Nadia Hassani, MD

The costs for wound care play a significant role in total health care costs and are expected to rise dramatically. A 2018 Medicare analysis estimated chronic wound care cost $28.1 to $96.8 billion in supplies, hospitalization, and nursing care: Most costs were accrued in outpatient wound care.¹ The global market for advanced wound care supplies is projected to reach $13.7 billion by 2027, and negative wound pressure therapy alone is projected to grow at a compound annual growth rate of 5% over the analysis period 2020 to 2027.² Chronic wound care also impacts the patient physiologically, socially, and psychologically. One study compared the 5-year mortality of a patient with a diabetic foot ulcer (30.5%) as similar to those patients with cancer (31%).³ Yet the investment in cancer research far outstrips wound care research.

There is no perfect wound dressing for all chronic wounds, but there is expert consensus on interventions that facilitate wound healing. In 2021, Nuutila and Eriksson stated that wound dressings should fulfill the following criteria: protection against trauma, esthetically acceptable, painless to remove, easy to apply, protection for the wound from contamination and further trauma, a moist environment, and an optimal water vapor transmission rate.⁴ Balanced moisture control is considered essential for healing chronic wounds. Indeed, moisture control within the wound bed may be the most important factor in chronic wound management and healing. The body communicates through a liquid medium, and if that medium is compromised, communication and marshaling of the immune and healing responses may become inefficient.⁴ Too much moisture, exudate, or fluid in the wound, and the healing is slowed; too little moisture in the wound results in a compromised responses from the body’s immune system, thus delaying healing. In 1988, Dyson and colleagues demonstrated that moist wound care was superior for the inflammatory and proliferative phases of dermal repair compared with dry wound care. The results showed that 5 days after injury, 66% of the cells in the moist wound were fibroblasts and endothelial cells vs 48% of those in the dry wounds.⁵

The question of dry vs moist wound care has resulted in various wound dressings that produce favorable moisture balance. Moisture balance in a wound creates the ideal environment for wound healing. Sound wound care practices promote the following physiologic responses: increased probability of autolytic debridement; increased collagen synthesis; keratinocyte migration and reepithelization; decreased pain, inflammation, scarring, and necrosis;enhancement of cell-to-cell signaling; and increase in growth factors.^5,6 All these processes are mediated through proper wound moisture control. In addition to proper moisture control, antibiotics added to the wound care milieu (either directly to the wound or systemically) may have a place in chronic wound care. In 2013, Junker and colleagues reported that low-dose antibiotics combined with appropriate moisture balance in wounds demonstrated less scar tissue compared with dry wound care.⁶

Approaches to chronic wound care are worlds apart: In developing nations the care of chronic wounds often involves traditional management with local products (eg, honey, boiled potato peels, aloe vera gel, banana leaves), whereas in developed nations, more expensive and technologically advanced products are available (eg, wound vacuum, saline wound chamber, hyperbaric oxygen therapy, antibacterial foam). Developing countries often do not have access to technologically advanced wound care products. Local products are often used by local healers, priests, and shamans. The use of these wound interventions in developing countries has produced satisfactory results. In contrast, developed countries have multiple chronic wound care products available (Table).

CASE Presentation

An athletic, healthy 60-year-old Utah National Guard member presented to the George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah, 6 days after experiencing a spider bite. For the first 6 days, the patient applied bacitracin at home. On day 7, the patient noticed that the wound was enlarging and appeared to be fluctuant. The patient was prescribed clindamycin 300 mg 4 times daily on an outpatient basis, which was taken on days 7 to 14.

The wound’s total surface area continued to expand, and the patient returned to the Salt Lake City Veterans Hospital wound care clinic on day 17 stating that the wound was very painful and more fluctuant. The wound care nursing staff were consulted, the wound was debrided, and attempts to drain the wound resulted in minimal exudate expressed from the wound. Clindamycin was increased to 450 mg 4 times daily. However, the wound continued to enlarge and become more painful.

On day 20, the patient reported to nursing services and was admitted to the Salt Lake City Veterans Hospital general surgery department with mental status changes and symptoms of septicemia (Figure 1).

Discussion

Traditional Wound Care

Honey. Honey has been used as a treatment for wounds for almost 3000 years. It has antiseptic and antibacterial properties and contributes to a moist wound care environment. In 2011, Gupta and colleagues reported on the use of honey in 108 patients with burns of < 50% of the total body surface area.⁷ This report stated that delay in seeking medical care increased wound infection rates, contamination, time to sterilization, and healing. Compared with silver sulfadiazine cream, honey dressings improved the time to wound healing (33 days vs 18 days, respectively), decreased the time to wound sterilization (1 day vs no sterilization), and had better outcomes (37% vs 81%, respectively) with fewer hypertrophic scars and postburn contractures.⁷

Separate studies in 2011 and 2010 from Fukuda and colleagues and Majtan and colleagues, respectively, reported that honey eliminates pathogens from wounds, augments correct moisture balance, and elevates cytokine activity.^8,9 Additional studies in 2006, 2008, and 2014 by Henriques and colleagues, Van den Berg and colleagues, and Majtan suggested that honey reduces reactive oxygen species, is responsible for direct antimicrobial effects in a healing wound, inhibits free radical production, and promotes antitumor activity, respectively.^10-12 Van den Berg and colleagues suggested that buckwheat honey is the most effective honey in reducing reactive oxygen species.¹¹

Sterile banana leaves. In medically underserved and rural areas, boiled banana leaves are used to treat burns and nonhealing wounds. In a 2015 study, Waffa and Hayah compared gauze dressings with sterile banana leaves wound dressing in patients with partial thickness burns. Topical antibiotics were added to each type of dressing. The results suggested that the banana leaf dressings were easier to remove, patients reported less pain overall, less pain with dressing changes, and demonstrated a decreased time to healing when contrasted with gauze.¹³ In 2003, Gore and Akolekar compared autoclaved banana leaves with boiled potato peels in the treatment of patients with partial thickness burns. The time to epithelialization, eschar formation, and skin graft healing were equal in both groups. However, banana leaves were 11 times cheaper and rated easier to prepare than boiled potato peels.¹⁴ In a study comparing petroleum gauze with sterile banana leaves, Chendake and colleagues reported that in measures of overall pain and trauma during dressing changes, patients with contused and sutured wounds on the face and neck achieved better outcomes with boiled banana leaves compared with petroleum gauze.¹⁵

Boiled potato peels. This treatment is used in rural areas of the world as an adjunct for wound care. In 2015, Manjunath and colleagues theorized that the use of boiled potato peels in patients with necrotizing fasciitis decreased the acidic environment created by the bacteria. Additionally, the study asserted that the toxic wound environment created by the bacteria was neutralized by the potassium content in the peel, and the flavonoids in the peel acted as a free radical scavenger.¹⁶ In 2011, Panda and colleagues, using povidone-iodine as a baseline control, reported that peel extract and a peel bandage of sweet potato showed an increased wound closure percentage measured by enhanced epithelialization.¹⁷ This increased epithelialization was attributed to the antioxidant effect of the peels enhancing collagen synthesis.¹⁷

In contrast, in 1996, a study by Subrahmanyam compared autoclaved potato peel bandages with honey dressings as adjuncts in burn patients with < 40% of the total body surface area affected. The author reported that 90% of the wounds treated with honey were sterile in 7 days, while infection persisted in the potato peel group after 7 days. In the same study, 100% of the wounds treated with honey were healed in 15 days vs 50% in the potato peel group.¹⁸ In 1990, Keswani and colleagues compared boiled potato peels with plain gauze as adjuncts in the treatment of burn patients and concluded that although the potato peels had no antibacterial effect, the wounds in both groups had identical bacterial species. But the wounds treated with the potato peels showed reduced desiccation, permitting the survival of skin cells, and enhanced epithelial regeneration.¹⁹

Aloe vera. First recorded by the Egyptians and Greeks, aloe vera gel has been used for centuries in many cultures for a variety of ailments, particularly burns and chronic wounds. In a 2016 wound healing study performed on rats, Oryan and colleagues demonstrated that aloe vera gel was superior to saline used as the baseline control. Aloe vera gel used in a dose-dependent fashion demonstrated increased tissue levels of collagen and glycosaminoglycans compared with controls. Aloe vera gel modulated wound inflammation, increased wound contraction, wound epithelialization, decreased scar tissue size, and increased alignment and organization of the scar tissue.²⁰

Gauze. Iodoform gauze is a highly absorbent wound product. Sterile gauze promotes granulation and wound healing. It is well suited for wounds with minimal drainage. However, although gauze is inexpensive, it is easily overwhelmed by the moisture content in the wound, requiring frequent dressing changes (up to 3 times a day), ideally by nursing staff. The resulting increase in nursing care may actually increase the cost of wound care compared with other care modalities.

