the sticky stuff, the peach colored fleshy stuff, beautiful dressing. So compact, elegant. I mean, it's like perfection of, of wound care engineering, your contact layer. And by the way, Telfa pads stick. Don't let, and no advertising would be like, this never sticks. You always got to soak Telfa pads off. People are like, I got the nonstick pads and they're ripping the skin off. Cause they don't, they don't do the nonstick stuff. Well, um, your contact layer is like, you can put like Vaseline and gauze and then put a pad behind that. That would be a contact layer. You can put Vaseline on an ABD pad and the contact layer is really the Vaseline. That's what comes in contact with the wound behind the ABD pad is, is a, the ABD pads are meant to be nonstick as well. There's a, that, that, they're nonstick bag that whatever their cotton's kept in does a better job than Telfa pads do. Um, to make something super nonstick coated in Vaseline, put a thin layer of Vaseline on it, stick it right on the wound. It will still absorb moisture through it, but it'll also provide like a little bit of moisture to the wound bed and keep the edges and everything kind of sealed up and moist. Um, and I think layer is my favorite. The thing that seems to work best and is easiest for participants to use and continuously use and is safe across the spectrum for wounds is Xeriform. Um, we'll get into that in a minute. Um, petroleum, petroleum jelly, that kind of stuff. And the ointment. Uh, those are all great things. I'll talk about honey and Xeriform in a moment. Um, I had an aside for you. Oh, ABD pads. See, I always thought as a nursing student, I was told they meant abdominal pad, but it actually doesn't. ABD means advanced battle dressing. So when everybody says war doesn't, you know, nothing good comes from war, wound vacs, direct result of war. ABD pads, apparently a direct result of war. Um, the military designed ABD pads to be a quick battle dressing to put on highly absorptive nonstick and easily dispose of and easy to carry. I use them. We have cases of them in our office. I use them like ad nauseum. They tell you, you can't cut them. I cut mine all the time. You just put the edge you cut up so that the filling doesn't come out. I warn people like, Hey, you know, you mess around with this a lot. The cotton is going to come out, but, um, I love them. Anyway, that's my two bits. Those are those little pad pills at the top left under cleanse. You add water to it and boom, you got a towel. Um, they do take a lot of water to, to rehydrate. So be mindful that when you're giving bottles of water to folks for wound cleansing, just let them know that this pill is going to open up. It's going to give you a large towel, but it's going to take a little bit of water to do. Those are those saline bullets that people just squirt at the wound and miraculously cleansed. And the bottom is Vash. Vash is really a stabilized version of a very old wound care product called Dakins. Dakins solution is made with like bleach and baking soda and something else. Dakins is a non-stabilized version. Um, and when I say stabilize, it'll break down quickly, uh, into water and like chlorine evaporates off as chlorine. Um, same thing with Vash. Vash comes in a blue bottle cause it's a sun sensitive. The blue, uh, filters out some of the wavelengths that break it down. Um, Vash has been stabilized. Some grocery stores use a different version of the same chemical made by the same company to spray on the vegetables. Um, it rinses clean. It does leave a slight bleach odor in the Vash form for wound care. Um, it works great. It's just really expensive. The value for it, it lies in your clinics, um, that can reuse a bottle and not give it away to participants. Uh, you lose value exponentially when you hand it off to a participant, um, because they just squirt the whole thing on instead of using it correctly. Jason, your contact layers. The top one is zero form. Zero form is an old dressing. It's old. It hasn't been copyrighted. There's no patents on it. Um, it's one of those things that just always has been there's every company makes their own form is zero form. It is a linen dressing. It's a very thin, they call it a woven gauze, but it's actually a sheet of fabric. Very cheap. Think the cheapest dish towel and then make it like two clicks cheaper. It's super thin and it's impregnated with Vaseline and a naturally occurring element called bismuth in labs. Bismuth, bismuth, bismuth stops bacterial growth. The reality is it's really mixed as far as research goes, what they found is the most recent research is showing that the xeriform by itself in the form you're seeing there, that linen sheet with the Vaseline and Bismuth in it, is actually bacteriostatic. What that means is something in the bacterial wall attaches to the dressing itself and when you remove the dressing, you remove the bacteria with it. Bacteriostatic is just like it sounds. Bacteria sticks to it in like a static nature. Think Swiffer, but for bacteria. The kicker for this is it's occlusive. A little bit of fluid will go through that. The majority of fluid doesn't necessarily need to. A lot of these xylosine wounds and the wounds you see on the street just need moisture to be moist. They're usually pretty dry. We found that covering these