Thank you very much. And I should say happy Valentine's Day to everybody. I have had the most horrible flu and lurgy for the past week, so I'm gonna try my best not to cough all the way through this.
So, I've at least got a voice on Tuesday. I had no voice whatsoever. So in this session, we're gonna talk about dealing with difficult to heal wounds.
And this is something that I encounter quite commonly. I get regular emails from people that I've got patients that I've got wounds that they're really struggling with. And I kind of really take a logical approach to when I'm dealing with these wounds, to figure out why we are seeing these problems, because generally, Wounds are gonna heal in a very predictable manner, and I've included a lot of more information about the wound healing process within your notes because there was only so much that I could fit into this hour.
So that's really quite detailed. I'm not gonna go into that during the course of this session, but I'm gonna look at the common reasons. Why we see delayed wound healing in veterinary patients.
But I have to say, for our group of patients compared to human patients, we have a much easier deal. When I talked to, human tissue viability nurses, they can have wounds that on humans, obviously, that have taken decades and they still can't get them to heal because humans have more complications compared to our veterinary patients. Our patients don't smoke.
Few of them have diabetes, so we don't encounter those same issues in the same way humans will do. So we can look at things kind of In a predictable fashion, in a logical fashion, and figure out why we have wounds that are not healing in an expected time frame. And for me, if a, if a womb doesn't heal within about a 6 to 8 week period, I start to think, what's going wrong?
Why has this patient got issues, and then work through the reasons that I, that, that may be. So, we're gonna talk about various different aspects, and I'm gonna cover wound lavage and wound debridement during the course of this process. But there are reasons why we see delayed wound healing, and they can be down to intrinsic factors within that wound itself.
They can be down to patient-related factors, and they can also be down to surgeon-related factors. We probably have all seen, you know, maybe new graduates that aren't maybe quite as experienced at surgery, and they're causing a degree of tissue trauma when they're doing. Surgical debridement, things like that, or they just don't have that knowledge because having that knowledge of wound dressings.
And that whole wound healing process is something that develops over the period of time as you become more experienced. So we'll look through each of these individual reasons. And there are very common impediments to wound healing.
Probably the biggest one that we tend to see are excessive bacteria or infection. We've all seen those wounds where, particularly things like dog bite wounds, where owners think, Oh, it won't be that bad. It'll be all right in a few days.
You know, I would say, owners that have horses. Are probably, you know, the ones that we see this happening with, where they'll put some blue spray or some purple spray on that wound or even worse, chuck a load of wound powder in there. That's not going to help that situation.
So we need to think about how we're going to get rid of that infection and thinking about the types of wounds where we know they are predictably like to get infected. For material at presentation, those animals that get dragged along the roads, and those wounds are full of debris, full of gravel, full of leaves. Well, we've got necrotic tissue.
All wounds to a certain extent, and again, we'll talk about the different aetiology of wounds. All wounds are going to get a degree of necrotic tissue within them, but we know that's gonna be much more severe in certain types of, of, of aetiology of wounds. Seroma hematomas, which can go along with surgeon-related factors, so creating lots of dead space, movement in that area where that wound is.
If there's poor oxygen supply, poor blood supply to that wound. We need to get that oxygenated blood flow to those tissues and also that's important if we've got infection. If we're we're dealing with a wound that's in a region where it doesn't have a good blood supply, that can start to become an issue.
Normally not so much of a problem is poor nutrition or poor health, but certainly in those geriatric patients, we know they can take a longer period of time to heal. Nut nutrition for us tends not to be a massive issue than it is compared to in human wound management, where they're dealing with geriatric patients that aren't actually getting adequate calorie intake. Mechanical damage during surgery, so again, lots of trauma created during that surgical procedure.
Borrow material during surgery. On all of these, I'm going to talk through, in a second. And if we think about those wounds, the easiest ones in some ways we've got to deal with, and the ones that are probably most common are that infection, that foreign material, and that necrotic tissue.
And these are the ones that we can do something about. Right at that first, that, those first few stages of wound healing. And when we think about bacterial contamination, it's not just the number of bacteria, but it's that combination of that bacterial population and the environment.
We've all probably been bitten by a cat at some point, and I know if I get bitten by a cat, Fairly well, or fairly badly, I'm gonna have to go to my GP and I'm probably gonna have to have some antibiotics. Where if I fall over the road and scrape my knees, that's probably not going to be the case. So it's very, very different.
As I said, aetiology is very different scenarios. And when we look at those etiologies in our patients, there are certain things that we really can predict. So we'll look at those wound related factors.
So we'll talk through etiologies next. We'll look at things like infection, we'll look at movement, we'll look at foreign material, foreign bodies in that wound, and we'll also look at what we can do about necrotic tissue, and we'll cover that more when we look at wound debridement as well. So I mean we look at wound aetiology, when we look at how those wounds have been created.
They're created in very, very predictable fashions. We've got avulsion on the gloving injuries, we've got abrasions, which I'm not going to talk about because they tend to be very superficial, moving only the top layer or two of that patient's skin, and it doesn't normally create wound healing problems. Shearing injuries, massive tissue loss.
Lacerations can be very variable. Puncture wounds, which can be created through projectiles, through stick injuries, through bite wounds. We've got our burn wings patients, which are probably the only group of patients where I would advise owners to do anything at home with burn wound patients.
If they contact us, I'll generally advise them to to run. Cool running water, so tepid water, about 15 °C, so it's tolerable over that patient's wound for somewhere between 10 and 30 minutes. The longer the better.
And what that's gonna do is that's gonna minimise the depth of that burn because it's gonna cool that skin more quickly. And limit that tissue damage as much as it's possible, and then we'll also talk about degloving injuries as well. So as I said, wound etiologies, we can look at any wound, and we're gonna have entirely different situations going on.
If we look at that wound on the right, cause that's the simplest one to look at, this is, a very, it's a very extensive laceration, but actually, we know from this it's gonna have minimal contamination with, with, with foreign material. It's gonna have minimal bacterial contamination. This was a dog that jumped through a glass door.
So a nice clean, almost surgical laceration versus that limb on the left, which we did manage to salvage, but that's got massive tissue loss. It's got a, you know, a horrendous, comminuted fracture going on. So we know that it was a dog that was, hit by a lorry and dragged on the lorry.
We know it's going to be full of foreign material. We know it's probably like to have heavy bacterial contamination by the time it comes in. How we deal with these wounds is going to be very, very different.