Petroleum gauze is often used in the care of acute and chronic wounds. However, petroleum-impregnated gauze has a water vapor transmission rate that needs to be remoistened every 4 hours. If the affected area is not remoistened during the exudative phase of wound healing, it may precipitate a delay in healing and increase pain and the prevalence of clinical infections compared with hydrocolloid, film, or foam dressings. Bolton suggested stopping the use of petroleum gauze as the control in studies because it does not provide a balanced and moist wound healing environment.²¹

Advanced Wound Treatments

Film products. Film products, including plastic food wrap, can be used as wound dressings and meet many of the necessary criteria for enhancing wound healing. These include moisture permeability, carbon dioxide, oxygen transfer, and wound protection. Transmission of moisture varies among products known as the moisture vapor transpiration rate. Film dressings have no absorptive qualities and are unsuited for highly exudative wounds.^22,23 Adding polymers, antibacterial, and bioactive agents may increase the wound care properties of film dressings.²² Film dressings excel in protecting shallow nonexudative wounds, are waterproof, and help protect the wound. These products are transparent, allowing clinicians to monitor the progress of the wound without removing the covering, and allowing the dressing to remain in place longer, which decreases the repeated trauma that can occur with dressing changes. Film dressings for wounds differ from those used for IV dressings and should not be used interchangeably.²³

Bioactive wound care. These solutions contribute to a moist wound-healing environment. Found naturally in brown seaweed, alginate-containing compounds were used by sailors for centuries to heal wounds. This was known in traditional medicine as the mariner’s cure. Alginate dressings are highly absorbent and can absorb up to 20 times their weight, which makes them desirable for use in highly exudative wounds. First synthesized more than 50 years ago, newer products contain bioactive compounds that prevent tissue damage, stimulate wound healing, improve cell proliferation and migration, and enhance metabolite formation.^24-26

In 2018, Aderibigbe and Buyana reported that polymers in the form of hydrogels were able to absorb fluid, making them a suitable choice for minimally exudative wounds. However, in their distended state, the hydrogel subgroup of these products became unstable (perhaps making them a poor choice for extensively exudative wounds), tended to dehydrate, and often needed a secondary dressing, which could lead to wound maceration.²² Most commonly used for wounds with minimal exudate, these dressings shine when used in nominally exudative dry wounds to promote autolytic debridement and hydrate the wound that has formed an eschar.

Hydrocolloid dressings are another type of bioactive wound dressing. These dressings are composed of 2 layers: an inner hydrophilic layer and an outer vapor-permeable layer that promote a moist wound environment. Hydrocolloid dressings assist in hydrating dry eschar wounds and have slight absorbency for exudative wounds. These dressings are not designed to be changed daily and can remain in place for 3 to 6 days. In a 2008 extensive review article, Thomas compared the utility of these dressings in patients with superficial or partial thickness burns, donor sites, surgical wounds, and minor traumatic wounds with basic wound dressings. The results of the review suggested that hydrocolloid dressings conferred statistically significant advantages in measures of decreased pain, healing times (decreased in donor sites by 40%), mobility restriction, and number of dressing changes.²⁷ Although more expensive than basic dressings, the longevity of the hydrocolloid dressing helps defray the original cost. Unfortunately, as these dressings remain in place and continue absorbing exudate, they can take on a very unpleasant odor.

A 2013 Cochrane database review comparing hydrocolloids with foams, alginate, basic wound dressing, and topical treatment found no statistical difference between hydrocolloids and basic wound dressings in patients with diabetes who have noncomplex foot ulcers.²⁸ In 2014, Pott and colleagues suggested a slight superiority in the performance of polyurethane foam dressings over hydrocolloid dressings used in pressure ulcers in older adults.²⁹ In a large pooled analysis in 2010, Davies compared foam to hydrocolloid dressings used in exudative wounds and reported that in 11 of 12 studies, foam dressings were superior to hydrocolloid in terms of exudate management, conformity to the wound, ease of use, decreased trauma and pain at dressing changes, and reduced odor of the wound.³⁰

Foam dressings. These products are typically composed of silicone or polyurethane. Consisting of 2 to 3 layers with a hydrophilic surface, foams are cut to approximate the wound size and serve to wick the macerated wound products to a secondary dressing above the foam. The micropores in the foam matrix absorb exudate from the wound bed while maintaining moisture equilibrium in the wound by donating back moisture to the wound, creating an environment conducive to wound healing. Foam dressings can be combined with various antiseptics (silver, GV/MB, etc) and serve as a delivery vehicle of those products directly to the wound surface.

A 2011 review comparing 8 studies found no difference among foam products available at that time in the use for chronic wounds.³¹ However, newer products on the market today have produced intriguing results with chronic wounds.

In 2017, Woo and Heil observed that chronic wounds treated with foam products containing GV/MB produced significant improvement when measured at week 4 in the areas of mean wound surface area (42.5%), decrease in baseline Pressure Ulcer Scale for Healing scores (from 13.3 to 10.7), wound coverage by devitalized tissue reduced (from 52.6% to 11.4%), and mean upper and lower wound infection scores were reduced by 75%.³² Further, the researchers reported a moist wound bed was achieved at dressing changes with polyvinyl alcohol (PVA) foam dressing. This led to the presumption that adequate moisture balance and autolytic debridement were facilitated using GV/MB antibacterial PVA foam dressings.

Many foam products on the market today exert an antibacterial effect on the wound bed. Antibiotic properties of various foam dressings create a microenvironment hostile to bacterial growth.³² In addition, the antibacterial properties combined with foam products contribute to the following: autolytic debridement, absorptive qualities (which reduce the bioburden of the wound), and maintenance of moisture in the wound bed. These qualities contribute significantly to the effectiveness of foam products with antibacterial properties.³² The correct balance of moisture in the wound has been identified as a superior environment and perhaps the most important component in chronic wounds.⁴ Foam dressings are less painful to change, easier to change, and in this case report, contributed to faster wound healing than gauze alone. In 2016, a study by Lee and colleagues suggested that the makeup of the foam product, defined as smaller pore and uniform cell size (foam density), resulted in greater permeability and better moisture absorption and retention capacity, contributing to improved wound healing.³³

In 2004, Sibbald and colleagues reported that in a 4-week study of nonhealing chronic wounds, foam wound dressing impregnated with sustained-release silver compared with foam dressing without silver resulted in a reduction in wound size (50% vs 30%, respectively), decreased fluid leakage (27% vs 44% respectively), and reduction in ulcer size measured from baseline (45% vs 25%, respectively).³⁴

In a 2006 study, Varma and colleagues compared sterilized, saline-soaked, nonmedicated polyurethane industrial upholstery foam in nonhealing wounds used in patients with diabetes with conventional techniques using topical antibiotics, hydrocolloid or hydrogel dressings as necessary, and desloughing agents as controls. At the end of a 3-month follow-up period, 100% of the wounds of the foam group had healed compared with 29.2% of the control group. Additionally, the time to wound healing was less than half for the foam group (22.5 days) compared with the control group (52 days), and the time to granulation and epithelialization was faster in the foam group.³⁵

In a 2012 meta-analysis, Aziz and colleagues reported that silver-impregnated dressings and topical silver were no better or worse than controls in preventing wound infection and promoting the healing of burn wounds.³⁶ The authors also noted that the nonsilver dressing groups continuing povidone-iodine, ionic hydrogel, or silicone-coated dressing showed reduced healing time compared with the silver-containing group.³⁶ This is intriguing because silver has long been used as a standard for the treatment of burn wounds.

