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Venous, Arterial or Mixed Ulcer…How Do I Know For Sure?

December 15th, 2014

Your patient has a lower extremity wound. You aren’t sure what exactly you are dealing with. You know you need to do that ABI to be sure, but while you are waiting to have that done some of your wound assessment findings will help clue you in as well.

Let’s start with the venous ulcer, typically found on the medial lower leg, medial malleolus and superior to the medial malleolus. Seldom will you see them on the foot or Venous_Arterialabove the knee. They tend to be irregular in shape, are superficial, have a red wound bed, have moderate to heavy amount of exudate and the patient may have no pain or a moderate level of pain. Surrounding skin can be warm to the touch, edematous, scaly, weepy and you may see hemosiderin staining present. Your ABI will be the definitive answer and will come back at 0.9.

The arterial ulcer is typically found on the lateral malleolus, over the phalangeal heads, between the toes, tips of toes and areas that are subject to trauma and rubbing. They tend to be regular in shape, round punched out in appearance. Deep pale wound beds with necrotic tissue present are common in the arterial patient. There will typically be minimal amounts of exudate, and the patient will have complaints of extreme pain. The pain typically starts out as intermittent claudication or cramping in the lower extremities and then continues to progress.  Surrounding skin will be cool to the touch, pale, cyanotic, hairless on ankle and foot with thickened toenails. The ABI will come back abnormal and low at 0.5, indicating significant arterial disease.

Unfortunately sometimes the answer isn’t so clear, the patient with a lower extremity ulcer may present with signs and symptoms of both arterial and venous issues. You may see a full thickness wound, irregular in shape with minimal exudate on a cool pale lower extremity. What then? Then we go back to the gold standard of bedside tests, our ABI to determine what we are dealing with for sure.  Here most likely the patients ABI will fall somewhere between 0.6-0.8, this reading is indicative of a “mixed” lower extremity ulcer.

Our assessment skills can help guide us in differentiating these lower extremity wounds, but it is important to remember that not every ulcer always follows the rules. For example you may have a venous ulcer on the lateral side, it would not be unheard of. This is why ultimately the ABI is the gold standard of care and must be done to rule out arterial disease.  We always need to do a full comprehensive assessment, and one that includes the ankle brachial index (ABI) for our patients with lower extremity wounds.

Click Here for a FREE Webinar “Pressure Ulcers – Choosing The Right Treatment”  use coupon code: ULCER.

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Tips for Trimming Those Diabetic Toenails

December 8th, 2014

Make sure you have the proper tools. A set of toenail nippers, nail file, and orange stick are typically used.  Always follow your facility or healthcare’s settings policy for nail clip blog imagesinfection control. Single use disposable equipment is favorable.
Nails are easiest to trim after they have soaked for 10 minutes in a footbath to soften them. It is important to remember and educate our patients that the soaking of a diabetic patients feet should only be done by a healthcare professional. You can save some time by cleaning under the patient’s toenails with an orange stick wiping on a clean washcloth in between each toe while the feet are soaking.
After soaking and washing of the feet are completed, dry the patient’s feet completely. Wash your hands and put on new gloves to trim the toenails. Use your dominant hand to hold the nipper. Start with the small toe and work your way medial toward the great toe. Squeeze the nipper to make small nips to cut along the curve of the toenail. Be careful not to cut the skin. Use your index finger to block any flying nail fragments. Nippers are used like a pair of scissors – make small cuts, never cut the nail in one clip all the way across the nail. Never use two hands on the nipper. The nail is trimmed in small clips in a systematic manner. The nail should be cut level with the tips of the toes, never cut so short or to break the seal between the nail and the nail bed. The shape of the nail should be cut straight across and an emery board should be used to slightly round the edges. When filing nails always use long strokes in one direction, avoid using a back and forth sawing motion.
When all toes have been trimmed and filed, remove gloves and wash hands. Apply clean gloves and apply lotion to the top of the foot and to the bottom of the feet, rubbing lotion in well, wipe excess lotion off with a towel. Put patients socks and shoes back on as needed. Wash your hands again and smile, you are done!