xylosine wounds, especially a guy with both arms, if we cover it with xylosine, or xeriform, excuse me, and put an ABD pad around it and told him not to mess with it for three days and kept doing the same thing, all that dark hard stuff would soften up and come off. And underneath you'd end up with a healthy looking wound. There's a picture at the end of this presentation, I believe, it may be, I can't remember if it's in this one or not, showing a hand that's healed that way. A.D. ointment, again, baby dressing. It's the stuff they use for diaper rash. It's an emollient base, so it's a moisturizing base with vitamins A and D in it. And then metahoney. Metahoney is very expensive. The metahoney gel that you're seeing there, I think this is a one and a half ounce tube. Your one and a half ounce tubes are about $7 a tube. Insurance doesn't cover it. When your participant leaves the hospital with the prescription, they'll go pick up their prescriptions, if they're on Medicaid or Medicare, one of those, and then they'll be hit with a price. The price is for the metahoney. It's not covered. A lot of wound care dressings, especially like this, isn't really covered by, at least in the state of Maryland, Medicaid does not cover metahoney. Metahoney, it works great. Honey is a great wound dressing, it's been used since the dawn of time. Wound care is, we wouldn't be here unless people figure out how to heal wounds. If it were medicine, people are still healing themselves. Honey, so it makes it inhospitable for bacteria. It's concentrated. Honey is just the concentrated sugars and whatnot. The concentration causes fluid to go from an area of low concentration, like just loose fluid to high concentration to dilute it. You're pulling fluid out of that inflamed tissue, helping soothe it down on the wound bed. There's chemicals in it that are actually antimicrobial in and of themselves. There's one other one, I forget what it is, but it's in and of itself. It keeps the wound moist, keeps it, for the most part, microbial free. The issue with metahoney is, one, it attracts bugs. It is honey, plain and simple. Bugs will eat it. Flies love it. You see where I'm going with this? We had to move a whole encampment because the ants and maggots in people's wounds, because our health department in the community I used to work in was giving it out like candy, and everybody had it. They left tubes open. It was attracting ants, ants I'd never seen before, crazy big ants. Anyway, we had to totally relocate about seven people because of an ant infestation. We found maggots in the wounds and stuff. You got to stay on top of metahoney. It can cause increased drainage. If you're not changing the dressings appropriately, metahoney just becomes sugar on a wound. It's one of those things. In a facility, it works great. If you see the person every day, fantastic. You can take a peek at it. If it needs to be changed, change it. Honey works best when it's put new on. Leaving it on for multiple, multiple days doesn't do you any justice, that kind of thing. Yeah, like I said, facilities, outpatient, where you see them every day or you see them every other day, that kind of thing, but if you're giving it to someone, it's a very expensive dressing. Your dressings, your gauze, your demov... Yes? Jason, I'm sorry. I thought you were done. Oh. I just wanted to let you know there's about 25 minutes left in time, and there was one question that's in the chat, and it's, you mentioned occlusive dressings for three days for assisting in eschar removal, but for a more run-of-the-mill granulation or sloth, should we be using occlusive dressings? How often should we be having folks change them outside of the office? That's a personal choice on that. For me, I use the same dressing to keep it simple. We found that a lot of folks were selling the dressings we were giving and the health department was giving, and there was this whole underground market of wound care. I just went simply for Vaseline or Xeroform, ABD pad, and Coban, and cut to fit with the ABD pad and the Xeroform. They work great for granulating wounds as well. Keeps it moist, keeps it covered. The occlusive nature of the Xeroform works wonders for that. Your other dressings, if you have access to the more expensive dressings, by all means, use them. Use what you have resources for. The majority of this presentation was actually geared for places like On Point in New York City where it's less medical staff, more peers and whatnot, and to give them a taste test. But if you have access to the more expensive occlusive dressings, your silicone-based dressings and stuff like that, the full occlusive foam-backed stuff, use them by all means. It's really about what you feel comfortable with your participants. We have an issue, because we're outreach, we have an issue of not seeing the same people every week. We're in different locations twice a week, and I may go three weeks without seeing the same person. They're still doing dressing changes, but I can't give them the more advanced things that require maybe keeping an eye on it or that kind of stuff, or even knowing how frequently they're changing it and how many they need. We have a tendency to keep it simple. For me, it's keeping the cost down to make this a renewable resource as opposed to shoving