And that time frame that we expect for wound healing is also going to be very different as well. So as we said, we've got avulsion or degloving injuries. Because these wounds can have varying contamination.
The dog that you can see in the image was, a dog that was grabbed by another dog by the muzzle, and it completely tore it away from the bone. So it was a bite wound, so we know that's going to be contaminated with bacteria. Probably minimal, contamination with foreign material.
But if you think about cats with the glove jaws, they're definitely gonna have foreign material contamination. The big thing that we would think about in this patient, It's that damage to that underlying vascular supply, thinking about how we're gonna be able to get blood flow. We probably see this when we see the gloving injuries in limbs where sometimes we actually have to do a lot of reconstruction.
Because that blood supply to that, that distal part of that limb is no longer viable. So lots of things going on. So as we said, we can see these from bite wounds, we can see these from road traffic accidents.
So lots of issues in terms of damage to the local blood supply, risks in terms of this. Ischemia of that area. So what we can end up with these patients is the necrosis and sloughing of that skin over the foreign following few days.
We also can see see bacterial contamination and, and that occurs along with that sloughing all of that type of injury. So again, these types of patients, we really need to plan for what we're gonna do with them from the offset. Shearing injuries, very similar etiologies in terms of degloving injuries, they've got a combination of often degloving, they've got abrasion injuries.
We see them lots while in road traffic accidents, probably most commonly. Particularly seeing them on patients distal limbs, particularly we tend to see them on the medial aspect of the carpus, the lanes, the tarsal metatarsal joint. They're deeper, as I said earlier, than abrasion injuries, and they will often involve underlying joints, which can make them much more complicated.
Because they may have fractures, they may have tendon or ligament injuries that we need to deal with ultimately, but actually, we're not going to be able to do that until we can get on top of removing that that foreign material from that wound, getting on top of that contamination. That infection and then as well as that or the orthopaedic injuries we can get, thinking about what we're gonna do if we've got, if we've got fairly extensive tissue loss, and that tends to be a very difficult again if they're on distal limbs because you've not got lots of soft tissues that you can pull together. So often what we have to look at doing in these patients is using flaps or using grafts to cover that soft tissue loss, which can get quite complicated.
The image that I that we write that you've already seen is that dog. So, laceration injuries. So, again, depending on how that laceration happened, we've got a combination.
Of contamination. So the dog on the left was actually a road traffic accident. It was hit by a car.
So it was the front end of the car that did all this damage. And this was a huge Rottweiler with a really extensive tissue injury. And so with lacerations, it tends to be traumatic wounds.
We've got a sharp objects, so often glass or metal shards. They're moving in a plane parallel to that skin surface. So typically, they may have fairly clean regular edge edges, which we can see and that wound on the right.
The wound on the left, maybe not so much. But again, We can really have extensive damage to deeper tissues, so we can have muscle and tendon, nerve and blood vessel damage. Which is why it's so important when we, we really need to explore these wounds because you can't always see that on an immediate inspection.
So, highlights how important that proper tissue wound exploration is. We tend not to see, contamination of much with these type of injuries, but again, it's going to very much depend how much it happens. I said, we tend to see smaller amounts of narcotic tissue.
But in that dog on the left, I'd be worried about being hit by a car, that's gonna cause damage to those blood vessels, and so they're gonna die off, and we can pretend it, potentially end up with more necrotic tissue because of poor blood supply to that region. Puncture wounds, we've got a variation in puncture wounds that you can see here. So with puncture wounds with those bite wounds particularly, we've got real issues with crushed tissue.
With bite wounds they're a problem. Because what we've got is that penetrating injuries. So, with that bite injury, we'll tend to have that puncture wounds from those canine teeth.
And then what also happens is we've got the carnassios that are gonna put real, you know, cause a lot of damage because they're gonna crush tissues. They've got a force of between 100 and 450 PSI. So we've got that combination of puncture and laceration from the canines and then those carnacal teeth really crushing down onto those wounds, and this is what again, why we really need to thoroughly explore those wounds.
So we've got crushed tissue. Again, damage to underlying structure, damaged vasculature, deep inoculation of bacteria. It's our classic cat puncture wounds.
These are the ones where owners think it only looks like quite a small wound. It's not going to be that bad. But as you'll see in a second, these wounds are the ones where we predict that they're going to get much worse over the course of time.
And we get that deep inoculation of bacteria, so we're gonna have infection on top of that. So, we can see we've got top left, we've got, a Westie that had a penetrating chest wound. You can see probably just about, he's got some puncture wounds here as well as other scrape injuries.
This was a dog, and you can't see particularly well. There's an area of bruising and necrosis down here. This was, a police dog that had, with a stick injury, and they only brought him in because he noticed this purple swelling developing under his chin.
Which predictably was from that skin. The image on the right is a black Labrador that also had a stick injury. It ran down onto a stick, which completely degloved its oesophagus from the back of its pharynx.
So, what we've got here is two stay sutures holding open the end of that dog's oesophagus, which our surgeon had to then go in and reattach. And then we've got complications thinking about. We don't want this dog to eat for a period of time, so it then gets further complicated because we've got to look at putting feeding tubes in and things like that.
Because we want to avoid that bit of the oesophagus. This was, a staffy that came into me when I worked in my previous practise, that had a bite wound, this dog. This was the, the, the morning after it happened.
So the owner had been out walking. I think it was an Akita that had attacked this dog. And we knew this was going to get much, much worse over a period of time.
And you can see from that initial injury, as we've got top left to the bottom middle image. We had extensive tissue loss because of necrosis, because of infection, even though we started treating it immediately of antibiotics, we knew it was going to get much worse before it got better. And actually, On both the cosmetic point of view and a time frame point of view, what we actually did with this patient was we did a superficial cord lipiggastric flap.
So we spent a period of time. Sorry, of, debridement, we predict we most commonly did, mechan mechanical debridement with wet to dry dressings, a little bit of a period of open wound management to make sure we got rid of necrotic tissue. We've got on top of the infection.
And then we raise this tissue flap which carries with it a direct cutaneous artery and vein, so it's got a good blood supply and we could swing this flap around. And cover that tissue defect. And we actually did this in a stage process on both sides, so we could get both those wounds covered and further on that healing process and we would have been able to do, treated them as open wounds within a 4 to 6 week period.
And the dog does have some nipples up its side, but the owners were happy to cope with that. And again, you're not going to get a perfect cosmetic results because the, the, the skin, this is a little stuffy, the skin on their belly is always going to be less hairy. Than it is, on the side.