FREE WEBINAR:  Skin and Nail Changes in the Diabetic Foot.  Click Here and use coupon code: NAILS

 

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Debridement Basics. How Many Methods Are There?

December 1st, 2014

beamsDebridement is the removal of necrotic, dead tissue from the wound bed. It also plays a vital role in the tissue management concept of Wound Bed Preparation.  Wound Bed Preparation is the comprehensive approach we use to get our chronic wounds to heal. There are two main categories of debridement:  selective and non- selective debridement.  Selective debridement are methods where only necrotic, non-viable tissue is removed from the wound bed. Non-selective debridement methods remove both necrotic tissue and viable living tissue.

There are 5 major debridement methods. They are known by the acronym BEAMS.  The Selective methods include:  Biological, Enzymatic and Autolytic debridement methods.  The non-selective methods are: Mechanical and Sharp debridement methods.

Biological debridement is also known as maggot debridement using sterile medical maggots to remove necrotic tissue. These sterile maggots debride necrotic tissue by liquefying and digesting it, they also kill and ingest bacteria while stimulating wound healing.

Enzymatic debridement is the use of collagenase ointment (Santyl) once daily to the wound bed. The ointment works from the bottom up to loosen the collagen that holds the necrotic material to the wound bed. It is a faster method than autolytic debridement, but slower than sharp debridement.

Autolytic Debridement is the slowest type of debridement. It uses the body’s own enzymes to assist in breaking down the necrotic tissue. This is achieved by using products that maintain a moist wound environment. This type of debridement is not appropriate for large amounts of necrotic tissue or infected wounds.

Mechanical debridement is a method that uses an external force to separate the necrotic tissue from the wound bed. This may be painful and removes non-viable as well as viable tissue.  Methods include wet to dry dressings, scrubbing, whirlpool and irrigation. Contraindications for mechanical debridement would be epithelializing and granulating wounds.

The fastest method of debridement is Sharp debridement. There are 2 types, Sharp surgical (done by a surgeon, physician or podiatrist) or sharp conservative (done at bedside by a trained clinician). It involves the use of scalpels, scissors, curettes or forceps.  Sharp surgical is a major procedure that sacrifices some viable tissue where sharp conservative is a minor procedure done at the bedside that removes non-viable tissue.

The debridement method used will be chosen on a variety of factors including the wound characteristics, amount of necrotic tissue in wound, efficiency and selectivity of the debridement method itself, pain management for your patient, the cost of the procedure, exudate levels of the wound, presence of or risk of infection, the patients care setting, and the patients overall medical condition all need to be taken into account.

It is also important to remember not every patient with necrotic tissue will always be a candidate for debridement. Be sure that you understand indications and contraindications for each debridement method when you are selecting the method for your patient.

Click Here for FREE WEBINAR HOW TO: Debridement Options: BEAMS Made Easy use coupon code BEAMS when registering.

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What’s Up Down There? Identifying and Treating IAD

November 24th, 2014

Identifying Incontinence Associated Dermatitis or IAD can be a challenge for wound care clinicians as often it is confused and mislabeled as a pressure ulcer. We need A Questionto get good at identifying the true root cause of what has caused the skin breakdown. This IAD skin damage is damage that occurs from the top layers of the skin down where the pressure ulcer damage starts down deep when vessels are occluded from pressure. IAD is an inflammation of the perineal skin that has come into contact with urine or stool for an extended period of time and this has lead to skin damage.

IAD may present as an area of erythema, blistered, edematous and or a denuded area, but it will be free of necrosis. There may be epidermal loss and the skin damage will always remain partial thickness in nature. The patient may experience pain and complain of itching or burning as well.

Contributing factors for developing IAD include the patients generalized tissue tolerance of the skin, the tissue perfusion and oxygenation. The patient’s perineal environment is another risk factor, how much is moisture present on the skin. The toileting ability of the patient can also increase the risk for developing IAD and any mechanical trauma the skin must endure must also be considered a risk factor as well.

