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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “He has a chronic medial malial ulcer. This is a stasis ulcer and there's a lot of this chronic buildup of the outer layers of the skin that needs to come off. This material needs to come off otherwise it's going to get infected underneath. Fungus and bacteria will overgrow in this layer. Now we've cleaned the wound. You can see it's a good bit cleaner. We have a lot less of the epithelium. We're just going to rinse everything off and this down has a what's called a verrucoid appearance. You can see that it's almost like it's a much thicker layer and it has a little papillae and basically that's because inside each little papillae of our skin there is a little nest of capillaries. There's more pressure down here than there is here because there's a long distance all the way from the heart to the foot and there's no pump that pumps it up. It has to be pumped by our muscles. In his case because the valves in the vena system are not patent anymore there's a lot of pressure in each one of those little capillary beds so the papillae pushed out from the pressure.
Now what we're going to do we've cleaned all this off we're going to I've curetted this and now I'm going to apply a skin substitute and basically the difference between a skin substitute and a dressing is that a dressing is just a barrier to dirt. It can be a barrier to bacterial growth for example some of the dressings that have silver are inhibit the growth of bacteria but a skin substitute is actually biologically active it's trying to recreate some of the natural chemicals that cells use to communicate with each other those are called cytokines just means cellular messages and in some cases collagen which is the natural constituent of the dermis of the skin and in some cases actually living cells so those three things cellular communicating chemicals cytokines collagen and actual cells so those three things are the components of biologic dressings they can be made out of amnion which is the bag that a baby is delivered in when the stork flies back to deliver a baby the baby comes in a sack and that sack is filled with fluid when the baby comes out of the sack the fluid comes out but that sack is still intact and that's part of the products of conception and we can recycle that and use that for dressings the other materials are umbilical cord the actual umbilical cord and then we can make the collagen products and some of the other products from animal parts that are left over so anyway that's the ABCs of the dressing the final component will be the compression wrap which we'll deal with in another video so we're going to apply the skin substitute this is a collagen based product and we'll need Sonya is doing such a good job we're training her to work as a winter MA she's already first class surgical tech and maybe one more only you have one more no okay that'll be good we will make do now we're going to put a zero form or adaptic all the green mesh okay so the green mesh is green mesh is a nice product because it's allows exudate from the wound that is fluid coming out of the wound and at the same time it's inhibits bacterial growth this is a called an ABD pad a burn dressing or a big dressing depending on the source you believe this is a web real cast padding that's the whole the dressing on it also create a little soft layer there and when we're on a when we're on a surface that is tapered then we want to do a figure a kind of wrap this and that way it will hold itself up and have less tendency to crinkle down and accumulate down at the ankle at the bottom this goes for putting dressings on the trunk as well especially women who have more more of a curve and the dressing will have more tendency to slip down earlier we wrapping his foot as well.
No, okay so normally I would like to begin the dressing here at the base of the toes because if I squeeze here this is going to tend as well so we'll let you get away with it today but if this foot starts to swell and you can see a little bit of what's called pitting edema here so if that starts swelling more I just told gentle pressure I'm pushing that fluid out of the way and you can see that that pit that'll fill up with fluid again that's just the interstitial fluid that means interstitial simply means in between cells so this is a a strap it has an elasticity to it so when we apply an a strap we don't want to put it on too tight because that can inhibit the blood flow going in or it'll allow blood flow going in but not blood flow going out so which is even worse so we want to apply it with just enough tension to keep the dressing on to give a small amount of compression and again using that figure eight technique and the way you properly use an a strap is not by unrolling it like this but rather unroll enough that you can apply it so you can now control exactly how much tension you have on that wrap wrap it when you're ready to wrap again unwrap a little bit unroll a little bit and then you're going to wrap and you're going to be happy with how much tension you have if there's too much we'll not be afraid to go back and unwrap and rewrap it again so it's just the right amount of tension.
I'm going to unroll I'm going to wrap again you know I'm going to wrap again Earl how did I do my question is how would you tell if you did it too tight that's a good question and I'll tell you the answer it's just like how do you know your grandma when you go to the train station to pick her up you know her when you see her it's a judgment call if you're not sure unwrap it and put her on loose basically a just the amount of tension you need to keep that flat and keep it from unraveling flatness yeah if there's pain from the wrap typically you should instruct the patient to just unwrap it or cut it with a scissor because you'd rather not have a problem with a wrap that's too tight I've seen horrible injuries from wraps that are too tight so you want to err on the side of not having it too tight excellent question in general as you get more I'll let you do the co-band Sonny may have a little piece of tape in in general no tape I'll just hold that in hold that temporarily in general there's a problem in general as you get more expert at applying the compression wrap you'll you want to have a little bit more compression lower and a little tighter as you go up so that we're squeezing up and down here requires less tension to accomplish the same amount of compression than up here when the diameter is smaller that the tension on the wrap or the skin for that matter is going to be less to accomplish the same amount of pressure inside then when the diameter is larger and we know that because of that wonderful Frenchman Mr. Laplace who gave us Laplace's law that tells us that and for extra credit points you can look up the losses law and and message us back and explain it to us why it's that way and one day when we're in the mood for math we'll show you a demonstration of the law of Laplace which is very very helpful in medicine.”
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