Wound vacuum dressings. These dressings are very effective on highly exudative wounds involving a large surface area. However, wound vacuum dressing changes are time intensive and often painful to change. This is a foam dressing placed in the wound and attached to a vacuum device. The wound and foam are then covered with an impermeable membrane and attached to a negative pressure device that exerts a small negative pressure within the wound bed. This negative pressure increases the flow of blood to the less oxygenated areas in the center of the wound, promoting an increased concentration gradient of blood and nutrients and enhancing the evacuation of exudative material from the wound. Thus, a wound vacuum assists in forming an excellent moist wound-healing environment. Reporting in a review article in 2019, Agarwal and colleagues suggested that intermittent negative pressure was superior to constant negative pressure in wound healing due to the increased blood flow in the off phase, and 125 mm Hg negative pressure was optimal for wound healing.³⁷ This type of wound care has been touted as superior in wound care circles, and it may be; however, its cost, time commitment, and painful dressing changes along with cumbersome equipment make the choice difficult for some patients.

Conclusions

Although there is no perfect wound dressing, some wound care products seem to perform better due to fewer adverse effects and a much lesser cost. Important aspects of wound care appear to be time from injury to wound care, cleanliness of the wound, moist wound environment, cost, ease of use, and pain of dressing changes.

Primitive wound care products perform admirably in many situations. Modern medicated foam dressings containing antibacterial properties may have beneficial properties compared with other wound care products; however, comparison studies are lacking and need broad-based, randomized, controlled trials to confirm utility. Finally, any choice of wound care product must be tailored to the particular wound and individual patient needs. More large, robust, randomized controlled trials are needed.

Acknowledgments

The authors thank Sarah Maria Paulsen and Rosemary Ellen Brown Smith for their editing, proofreading, and preparation of the manuscript.

The costs for wound care play a significant role in total health care costs and are expected to rise dramatically. A 2018 Medicare analysis estimated chronic wound care cost $28.1 to $96.8 billion in supplies, hospitalization, and nursing care: Most costs were accrued in outpatient wound care.¹ The global market for advanced wound care supplies is projected to reach $13.7 billion by 2027, and negative wound pressure therapy alone is projected to grow at a compound annual growth rate of 5% over the analysis period 2020 to 2027.² Chronic wound care also impacts the patient physiologically, socially, and psychologically. One study compared the 5-year mortality of a patient with a diabetic foot ulcer (30.5%) as similar to those patients with cancer (31%).³ Yet the investment in cancer research far outstrips wound care research.

There is no perfect wound dressing for all chronic wounds, but there is expert consensus on interventions that facilitate wound healing. In 2021, Nuutila and Eriksson stated that wound dressings should fulfill the following criteria: protection against trauma, esthetically acceptable, painless to remove, easy to apply, protection for the wound from contamination and further trauma, a moist environment, and an optimal water vapor transmission rate.⁴ Balanced moisture control is considered essential for healing chronic wounds. Indeed, moisture control within the wound bed may be the most important factor in chronic wound management and healing. The body communicates through a liquid medium, and if that medium is compromised, communication and marshaling of the immune and healing responses may become inefficient.⁴ Too much moisture, exudate, or fluid in the wound, and the healing is slowed; too little moisture in the wound results in a compromised responses from the body’s immune system, thus delaying healing. In 1988, Dyson and colleagues demonstrated that moist wound care was superior for the inflammatory and proliferative phases of dermal repair compared with dry wound care. The results showed that 5 days after injury, 66% of the cells in the moist wound were fibroblasts and endothelial cells vs 48% of those in the dry wounds.⁵

The question of dry vs moist wound care has resulted in various wound dressings that produce favorable moisture balance. Moisture balance in a wound creates the ideal environment for wound healing. Sound wound care practices promote the following physiologic responses: increased probability of autolytic debridement; increased collagen synthesis; keratinocyte migration and reepithelization; decreased pain, inflammation, scarring, and necrosis;enhancement of cell-to-cell signaling; and increase in growth factors.^5,6 All these processes are mediated through proper wound moisture control. In addition to proper moisture control, antibiotics added to the wound care milieu (either directly to the wound or systemically) may have a place in chronic wound care. In 2013, Junker and colleagues reported that low-dose antibiotics combined with appropriate moisture balance in wounds demonstrated less scar tissue compared with dry wound care.⁶

Approaches to chronic wound care are worlds apart: In developing nations the care of chronic wounds often involves traditional management with local products (eg, honey, boiled potato peels, aloe vera gel, banana leaves), whereas in developed nations, more expensive and technologically advanced products are available (eg, wound vacuum, saline wound chamber, hyperbaric oxygen therapy, antibacterial foam). Developing countries often do not have access to technologically advanced wound care products. Local products are often used by local healers, priests, and shamans. The use of these wound interventions in developing countries has produced satisfactory results. In contrast, developed countries have multiple chronic wound care products available (Table).

CASE Presentation

An athletic, healthy 60-year-old Utah National Guard member presented to the George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah, 6 days after experiencing a spider bite. For the first 6 days, the patient applied bacitracin at home. On day 7, the patient noticed that the wound was enlarging and appeared to be fluctuant. The patient was prescribed clindamycin 300 mg 4 times daily on an outpatient basis, which was taken on days 7 to 14.

The wound’s total surface area continued to expand, and the patient returned to the Salt Lake City Veterans Hospital wound care clinic on day 17 stating that the wound was very painful and more fluctuant. The wound care nursing staff were consulted, the wound was debrided, and attempts to drain the wound resulted in minimal exudate expressed from the wound. Clindamycin was increased to 450 mg 4 times daily. However, the wound continued to enlarge and become more painful.

On day 20, the patient reported to nursing services and was admitted to the Salt Lake City Veterans Hospital general surgery department with mental status changes and symptoms of septicemia (Figure 1).

Discussion

Traditional Wound Care

Honey. Honey has been used as a treatment for wounds for almost 3000 years. It has antiseptic and antibacterial properties and contributes to a moist wound care environment. In 2011, Gupta and colleagues reported on the use of honey in 108 patients with burns of < 50% of the total body surface area.⁷ This report stated that delay in seeking medical care increased wound infection rates, contamination, time to sterilization, and healing. Compared with silver sulfadiazine cream, honey dressings improved the time to wound healing (33 days vs 18 days, respectively), decreased the time to wound sterilization (1 day vs no sterilization), and had better outcomes (37% vs 81%, respectively) with fewer hypertrophic scars and postburn contractures.⁷

Separate studies in 2011 and 2010 from Fukuda and colleagues and Majtan and colleagues, respectively, reported that honey eliminates pathogens from wounds, augments correct moisture balance, and elevates cytokine activity.^8,9 Additional studies in 2006, 2008, and 2014 by Henriques and colleagues, Van den Berg and colleagues, and Majtan suggested that honey reduces reactive oxygen species, is responsible for direct antimicrobial effects in a healing wound, inhibits free radical production, and promotes antitumor activity, respectively.^10-12 Van den Berg and colleagues suggested that buckwheat honey is the most effective honey in reducing reactive oxygen species.¹¹

Sterile banana leaves. In medically underserved and rural areas, boiled banana leaves are used to treat burns and nonhealing wounds. In a 2015 study, Waffa and Hayah compared gauze dressings with sterile banana leaves wound dressing in patients with partial thickness burns. Topical antibiotics were added to each type of dressing. The results suggested that the banana leaf dressings were easier to remove, patients reported less pain overall, less pain with dressing changes, and demonstrated a decreased time to healing when contrasted with gauze.¹³ In 2003, Gore and Akolekar compared autoclaved banana leaves with boiled potato peels in the treatment of patients with partial thickness burns. The time to epithelialization, eschar formation, and skin graft healing were equal in both groups. However, banana leaves were 11 times cheaper and rated easier to prepare than boiled potato peels.¹⁴ In a study comparing petroleum gauze with sterile banana leaves, Chendake and colleagues reported that in measures of overall pain and trauma during dressing changes, patients with contused and sutured wounds on the face and neck achieved better outcomes with boiled banana leaves compared with petroleum gauze.¹⁵

