Tools for practicing wound care in settings with very low resources
The majority of Africans live in rural areas where only basic supplies for wound care are often available. In all chapters of WoundsAfrica, we try to find a balance between advanced wound care with modern dressings and alternatives for caregivers with very limited resources. Even if you work in an off-the-grid clinic and have only a limited number of available tools, we recommend you read the chapters concerning more advanced methods to understand better wound care. If you take the time to read many of our chapters, you will find pearls of knowledge around every corner.
This chapter has listed products that are usually readily available, even in most rural areas in Africa. You will find a more detailed description of each of these products and how to use them in the general chapter on wound care products. As for many other products we use in wound care today, there may be little scientific evidence to prove their effectiveness. A lot of the advice given here is a collection of personal experience and expert opinion. If you choose to use one or more of the methods described here - you are doing so at your discretion.
When authors come with undocumented recommendations, like, for example, using regular household sugar to treat difficult ulcers, there usually arises some form of criticism from some people or certain manufacturers of wound care products. We are used to that. Most of these critics have obviously never been to the most remote regions of Africa, where sometimes not even cotton gauze is available. They may not have understood that there are many patients with leg ulcers in some areas of the continent that do not have any dressing to cover the wounds at all. We advocate the use of improvised methods in these regions because, frankly, this is better than not treating the wounds at all.
Applying charcoal to open wounds is an ancient method in wound care. Historically, regular charcoal was used for this. Today, activated charcoal is advised for this purpose as it has better absorptive properties. Activated charcoal can absorb some bacteria from the wound but, more importantly, neutralizes many bacterial toxins, which cause wounds to deteriorate. In our own experience, it is a useful tool in wounds with pseudomonas infection but can also be used in most other ulcers. It can be applied directly to the wound bed. Some caregivers make a 50:50 mix of activated charcoal and honey or zinc paste, for example, and apply this mix onto the woundbed.
Vinegar ( Acetic acid)
Regular clear household vinegar at a 3,5-5% concentration gives you an excellent anti-bacterial rinsing solution. If the wound shows signs of pseudomonas infection, vinegar is an excellent tool to eradicate this. Vinegar is very cheap and readily available throughout rural Africa. Most shops sell vinegar at concentrations of around 7%, so you will have to dilute it before using it on a wound. Be aware that vinegar, even when diluted, may cause a burning sensation- always start with using the 3,5% solution first. If that is still causing pain, you may try a 1% solution. You can make a topical vinegar gel by adding methyl-cellulose to vinegar. This gel can be applied to any wound if the patient does not experience pain when using this.
As you probably already know, sterile medical-grade honey is commonly used in modern wound care in western countries. This will not be available to you in an off-the-grid setting, as it is expensive. Regular household honey has been used in ancient times to heal wounds successfully, and the method is also used in traditional medicine in Africa. It is by no means a primitive method of treating wounds! We advise you to purchase honey at a shop rather than using honey from local gatherers. This is because the honey sold in shops usually is cleaner - it has typically been prepared by beekeepers who have to adhere to specific hygiene standards during the production process.
Granulated white sugar
Did you know that granulated white sugar is regularly used for treating wounds at several clinics in the UK? This is not a new method of treating wounds, but it has seen a revival in the past years. The osmotic effect sugar has on the wound bed deter the growth of most bacteria. We have used sugar treatment in wound care for the past two years and like the results. It is extremely cheap, available everywhere, and easy to apply. One of the drawbacks of using granulated sugar is that it increases the amount of exudate manifold, especially at the start of the treatment. You will have to accommodate for that with a good absorptive dressing or change the dressing very often. Also, because the sugar melts rapidly, it needs to be applied frequently, at least daily.
"Sugardine" - Sugar + 10% Povidone Iodine
While white granulated sugar alone often is very effective at kick-starting stalled wounds, a combination of sugar and iodine may be even better. This combination is sometimes called Sugardine or Betadine-Sugar. There is no concensus as to how to blend these two ingredients. Often nine parts white granulated sugar and one part iodine are mixed together but some recipes call for more iodine to make a mix with the consistency of peanut butter. As with sugar treatment the osmotic effect may cause an increase in wound exudate, and daily wound dressing changes are usually necessary.