What we've actually done here is we put a couple of active suction drains in because we don't want lots of seroma or hematoma forming. We want that skin to adhere down well onto that tissue bed. So as I said, infection really common when we see, we know that infected wounds are gonna heal much more slowly compared to non-infected wounds.
Mixed infections are common. We see aerobic, anaerobic bacterial infections. So we want to make sure we do swabs.
Make sure we're treating these appropriately with an antibiotics, and that's becoming more and more important these days as we're beginning to see more antibiotic resistance and as we're beginning to be much better when it comes to the appropriate use of antibiotics. What we'll generally do in these types of patients, where we have got obvious infection, is we'll take a macerated tissue culture. So we'll take more of a biopsy rather than just a swab, because the swab is just going to tell us about often the bacteria that that patient's coming into contact with.
On a daily basis, whether it's in our hospital, whether it's at home. And what we'll do is we'll do aerobic, anaerobic, mycobacterial and fungal cultures along with histopathology if we think that there may be something else going on. And most of the time infected wombs are going to respond well to debridement, open wound management, and systemic and potentially local and antimicrobial therapy.
And again, I'll talk about the use of antimicrobial dressings towards the end. So again, it's just about knowing how we're going to treat these wounds and making sure we're selecting that appropriate debridement technique, the appropriate open wound management technique. Movement can be an issue.
So this is a dog with a wound over its elbow. So if we've got movement either at that site or in around the surrounding tissues, that's gonna slow down wound healing, because what we get is we get excessive motion of and disruption of those capillary buds. That increases the amount of collagen being laid down in that wound.
And then what we get is a more of a chronic inflammatory status that really slows down that wound healing process. So, we don't want lots of movement, but equally, we don't want a total lack of movement, because what we want to happen over a period of time is that collagen to become more organised along the stress lines. So this was a a wounded, in a practise.
That my friend works in, and they've been treating this wound for months. And I think they just hadn't given any dress in a period of time to actually work, and not thought about the amount of movement they've got. So actually, they switched to a different type of dressing.
They persisted with that dressing for a few weeks. They got that wound looking healthier, because as you can see, compared top with bottom, That bottom wound looks much better. And then we actually, they did was they made, an, a separate incision.
So they created a separate wound along the side where there was less movement and closed that original injury which allowed it to heal. This is my best one body photo. This is a dog that jumped down onto a wrought iron gate and it went in like a big fish hook.
And we had to go out to cut this dog off. So foreign bodies is one of the commonest reasons again, along with infection for non-healing wounds, and that foreign material can be it can be foreign bodies or it can be necrotic tissue. Some of that foreign material is going to be removed by phagocytes, but we want to be much more efficient in getting rid of that material.
So that's where that whole debridement process becomes more important. Remembering as well that suture material is a foreign material, and we don't want too much of that within that wound, particularly if we've got any sort of infection present. What can happen is over a period of time that foreign material can become encapsulated and become effectively inert, but sometimes these patients will develop sinuses, things like that, and then we've got to go back in.
And find that source of foreign material. Necrotic tissue, as we said, again, is kind of a, a foreign body, and that's going to slow down that wound healing process. We don't rush in too quickly.
We want to take, make sure we're only taking away as much as we need to take away. So what we'll often do is allow natural demarcation of that non-viable tissue to become apparent. We want to see what's necrotic and then think about the brant technique that we're going to use.
We want to carefully debride all non-viable tissue. Early on in that wound healing process, but not too early, because if we don't get rid of it, that body's got to do that itself, and that's going to take time, so that can slow down that wound healing process. And we'll look at this patient later on.
We've got patient factors, so poor blood supply, poor nutrition, poor health status, and local factors as well. So, poor blood supply can happen because we've got major blood vessel lacerations. So we're in a really serious laceration, something like that.
It can be happen because we've got crushing injuries. So we've got thrombosis, we've got edoema, we've got contusions. That's going to impair local blood supply.
So we've got what we've got in that situation is damage to that microcirculation from ischemia. It can happen in anaemic patients. We need to have oxygenated blood flow into those tissues that those wounds need oxygen delivery to them.
We also need to make sure they've got a glimpse of blood supply to carry all those neutrophils and macrophages early on in that wound healing process, and also to carry our antimicrobials if we do have wound infection. And so what we can sometimes see is also, we can see, delayed wound healing if you've got any sort of delaying capillary formation. One of the times I'll sometimes see an issue is if owners have put in, Plastic bags on c pads, things like that, and they're not actually taking them off as much as they should do, and they're reducing oxygen tension of that surface of that wound.
So this is why a really careful question of owners about what they're doing with these patients is so important. Nutrition and health status, as I said earlier on, debilitated and our old patients are gonna heal much more slowly compared to our healthy animals. We know that logically.
We also tend to have a decreased ability to fight infection. So that can be more of an issue. So we want to look at addressing nutrition early on for so many reasons in these patients, but wounds need calories and they need energy to heal.
And we also want to make sure they've got an appropriate diet. If we've got hyperalbumia present, that's going to slow down wound healing, we can start to see chronic inflammation occurring. This was a dog that presented with the cubital ulcer.
It didn't happen in our clinic. It happened at home. And the owners didn't notice it was a recumbent, fairly recumbent elderly dog, and they didn't notice until this ulcer had really broken through.
And we've got local factors, and these are the things that we really want to plan for. So if we've got poorly draining wounds, or wounds with lots of dead space, that, that they can fade to heal because they've got seroma, or they've got hematoma formation. So this is where we plan ahead, particularly where we're doing surgical closure for putting things like active suction drains in.
To get rid of that fluid. And another reason we do because we want that skin to, to, to adhere really well down onto that wound bed. Another reason is that accumulated fluid can be an ideal medium for bacteria replication.
That's why when we do have seromas, things like that, we tend to avoid going in and draining them because we potentially risk introducing bacteria. Into that site through our needle. We've also got surgical, surgeon factors, so they can be arogenic, they can be the use of steroids.
So how we do surgery is important. So, how we make incisions, so a nice bold incision, not 1000 cuts, how we swab that wound. Making sure we're, we're achieving effective hemostasis.
So using, but again, being careful because forceps, ligatures, electrocautery are all gonna damage those tissues. So we're trying to Do the best to avoid haemorrhage and avoid hematomas, but equally not causing tissue damage. And we can really try and reduce adverse reactions by using the smallest gauge suture material that we need to do.
Using a traumatic needles, and I think these days more and more people are using waged on suture material which tend to have much better quality needles. Appropriate suture patterns, making sure there's not too much tension on that wound, and ultimately using the least amount of suture material that we can do. How we dress these wounds is so important.