When our patient is at risk for IAD or develops IAD we must put appropriate interventions in place. These include a good skin care regimen with a gentle cleansing of the skin using a mild soap or no rinse soap. We need to use products that will maintain the PH of the skin.  Institute interventions such as patting the skin dry, no rubbing. Moisturize the skin with a product that contains humectant like glycerin, lanolin or mineral oil and use emollients to restore the lipids that have
been lost and apply to the skin when damp. Protect the skin from urine and stool with a moisture barrier ointment that contains zinc oxide, dimethicone or petrolatum or a combination of them.

Institute patient specific interventions for those risk factors that have been identified.  Interventions such as toileting schedules, open systems at night to avoid use of briefs, fecal collection devices, urinary catheters, and low air loss support surfaces may be needed and appropriate. If the IAD is severe topical wound therapy with dressings may be necessary. If candidiasis were suspected further fungal treatment and medical evaluation would be warranted as well.  A good preventive plan of care for the incontinent patient is a must!  For further information Click Here.

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Cartilage Is Present…Now How Do I Stage It?

November 17th, 2014

In the human body the cartilage is found in joints, rib cage, ear, nose, bronchial tubes, and between the inter-vertebral discs. Most often we as wound clinicians see Printcartilage just below the bridge of the nose or on the ear in our patients with pressure ulcers.

Many clinicians continually question themselves how to stage a wound with visible or palpable cartilage present. After all cartilage does serves the same function as bone, but the word “cartilage” itself is not found in the stage IV definition from the NPUAP.  So how do you stage the pressure ulcer with visible or palpable cartilage?

Well here is your answer: In August of 2012 the National Pressure Advisory Panel released a statement that stated: “Although the presence of visible or palpable cartilage at the base of a pressure ulcer was not included in the stage IV terminology; it is the opinion of the NPUAP that cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage IV.”

What that means is any pressure ulcer where you can see or feel cartilage, it will be classified as a stage IV pressure ulcer. There is your answer, simply put: if you have cartilage present in the wound, you stage it as a stage IV pressure ulcer.

For a FREE Webinar called “Pressure Ulcer Staging and Tissue Types”  Click Here or visit http://www.wcei.net/webinars.   Use Coupon Code: BLOG.

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A Stinky Situation… When Wound Odor is a Problem

November 10th, 2014

As healthcare clinicians, in a way, we are lucky.  We become desensitized to things we encounter over and over again, they just don’t bother us like the first time we were shutterstock_193144973exposed. This stands true for those wounds with odor. We almost become immune, yes we are aware the odor is there; but to our noses it is not an issue. The real issue is for our patients and their friends and family. Odor is subjective. Depending on the patient and family members ability, they may be very much aware of the odor. It can be very bothersome to the patient and their loved ones. The patient maybe embarrassed by it, and may try to self-isolate. They may not want to have people around them because of the way their wound smells. This is something as wound care clinicians we need to fix.

The first thing we need to look at is, what is causing the odor? Is it from necrotic tissue that supports the growth of anaerobic bacteria? Is it from a high level of wound exudate? Is there an actual wound infection? Do we have the wrong wound dressing on the patient?

Once we figure out the cause then we need to remove it, whether its debridement of necrotic tissue, managing the high level of exudate with dressings or using Negative Pressure Wound Therapy; we need to find what works.  With an actual wound infection, treating with antimicrobial dressings or antiseptic’s/antibiotic’s are a must to remove the organism causing the infection and the odor. Sometimes just changing the dressing more frequently will help.  Using dressings like those with activated charcoal, or those dressings with medical grade honey in them may help the wound odor. Another option is topical Metronidazole Gel to the wound bed, this may help eliminate wound odor as well.

Just because the odor in the wound bed isn’t offensive to us as wound care clinicians, doesn’t mean it isn’t offensive to others. As a rule, if your patient has odor in the wound bed, consider it a problem that you need to fix.

