Surgeons share how they evaluate whether a wound bed is ready for either an acellular dermal matrix or a skin graft
In this episode, Dr. Jeffrey Carter, Medical Director of the University Medical Center Burn Center in New Orleans, is joined by Dr. Roselle Crombie, general and burn surgeon from CT Burn Center, Yale New Haven Health System, to discuss why it’s so important to talk about failures with excisional debridement. Listen below to discover what Dr. Crombie wished she knew when she excised a facial burn early in her career.
Deep Cuts is a multimedia series on excision, in which surgeons from a variety of specialties discuss excisional debridement, one of the cornerstones of successful wound reconstruction. In Season 1, burn surgeons from across the country—and from a variety of backgrounds—share the challenges and their best practices for optimizing wound bed preparation.
The opinions expressed, and techniques described, herein are general in nature and based on the clinical experience of the presenting physician. Physicians should use their own professional judgment and consider patient-specific factors in treating their own patients.
Dr. Crombie has a consulting relationship with Integra LifeSciences. Neither Dr. Crombie nor Dr. Carter was compensated for their participation on this podcast.
Complete transcript of this episode:
Dr. Crombie, it’s great to get to sit down and have a conversation with you on this.
You’ve been preparing wound beds for burn reconstruction for a number of years. Do you mind telling me how long you’ve been doing it and where you acquired this craft?
Total number of years is probably a little bit closer to 20 at this point, if you include training, fellowship and all that stuff. I’m from the Northeast. I’ve had the amazing privilege to have been trained by some of our forefathers that are now riding off into the sunset, having shared their ideas and their techniques with us.
Was there anything that you had missed in your training if you had to do over, you’d like to gain when it comes to wound bed preparation?
When we look back at that time, we didn’t have as many things as we did back then. We had just our weck knives or even when I talk to some of the elders, they were doing pinch grafts. They didn’t have fancy dermatomes. And now we have two different kinds of dermatomes. One of the things that I wished that we spoke a lot more about was what you’re looking at in the wound bed. What do I want to excise? What I want to avoid? And then those certain things that come with time, that’s almost sometimes very difficult to delineate and tell somebody, which is you really start managing the scar with the initial excision and debridement.
I am so much more thoughtful about that now in my career than I was when I was starting out.
What did you have to figure out on your own as a surgeon that you did not get in your training?
Timing of the operation makes a big deal and a lot of people like yourself and like me, we don’t necessarily have that luxury because depending on when the patient is referred to us as a tertiary referral, do we get them right off the bat? Do we get them two and a half weeks later? Do I get them a month later after somebody had excised them already and I’m dealing with the scar? That’s one huge thing that I had to kind of figure that out on my own.
Certainly, the basic things such as the role of underlying medical problems specifically, like If somebody has a hemoglobin A1C of 12, is that going to be something that’s going to be helpful in healing your wound? The answer is no.
Certainly the impact of medical conditions on it is tremendous. And the types of dressings and debridement that we do outside of the operating room are also just as important. I don’t think that’s something that I realized at the beginning of my career that I’ve kind of had to figure out on my own, but then when I talk to colleagues like you, we have a lot of “Hey, I figured that out too.” I think the more and more we share ideas, it’s going to be beneficial.
What are the challenges you see for today’s new surgeons going into burn care?
Part of the reason that I fell in love with burn surgery was not only because of the people and how open they are. You and I are both trained in critical care and trauma. If I go to an analogous trauma group, it’s a very competitive —not collaborative industry. Those are the things that I springboard upon to know that we have to work together to look at different debridement techniques, timing issues, and things like that.
Was there a particular case that really kind of made a change or made you pivot when it came to wound bed preparation or excision going back and looking at your training in your early career?
I think surgeons in some senses are afraid to cut off too much. In the initial operating timing, if you take a patient to the operating room too soon, say within 24 hours, there’s some tissue that’s going to be preserved and that can heal on its own.
The one case that I recall was a pilot. He had been in a significant crash and it had taken a while for us to kind of get him stable and took him to the operating room. And it’s funny because the overall body, we were almost under excising. So we would take him to the operating room, take off the debris. We were like, “That kind of looks good.” Put some allografts, send him out. But then for whatever reason with the face, we ended up over excising.