So making sure people have got good bandaging techniques. So the dog on the top right was a dog that had a closed metatarsal fracture that was dressed at a practise. And they told the owners that the dressing had to stay on for 7 days.
They came back to that practise after a couple of days because the dog was interfering in the wound, probably because that dressing was too tight. We're given a buster collar and told it had to stay on. And it came into us another 3 days later, because the smell was just getting too bad, and this is what we found under that dressing, and it did absolutely stink.
This dog ended up being euthanased and the reason why it was euthanased was because it actually got tetanus through that wound. So again, making sure people have good techniques. Like it is something that you need to practise, like, I, the only thing I have OCD about, if you saw my house, you'd know I've got no OCD.
The only thing I've got OCD about is how I take catheters in. And how I bandage things in and I like a nice smooth, even layer of cotton wool, particularly on things like Robert Jones dressings. I use white, I use fairly wide conforming bandage as well, so I get a nice even pressure.
Also making sure if we've got things like Robert Jones is on that that won't bend because that's going to create areas of tension. And almost like a tournique effect on that wound. And we know that we've got a period of about 48 hours if we do have bandages that are too tight, anything over that 48 hour period, it's likely to cause severe tissue damage that is gonna be irrepairable or will require fairly extensive repair.
Use of steroids, cor corticosteroids are gonna, result in suppression of acute and chronic inflammatory signs. They're gonna slow down angio angiogenesis, the formation of those new blood vessels. They're gonna slow down fibroplasia.
We're gonna slow down whim contraction, which is really important in vein patients. A lot of the reduction in the size of wounds that we see because of that contraction that we see. And that use of steroids includes both topical corticosteroids, but also exogenous steroids.
Look steroids can encourage infection because they will suppress macrophagage and neutrophil activity, which are really essential early on in that wound healing process for trying to clean that wound up as much as it is possible. But when I get a wound in, I look at it and to try and figure out what we need to do next in that wound healing process to think, is it inflamed? Sorry.
Is it infected? Is it contaminated? Is it necrotic?
I need to think, do we need to remove any foreign material, and necrotic material from that wound? So does it need further debridement? And this can be, it doesn't have to be.
The same day or 2 or 3 days later, that may be a week later or so. Thinking about the type of dressing that we're going to use, and this is all the time that any dressing change thinking about, do we need to absorb extra dates to pull it away from that womb, to stop it, that skin around that wound getting macerated and soggy. And we want to make sure we're controlling.
Or at least not promoting infection in that wound. I look to see if that wound is granulating. So if that wound's granulating, and I'm selecting a dressing, I want that dressing to be non-adherent.
I don't want that dressing to act like a wet to dry and remove some of those cells when we take it off. That's in inevitably going to happen to a certain extent, but I don't want this to be extensive. I want it to maintain a moist wound environment.
That's essential to allow those cells to leapfrog over each other. Also, we want to make sure we're not splinting that wound open and preventing contraction as well. So, I know.
When Monuka Honey came out, people were sometimes using that in combination with our dry dressings, things like melanin. We're just allowing that honey to dry out and become hard and stop that wound from contracting down and in effect slowing down that wound healing process. If there's chronic granulation tissue present, we may need to look at debriding that further.
So deriding that chronic granulation tissue, kickstarting that wound healing process again, or looking at dressings that can actually re-stimulate activity. In that grain granulation bed, and I'll mention a few of the dressings that we, we use later on in this lecture. If that womb's not doing anything, we need to figure out why that's not happening.
So we would look at biopsying that womb to make sure we don't have neoplasia, taking some bloods, looking at systemic condition of that animal. Thinking about blood supply. So this is your classic cats that get bitten on the, as I call it, the bottom belly fat, which doesn't have a good blood supply.
So therefore, we don't get great antibiotic penetration in that region. So what we did on this cat is we debrided these areas back, and we actually did a mental graph. We went into this patient's abdomen, pulled out a little bit of momentum, tunnelled it subcutaneously and used it to cover that area.
And that momentum's got a good blood supply and we saw a a a a a massive change fairly quickly in this patient and we got womb closure eventually. So when we look at ultimately wound management, it's a combination of preparation of that wound, looking at lava techniques, what debridement techniques going to be appropriate, selecting an appropriate dressing and potentially, and I'm not going to talk about this during this session, looking at how we're going to reconstruct that wound. So, Whenever I'm look at a wound in straight away, we need to prevent further contamination.
I'm gonna look at clipping that womb up, but before I clip it, I want to pack that wound out and how you pack it out for me is gonna depend on how deep that wound is. Now I'll either use a water soluble lubricant gel, something something like KY jelly, you can use hydrocholoids. If it's a deep wound, I'll tend to use swabs either soaked in a gel or soaked in saline to pack into that wound, and I will flush this out regularly, and this is just to avoid as we're clipping that wound.
Her getting in there and providing further foreign material. If I'm using swabs, things like that, I'll change those out as I'm, I'm, I'm clipping that wounded up. So we're gonna cli clip widely around that wounded.
I know they're not always easy to find in practise, but clipper blades that are sharp, clean, no missing teeth. We don't want to traumatise those wound edges so often around the edge of that wound. I'll use some sterile scissors that I've dipped in some KY jelly or something like that, again, just to avoid lots of hair getting into that wound.
We're gonna prep that wound due using standard aseptic preparation. We want to avoid contaminating that wound with antiseptic solution. We tend to use a fairly dilute chlorhexidine solution like a 0.05% chlorhexidine solution if we know it's going to come into contact with an open wound.
If it's that early, really early stages. It's probably not much of an issue, because we're going to lavage that wound really well afterwards. But what we need to remember is iodine and chlorhexidine are toxic to fibroblasts.
So if you've got a, a wound that's an ongoing wound, we really want to avoid using these substances because you can slow down that wound healing process. We're then going to lavage that wound, and I've put loads of information about lavage fluids, and lavage techniques in the note. So we're gonna lavage to remove loose form material and some of that necrotic tissue from the wound.
And also importantly, to dilute bacterial contamination in that wound. We want to blast, in effect, those bacteria off of that skin. And by doing this process effectively, we're going to remove impediments to wound healing, and we're gonna reduce that risk of infection, provided we do it appropriately early on.
So, provided we do it appropriately it means making sure we use sufficient volumes of lavarge fluids. The bigger the volume of lavage fluid, the less the extent of infection. The more contaminated that wound is, the greater the volume of fluid is that we're gonna need.