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The Winter of 1962

November 3rd, 2014

Why do we do what we do today in wound care? Modern wound management all started back in the 1960’s when Dr. George Winter found that wounds that were kept moist healed twice as fast. By keeping the wound environment moist it mimicked the natural environment of the cells in the body and we had decreased cell death, increased angiogenesis or new blood vessel formation, enhanced autolytic debridement, increased re-epithelialization and the patient had decreased pain. In short better wound healing was occurring with moist healing principles.  Moist_Dry_Wound_Healing

More studies continued and focused on water vapor loss, which lead to heat loss of the wound. The loss of moisture from any surface is accompanied by cooling of that surface, and when the wound loses tissue moisture there is cooling off the wound. Epidermal cells will only migrate over viable tissues; a dry crust or scab impedes the resurfacing process. Our wounds need to be maintained at or near normal body temperature to heal. A drop in temperature in the wound bed of 2°C is sufficient to alter healing and slow or stop healing, and it can take up to 4 hours for that wound to get back to normal healing temperature! As our wound cools off other negative things occur too, vasoconstriction occurs and the wound bed doesn’t get the needed blood and oxygen for our white blood cells to function effectively. This results in the white blood cells not being able to fight off bacteria, and the wound ends up at risk or with an actual infection.

In summary, for wound care, the 1960’s were really the start of something great! Faster healing times and better out comes for my patient! We now practice moist wound healing principles, we know the wound needs to be kept warm and moist, and needs to have a constant supply of oxygen to fight off infection.

Today we accomplish this with dressings that support moist wound healing. We use dressings that have the technology to be left in place for long periods of time and keep the wound bed warm. Long gone are the days of TID dressing changes, remember it takes the wound bed 4 hours to return to normal healing temperature! When it comes to modern day wound care, the 60’s is where we still are at!

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Diabetic Ulcers – Identification and Treatment

October 27th, 2014
Gail Hebert RN, BS, MS, CWCN, WCC, DWC, OMS, LNHA, Clinical Instructor

Gail Hebert RN, BS, MS, CWCN, WCC, DWC, OMS, LNHA, Clinical Instructor

Don’t miss this energetic webinar brought to you by Wound Care Education Institute®:  Another popular session recorded from the Wild On Wounds National Conference and providing continuing education credit.

Chronic foot ulcers in patients with diabetes cause substantial morbidity and may lead to amputation of a lower extremity and mortality. Accurate identification of underlying causes and co-morbidities are essential for planning treatment and approaches for optimal healing. In this one-hour recorded session, Gail Hebert will review evidence-based approaches for identification and treatment of chronic neuropathic, neuro-ischemic and ischemic diabetic foot ulcerations.

Wound Care Education Institute is featuring various webinars on topics from this years’ conference.  TO REGISTER CLICK HERE or visit www.wcei.net/webinars.

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WHY ABI?

October 20th, 2014

What exactly is an ABI?  ABI stands for Ankle Brachial Index. This is a non-invasive bedside tool that compares the systolic blood pressure of the ankle to that of Doppler_BloodPressureCuffthe arm. It is done to rule out Peripheral Arterial Disease in the lower extremities. The ABI is considered the “bedside” gold standard diagnostic test and can be done by any trained clinician in a clinic, hospital, nursing home and/or even the home care setting. All you need is a blood pressure cuff and a hand held Doppler.

Why do we do the Ankle Brachial Index or ABI?  Well, there are several reasons why we include the ABI as part of our assessment for the patient with lower extremity wounds. First of all, in order to heal a wound we have to be sure that our patient has adequate blood flow. The ABI will tell us if the patient has impaired arterial blood flow, and how significant that impairment is.  We also need to know the amount of compression that we can safely apply to the venous patient, in general the lower the patients ABI reading, the lower the amount of compression that can be safely applied.

When do I need to do the ABI? Standards of care and Guidelines dictate when we should be doing the Ankle Brachial Index. Our current standard of practice states to do the ABI: Anytime a patient has a lower extremity ulcer, when foot pulses are not clearly palpable, prior to applying compression wraps / garments or when the lower extremity ulcer is no longer healing.

What does the ABI “number” mean? First we need to be aware that not everyone’s ABI is reliable, in fact patients with diabetes or end-stage renal disease may have incompressible vessels rendering a falsely high ABI score. For these patients we use another diagnostic test called the Toe Brachial toe_cuf_wound_care_education_institutePressure Index (TBPI) instead of the ABI.  For those with ABI readings, in general as the patients ABI score decreases, this signifies that the patient has arterial disease of the lower extremity, and poor blood flow. Any patient with an abnormal reading needs a referral to a vascular specialist. Bedside interpretations of the ABI that we use as wound clinicians are: 1.0 considered a normal reading, an ABI of 0.9 indicate more venous, 0.6-0.8 indicate a mixed etiology (venous and arterial) and less than or equal to 0.5 is indicative of arterial disease of the lower extremity.