Boiled potato peels. This treatment is used in rural areas of the world as an adjunct for wound care. In 2015, Manjunath and colleagues theorized that the use of boiled potato peels in patients with necrotizing fasciitis decreased the acidic environment created by the bacteria. Additionally, the study asserted that the toxic wound environment created by the bacteria was neutralized by the potassium content in the peel, and the flavonoids in the peel acted as a free radical scavenger.¹⁶ In 2011, Panda and colleagues, using povidone-iodine as a baseline control, reported that peel extract and a peel bandage of sweet potato showed an increased wound closure percentage measured by enhanced epithelialization.¹⁷ This increased epithelialization was attributed to the antioxidant effect of the peels enhancing collagen synthesis.¹⁷

In contrast, in 1996, a study by Subrahmanyam compared autoclaved potato peel bandages with honey dressings as adjuncts in burn patients with < 40% of the total body surface area affected. The author reported that 90% of the wounds treated with honey were sterile in 7 days, while infection persisted in the potato peel group after 7 days. In the same study, 100% of the wounds treated with honey were healed in 15 days vs 50% in the potato peel group.¹⁸ In 1990, Keswani and colleagues compared boiled potato peels with plain gauze as adjuncts in the treatment of burn patients and concluded that although the potato peels had no antibacterial effect, the wounds in both groups had identical bacterial species. But the wounds treated with the potato peels showed reduced desiccation, permitting the survival of skin cells, and enhanced epithelial regeneration.¹⁹

Aloe vera. First recorded by the Egyptians and Greeks, aloe vera gel has been used for centuries in many cultures for a variety of ailments, particularly burns and chronic wounds. In a 2016 wound healing study performed on rats, Oryan and colleagues demonstrated that aloe vera gel was superior to saline used as the baseline control. Aloe vera gel used in a dose-dependent fashion demonstrated increased tissue levels of collagen and glycosaminoglycans compared with controls. Aloe vera gel modulated wound inflammation, increased wound contraction, wound epithelialization, decreased scar tissue size, and increased alignment and organization of the scar tissue.²⁰

Gauze. Iodoform gauze is a highly absorbent wound product. Sterile gauze promotes granulation and wound healing. It is well suited for wounds with minimal drainage. However, although gauze is inexpensive, it is easily overwhelmed by the moisture content in the wound, requiring frequent dressing changes (up to 3 times a day), ideally by nursing staff. The resulting increase in nursing care may actually increase the cost of wound care compared with other care modalities.

Petroleum gauze is often used in the care of acute and chronic wounds. However, petroleum-impregnated gauze has a water vapor transmission rate that needs to be remoistened every 4 hours. If the affected area is not remoistened during the exudative phase of wound healing, it may precipitate a delay in healing and increase pain and the prevalence of clinical infections compared with hydrocolloid, film, or foam dressings. Bolton suggested stopping the use of petroleum gauze as the control in studies because it does not provide a balanced and moist wound healing environment.²¹

Advanced Wound Treatments

Film products. Film products, including plastic food wrap, can be used as wound dressings and meet many of the necessary criteria for enhancing wound healing. These include moisture permeability, carbon dioxide, oxygen transfer, and wound protection. Transmission of moisture varies among products known as the moisture vapor transpiration rate. Film dressings have no absorptive qualities and are unsuited for highly exudative wounds.^22,23 Adding polymers, antibacterial, and bioactive agents may increase the wound care properties of film dressings.²² Film dressings excel in protecting shallow nonexudative wounds, are waterproof, and help protect the wound. These products are transparent, allowing clinicians to monitor the progress of the wound without removing the covering, and allowing the dressing to remain in place longer, which decreases the repeated trauma that can occur with dressing changes. Film dressings for wounds differ from those used for IV dressings and should not be used interchangeably.²³

Bioactive wound care. These solutions contribute to a moist wound-healing environment. Found naturally in brown seaweed, alginate-containing compounds were used by sailors for centuries to heal wounds. This was known in traditional medicine as the mariner’s cure. Alginate dressings are highly absorbent and can absorb up to 20 times their weight, which makes them desirable for use in highly exudative wounds. First synthesized more than 50 years ago, newer products contain bioactive compounds that prevent tissue damage, stimulate wound healing, improve cell proliferation and migration, and enhance metabolite formation.^24-26

In 2018, Aderibigbe and Buyana reported that polymers in the form of hydrogels were able to absorb fluid, making them a suitable choice for minimally exudative wounds. However, in their distended state, the hydrogel subgroup of these products became unstable (perhaps making them a poor choice for extensively exudative wounds), tended to dehydrate, and often needed a secondary dressing, which could lead to wound maceration.²² Most commonly used for wounds with minimal exudate, these dressings shine when used in nominally exudative dry wounds to promote autolytic debridement and hydrate the wound that has formed an eschar.

Hydrocolloid dressings are another type of bioactive wound dressing. These dressings are composed of 2 layers: an inner hydrophilic layer and an outer vapor-permeable layer that promote a moist wound environment. Hydrocolloid dressings assist in hydrating dry eschar wounds and have slight absorbency for exudative wounds. These dressings are not designed to be changed daily and can remain in place for 3 to 6 days. In a 2008 extensive review article, Thomas compared the utility of these dressings in patients with superficial or partial thickness burns, donor sites, surgical wounds, and minor traumatic wounds with basic wound dressings. The results of the review suggested that hydrocolloid dressings conferred statistically significant advantages in measures of decreased pain, healing times (decreased in donor sites by 40%), mobility restriction, and number of dressing changes.²⁷ Although more expensive than basic dressings, the longevity of the hydrocolloid dressing helps defray the original cost. Unfortunately, as these dressings remain in place and continue absorbing exudate, they can take on a very unpleasant odor.

A 2013 Cochrane database review comparing hydrocolloids with foams, alginate, basic wound dressing, and topical treatment found no statistical difference between hydrocolloids and basic wound dressings in patients with diabetes who have noncomplex foot ulcers.²⁸ In 2014, Pott and colleagues suggested a slight superiority in the performance of polyurethane foam dressings over hydrocolloid dressings used in pressure ulcers in older adults.²⁹ In a large pooled analysis in 2010, Davies compared foam to hydrocolloid dressings used in exudative wounds and reported that in 11 of 12 studies, foam dressings were superior to hydrocolloid in terms of exudate management, conformity to the wound, ease of use, decreased trauma and pain at dressing changes, and reduced odor of the wound.³⁰

Foam dressings. These products are typically composed of silicone or polyurethane. Consisting of 2 to 3 layers with a hydrophilic surface, foams are cut to approximate the wound size and serve to wick the macerated wound products to a secondary dressing above the foam. The micropores in the foam matrix absorb exudate from the wound bed while maintaining moisture equilibrium in the wound by donating back moisture to the wound, creating an environment conducive to wound healing. Foam dressings can be combined with various antiseptics (silver, GV/MB, etc) and serve as a delivery vehicle of those products directly to the wound surface.

A 2011 review comparing 8 studies found no difference among foam products available at that time in the use for chronic wounds.³¹ However, newer products on the market today have produced intriguing results with chronic wounds.

In 2017, Woo and Heil observed that chronic wounds treated with foam products containing GV/MB produced significant improvement when measured at week 4 in the areas of mean wound surface area (42.5%), decrease in baseline Pressure Ulcer Scale for Healing scores (from 13.3 to 10.7), wound coverage by devitalized tissue reduced (from 52.6% to 11.4%), and mean upper and lower wound infection scores were reduced by 75%.³² Further, the researchers reported a moist wound bed was achieved at dressing changes with polyvinyl alcohol (PVA) foam dressing. This led to the presumption that adequate moisture balance and autolytic debridement were facilitated using GV/MB antibacterial PVA foam dressings.

