Poll any group of physicians for questions about wound care, and questions will inevitably be asked about prep solutions or antibiotics. The goal implied by the questions is sterility or virtual elimination of bacterial contamination.

The disadvantage of placing so much emphasis on sterility is that other aspects of wound care more crucial to success might be neglected. Furthermore, sterility is simply not a feasible option for any skin surface.

In the absence of the traumatic injury, healthy skin lives in relative harmony with bacteria - non-pathogens and pathogens alike. Quantitative assays of tissue biopsies show bacterial densities in the range of 10³ organisms per gram. Most cutaneous bacteria live in the interstices of epidermal recesses - sweat glands, hair follicles, and other skin appendages. Nevertheless, the skin serves as an important barrier to infection.

Many variables can influence bacterial growth within the skin: including tissue pH, dryness of the outer skin layers, and local secretions. The fatty acids produced in sebaceous glands are particularly effective inhibitors of streptococcal growth.

However, an injury changes the equilibrium dramatically. Even minimal trauma such as shaving the skin before surgery will increase bacterial levels. A burn will destroy the keratin barrier against bacterial invasion. A laceration exposes deeper tissue layers. A crushing blow induces additional cell injury. When treatment is delayed, the problem worsens. Add gross soil contamination, and bacteria flourish.

All the prep solutions in the world cannot change these factors, except by removing visible dirt. A prep solution cannot eliminate native bacteria, nor will it reverse cell death or alleviate the effect of treatment delay. In fact, some commonly used prep solutions will actually worsen the environment for healing. Those containing alcohol or hydrogen peroxide are lethal to healthy cells and solutions containing powerful detergents are anything but physiologic. Deeply pigmented solutions stain the wound and obscure the differences between non-viable and viable tissue.

The use of shaving is another popular ritual. Not uncommon today are patients with bald spots because over-zealous emergency room personal set out to halt hair growth from the vicinity of the smallest scalp laceration.

Assuming basic cleanliness, hair is no more "dirty" than skin; it is neither sterile nor extraordinarily contaminated. However, hair is a protein, and if sewn into the wound, it will behave like a foreign body.

What does constitute satisfactory wound preparation? Begin by filling a 30 cc syringe with saline. Attach a 25 gauge needle and irrigate the wound under pressure. You are now acting as a monocyte; removing clot, necrotic tissue, foreign body, and some bacteria. Don't be reluctant to inject Xylocaine before you begin to cleanse dirt and debris from the wound; you will not spread infection and you will do a better job if sensitive nerve endings are to rest.

Don't put any substances into the wound that can damage cells. Reject all alcohol and detergent-containing solutions!

A simple balanced salt solution is perfectly appropriate as both a prep and an irrigant. You don't need anything stronger!

If your hospital likes Povidone iodine, use the solution (not the detergent) and then wash it off with saline. Just don't fool yourself into thinking its application has lessened the chance of infection.

After cleansing, you can then become a myofibroblast by helping to approximate the wound edges with sutures. Suturing will be discussed in Chapter 9.

Just a few more words about measuring infection in wounds: biopsy culture allows numerical determination of bacterial density. Studies show that when quantitative cultures show greater than 10⁵ organisms/gm, the infection rate will be high if the wound is sutured. Below that level, suturing rarely leads to infection unless other mechanical errors are committed, such as tight closure, inadequate debridement, etc. Strepococci are a notable exception to this rule; their presence is bad in any number!

If your practice involves frequent encounters with bad contaminated wounds, you might wish to delay closure and ask your microbiology laboratory to provide you with biopsy culture technology. Secondary closure is best completed after the inflammatory phase of wound healing has diminished bacterial density to safe levels.