Vaseline (petroleum jelly)
Vaseline is cheaply available in every corner shop in Africa. It is a very useful tool in wound care. We can use it as a barrier cream to protect the wound edges from maceration as it repels water. We can cover gauzes on one side with vaseline to make improvised burn dressings that will not adhere as much to the wound. We can mix it with sugar, honey, or activated charcoal and make our own antibacterial wound fillers. Vaseline can solve many of our challenges in low-resource settings with a bit of ingenuity.
Modern sanitary pads make excellent, highly absorbant dressings for wound care! They absorb very well and can lock fluid in the core of the pad. And they are much, much cheaper than wound care products. A pack of 10 pads from a very well-known brand like Libresse costs about 3 US Dollars, and if you are dealing with a wound where the dressing is changed twice weekly, this translates into 60 cents per week for the dressing. Other, less-known brands cost even less.
In situations where you have heavily exudating wounds, you need a superabsorbent dressing to prevent the breakdown of skin around the wound edges. Modern superabsorbant dressings are usually excellent but also prohibitively expensive, especially in large sizes. When you are dealing with a huge leg ulcer with lots of exudate for example, then a modern disposable diaper will function as a very good, highly absorbant dressing which you can wrap around the leg. If you take some time to compare prices you can get disposable diapers cheaply. In Tanzania a 60 diaper pack (Huggies Size 4) costs about 18 US Dollars at the online pharmacy dawa.co.tz - that is 30 cents/ diaper.
Homemade 0,9% saline
Most tissue viability clinics use 0,9 % saline as their go-to wound rinse solution for everyday use. You can easily make this yourself by adding 0,9 grams of household salt to 100ml of clean water. If you are using tap water you will have to boil the water for 5 minutes. The bottles you store the saline in should also be boiled beforehand. We recommend glass bottles like soda bottles for this purpose. Perform the process of pouring your homemade saline into the bottles, in an aseptic manner. The solution is not sterile but clean enough for the use in chronic wounds. The shelf life of homemade saline is not long - we recommend you to make new batches every week.
Homemade antibacterial rinse solution
While 0,9 saline will be sufficient to rinse many types of wounds, we sometimes like to use a rinsing solution with antimicrobial properties. For this purpose, 0,9% saline containing 1-2% vinegar can be used. Make the 0,9 solution in the usual way and add the vinegar once the saline solution has cooled down to about 50 degrees Celcius or lower. This is a gentle antibacterial rinse but be aware that some patients may feel that it gives a burning sensation when used. Start off with a 1% vinegar/0,9% saline solution and test this on a smaller area of the wound first. Most patients will not feel any significant discomfort at these concentrations.
Note: earlier we described using a 3,5-5% vinegar solution. Here we are describing a 1-2% vinegar solution. What is the difference? When we have a definite bacterial problem in the wound we will want to use the stronger formula. When we simply want to use a mild antibacterial solution for the sake of preventing bacterial growth we can use the weaker fomulation of 1-2% vinegar.
Gauze soaked in povidone-iodine remains one of Africa's most common wound dressings, especially when there are signs of infection. You may be aware that there have been discussions about the possible cytotoxic effects of PI. However, more recent articles have shown that PI is beneficial to wound healing ( for example, Bigliardi et al., 2017; Povidone-iodine in wound healing: A review of current concepts and practices; International Journal of Surgery).
In our experience, PI dressings are highly effective at treating wounds that have a heavy bacterial burden. We have, for example, used them successfully in wounds with severe Pseudomonas aeroginosa or enterococcal infections. The PI dressing should be changed frequently - at least every second day. Quite often, you will see that the brownish color of the iodine is gone within a day or two. This indicates that the iodine needs to be replenished to maintain the antibacterial effect.