Many foam products on the market today exert an antibacterial effect on the wound bed. Antibiotic properties of various foam dressings create a microenvironment hostile to bacterial growth.³² In addition, the antibacterial properties combined with foam products contribute to the following: autolytic debridement, absorptive qualities (which reduce the bioburden of the wound), and maintenance of moisture in the wound bed. These qualities contribute significantly to the effectiveness of foam products with antibacterial properties.³² The correct balance of moisture in the wound has been identified as a superior environment and perhaps the most important component in chronic wounds.⁴ Foam dressings are less painful to change, easier to change, and in this case report, contributed to faster wound healing than gauze alone. In 2016, a study by Lee and colleagues suggested that the makeup of the foam product, defined as smaller pore and uniform cell size (foam density), resulted in greater permeability and better moisture absorption and retention capacity, contributing to improved wound healing.³³

In 2004, Sibbald and colleagues reported that in a 4-week study of nonhealing chronic wounds, foam wound dressing impregnated with sustained-release silver compared with foam dressing without silver resulted in a reduction in wound size (50% vs 30%, respectively), decreased fluid leakage (27% vs 44% respectively), and reduction in ulcer size measured from baseline (45% vs 25%, respectively).³⁴

In a 2006 study, Varma and colleagues compared sterilized, saline-soaked, nonmedicated polyurethane industrial upholstery foam in nonhealing wounds used in patients with diabetes with conventional techniques using topical antibiotics, hydrocolloid or hydrogel dressings as necessary, and desloughing agents as controls. At the end of a 3-month follow-up period, 100% of the wounds of the foam group had healed compared with 29.2% of the control group. Additionally, the time to wound healing was less than half for the foam group (22.5 days) compared with the control group (52 days), and the time to granulation and epithelialization was faster in the foam group.³⁵

In a 2012 meta-analysis, Aziz and colleagues reported that silver-impregnated dressings and topical silver were no better or worse than controls in preventing wound infection and promoting the healing of burn wounds.³⁶ The authors also noted that the nonsilver dressing groups continuing povidone-iodine, ionic hydrogel, or silicone-coated dressing showed reduced healing time compared with the silver-containing group.³⁶ This is intriguing because silver has long been used as a standard for the treatment of burn wounds.

Wound vacuum dressings. These dressings are very effective on highly exudative wounds involving a large surface area. However, wound vacuum dressing changes are time intensive and often painful to change. This is a foam dressing placed in the wound and attached to a vacuum device. The wound and foam are then covered with an impermeable membrane and attached to a negative pressure device that exerts a small negative pressure within the wound bed. This negative pressure increases the flow of blood to the less oxygenated areas in the center of the wound, promoting an increased concentration gradient of blood and nutrients and enhancing the evacuation of exudative material from the wound. Thus, a wound vacuum assists in forming an excellent moist wound-healing environment. Reporting in a review article in 2019, Agarwal and colleagues suggested that intermittent negative pressure was superior to constant negative pressure in wound healing due to the increased blood flow in the off phase, and 125 mm Hg negative pressure was optimal for wound healing.³⁷ This type of wound care has been touted as superior in wound care circles, and it may be; however, its cost, time commitment, and painful dressing changes along with cumbersome equipment make the choice difficult for some patients.

Conclusions

Although there is no perfect wound dressing, some wound care products seem to perform better due to fewer adverse effects and a much lesser cost. Important aspects of wound care appear to be time from injury to wound care, cleanliness of the wound, moist wound environment, cost, ease of use, and pain of dressing changes.

Primitive wound care products perform admirably in many situations. Modern medicated foam dressings containing antibacterial properties may have beneficial properties compared with other wound care products; however, comparison studies are lacking and need broad-based, randomized, controlled trials to confirm utility. Finally, any choice of wound care product must be tailored to the particular wound and individual patient needs. More large, robust, randomized controlled trials are needed.

Acknowledgments

The authors thank Sarah Maria Paulsen and Rosemary Ellen Brown Smith for their editing, proofreading, and preparation of the manuscript.

The costs for wound care play a significant role in total health care costs and are expected to rise dramatically. A 2018 Medicare analysis estimated chronic wound care cost $28.1 to $96.8 billion in supplies, hospitalization, and nursing care: Most costs were accrued in outpatient wound care.¹ The global market for advanced wound care supplies is projected to reach $13.7 billion by 2027, and negative wound pressure therapy alone is projected to grow at a compound annual growth rate of 5% over the analysis period 2020 to 2027.² Chronic wound care also impacts the patient physiologically, socially, and psychologically. One study compared the 5-year mortality of a patient with a diabetic foot ulcer (30.5%) as similar to those patients with cancer (31%).³ Yet the investment in cancer research far outstrips wound care research.

There is no perfect wound dressing for all chronic wounds, but there is expert consensus on interventions that facilitate wound healing. In 2021, Nuutila and Eriksson stated that wound dressings should fulfill the following criteria: protection against trauma, esthetically acceptable, painless to remove, easy to apply, protection for the wound from contamination and further trauma, a moist environment, and an optimal water vapor transmission rate.⁴ Balanced moisture control is considered essential for healing chronic wounds. Indeed, moisture control within the wound bed may be the most important factor in chronic wound management and healing. The body communicates through a liquid medium, and if that medium is compromised, communication and marshaling of the immune and healing responses may become inefficient.⁴ Too much moisture, exudate, or fluid in the wound, and the healing is slowed; too little moisture in the wound results in a compromised responses from the body’s immune system, thus delaying healing. In 1988, Dyson and colleagues demonstrated that moist wound care was superior for the inflammatory and proliferative phases of dermal repair compared with dry wound care. The results showed that 5 days after injury, 66% of the cells in the moist wound were fibroblasts and endothelial cells vs 48% of those in the dry wounds.⁵

The question of dry vs moist wound care has resulted in various wound dressings that produce favorable moisture balance. Moisture balance in a wound creates the ideal environment for wound healing. Sound wound care practices promote the following physiologic responses: increased probability of autolytic debridement; increased collagen synthesis; keratinocyte migration and reepithelization; decreased pain, inflammation, scarring, and necrosis;enhancement of cell-to-cell signaling; and increase in growth factors.^5,6 All these processes are mediated through proper wound moisture control. In addition to proper moisture control, antibiotics added to the wound care milieu (either directly to the wound or systemically) may have a place in chronic wound care. In 2013, Junker and colleagues reported that low-dose antibiotics combined with appropriate moisture balance in wounds demonstrated less scar tissue compared with dry wound care.⁶

Approaches to chronic wound care are worlds apart: In developing nations the care of chronic wounds often involves traditional management with local products (eg, honey, boiled potato peels, aloe vera gel, banana leaves), whereas in developed nations, more expensive and technologically advanced products are available (eg, wound vacuum, saline wound chamber, hyperbaric oxygen therapy, antibacterial foam). Developing countries often do not have access to technologically advanced wound care products. Local products are often used by local healers, priests, and shamans. The use of these wound interventions in developing countries has produced satisfactory results. In contrast, developed countries have multiple chronic wound care products available (Table).

CASE Presentation

An athletic, healthy 60-year-old Utah National Guard member presented to the George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah, 6 days after experiencing a spider bite. For the first 6 days, the patient applied bacitracin at home. On day 7, the patient noticed that the wound was enlarging and appeared to be fluctuant. The patient was prescribed clindamycin 300 mg 4 times daily on an outpatient basis, which was taken on days 7 to 14.

The wound’s total surface area continued to expand, and the patient returned to the Salt Lake City Veterans Hospital wound care clinic on day 17 stating that the wound was very painful and more fluctuant. The wound care nursing staff were consulted, the wound was debrided, and attempts to drain the wound resulted in minimal exudate expressed from the wound. Clindamycin was increased to 450 mg 4 times daily. However, the wound continued to enlarge and become more painful.

On day 20, the patient reported to nursing services and was admitted to the Salt Lake City Veterans Hospital general surgery department with mental status changes and symptoms of septicemia (Figure 1).