Now, many years later, I realized that so much of who we are is the contour of your face so you want to preserve that contour as much as possible. You don’t want to debride until almost the very end, but see what will heal on its own. I just remember that he was definitely over debrided and that changed his scars so tremendously.
Even now, when I see him, it’s just one of those things that you see. I think back and I was like, “We could have done better about it.” We could have debrided a little bit less on the face. We could have debrided a little bit more on the body and it would’ve been a better outcome.” I mean, the good thing with that is that happened very early on in my career. And he subsequently went on to be an anesthesiologist. He was inspired by his burn to do that. And it doesn’t bother him, but it bothers me.
Dr. Crombie, you’re very thoughtful and compassionate surgeon and we don’t always bring those components in when we’re thinking incision and removal of tissue. You also are a very good instructor. What would you change about the training of your trainees to help them better be prepared for wound preparation and excision?
It was one of my trainees that inspired me to do this: He was looking at me, and he could tell that my mind was going as I was looking at the patient. He says, “I wish I could know what you were saying in your mind.” So what I’ve gradually started to do over time is starting from the beginning, asking them in the trauma bay, “What do you see? What do you see?” And it’s actually nice because Epic or other EMRs now, we have the photos. So even if I’m coming to day three and my partners have been operating on day one and two, we start from the beginning and say, “What do you see in the wound? What happened 24 hours later? What happened 48 hours later?” Just so that I get them to always be thinking about from the beginning, where do we need to start? What do we have to kind of leave and manage by expectant management? Or what should we address right away?
The other thing is really to educate them about what are the other options in terms of using a Weck blade. Can you micro debride with a different instrument? Could you chemical debride because that’s going to allow you to maintain the contour? So that’s the operative phase of it. And then certainly the timing of the OR, I think is huge, as we talked about earlier. And just being able to manage a busy service and figuring out who’s going to… Because all our time is limited. Who are we going to address first because they need this on this specific day? And I’ve talked to them a lot about the thought processes behind why I might leave this person’s dressing on for a certain period of time versus take this one’s off because I’m worried about this. And then certainly the various infection issues that come with burns. We talk a lot more about that now.
And then, the role of the team. I mean, none of us is in a burn center by ourselves, right? I always tell my residents when they’re going to interview for a job. You won’t really realize how important it is to have your family around you and your partners be working together. You don’t necessarily need to do the same thing, because I think the variety brings a lot of richness to the patient’s care, but you do have to communicate. When we’re lucky enough to have two fellows on board instead of just one fellow, those are things that I talk about. And we just have our typical one fellow, we have a lot of plastic surgery residents, I’m having them kind of communicate what are the things that they’re seeing?
And then also to talk about our failures. We’re not always successful. And then to kind of look back and be very thoughtful about why did we fail here? What did I miss on the bed and the initial debridement that we could have done better? And I think as surgeons, sometimes it’s very hard for us to talk about that because we’ve been just running, running, running and being so competitive with everybody else. So that’s also an incredible learning experience, I think for both the surgeon and the trainee.
As of the last six years ago, the American College of Surgeons hasn’t required us to have a burn rotation. I think it’s incredibly important for us to have that. I mean, I don’t know if you would be here. For me, I was going into pediatric surgery and it was a rotation that inspired me and I’m so glad. I think the importance of trying to find and inspire the next generation of burn surgeons is something I always talk to them about as well.
Dr. Crombie, you do a great job characterizing communication and collaboration with your team. And as you pointed out, sometimes even with the best of efforts, we miss the mark when it comes to wound bed preparation and excision. What are some of the challenges you’ve seen?
Just by the nature typically of a typical burn, there’s a lot of variation and depth throughout the body. So I think part of the challenge is being able to visualize that and see what’s going to convert and what’s going to be able to heal on its own so that some of it is experience. But I think also some of it is a fear. I certainly have colleagues that are 10 years into their practice and they want to cut less because they’re just afraid to take more. But what happens with that is it doesn’t allow the underlying wound bed that could potentially regenerate to heal because it’s just worrying about debriding the actual eschar.