everybody with metahoney and losing our case is all we got for the month. Hopefully that answered. From a practitioner point of view, laying eyes on it, you'll know if it's healing or not. You'll know if it needs more moisture. The edges are dry, crisp and brittle, it needs more moisture. The base is just tacky looking and not moist, it needs more moisture. If it's wet and dripping, you obviously need to protect the edges and maybe less occlusive, a little bit of absorbency might be needed. This is going to be available to you guys. The Ideal Supplies, this was created with the University of Pittsburgh. Myself and a couple other people were dabbling around trying to find prices for stuff. This was a couple years old, so these prices are going to be very different. This was just added in to give people an idea of the cost, what it is, and this is how some places will order things. They'll put down the item, what it's used for and the price on a sheet and update it as when they find clinical time or time to, they have a student or something that can update the prices so they can just order. Sometimes it's easier to order from Amazon somehow. A lot of times we found that ordering from McKesson, which is a wound care provider, some of the prices may fluctuate, but over time you're actually saving more money on shipping and getting the stuff product as you need it. You're not waiting for things. We still have orders out on Amazon that have been pending for like a month. So we found that ordering from one location, there's plenty of places out there, but McKesson for us in this area, it was the easiest and the fastest. And there's another slide of the same thing, talks about what we do, how they put it away, how they're giving it out. Different places do a lot of different things. I always recommend places to do what works for your participants. Don't let other places lead you and tell you what they need. Your participants will let you know what they need. Some places need like cleansing kits. If your participants are utilizing them correctly, then your participants need that. Some other places, we don't do those. We tried them and people didn't know what to do with it. It was just extra junk they would just leave around. We have a lot more transient folks that are unhoused and alleyways or tents, wherever they can set it up or disappear to. This is the wound healing part. This is my brain and this goes back to everything we've talked about. If the wound's dry, add moisture, zero form A and D ointment, petroleum jelly. If the wound's too wet, decrease drainage, ABD pad, baby diapers, and remove the little elastic sides are amazingly absorptive and relatively cheap. That would be to do more frequent dressing changes. Infected, we went over what infection looks like, antibiotics, medical treatment, keep an eye on it, and then necrotic, clean it out, metahoney. Metahoney helps with debridement because it softens everything, brings that excess moisture and helps flush it out, if you will. This is an example. This is not my wound care education. We have a handout we hand to people. I hate handouts. They just end up as trash. My education for folks is verbally. See one, do one, teach one. I'm a firm believer in that throughout my entire life, whether it's learning a new nursing skill or it's actually teaching someone something. If I feel like they don't know, I'll take the dressing off of them and ask them to reapply it. I will work through it and then they'll do it and then if I'm comfortable, they're good to go so they know how to do it. This is what my original looks sort of looks like. Warnings about not wrapping too tight. Different types of, if you use Curlex roll gauze, it has no stretch. You can make a tourniquet with it. If you're using conforming roll gauze, different type, it's got stretch. But this is kind of an idea of what to hand out or what to tell people. The gist of this is like, you should have something, whether it be your canned conversation and it's standardized or you have a handout. You got to understand your patient better. You understand your patients better than I do. And the first part about using hand sanitizer, we give out hand sanitizer. That's why it's added here. It's not something that we tell people to go out and seek. Wash your hands as possible. If people like the guy in the tent that doesn't leave, I gave him a box of gloves. I was like, forget it. I'm just leaving these here and he's using them. I gave him a trash bag also because if you don't hand that kind of stuff out, they end up all over the encampment. But he's using them. I don't know what he's using them for, but there's a trash bag full of plastic gloves. That makes me happy. I think he might have wounds, but he won't let me address them. And this is a do's and don'ts. This is added because of me. This is something that I take near and dear. You're treating the person and not the wound. Be mindful. It's a human being with a hole in their body, not a hole in their body attached to a human. We really need to address the person. Go at their pace. If they want privacy, provide it. If they don't, if they're comfortable with that, as a nurse, I try to maintain the highest level of dignity and privacy without making them feel uncomfortable. If they want to be outside, by all