If it's a conscious patient, we tend to use warm fluids. They're gonna be only slightly warmed, they're gonna be more more comfortable for the patient compared to cooler room temperature fluids. And as we said, we do it early on and that's gonna help to remove that bacteria much more efficiently.
In terms of selection of lavage fluids, Yeah, lots and lots of details in the notes. We know the solution that is least cytotoxic is Hartman's solution or lactated Ringer solution. But, so that tends to be our first choice.
It's, it's got a more neutral pH. It's closely followed by saline. In the studies that I mentioned in the notes, they talk, they talk about using drinking water or tap water.
And it all very much depends on where that wound is in that wound healing process. If I've got a patient that's been hit by a car, dragged along the road, I will get that patient and I'll put them on the tub table, and I will just rinse that wound out with the showerhead with tap water, because at that point in time, it's not gonna make a massive difference, and I want to get volume into that patient. If it's an ongoing wound, I'll use hearting solution.
If it's a massively infected wound, we potentially could look at using dilute chlorhexidine, but only it's massively infected. Antibiotic solutions, antiseptic solutions really aren't recommended as Lavar solutions in these patients. And then we're gonna look at debridement techniques after that.
So we've got lots of options in terms of the wound debridements. I think probably most of us. Tend to go mechanical debridement with things like wet to dry dressings, or surgical or sharp debridement, but also without maybe realising, we tend to do some autolytic debridement as well in our patients, but we have other debridement techniques available.
So, autolytic debridement is where we basically, it's a selective debridement process that's brought about by the release of that patient's own proteolytic enzymes. That's like things like colgenase or elastase. And we actually activate phagocytes using this process.
So, The release of those enzymes helped to break down and soften necrotic tissue, and they, and that that's produced mostly by the leukocyte. So it's a natural process that happens in all wombs, but we can help to enhance it by using products that are going to promote and maintain a moist wounded environment that are going to promote the activity of leukocytes and macrophages. So common things that we're going to use for that process are going to be things like, our hydrogels.
Manuka honeys will also do this, as well. So hydro gels useful in, in this situation. They are polymers that are saturated with water, and different gel forming agents, so things like carboxymethyl cellulose.
Included in those hard shells and we also use them as we'll be familiar with as part of that open we management process as well. We don't really use this technique in the UK, but that we have enzymatic debridement, so enzymatic agents, are fairly selective in terms of loosening and removing necrotic tissue. In the UK we don't have any products that exist.
But in the UK they've got, in the USA they've got ointment. That are made from bacteria, and that contain an enzyme called cetylane, and that's used in wounds that tend to have minimal crotic tissue. They use it in lots in humans that have got, sinuses and things like that.
So, We also have In proteolytic enzyme preparations for humans that contains, enzymes from plants, or things like pineapple, from bacteria, and also from, Antarctic krill as well. So lots of things available. I apologise if you've eaten your tea, which most of you will have done.
We've also got larval therapy available. So maggot therapy in small animal wombs has not been that, that popular. But in human medicine, it's lots and lots and lots.
Because if you think about humans, you know, we can sedate our patients a lot of the time on a daily basis to deprive them. In humans, that's not going to be a possibility. So marvel therapy is really useful.
It's been used for hundreds of years in humans. And they use the green bottle fly. They use the 3rd stage larvae, and those, those young larvae will selected debride necrotic tissue while sparing healthy structures.
So it's very different to what we see in rabbits with fly strike. So that's really useful in areas where there's vital structures. You're really useful where we can't do surgical debridement.
In humans, they tend to use these little, almost like tea bags. So these little mesh dressings, and they, they're placed into the wound with very early, maggot larvae on there, and then they're removed after 3 days when you as you can see they look much bigger and much juicier. Hydrosurgical fragment has been used in humans as an alternative to larval therapy.
This is a technique that basically uses a high pressure saline jet. So if you can see this hand piece, what it's actually got is a little window at the bottom. So saline fires at up to 1000 miles an hour, in effect, cuts tissues away because it's firing so fast, it's actually sucked away and spat down a handpiece, so it doesn't get the wound and the patient really, really wet.
So, use lots as an alternative to larval therapy in humans to debride wounds, chronic ulcers, burns, really useful in shearing injuries on lower limbs because you can debride all the way down onto the periosteum and I've got a little video that I'll just play and I've got more videos later as part of a case study, so you can just see the way it kind of cuts away those tissues. That I updated with the world's shortest video, apologies. The most common dressing that I think we tend to use.
In our clinics on a regular basis in the wet to dry dressing. So wet to dry dressings is basically where you moisten, a, a, a gauze swab or a sponge. And only so it's only just moist and apply that down onto that womb bed, you leave it in place for at least 12 hours, more like 24 hours, and then it's, the patient has to be sedated or anaesthetized, and it's ripped out of that womb bed, taking with it bacteria, taken with it necrotic tissue.
A really nice cheap way of doing things. As you said, it's one of the one ones that we commonly do on a daily basis early on in that wound process. And what you can see here is we've got a tie of dressing, so little loops of suture material all the way outside that we shoelace over and those little loops stay in place and we reuse them on a daily basis and we reuse those little loops to hold, Primary dressings in place as well.
Another SIM product that works also as a mechanical bribing products is Debrissoft. So Debrisoft, I I, I kind of describe it as looking a bit like sheepskin. A little bit like a gentle scouring pad, so it's not gonna heavily debride wounds, but it'll take away that surface layer.
So it's moistened with saline, and they use these conscious in humans, just take away any surface kind of purulent sluffy material. So another option. In terms of debridement.
We've then got sharp debridement or surgical debridement, where we are literally cutting away devitalized tissue from that womb. So a really effective technique where we can see we've got a lot of, of necrotic tissue present. So rapid effective removal of tissue, that also allows us the opportunity to assess, explore that wound and assess underlying structures as well.
So again, As we would for any surgical procedure, strict aseptic technique when we're carrying out sharp or surgical debridement. We've also got in block debridement. So in block debridement is if we've got areas where we've got necrotic tissue or infection, where we can take a block of a structure as well.
So it's almost like taking a tissue mass away. And the, the advantage of that is it allows us to close that wound afterwards. So we can excise a border of healthy tissue using this process.
And cover it, cover it with healthy margins in all tissue planes. We tend to do this, in patients with mastitis, things like that, where we can chuck away a big chunk chunk of tissue and also particularly where we know, owners are less likely to come back, for post-op checks, things like that. For that, we're gonna do some open wound management, and we've got to then think about what types of dressings we're gonna use.