We as wound care clinicians are held to certain standards of care and must follow those guidelines established by the experts.  Performing the ABI on patients before applying compression and on patients with lower extremity ulcers is one of them.  As wound clinicians we use the ABI and our clinical assessment to help guide us into determining what type of ulcer we are dealing with so we can make appropriate referrals and develop the best treatment plan for our patients. It’s a step we can’t afford to leave out; our patient’s limb may depend on it.

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How To: Creating the seal by making the right choices

October 13th, 2014
Joy Hooper RN, WOCN, OMS, WCEI Instructor, Medical Craft, LLC, Tifton, GA

Joy Hooper RN, BSN, CWOCN, OMS

Ostomy Webinar now available through Wound Care Education Institute®:  This popular session is recorded from the Wild On Wounds National Conference and provides ostomy continuing education credit.

Achieving a leak-proof seal between the skin barrier and the abdominal skin surrounding the stoma is the cornerstone of ostomy management. In this session, Joy Hooper will focus on assessment, interventions, and techniques for choosing the right ostomy products for creating dry surfaces, contour management, securement, and peristomal skin protection. 

Wound Care Education Institute is featuring various webinars on topics from this years’ conference.  TO REGISTER CLICK HERE or visit www.wcei.net/webinars.

 

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Hot Topic at WOW – Nutrition Gems

October 6th, 2014
Dr. Nancy Collins PhD, RD, LD/N, FAPWCA, President/Executive Director Nutrition 411.com

Dr. Nancy Collins PhD, RD, LD/N, FAPWCA, President/Executive Director Nutrition 411.com

Dr. Nancy Collins received an overwhelming positive response from attendees after her lecture on “Nutrition Gems:  Hot topics in Nutrition”. One attendee remarked that she learned more from this one hour lecture than any previous presentation she has heard on this topic.

It was fascinating to hear about the advances in the field from an expert who has helped shape the current landscape yet remembers when her most common intervention when assessing wound patients nutritionally was to order “Milk and graham crackers!”

She covered a new development on the timing of when protein should be ingested based on recent research.
Breaking up protein ingestion at each meal has been shown to make it better available to the body to use verses protein loading at one meal, usually dinner. This can help our patients heal faster by providing the body with the protein it needs to build in that new tissue.

Did you know why Arginine and Glutamine, Conditionally Indispensable Amino Acids, are often need to be supplemented in the diet of our wound care patients?

Because under the stress of a wound, the body may not be able to keep up production of these important nutrients. Without adequate amounts of Arginine and Glutamine in the diet, the signaling pathway to build in new tissue is not activated and wound healing can stall.

Another key point made by Dr. Collins was the need to interpret lab data (Albumin, Pre-Albumin and Transferrin levels) only in conjunction with a full body nutritional assessment. These lab values have been shown to be inaccurate in patients with inflammation occurring in their bodies. Changes in Albumin, Pre-Albumin and Transferrin should not be used to suggest changes in protein status in individuals with acute or chronic inflammatory states. That can and should help all of us to do a better job in conducting a nutritional evaluation of our patients.

Dr. Collin’s passion for nutrition science and her ability to make it relevant to the wound care world was greatly appreciated by all who had the good fortune to attend this lecture.  To learn more about Dr. Collins go to: http://www.drnancycollins.com/

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Diabetic Foot Ulcer Assessment and Hands On Lab

October 1st, 2014
Donna Sardina RN, MHA, WCC, DWC, OMS

Donna Sardina RN, MHA, WCC, DWC, OMS

Do you know the components of a Diabetic Foot Exam? It is so important that all of us in wound care know the steps to preventing foot ulcers on our diabetic patients.  And that starts with a routinely scheduled comprehensive foot exam.

Donna Sardina took us through all the aspects of a comprehensive exam during the pre-conference session “Diabetic Foot Assessment.”