The color of the fat, I always point that out to the trainees. When you’re in your dark operating room or you’re doing whatever, I always try to focus, whoever I’ve got in the room and teach them about that because that’s an important telltale sign. Nothing you’re going to put on top, whether it be skin or some secondary dermal substitute is going to live if you have fat that isn’t going to live if you’re going to be grafting onto the fat.
The other thing is really checking such simple things. We have a lot of elderly burn patients. Some of them never been to a doctor before, some of them have, but they just haven’t checked their pulses. They haven’t checked their hemoglobin A1C. They’re actually undiagnosed diabetics. And those are things that I kind of can discover in the wound bed in the operating room at times. And certainly if you have a failure of some sort of… Even if’s just say, an allograft that you’re putting on and it’s not for some reason sticking, well, why is that happening? And sometimes it’s the fat, sometimes it’s the biofilm that’s on there. So these are all factors that I look at in the wound bed, starting from the medical background of the vessels.
Blood pressure is another thing. If you’ve got a guy that’s on [inaudible], they’re not necessarily going to be taking a graft. So that should be not a time that we should be thinking about that. Even if the wound bed looks good, I know that this guy’s trying to chemically maintain his blood pressure that could convert.
Dr. Crombie, how do we inspire and educate the next generation of burn surgeons?
I think each one of us thankfully has the privilege of being at some training site where we get residents of some sort in an institute at our residency program. I think being really enthusiastic about our rotation is where it starts. Usually, if I’ve had residents for a couple weeks, I try to tell them why I fell in love with burn surgery and what I like about it and share the various aspects of that.
I think the other thing is to talk about how you can change somebody’s life with the things that we’re doing. I mean, everybody changes lives, but burns are a very unique specialty for a bunch of different reasons. You can have somebody come into burn care and really just like the critical care, because the critical is so challenging. And then you have somebody like a plastic surgeon that is really just there because he or she likes the reconstructive aspects. So they work with their partners to get them through the acute burn phase and then be thinking about and having involvement in that way.
the variations within our specialty are a blessing, but there’s a lot of differences in standardizations. So I think the more that we can collaborate, we can come up with, what do we think are the important factors that are important for us to standardize yet leave enough room to not be so rigid to allow that creativity? So that we can continue to move into the next decade and still be able to openly solve problems.
We have to stick together and work together.
Dr. Crombie, you take care of patients acutely and then in the aftercare phase. For your wound bed preparation and excision, is there anything you do differently from the acute burn versus the reconstruction?
Absolutely. So the acute burn, the goal is really to get the devitalized tissue off. I did say that the wound and the scar always starts with your initial incision, but you’re also in the acute burn dealing with really the massive burn SIRS, which just the physiologically the body is different. There’s not going to be a lot of that rotation of tissue flaps and advancements that you’re going to be able to do in somebody that’s more stable. For the reconstructive burns, that is a different beast primarily because at that time, the tissue is tremendously changed. It’s gone through an inflammatory phase. There’s typically a lot of scar that you have to think about. It’s certainly a preoperative field. So when I talk to the residents, I talk to them about specifically just operatively the management of just the handling of the tissues.
And then I spent a lot of time looking at how does the patient move out of the OR because looking at the different lines of tension and contraction. And then going through the pictures and the chart and how has this patient’s scar changed over time? Because as we all know, a lot of it is due to genetic variation. There are going to be some patients that have elastic scars and they do fine and they don’t need any reconstruction. They may need a little laser here and there. And then there’s some that you’re going to have to do a significant release on. That’s a different thought process.
A lot of those different issues, both from the acute burn phase and the wound bed and the reconstructive phase you can apply to… I mean, you and I are general surgeons. You can apply to other types of injuries, whether it be… Certainly necrotizing fasciitis is being referred to burn centers now. There are techniques that we learn in burns and the debridement and when to debride and how much to debride. I mean, that’s a much more or aggressive type of etiology that You have to cut out basically everything or else the patient’s going to die in necrotizing fasciitis. Versus the acute burn, where you can kind of see some parts of the body in parts of the wound bed, you can allow to just be managed by expectant management.
The other thing is just thinking about the analogous techniques for the wound bed in say, a cancer excision. Those are very different than in between where the acute burn is and where the reconstructive burn is. The wound bed and the preparation is so different in each one of those different scenarios, but it’s just something to draw upon as you are going through each one of those types of diseases and share those techniques.