When we think about the role of a wound dressing, it's got several functions. We need it to manage, exudate effectively. So we want that dressing to remove exudate from that womb bed and the skin around that's wound.
As we said, we want to avoid that hairy wound skin getting macerated and soggy and crinkly. And that we want that extra to be retained within that dressing. So we need to make sure that that dressing can absorb the appropriate amount of extraate.
We want it to manage bacteria both in the wound and the dressing. We want these patients to be comfortable. So we want to provide patient comfort whilst they've got that dressing in place, but also at the time of dressing change, they're using more and more, Dressings that are kind of non-adherent.
So using more of kind of silicone adhesives in dressings, which are much more comfortable for patients when we removed them. You want that dressing also to conform well onto that wound bed. That, that dressing also wants to protect that wound from further trauma and from bacterial contamination, and ultimately create that ideal environment for that wound to healing.
So, moist wound environment, thermal insulation, We wanted to stop that wound from drying out, but also allow gas exchange. There is so much technology goes into human wound management to make sure we can get that oxygen into that wound, and we can get carbon dioxide out. And a lot of these best dressings are going to be, water vapour permeable.
So it again helps to stop those that wounds getting too, too moist. More of these dressings that we're getting on the market now are what we call antimicrobial dressings, so I think probably lots of people are familiar with using honey. With using silver dressings, human in veterinary medicine, we're not using that much iodine because again, iodine, as I mentioned already, is toxic to to fiberblasts, so.
It's not a dressing that I've ever particularly used. And another dressing that's becoming more and more common is what we is PHMB, so polyhexamethylene biwanide, which is bigranate, so it's kind of in the same group as coorhexidine. And these are really useful because they often will avoid us having to use lots of systemic antibiotics in our patients, because we're using these antimicrobials locally.
And also that has the advantages of it makes us focus our attention on that patient's wound and think about what dressing isn't appropriate at that point in time. So how these antimicrobials work is all very different. So silver interacts with DNA.
It binds to proteins, it binds to functional groups, and that's how it exerts its mode of action. Iodine is an oxidising agent that destroys microbial protein and DNA. And it's got lots of different actions.
It's got an osmotic action, so, it will increase the amount of extra. It pulls fluid towards it. It contains leuconic acid, which makes that honey quite acidic and too acidic for microbial microbial growth.
It also produces, a little bit of, Hydrogen peroxide, which increases the amount of oxygen within that we embedding. It's a very, very small amount, but that can be significant if we don't use this stress it appropriately. And then we've got that PHMB.
So PHMB damages that cell membrane. If there's no cell membrane, everything from the entire inside that cell leaks out. So silver dressing is really important in terms of what we management.
It's been, silver's been used for hundreds of years, and the use of silver really has changed dramatically. Originally they used to put silver wires into wounds. But now we've got a huge range of, of silver dressings available on the market.
So silver we put into one of three categories. They're either inorganic nanoparticles or nanocrystalline. And when they're exposed to wind fluid or moisture, that silver gets released into its it's ionic form.
And those silver ions are highly reactive, and it can affect multiple sites, as we mentioned already, within bacterial cells. And ultimately what they do is cause cell death. So they bind to bacterial cell membranes, they disrupt that bacterial cell wall, they cause cell leakage.
The silver ions are transported into that cell, they'll disrupt cell function by binding to proteins that interfere with energy production, with enzyme function and cell replication. They're also really effective against a range, a broad range of bacteria, fungi, and viruses which include a lot of those multi-drug resistant bacteria, things like MRSA. So, really useful dresses.
They're very very rapid, acting, so they'll start to work within 30 minutes, and they have a sustained action. So, they've got an action of somewhere between 3 and 7 days, which makes them very useful because we actually don't want to go in a lot of the time and change that dressing any more than we have to. Because, as I mentioned earlier, every time we change a dressing, we're removing some of those healthy cells that we've got growing within that wound, which we actually want to be there.
So. And we want to think about dresses that we don't have to change as often. Honey dressings, I'm sure everyone is familiar with the use of honey, so .
We've used honey dressings for, for, for centuries now. And honeys, as we mentioned already, it's got an antimicrobial activity. It's got a deodorising action.
It's got an osmotic effect. It has like, anti-inflammatory activity. It's got antioxidant activity.
It can actually speed up the rate of wound healing because it helps to provide that moist wound healing environment. So again, thinking about how that honey works. Now, I mentioned earlier on that honey releases a little bit of, hydrogen peroxide as a byproduct, which is good in terms of increasing the amount of oxygen within the wound.
But actually, this is a cat that we had in my previous practise, and this is a cat that we weren't sure what happened. The owner thought it had been bitten either by a, a cat or potentially a fox. And they've been treating this dress, this cat on a daily basis, using a honey along with a foam dressing.
And every day it looked like this. It had this brown, what we thought they thought was necrotic tissue. And I've got some more closer up photos.
When, and I was actually off work and I came back in and they talked about this, this cat and they couldn't get the wound to heal, and the owner was thinking about euthanasia. And for me, it looks, if you look at it, it looks a little bit charred. OK.
So, My concern was, actually, we didn't have infection within this wound. And what was happening, it was actually getting a burn, either from that honey bean to acidic or a hydrogen peroxide burn. So, we divided it back and we switched to a different dressing for a few days.
We actually used a PHMB dressing in combination with a hydrogel. And we braved it. I'm going to talk about PHHMB dressings in a second.
We braved it and we left that dressing in place for 3 days, and that's what it looked like after 3 days. So the only thing that we could conclude from that is it actually was either the acidity or the hydrogen peroxide being released from that wound that was delaying that wound healing process, which is why it's so important to understand how these different dressings, dressings work, how these different debridement techniques work, because You should only be using honey in infected wounds. If you're using it on a healthy tissue, as you can see, it can cause problems.
As I mentioned, we've got these PHMB problem products. So PHHMB belongs to that, that family of antimicrobial agents, so the biguanides. We will probably come into contact with PHMB.
It's been used for, I said 75 years. It's probably more like 85 years now, using contact lens solutions, baby wipes. It's been used in cleaners for swimming pools and jacuzzis.
It's used as cleaners in brewery tanks, really effective antimicrobial antimicrobial agent. It's incorporated into foam dressings normally at a 0.5%.