The key word here is comprehensive. A proper exam involves much more than just a test of sensation using a Semmes Weinstein monofilament or a tuning fork. What about skin color, texture, temperature, foot deformities, nail deformities, glucose control, and critically important perfusion status. Did you know that it is estimated that 50% of amputations in diabetics are a direct result of improper footwear? That statement gets my attention every time I hear it.

In this session we learned how to examine our patient’s footwear for signs of trouble. Included in the handouts was a document “Diabetes: Shoe Fitting Tips” that will be extremely helpful when putting our knowledge into practice. In recognition of the fact that we are not all specialists in the diabetic foot, Donna shared a “Simplified Sixty Second Foot Screen” published by Dr. Sibbald in 2012. It is a validated tool that has just 10 items on it that can be completed in less than 60 seconds. This seminar was empowering to all who attended and gave us the tools we need to make a difference in this at risk population.

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2014 Annual Wild On Wounds, (“WOW”) National Conference Sets Record Attendance

September 26th, 2014

For Immediate Release – PRN Newswire:

2014 Annual Wild on Wounds, (“WOW”) National Conference

Sets Record Attendance

Plainfield IL – September 29, 2014 The Wound Care Education Institute® (WCEI) successfully completed its largest “Wild on Wounds” (WOW) conference in Las Vegas, NV. WOW is fast becoming the largest fall wound care conference in the United States drawing close to 1,000 clinicians, students and industry professionals to the four day event.   Picture1

WOW is specifically designed to advance the skills and knowledge of healthcare professionals specializing in wound care.  The educational sessions and hands-on workshops help them stay on top of ‘today’s standards of care’ and teaches the latest in wound care treatments and technologies.  “I  was  overwhelmed  by  the  outpouring  of  thanks  and  gratitude  from  the attendees,” said Nancy Morgan, Cofounder of WCEI and WOW.

This conference appropriately themed “Skin is in” was held at the Rio Hotel and Convention Center, September 17-20, 2014. Highlights of the conference included:

  • Close to 1,000 practicing nurses, therapist, physicians and industry professionals who influence wound care decisions from all care environments
  • 50+ basic to advanced educational sessions
  •  20 “How-To” and “Hands-On” programs
  • Renowned speakers and industry experts
  • Live certification courses include Skin and Wound Care, Diabetic Wound Care and Ostomy Management
  • Exhibitor partners
  • Clinical poster presentations
  • Wound Care Certified (WCC®) Outstanding Achievement and Scholarship Awards

WOW 2015

Next year’s WOW conference will be held September 2-5, 2015 in Las Vegas, NV.  If you are interested in receiving more details about WOW 2015 email WCEI at info@wcei.net.

 

About the Wound Care Education Institute

WCEI provides healthcare professionals with ongoing education support and comprehensive online and nationwide onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and

OMS™ national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®).   Website: www.wcei.net

Wild On Wounds National Conference Brings Back the Maggots to Las Vegas!

June 3rd, 2014
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This is just one of the sessions you can enjoy at our
National Wound Conference
Session 305 
HANDS ON:
Maggot Debridement Therapy
Dr. Ronald A. Sherman, M.D., M.Sc., D.T.M.H., Director, BioTherapeutics
We are pleased to welcome back Dr. Sherman, leading expert in maggot therapy and currently Chairman of the Board of Directors of the non-profit BioTherapeutics, Education and Research (BTER) Foundation, which supports patient care, education and research in maggot therapy and the symbiotic medicine.
Taught in two sessions, this course will give you the didactic and the practical hands on education on maggot therapy. Learn about the history, current status, mechanisms of action, as well as indications and contraindications for maggot therapy. Then put all that to use when you actually learn the technical aspects of maggot debridement therapy by applying live maggot dressings to mock wounds.
This session has limited seating and fills up fast so don’t wait.
 REGISTRATION INCLUDES:
  • 3 days filled with wound care education
  • 2 days of vendor showcase exhibits
  • Lunch all 3 days with a lunch speaker on day 3
  • Party poolside with a robust buffet and drinks!
  • Complimentary collectible event T-shirt
  • and MORE!

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