Discussion

Traditional Wound Care

Honey. Honey has been used as a treatment for wounds for almost 3000 years. It has antiseptic and antibacterial properties and contributes to a moist wound care environment. In 2011, Gupta and colleagues reported on the use of honey in 108 patients with burns of < 50% of the total body surface area.⁷ This report stated that delay in seeking medical care increased wound infection rates, contamination, time to sterilization, and healing. Compared with silver sulfadiazine cream, honey dressings improved the time to wound healing (33 days vs 18 days, respectively), decreased the time to wound sterilization (1 day vs no sterilization), and had better outcomes (37% vs 81%, respectively) with fewer hypertrophic scars and postburn contractures.⁷

Separate studies in 2011 and 2010 from Fukuda and colleagues and Majtan and colleagues, respectively, reported that honey eliminates pathogens from wounds, augments correct moisture balance, and elevates cytokine activity.^8,9 Additional studies in 2006, 2008, and 2014 by Henriques and colleagues, Van den Berg and colleagues, and Majtan suggested that honey reduces reactive oxygen species, is responsible for direct antimicrobial effects in a healing wound, inhibits free radical production, and promotes antitumor activity, respectively.^10-12 Van den Berg and colleagues suggested that buckwheat honey is the most effective honey in reducing reactive oxygen species.¹¹

Sterile banana leaves. In medically underserved and rural areas, boiled banana leaves are used to treat burns and nonhealing wounds. In a 2015 study, Waffa and Hayah compared gauze dressings with sterile banana leaves wound dressing in patients with partial thickness burns. Topical antibiotics were added to each type of dressing. The results suggested that the banana leaf dressings were easier to remove, patients reported less pain overall, less pain with dressing changes, and demonstrated a decreased time to healing when contrasted with gauze.¹³ In 2003, Gore and Akolekar compared autoclaved banana leaves with boiled potato peels in the treatment of patients with partial thickness burns. The time to epithelialization, eschar formation, and skin graft healing were equal in both groups. However, banana leaves were 11 times cheaper and rated easier to prepare than boiled potato peels.¹⁴ In a study comparing petroleum gauze with sterile banana leaves, Chendake and colleagues reported that in measures of overall pain and trauma during dressing changes, patients with contused and sutured wounds on the face and neck achieved better outcomes with boiled banana leaves compared with petroleum gauze.¹⁵

Boiled potato peels. This treatment is used in rural areas of the world as an adjunct for wound care. In 2015, Manjunath and colleagues theorized that the use of boiled potato peels in patients with necrotizing fasciitis decreased the acidic environment created by the bacteria. Additionally, the study asserted that the toxic wound environment created by the bacteria was neutralized by the potassium content in the peel, and the flavonoids in the peel acted as a free radical scavenger.¹⁶ In 2011, Panda and colleagues, using povidone-iodine as a baseline control, reported that peel extract and a peel bandage of sweet potato showed an increased wound closure percentage measured by enhanced epithelialization.¹⁷ This increased epithelialization was attributed to the antioxidant effect of the peels enhancing collagen synthesis.¹⁷

In contrast, in 1996, a study by Subrahmanyam compared autoclaved potato peel bandages with honey dressings as adjuncts in burn patients with < 40% of the total body surface area affected. The author reported that 90% of the wounds treated with honey were sterile in 7 days, while infection persisted in the potato peel group after 7 days. In the same study, 100% of the wounds treated with honey were healed in 15 days vs 50% in the potato peel group.¹⁸ In 1990, Keswani and colleagues compared boiled potato peels with plain gauze as adjuncts in the treatment of burn patients and concluded that although the potato peels had no antibacterial effect, the wounds in both groups had identical bacterial species. But the wounds treated with the potato peels showed reduced desiccation, permitting the survival of skin cells, and enhanced epithelial regeneration.¹⁹

Aloe vera. First recorded by the Egyptians and Greeks, aloe vera gel has been used for centuries in many cultures for a variety of ailments, particularly burns and chronic wounds. In a 2016 wound healing study performed on rats, Oryan and colleagues demonstrated that aloe vera gel was superior to saline used as the baseline control. Aloe vera gel used in a dose-dependent fashion demonstrated increased tissue levels of collagen and glycosaminoglycans compared with controls. Aloe vera gel modulated wound inflammation, increased wound contraction, wound epithelialization, decreased scar tissue size, and increased alignment and organization of the scar tissue.²⁰

Gauze. Iodoform gauze is a highly absorbent wound product. Sterile gauze promotes granulation and wound healing. It is well suited for wounds with minimal drainage. However, although gauze is inexpensive, it is easily overwhelmed by the moisture content in the wound, requiring frequent dressing changes (up to 3 times a day), ideally by nursing staff. The resulting increase in nursing care may actually increase the cost of wound care compared with other care modalities.

Petroleum gauze is often used in the care of acute and chronic wounds. However, petroleum-impregnated gauze has a water vapor transmission rate that needs to be remoistened every 4 hours. If the affected area is not remoistened during the exudative phase of wound healing, it may precipitate a delay in healing and increase pain and the prevalence of clinical infections compared with hydrocolloid, film, or foam dressings. Bolton suggested stopping the use of petroleum gauze as the control in studies because it does not provide a balanced and moist wound healing environment.²¹

Advanced Wound Treatments

Film products. Film products, including plastic food wrap, can be used as wound dressings and meet many of the necessary criteria for enhancing wound healing. These include moisture permeability, carbon dioxide, oxygen transfer, and wound protection. Transmission of moisture varies among products known as the moisture vapor transpiration rate. Film dressings have no absorptive qualities and are unsuited for highly exudative wounds.^22,23 Adding polymers, antibacterial, and bioactive agents may increase the wound care properties of film dressings.²² Film dressings excel in protecting shallow nonexudative wounds, are waterproof, and help protect the wound. These products are transparent, allowing clinicians to monitor the progress of the wound without removing the covering, and allowing the dressing to remain in place longer, which decreases the repeated trauma that can occur with dressing changes. Film dressings for wounds differ from those used for IV dressings and should not be used interchangeably.²³

Bioactive wound care. These solutions contribute to a moist wound-healing environment. Found naturally in brown seaweed, alginate-containing compounds were used by sailors for centuries to heal wounds. This was known in traditional medicine as the mariner’s cure. Alginate dressings are highly absorbent and can absorb up to 20 times their weight, which makes them desirable for use in highly exudative wounds. First synthesized more than 50 years ago, newer products contain bioactive compounds that prevent tissue damage, stimulate wound healing, improve cell proliferation and migration, and enhance metabolite formation.^24-26

In 2018, Aderibigbe and Buyana reported that polymers in the form of hydrogels were able to absorb fluid, making them a suitable choice for minimally exudative wounds. However, in their distended state, the hydrogel subgroup of these products became unstable (perhaps making them a poor choice for extensively exudative wounds), tended to dehydrate, and often needed a secondary dressing, which could lead to wound maceration.²² Most commonly used for wounds with minimal exudate, these dressings shine when used in nominally exudative dry wounds to promote autolytic debridement and hydrate the wound that has formed an eschar.

Hydrocolloid dressings are another type of bioactive wound dressing. These dressings are composed of 2 layers: an inner hydrophilic layer and an outer vapor-permeable layer that promote a moist wound environment. Hydrocolloid dressings assist in hydrating dry eschar wounds and have slight absorbency for exudative wounds. These dressings are not designed to be changed daily and can remain in place for 3 to 6 days. In a 2008 extensive review article, Thomas compared the utility of these dressings in patients with superficial or partial thickness burns, donor sites, surgical wounds, and minor traumatic wounds with basic wound dressings. The results of the review suggested that hydrocolloid dressings conferred statistically significant advantages in measures of decreased pain, healing times (decreased in donor sites by 40%), mobility restriction, and number of dressing changes.²⁷ Although more expensive than basic dressings, the longevity of the hydrocolloid dressing helps defray the original cost. Unfortunately, as these dressings remain in place and continue absorbing exudate, they can take on a very unpleasant odor.