You can get it in a gauze form as a product called curli, which sometimes in very, very, very infected wounds, we'll use that early on as part of the electric dry dressing. So we're getting on top of that infection really, really on. As I said, I mentioned this earlier on, PHMV has got a mode of action of basically it attaches to the bacterial cell wall, that disrupts that cell wall.
All the contents leak out, that cytoplasm leaks out. That cell's gonna collapse and die. And because that protective layer is disintegrated, there is nothing left to replicate or mutate, which hopefully means we're not going to get resistance happening within these products.
Also, because we're incorporating that into addressing. It provides a bacterial barley barrier and that's gonna help facilitate that wound healing. Different products available.
So a lot of them are antimicrobial foam dressings, which have got PHM being impregnated. It's a broad spectrum antimicrobial. It attacks that wound actuallyate.
It's effective against so many different bacteria and viruses, and again, our common multi-drug resistant bacteria that we tend to find. And again, we're treating these things locally. Also, these PHMB dressings are great because they've got an activity for up to 7 days, and we do leave them in place for 7 days, which means we are minimising disruption of that wound.
And, We use a lot of these dressings in my practise because we see fairly rapid wound healing, and a lot of that, I think, is down to, we're getting on top of the infection and we're disturbing that wound as little as we really, really have to. There are other products, and I'm, again, not endorsing any of these. There is another PHMB product available called Prontosan.
So prontozan is this product, in effect, incorporated into a solution. It contains beta, beta, which is a surfactant, so surfactants helps to break down and debris and. Biofilms.
So, biofilms are communities of bacteria that stick onto surfaces, including things like wounds, and are very difficult for antibiotics to penetrate. So often when we've got biofilms present, it's very difficult to get on top of them, because we can't, if we've got infection in that wound, we can't get rid of that infection because antibiotics can't penetrate that wound. So really effective as well against that bio burden, as we said, the antimicrobial.
Another fairly newish group of dressings are our DACC dressings. I'm not even going to try and say that Dialal that word. But, these products basically are hydrophobic.
So the water repellents, the water repellent, hydrophobic fatty acid derivative. That's used to coat dressing materials. So what we end up with is a dressing that's got highly hydrophobic properties.
So these dressings, rather than being physically trapped within the dressing matrix, those microorganisms become irreversibly bound to that dressing's foot surface using that hydrophobic interaction. Once they're bound within that dressing, bacteria and fungi are inert, so they're, we, they're not gonna, they're gonna, not gonna multiply, they're not gonna peripfolate. They're not gonna release harmful exotoxins or endotoxins.
So effectively, we're removing that bacteria from that wound bed, and therefore, therefore, removing that bacterial load. So, just for the last few slides, I wanted to talk about a case and look at, you know, patients where we have got wounds that aren't healing, and how we figure out why that's not happening. So, Freddie was a case that was referred to us in my previous practise.
He's a, he was a male domestic short hair. Hopefully he still is a male domestic short hair. He was 12 years old at the time.
The cat had previously been a reasonably big cat, he was just under 6 kg, and when he came into us, he was just over 3 kg. So he'd lost almost half of his body weight. He had had his, hind limb amputated, 2 months previously, been hit by a car, had a limb fracture.
When he came into us, he had a PCP of 16, and his own practise had done a, culture and sensitivity, and they groom Amarase. And this wound had broken down 3 times. So I'll run through some equally, it's been horrible photos otherwise.
This was Freddie's wound on initial presentation. So we looked at that wound. And we start thinking about, why is this wound repeatedly breaking down?
Why are we having issues in terms of infection? OK, so, again, just lots of horrid photos of that wound. We start to think about all those factors that I talked about right at the beginning.
So, thinking about that wound aetiology, how that wound was created, could that be a factor, potentially? Have we got infection? If I flip backwards, I think we're all happy that that wound looks infected.
Have we got movement? And again, if we go back and look at it, there was a fair bit of wiggle room. There was a fair bit of that cat's femur left.
So actually, that was wiggling around. Foreign material, foreign bodies, if we look, this cat's actually got viral sutures, which for us are contraindicated, there's gonna whip bacteria deep down with those tissues. So not ideal.
We can see there's necrotic tissue there. Poor blood supply, this cat's very anaemic. And, poor nutrition, he's lost half of his body weight.
Overall, I think all of us would say he's not in great health. Local factors, maybe, potentially, we don't know, could be nitrogenic factors. And we actually found out on discussion with the owner that the treatment that the, the practise had gone with was to give the owner, some flamazine ointment that we wasn't dressed.
And the owners were both actually, healthcare workers. One worked in a nursing care home, the other was a human nurse. So actually, we know that this patient was colonised with an RSA.
So they themselves could have been bringing that back home. The wound wasn't dressed, as we said, so this cat's dragging this open wound covered with flamazine around the house. It wasn't on steroids, fortunately.
So, so many things could have been an issue with that patient's wound. What we actually did to him early on is we treated it with, manuka honey and onto gauze just to try and get rid of that infection and use some mortalitic debridement. We actually over the top, put one of these PHMB dressings.
It was in the most awkward location because it was on that stump. It was next to his bum. Dressing that in place is a nightmare because that cat's got to be on the toilet.
So a really, really problematic wound in terms of dressings. So we did that debridement process, it actually, this whole situation got worse. So where we've got kind of two separate wounds, we just decided we're just gonna make that into one bigger wound.
We did use some of those, those, the, the, debris soft dressings that I talked about earlier, and this cat was sedated on a daily basis to carry out open wound management. This cat was so sick of this wound. It had broken down 3 times by this point, so you can understand him.
So we carried this out and we did culture and sensitivity on a weekly basis because what we wanted to make sure we do, we, we did was got rid of, any, any infection that we got and any multi-drug resistant bacteria present within that wound. And then our plan was to remove the rest of the femur that you can see that we've actually done here and do some sort of flap procedure. We were going to do some sort of advancement flap, on this patient.
So I'll just really quickly go through. We actually use, what we wanted to do is make sure we have a nice healthy tissue bed when we close that. So we actually use the, That hydrosurgical debridement, we use the the vertige as you can see, that's what we're doing here, just to take away that top surface layer.
If I go to the next slide, you can see this works because that saline is firing so fast, it creates what's called a venturi effect. So it actually sucks that, that saline that it's plied through down this tube which goes into a bucket, so it means that patient doesn't get all soggy. We, as we said, the plan was to remove the rest of that femur, and that's what we did, and you can see there's a fair bit of femur present left that was really, really wiggling around.