means, we're going to do it outside. But I'm going to suggest, hey, do you mind going around the other side of the truck? Some people don't want to be in a vehicle. Some people don't want to be alone with a guy. Some people don't want to be alone with a woman. They feel weird or they might be accused of something. So run with what they want. Let them lead your dance and dance with them. The amazing moment to use motivational interviewing, if you don't know what it is or you're not good at it, you can practice it with wound care. You have 20 minutes or more of undivided, that person's undivided attention because they're letting you into their private space, the most intimate space with a hole in their body. They're letting you in. So practice your motivational interviewing. You can find out a lot about these folks. You can find out new ways to help them, new things you can do to support them, or what's really holding them back. And some of the deeper, darker secrets come out during these 20 minutes of care. Always make sure you're explaining what you're doing. Just don't jump in. I get really excited over wounds, but I always tell people, I'm going to use these scissors. I'm going to cut these dressings off. If it's stuck, I'm going to pour some water on it. I'm going to let you take it off. I'm going to sit here and chat while we do it. Always tell people, don't assume you're allowed to just because they let you once. They have the right to pull back all consent at any moment. And you need to be aware of that. Ripping a dressing off, they will pull back the consent next time and you'll never see him again. Let them go at their pace. Give them the option to remove it. This isn't like, we're not in this situation where you have to do everything as a nurse or a nurse practitioner or even a nursing student. The patient can do it because they've been doing it to themselves. This is a joint effort where a team doing this with each other and you have a little bit of the knowledge helping that patient move on and treat themselves because ultimately the idea is get the patient to treat themselves because there's only one of you or a couple of you on a truck. Having someone being self-reliant and doing it themselves and healing is far easier than seeing that person every time you're in that area. Always moisten it. Try to get people to not use hydrogen peroxide or alcohol. Alcohol will actually suck the moisture out of new skin cells. There's little new epithelial cells. They dehydrate them immediately. Hydrogen peroxide makes them explode. So you have one or the other happening. A lot of people love the fizz from hydrogen peroxide or the burn from alcohol. Both of those are not really good for new skin cells and wound beds. So water is much safer to use. And hydrogen peroxide and alcohol are much harder to come by in bottles and stuff. But some people swear by it, use positive affirmation that there's better ways to clean a wound. It's simpler and it's easier to do. But some people always go back to it. It is in here. So this lady, her wounds were worse than this, but these are the best ones I have showing the progression. She's still injected in his hand for a while. I literally spoke to her yesterday, just reigniting the consent issue. I believe firmly that these people have every right for me to say I can't show their pictures or I can. And I asked her yesterday and she was still excited. I was talking to another team in a different state. These are dilazine wounds. She lost her other hand. She's right-handed. So I tricked her into shooting only into her left because she was going to lose both. She shot into her left. She went rogue, went missing, got very chaotic drug use. She came back with an infection and it had spread. I missed her for about two months. She just disappeared, but she's sober. She's doing quite well. She's super static and there's wound nurses are going to turn over in their graves right now. But one of the main things I used to clean this was a bucket and con dish soap. She wouldn't leave her house when she had both of her hands like this. And she was a sex worker. People would come to her house and she would wear long silk gloves and hide these hands. When we would get over to the house, I'd rinse a bucket out with bleach. I'd just rinse the whole bucket out with bleach, run fresh water in it, and I didn't have a really easy way to clean it. There wasn't soap available that I had that would rinse clean quickly because the dub soap requires running water and we didn't have that option. It was a trailer with no running water except for a hose that was outside. So I used two buckets and don dish soap. I lathered her hand up and she said, if it's safe for the baby duck, it's safe for her hand and it worked. It worked pretty well. I can't believe I did that. I said that on recording though, but it worked. This is her hand. It's healed up a lot better than it is now in that last photo. But this was just keeping it covered, keeping it moist and keeping an eye for infection. This was my first xylosine patient as well. Her name's April. We added this because, and very specifically, because people started asking about this. There's multiple types of debridement. There's five total. Sharp is what it sounds like, cutting dead tissue away. Autolytic uses