PI is considered safe up to concentrations of about 10%, and it is usually sold at that concentration. It is often diluted to 5% or 3% before applying to wounds. We have routinely used it at 10% for one or two days to quickly reduce bacterial loads and then switched over to 5% strength during further treatment. We have no scientific evidence to back this practice up.
Gentian violet solution at a concentration of 1-2% is widely used in wound care globally, especially in areas with low resources. It is available at most pharmacies in Africa. It is a very potent antimicrobial, killing most types of bacteria and fungi. It has astringent properties; that is, it is good at drying out macerated wound edges with broken skin, preventing further wound deterioration. It is our preferred treatment of choice concerning fungal infections in skin folds and in skin damaged by IAD.
There is an ongoing dicussion about how safe GV is. There are a few scientific reports about a cancerogenic effect when used at high concentrations for longer periods. The Food and Drug Administraion (USA) has approved the use of this product for short term treatment in wounds and even for the treatment of oral thrush in children. After looking at up-to-date available literature on this, we can conclude that GV at 1-2% concentrations should be safe to use for a time period of at least some weeks. It is rare that we need to use GV for so long anyway, often only a few days of treatment are sufficient.
Green bottlefly maggots
Medicinal maggots are probably the most precise and effective debridement tool available. Once a forgotten skill, the employment of medicinal maggots is on the rise again in western countries.
Lack of debridement is one of the greatest challenges in wound care in Africa today, and medicinal maggots could solve some of these issues and thereby save limbs and lives. Medicinal maggots are costly, as they are reared in laboratories under strict hygiene regulations. It is entirely unrealistic to think that these will be available in off-the-grid settings in rural Africa in the near future.
If you are working at a wound clinic " in the bush," you should consider rearing your own medicinal maggots. These will not be sterile like those sold by special laboratories but clean enough if you follow an aseptic protocol. We have written a separate chapter on " how to rear your own maggots for debridement." Please refer to that.
Substitutes for compression bandages
One of the biggest challenges in low-resource settings is finding something to substitute compression bandages with. Modern short-elastic compression bandages are usually expensive. There are cheaper versions from chinese manufacturers available, and you have to take your time and research the market to find reasonably priced models. Also: if the patient is lucky enough to posess a compression bandage this can obviously be re-used by the patient and be washed at regular intervals.
We have been trawling the internet to find clever ways to substitute modern compression bandages with something cheaper. We found very little information on this topic. However, at the South African IIWCC meeting in Cape Town back in 2012, Hiske Smart and Gary Sibbald demonstrated the "African Bandaging System" They showed how to make a compression bandage system by only using crepe bandages and a cotton roll as padding. We agree that this is a good workaround solution, and it is cheap. In the chapter on compression therapy there is a video showing the "African Bandaging System".
Regular cotton gauze
Cotton gauze is very cheap and readily available everywhere in Africa. It can be utilized as an excellent wound dressing and is by no means outdated. You only have to use it in the right way! Cotton has good absorptive properties, but it does not hold the fluid well once it is saturated. Then it gets really wet, which can lead to maceration of the skin surrounding the wound edges. The clue to achieving excellent results with cotton dressings is to change the cotton very often, sometimes several times daily. This means that cotton dressings require more resources in terms of labor because the bandages need to be changed significantly more often than modern dressings. But if you teach the patient, a family member, or anyone else to do the dressing changes, these logistical challenges can easily be overcome. By the way - cotton gauze is our favorite wound filler for pressure ulcers in low-resource settings. If you change the dressing at least daily ( more often if there is much exudate), you will see excellent results as long as you ensure good off-loading at the same time.
Hydrogen peroxide 3%
Yes, we know: this once popular antibacterial solution has gotten a somewhat bad reputation for maybe being cytotoxic. These studies are, however, done on cells in the laboratory. And yes, we are aware that the antibacterial effect is not long-lasting. But the antibacterial effect of any other rinsing solution is not long-lasting either.