A 2013 Cochrane database review comparing hydrocolloids with foams, alginate, basic wound dressing, and topical treatment found no statistical difference between hydrocolloids and basic wound dressings in patients with diabetes who have noncomplex foot ulcers.²⁸ In 2014, Pott and colleagues suggested a slight superiority in the performance of polyurethane foam dressings over hydrocolloid dressings used in pressure ulcers in older adults.²⁹ In a large pooled analysis in 2010, Davies compared foam to hydrocolloid dressings used in exudative wounds and reported that in 11 of 12 studies, foam dressings were superior to hydrocolloid in terms of exudate management, conformity to the wound, ease of use, decreased trauma and pain at dressing changes, and reduced odor of the wound.³⁰

Foam dressings. These products are typically composed of silicone or polyurethane. Consisting of 2 to 3 layers with a hydrophilic surface, foams are cut to approximate the wound size and serve to wick the macerated wound products to a secondary dressing above the foam. The micropores in the foam matrix absorb exudate from the wound bed while maintaining moisture equilibrium in the wound by donating back moisture to the wound, creating an environment conducive to wound healing. Foam dressings can be combined with various antiseptics (silver, GV/MB, etc) and serve as a delivery vehicle of those products directly to the wound surface.

A 2011 review comparing 8 studies found no difference among foam products available at that time in the use for chronic wounds.³¹ However, newer products on the market today have produced intriguing results with chronic wounds.

In 2017, Woo and Heil observed that chronic wounds treated with foam products containing GV/MB produced significant improvement when measured at week 4 in the areas of mean wound surface area (42.5%), decrease in baseline Pressure Ulcer Scale for Healing scores (from 13.3 to 10.7), wound coverage by devitalized tissue reduced (from 52.6% to 11.4%), and mean upper and lower wound infection scores were reduced by 75%.³² Further, the researchers reported a moist wound bed was achieved at dressing changes with polyvinyl alcohol (PVA) foam dressing. This led to the presumption that adequate moisture balance and autolytic debridement were facilitated using GV/MB antibacterial PVA foam dressings.

Many foam products on the market today exert an antibacterial effect on the wound bed. Antibiotic properties of various foam dressings create a microenvironment hostile to bacterial growth.³² In addition, the antibacterial properties combined with foam products contribute to the following: autolytic debridement, absorptive qualities (which reduce the bioburden of the wound), and maintenance of moisture in the wound bed. These qualities contribute significantly to the effectiveness of foam products with antibacterial properties.³² The correct balance of moisture in the wound has been identified as a superior environment and perhaps the most important component in chronic wounds.⁴ Foam dressings are less painful to change, easier to change, and in this case report, contributed to faster wound healing than gauze alone. In 2016, a study by Lee and colleagues suggested that the makeup of the foam product, defined as smaller pore and uniform cell size (foam density), resulted in greater permeability and better moisture absorption and retention capacity, contributing to improved wound healing.³³

In 2004, Sibbald and colleagues reported that in a 4-week study of nonhealing chronic wounds, foam wound dressing impregnated with sustained-release silver compared with foam dressing without silver resulted in a reduction in wound size (50% vs 30%, respectively), decreased fluid leakage (27% vs 44% respectively), and reduction in ulcer size measured from baseline (45% vs 25%, respectively).³⁴

In a 2006 study, Varma and colleagues compared sterilized, saline-soaked, nonmedicated polyurethane industrial upholstery foam in nonhealing wounds used in patients with diabetes with conventional techniques using topical antibiotics, hydrocolloid or hydrogel dressings as necessary, and desloughing agents as controls. At the end of a 3-month follow-up period, 100% of the wounds of the foam group had healed compared with 29.2% of the control group. Additionally, the time to wound healing was less than half for the foam group (22.5 days) compared with the control group (52 days), and the time to granulation and epithelialization was faster in the foam group.³⁵

In a 2012 meta-analysis, Aziz and colleagues reported that silver-impregnated dressings and topical silver were no better or worse than controls in preventing wound infection and promoting the healing of burn wounds.³⁶ The authors also noted that the nonsilver dressing groups continuing povidone-iodine, ionic hydrogel, or silicone-coated dressing showed reduced healing time compared with the silver-containing group.³⁶ This is intriguing because silver has long been used as a standard for the treatment of burn wounds.

Wound vacuum dressings. These dressings are very effective on highly exudative wounds involving a large surface area. However, wound vacuum dressing changes are time intensive and often painful to change. This is a foam dressing placed in the wound and attached to a vacuum device. The wound and foam are then covered with an impermeable membrane and attached to a negative pressure device that exerts a small negative pressure within the wound bed. This negative pressure increases the flow of blood to the less oxygenated areas in the center of the wound, promoting an increased concentration gradient of blood and nutrients and enhancing the evacuation of exudative material from the wound. Thus, a wound vacuum assists in forming an excellent moist wound-healing environment. Reporting in a review article in 2019, Agarwal and colleagues suggested that intermittent negative pressure was superior to constant negative pressure in wound healing due to the increased blood flow in the off phase, and 125 mm Hg negative pressure was optimal for wound healing.³⁷ This type of wound care has been touted as superior in wound care circles, and it may be; however, its cost, time commitment, and painful dressing changes along with cumbersome equipment make the choice difficult for some patients.

Conclusions

Although there is no perfect wound dressing, some wound care products seem to perform better due to fewer adverse effects and a much lesser cost. Important aspects of wound care appear to be time from injury to wound care, cleanliness of the wound, moist wound environment, cost, ease of use, and pain of dressing changes.

Primitive wound care products perform admirably in many situations. Modern medicated foam dressings containing antibacterial properties may have beneficial properties compared with other wound care products; however, comparison studies are lacking and need broad-based, randomized, controlled trials to confirm utility. Finally, any choice of wound care product must be tailored to the particular wound and individual patient needs. More large, robust, randomized controlled trials are needed.

Acknowledgments

The authors thank Sarah Maria Paulsen and Rosemary Ellen Brown Smith for their editing, proofreading, and preparation of the manuscript.

The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.

The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.

Background

The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. ¹

When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.^2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. ^2-5

Identified Needs

Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.⁶ Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.

Perceived Government Indifference

The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.⁷ A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.⁸ These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.

Access to Medical Care

Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.⁹ Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.

Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.¹⁰ The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.¹¹

Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.^10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.^2,3

Lack of Health Care and Radicalism

It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.^12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.¹⁵ In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.¹⁶ It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.

In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.¹⁷ Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.^17,18

Proposed Solutions, A Beginning

A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.¹⁷

In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.¹⁹ The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.

Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.

The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.

Disaster Response

Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.

Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.²⁰ Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.²¹ These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.

This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.

Underserved Communities

Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.¹⁷

The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.

Conclusion

This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.

The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.

The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.

Background

The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. ¹

When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.^2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. ^2-5

Identified Needs

Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.⁶ Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.

Perceived Government Indifference

The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.⁷ A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.⁸ These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.

Access to Medical Care

Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.⁹ Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.

Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.¹⁰ The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.¹¹

Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.^10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.^2,3

Lack of Health Care and Radicalism

It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.^12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.¹⁵ In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.¹⁶ It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.

In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.¹⁷ Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.^17,18

Proposed Solutions, A Beginning

A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.¹⁷

In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.¹⁹ The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.

Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.

The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.

Disaster Response

Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.

Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.²⁰ Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.²¹ These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.

This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.

Underserved Communities

Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.¹⁷

The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.

Conclusion

This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.

The relationship between the Kingdom of Morocco and the US began just after the US declared its own independence. It is one of the oldest of US partnerships with a foreign country, and since the end of the First Barbary War in 1805 it has remained one of the most stable. The Utah National Guard (UTNG) has an active state partnership program (SPP) with Morocco, which helps maintain that stability and fosters the relationship. The SPP provides the Kingdom of Morocco assistance in the areas of disaster medicine, prehospital medicine, and rural access to health care.

The objective of this review is to highlight the role the SPP plays in ensuring Morocco’s continued stability, enhancing its role as a leader among African nations, aiding its medically vulnerable rural populations to prevent recruitment by terrorist organizations, and maintaining its long-term relationship with the US.