those chemicals I said your body makes naturally. There's some things in nature that also make them and it cuts away the dead tissue. It's called cleaving, cleaves the proteins. Meta honey is one of those autolytic ones. It brings excess fluid. The enzymes come out, it chews it up. Enzymatic debridement. There's one enzyme that liquefies dead tissue. That's a prescription right now. I can't think of the name of it. Just escape me. But anyway, it's extremely expensive. I tend not to use product names anyway. Santel. And it's very expensive. There is a cost cutting site on their website now, but it's still very expensive. It needs to be changed daily and needs to be put on appropriately or it's wasting the product. It works great in institutions like hospitals. Phenomenal. Biologic, maggots, plain and simple. There's maggot wranglers that have sterile maggots. Don't recommend it. No participants ever been like, please use maggot therapy to get rid of the dead tissue. They're terrified of getting maggots in the wound. It's a sign of uncleanliness for our unhoused folks. It's not something I ever recommend people to even explore. And mechanical is what we can all do. We do it every day in the shower. We do it. We wash our face. We brush our teeth. It's using external force to remove dead, whatever, cleaning issues, scrubbing whirlpool. We don't use that wet to dry dressings or former torture they used to do in the past. You select wet dressing completely dry out, then you would rip it off of people, cause pinpoint bleeding and the dead stuff that go with it. Extremely painful. But scrubbing soap, water, clean washcloth, that's the main, main ingredient with mechanical debris man. We can do this with no medical license. You guys are all harm reductionists. We're coming up to the end. These are safer injection techniques. The only thing I don't, I disagree with on the little colored person on the right is the back of the hand. The finger should not be included. They should be a try to avoid in my mind, dialysing causes finger loss pretty rapidly if you hit an artery and you hit an artery from the wrist up the red area on the, on that person's right hand. The red stripes should, should, yeah, that's, you hit an artery. Your fingers are gone. I don't know why the back of the hand's okay, but the palm isn't. But those are areas to avoid your neck and your groin. You have big vessels, your veins and your arteries sit side by side, like holding your index and your second finger up next to each other. That's how your, your, your big arteries and veins sit. You might miss one and hit an artery. When you hit an artery, the blood goes right to the brain and your major organs and causes the big issue. If you can change your participants from injecting to sniffing and then flushing with one of those saline bullets, we have found that it decreases the risk for wounds in the nose and I'm not seeing them in the limbs distally when dialysing is present. That's an anecdotal observed moment, but we have, we've been able to decrease some people's wounds by changing from injecting to sniffing. There's also rumor that smoking, but most people in Baltimore do not smoke their opioids. And this split, this came from the harmreduction.org website, safe injection techniques. So normally in a group setting, we'll go through this really quick. Is the tissue healthy or unhealthy? This is kind of one of the trick ones. It is healthy. That's granulation tissue. It's red. It was recently cleaned. You can see soap bubbles to the left at almost like nine or 10 o'clock. It's epithelial. There's definitely some slough on it. That's the yellowy stuff. It looks adherent. There's also epithelial islands. It looks like this wound is probably moist. It might be a little too moist because up at 11 o'clock on the wound bed, there's an area that looks like it's eroding a little higher and that usually you see that kind of erosion in different areas due to moisture. But to me, as it stands, it looks moist. And for this purpose, keeping this covered with a Xeriform or something, keeping it covered, keeping it moist is safe for everybody on this call to do to help this wound heal. You adjust for drainage. If you need to change whatever you're using to absorb to more frequently, you can do that. But those dressings are very safe for this. This will be one of those moments where a Mepelex slapped on this for people that have those kind of advanced dressings, a silicone-backed foam dressing, it would be fine for this as well if you have those resources. There's your references. So she said in the beginning, this ORN survey is super-duper important to keep me coming to different communities as well. I didn't realize how important it was when I was alone and I always call them handlers. The ORN handlers weren't with me. I would like, oh, here's the QR code, please do this, blah, blah, blah. But these are really, really important. I got my hands slapped a couple times because of that. This allows me to keep coming at a free cost to you guys. I think she's going to send out the link as well.

Wound Care

Referral Protocol

Opioid Response Network

Kathy Whalen

Jason Beinart

Wound Types

Infection Signs

Treatment Resources

Xylosine Wounds

Harm Reduction

Self-Care Education

Community Needs

ORN Survey

Funding