We have used hydrogen peroxide for over twenty years and have never seen any adverse effects. It is still a widely used remedy, especially in areas with limited resources, as it is cheap. In our experience, we find that it speeds up the formation of granulation tissue and even speeds up the debridement process. It will also (temporarily) limit foul odors from the wound.
We wrote about making an antibacterial rinsing solution from 0,9% saline and 1-2% vinegar earlier, but if the patient feels that this burns, you can try hydrogen peroxide. Do not use it at concentrations of more than 3%
Cotton gauze with antibacterial properties
This implies taking the cotton-gauze dressing to a new level. If you can buy gentian violet in bulk, you can make an antibacterial wound filler cheaply by soaking regular cotton gauze in 100% gentian violet. Squeeze the cotton well afterward and hang it up to dry. Once dried, it can be stored like any other cotton gauze. The advantage of making this antibacterial variant of cotton gauze is the following. When we have a dressing like cotton gauze, which gets saturated with exudate, bacteria may happily thrive within the dressing and multiply there. If we add an antibacterial component to the dressing, we may counteract this phenomenon. Again, when using cotton gauze dressings, you will see very good results if you change them often enough. Remember also that you can apply a layer of honey or sugar beneath the cotton dressing for a topical antibacterial effect.
Negative pressure wound therapy
Negative pressure wound therapy (NPWT) is one of the most potent tools in wound care today. Nothing else speeds up the formation of healthy granulation tissue-like NPWT. However, you will need some supervision when starting off with NPWT as to avoid errors that can increase the chance of infection.
Most NPWT systems today involve the use of electrical powered pumps which usually also have a chargeable battery. These are often in a price range which is completly out of reach for people living in low-resource settings.
A workaround for this is using a plastic bellow as your suction device, This is an extremely cheap and reliable method, and it does not need a power supply. See our chapter on NPWT for more information.
image copyright Gita et al, 2015 in Globalization and Health
Negative pressure wound therapy pumps for large rural clinics
We are aware of some off-the-grid clinics in rural Africa that have actually managed to obtain several expensive negative pressure pumps for wound therapy. The patients are usually admitted for several weeks while the treatment continues. If you work in a large clinic with a high volume of woundcare patients, and are not lucky enough to get provided with such expensive pumps, you can create a "negative pressure centre" with some basic engineering skills. The work-around solution is a stationary single-stage vacuum air pump - models which provide 1L suction are usually good enough. Such pumps are for example used in laboratories where air suction is deployed, and they can be obtained quite cheaply- we have seen models for around 200 US Dollars. It is essential that the pump has a pressure gauge like the model in the image to the left, so that you can be sure that the right amount of suction is applied. You can serial connect the wounds from 5-10 patients (maybe even more) - ie. you can treat many patients at the same time with only one pump. You will need a lot of tubing and connectors, fluid collectors for each patient but this is not hard to do and a very cost-efficient way to provide NPWT to many patients. However, you need a power supply and preferably also a power generator in case of power cuts!
Sheep skin for offloading
In some regions of Africa - mainly South Africa, Ethiopia, and Nigeria, there is extensive sheep farming. If tanned sheepskin is cheaply available in your area, you should use it in wound care! It is an excellent tool for offloading pressure-prone areas of the body and can be used to prevent and treat pressure ulcers under the heels, sacrum and any other areas of the body. When you for example place the patients back end on sheepskin, it not only provides a good distribution of pressure and shearing forces, but also keeps the area dry. With only basic skills you can cut sheepskin into smaller pieces and sew on some form of soft strap and fasten this onto an elbow for example. The image to the left shows high quality sheepskin for sale in Kenya ( image copyright: shutterstock)
Alternatives for single use gloves
This is supposed to be a trick question. There are no real alternatives to single-use gloves. They are meant to be used once only. Always change to a new pair when treating a new patient. We consider it unethical not to follow this recommendation, as you will risk the transmission of potentially deadly bacterial- and viral infections. We are aware of the practice in low-resource settings where single-use gloves are washed in detergent and then hung up to dry. This is unacceptable, and you have to convince your employer that this practice will endanger the patients and yourself. Disposable single-use gloves are very thin (often they already tear as you put them on!), and the tears may be invisible to the naked eye.