We did give it a little bit of clean with some very, very dilute chlorhexidine, and then actually we didn't need to do too much of a flat procedure because by the time we got rid of that, that, the rest of that femur, we were actually left with a decent amount of tissue to play with. So we did a little bit of an advancement flap. Again, we're thinking about closing that wound.
We, we've created a, we've moved an awful lot of tissue around, we're gonna have a lot of, dead space present on that wound. So what we did, and you can probably just see them, one of them here is we actually used, active suction drains on this patient. So we are sucking any X-ray that is produced that stops that he hematoma or seroma formation, that's gonna slow down wound healing.
You can see that's what we've got here. So these are attached to grenades that apply negative pressure, suck that fluid away. And that was the final thing, the actual, the cat actually went back to the, they came quite a distance, so they actually went back to their own practise for ongoing treatment afterwards, but that cat made a full recovery.
But it took a month of Debrment, open wound management, appropriate use of antibiotics, because antibiotics that it, it was on when it came into the clinic weren't actually effective against the bacteria. And actually, as well as MRSA, we actually colonised a multi-drug resistant E. Coli, a multi-drug resistant hemolytic E.
Coli. So this had lots of problems going on. So, 2 minutes to go, so I didn't need to talk quite as fast.
So I don't know if it's got anyone's got any questions. I realised I tried to pack quite a lot into that session, so I'm more than happy to take questions about anything when it comes to in management because it's one of my favourite studies subjects. Louise, thank you so much for that and I have to say well done on your voice and everything else.
That was amazing. I, I do appreciate you coming in tonight for the folks that are attending. Louise has been so sick that she didn't actually even manage to go to work fully today.
So we really do appreciate the sacrifice and thank you so much for that. Thanks very much. We do have a a a couple of questions coming through.
. There are some very, very long questions. Folks, I, I'm not able to discuss cases at this stage, so we're gonna skip the ones that are, actual case questions. We have an anonymous question that says, they have used honey and found it causes quite a lot of maceration of the wound.
What do you feel on that? Yeah, I mean, we tend to use in combination with foam dressings, which will absorb Exudate. The problem is that honey has got that osmotic effect, so it's gonna pull exudate and it's gonna it's going to increase the amount of extraate in that womb.
So I think it's essential to look at using it in combination with a foam dressing and changing it regularly. So every time I do a dressing change, I look at the amount of of extra that's being produced from a wound and match up my dressing. To, to what's going on at that wound at that point in time, and I'm not gonna use that same dressing on day one or week 1 that I'm gonna be using on week 3 or week 4.
I'm gonna change my dressings to match what's happening in that wound at that point in time. Excellent. Another, question that we've got through here, the products that you've been talking about, are they easily available and where do you source them from?
So, am I allowed to use companies? Yeah, go on. Yeah, so I, we use, and, and I know direct medical supplies I got a PHMB product.
Pioneer have lots of the products that I've talked about, but I also know the wholesalers will have them. I know companies like Advances and have their own products, their own website, and you can buy those through JAK marketing. So they're all very, very easily available.
Yeah, so it's the general range of suppliers that most of us are using. Great question here. Manage the negative pressure balls and stop them flapping around and how often are they emptied?
So we empty them whenever they need empty and I know that sounds very obvious, but if they're, if you, if they're not squashed down, if they're full, they're not gonna exert negative pressure. So we It depends how much extra that wins producing. They're likely to produce more earlier on, and then we pull them when we're getting minimal amounts.
We tend to, I don't know if I can flick back through the slides if I've got any. What we tend to use is lots of the SurgiFix dressings. I don't know if we've got it on any images.
So the stuff that looks like there's a bit. So we use this Surgifi. And it comes in a range of sizes.
So we can put Sergiofi on cats. We can put Sergiofi on St. Bernards, and we tend to tuck it under that.
If they're bigger patients, we would tend to put little harnesses on them as long as it's not going to interfere and just clip them on. Or there are so many, like, pet body shirt things now available. We just took them in.
The patients obviously stay hospitalised while they've got them in place, but realistically, they're probably only going to stay in situ for 234, maybe 5 days. Excellent. And yeah, those, those sort of tubing net things that you put on are really good for holding those grenades.
They work incredibly well. Couple of questions coming through about laser and K laser therapy. Mm.
I've never used it. I've never used it. I've no experience in using it.
I, for me, the jury is out. Someone would need to do a lot of convincing for me to think that it can make a difference. I think maybe in patients with arthritis, it can make a difference, but the thing I always say is, no dressing will speed up wound healing.
There's nothing we can do to speed it up. A wound can only heal as fast as it can heal. All we're doing is optimising the conditions to stop it.
To to to make it the process as fast as it can possibly can be, if that makes sense. And then to do what she does best, you know, when I first started nursing. The reason why I got into win management was because we just put, we put hydrogel and melon on everything, which isn't open wound, it's not moist wound management.
And it just makes those cells, those, those tissues dry out and dead cells, dead tissues aren't going to contribute to wound healing. Yeah, it, it's it's an interesting topic and, you know, Anthony always likes to say if we were in an auditorium, you would have got a thunderous round of applause. There are so many comments coming through here that I, I think it's just worth giving you some of them.
Brilliant webinar, thank you very much. Very impressive, excellent presentation. And and it goes on and on and on.
So everybody is very, very happy. Louise, thank you. Thank you so much.
Great question which came to my mind as well, and I'm sure a lot of people are wanting to, to ask this or have this in their head. How much did it cost for that last cat to be put back together? That last cat, We were working in the in a practise where I was the clinical director and finances started.
It was, it ran into thousands, but we ended up capping the bill just because the owner had gone through most of their insurance by the time they presented to us. And I'm not very good when it comes to to money. I remember a few years ago, I was working in a, in a very high-end hospital and we got a similar sort of case where the cat had fallen out of a third floor window and when it hit the ground, the car went over the top of it.
And that one went home with a bill of just over 15,000 pounds. That's what, that's, that's why my cats and my dog are all insured to the highest possible. Kind of the top end so that if something goes wrong, I want them fixing properly.
Yeah, yeah. Folks, there's lots and lots of questions about cases and and specific studies and things that we, we really can't go into all of those. We just don't have time.
Louise has done an amazing job for us tonight with an awesome presentation and hanging in there with a bad throat and feeling very poorly. So I think we're going to call it a night tonight. Louise, once again, thank you so much for your time.
I've heard you speak a number of times and every time you just get better and better. Thank you, you're very kind. Folks, that's it for tonight's webinar.
To dawn, my controller in the background, thank you so much for making everything run seamlessly and we will see you on another webinar soon. Good night everybody.