Are there really no workaround solutions? Not really good ones, no. You may consider investing in several pairs of household rubber gloves. These are usually made of much tougher material, and some types even withstand repeatedly boiling them in water for 5 minutes. The Centre for Disease Control also describes a method to efficiently disinfect such rubber gloves by soaking them in 3-6% hydrogen peroxide for 2-3 hours. But if you have the resources to buy hydrogen peroxide in bulk, you will probably also be able to afford single-used gloves.
Engage your local shoemaker
Access to a skilled orthopedist who can alter shoes to fit better or are better cushioned, will often be limited in Africa Get into a dialog with your local shoemaker. These often have the skills to make adequate shoewear for patient with diabetic foot problems as long as we explain our needs well enough.
Focusing on nutrition
So far in this chapter, we have focused on what to place into the wound to make it heal. Again, we got ourselves lost in looking at the hole in the patient and not at the whole patient. Adressing the aspect of nutrition is crucial to woundhealing. We spend a lot of time scatching our heads as to what dressing to use, and completely forget to inform the patient about how he/she can speed up the healing with nutrition. Especially in very remote areas we often see protein- and vitamin deficiencies. These two susbtances are essential for wound healing. Even if the patient appears overweight, he/she may have deficiencies. As a general rule of thumb we can advise all patients to increase their intake of proteins, and multi-vitamine supplements and zinc tablets are also recommended. A handful of peanuts every day for example can make a big difference. Please also refer to our chapter on nutrition for more information.
Iron deficiencies will severely halt wound healing and if you are dealing with particularly difficult wounds you should routinely check the patients hemoglobin levels.
Empower your patient
For most people living in low-resource rural areas, traveling to a dispensary for wound treatment is a significant financial burden.
Always try to see if you can teach the patient himself, someone in their family, or someone close to the patient to do dressing changes. Obviously, we cannot expect these people to do a wound debridement or any other more demanding procedures. However, with a bit of training, performing a rinse of the wound and changing the dressing is something most people will learn quickly. We have excellent experience with involving non-health workers to help in this process. The best is to get the patient to do everything by themselves - this empowerment of the patient helps with the self-esteem and may reduce the stigma that comes with living with a chronic wound. Moreover, it is a very cost-efficient method of treating chronic wounds.
Telemedicine for follow-up
Telemedicine for follow-up is the perfect tool for Africa. Most people have access to mobile phones today; quite many have smartphones. Using social media platforms like WhatsApp, images, and text can be easily exchanged between the patient and a clinic. It is even more efficient to do a video consultation, but this will require access to a better internet connection. Be aware that there are some juridical limitations concerning medical data shared via such applications. However, as long as the patient agrees to share information about himself, this is legally acceptable. At our clinic, we use Microsoft Teams to do video consultations with home care nurses that carry out wound treatments at the primary healthcare level.
Using a pressure cooker to sterilize your equipment.
Even when working with woundcare in the most primitive settings, you have to make sure that you do not spread harmful bacteria and viruses from one patient to the next. That is your obligation as a caregiver. Having very few resources is no excuse to oversee this.
It is advisable to use stainless steel tools like fine forceps ,fine scissors and a scalpel holder with disposable blades in woundcare. We advise you to invest in a pressure cooker to sterilize your equipment between patients. We have written a seperate chapter about this. If you cannot afford a pressure cooker you will have to boil the equipment for at least 20 minutes to ensure that it is safe to use for the next patient.
Link 1 A review article from 2013 looking at some wound management choices for rural areas in the tropics. Click on the image above to get to a link to the article.
Link 2 A closer look at the evidence behind some locally accessible wound care products. This paper is provided by Curtin University, Australia. Click on the image above to get to the article on their website.