Background

The Kingdom of Morocco resides in a geologically and politically unstable part of the world, yet it has been a stable constitutional monarchy. Like California, Morocco has a long coastline of more than 1,000 miles. It sits along an active earthquake fault line with a disaster response program that is only in its infancy. The Kingdom has a high youth unemployment rate and lacks adequate public education opportunities, which exacerbate feelings of government indifference. Morocco’s medical system is highly centralized, and large parts of the rural population lack access to basic medical care—potentially alienating the population. The Moroccan current disaster plan ORSEC (plan d’ Organization des Secours) was established in 1966 and updated in 2005 but does not provide a comprehensive, unified disaster response. The ORSEC plan is of French derivation and is not a list of actions but a general plan of organization and supply. ¹

When governments fail to provide basic services—health care being just one—those services may be filled by groups seeking to influence the government and population by threatening acts of violence to achieve political, religious, and ideologic gain; for example, the Taliban in Afghanistan, the Muslim brotherhood in Egypt and in the West Bank, and the Islamic State in Iraq and Syria (ISIS) in Syria.^2-5 These groups gain a foothold and legitimacy by providing mosques, youth groups, clinics, hospitals, and schools. ^2-5

Identified Needs

Morocco is at risk of experiencing an earthquake and possible subsequent tsunami. In 1755, Morocco was impacted by the Great Lisbon earthquake and tsunami. Witnesses reported 15-meter waves with 24-meter crests.⁶ Building codes and architecture laws have changed little since the 1960 Agadir earthquake, which killed 12,000 people. The disaster response program—although improved since the 1960s—is still in the early stages of development, and another earthquake and possible subsequent tsunami would result in a disaster that could overwhelm the medical community of Morocco.

Perceived Government Indifference

The Moroccan constitutional monarchy is more stable than are the governments of its North African neighbors. King Mohammed VI presides over the government, and regular elections are held for members of Parliament, which names a prime minister. However, in August 2019, overall unemployment was at 8.5%, and youth unemployment was 22.3%.⁷ A United Nations report in August 2019 stated that literacy rates for Morocco were 71.7%. These data were from a 2015 census, the last year data were collected.⁸ These deficits in employment and education can foster anger toward the Moroccan government for not adequately providing these services and possibly introduce radicalization as a result of the population’s perceived government indifference and lack of economic mobility.

Access to Medical Care

Morocco has a 2-tiered medical system for providing services: urban and rural. In 2018 the Legatum Prosperity Index ranked Morocco 103 of 149 countries in health care. The prosperity index measures health variables, which include but were not limited to basic physical and mental health, health infrastructure, and preventive care.⁹ Outside the metropolitan areas, emergency medical care is nonexistent, primary care is sporadic, and there is little modern technology available.

Despite humanitarian efforts over many years, there is little to no medical care in the rural “medical desert.” A 2017 study from the University of Washington Institute for Health Metrics and Evaluation compared the global burden of disease in similar countries. The study found that Morocco was significantly higher than the mean in the prevalence of ischemic heart disease and Alzheimer disease, lower than the mean in the areas of neonatal disorders, lower respiratory infections, and tuberculosis, and statistically indistinct from the mean in stroke, congenital defects, road injuries, diabetes mellitus, and hypertensive heart disease compared with the disease prevalence of other countries of similar size and economic measures.¹⁰ The study also found a particularly acute disparity in access to health care in rural areas. In 2016, the Oxford Business Group reported staff shortages and disproportionate distribution of resources in the Moroccan health care system.¹¹

Additionally, the lack of trained health care personnel has added to an already overstressed health care system. A chief stressor in a health care system is an insufficient replacement rate. Health employees working for the Moroccan Ministry of Health retire at a rate of 1,500 per year.^10,11 These shortages may serve to further the feelings of frustration and government indifference. This frustration is momentarily decreased by humanitarian efforts that have taken place in the African continent in the past decades, but this band-aid approach to assisting the population that is medically underserved has done little to alleviate the long-term problem of access to care. And feelings of government abandonment can sow the seeds of discontent in the rural population, creating fertile ground for recruitment by terrorist organizations.^2,3

Lack of Health Care and Radicalism

It has been postulated that there is a link between radicalization and lack of medical care. Depression and perceived government indifference are considered contributors to radicalization.^12-16 In 2005, Victoroff suggested that there are certain psychological traits characteristic of “typical" terrorists: these include high affective valence regarding an ideologic issue, a personal stake (perceived oppression, persecution or humiliation, need for identity, glory, or vengeance), low cognitive ability, low tolerance for ambiguity, and a capacity to suppress instinctive and learned moral constraints against harming innocents.¹⁵ In 2009, Lafree and Ackerman suggested that terrorism feeds on the ability of groups to portray governments and their agents as illegitimate.¹⁶ It is possible that part of the illegitimacy campaign of radicalization and terrorist recruitment may be identification of the lack of health care by the government thus magnifying feelings of government abandonment in a vulnerable population.

In 2011, the new Moroccan constitution identified access to basic health care as a right of the Moroccan people.¹⁷ Additionally, in 2013, a government white paper was produced outlining the need to increase access to health care, particularly in rural areas, including a focus on infant and maternal mortality, diabetes mellitus (DM), heart disease, and respiratory problems.^17,18

Proposed Solutions, A Beginning

A health outreach program with a regional health professional training center in a relatively stable country within the African Union (AU) would be a step toward delivering health care to Morocco and interested AU members. Interested nations have been and will continue to be invited to train at the Moroccan center and return to their countries and start training programs. This idea was echoed by the World Bank in a 2015 loan proposal to Morocco, which suggested that addressing disparities in access to health care is a social justice issue, with other benefits such as increased productivity, employment, lower out-of-pocket expenditures, and promotion of good governance.¹⁷

In 2012, Buhi reported that a positive regard for authorities and healthier influences seemed to be a protective factor against radicalization. He also suggested a public health approach to understanding and preventing violent radicalization.¹⁹ The solutions are complex, especially in rural areas and in vulnerable nations common to Africa.

Medical training efforts by the US Department of Defense (DoD), Medical Readiness Training Institute (DMRT), and international health specialists working with the military and civilian entities in neighboring African countries have improved response to regional disasters. However, to address the broader issues, a more permanent, cooperative possible solution may begin with the establishment in Morocco of a regional education center for disaster preparedness and for health care providers (HCPs). This would serve as a training program for disaster first responders. Graduates of the program would receive additional training to become HCPs similar to physician assistant (PA) and nurse practitioner (NP) programs in the US. Morocco is uniquely positioned to accomplish this due to its location, political stability, and ties with other African nations.

The goal of the Moroccan regional education center (within the King Mohammed V Hospital) is to bring together global health experts and increase the intellectual infrastructure of not only Morocco, but also offer this training program to interested countries within the AU. Advancement of the regional education center will require legislative changes to expand prescriptive privileges and scope of practice within each country. The medical element of the SPP as presently constituted without the regional education center will continue its humanitarian goals, but the proposed creation of the regional education center will educate participants to serve the rural communities within each participating country. Eventually the entire educational program will be the responsibility of the Moroccan military and the AU participants. This will require reprioritizing resources from the provision of humanitarian health care services to an HCP education approach.

Disaster Response

Deficits in disaster response capabilities have been identified by members of the Moroccan military with the assistance of the UTNG. The most glaring deficit identified was the disparity in training between military and civilian first responders. Thus, a training program was initiated by the Moroccan military and the UTNG that combined internationally recognized, durable, robust emergency training programs. These programs consisted of, but were not limited to, parts or entire programs of the following: basic disaster life support, advanced disaster life support, disaster casualty care, and advanced trauma life support. The goal of this training was to improve communication, reduce mortality, and create strike teams, which can quickly provide health care independent of a hospital during a disaster.

Patients can overwhelm hospitals in a disaster when need exceeds resources. In 1996, Mallonee reported that at least 67% of the patients who sought care at a hospital during the Oklahoma City bombing disaster did not need advanced medical treatment.²⁰ Such patients could be seen at an identified casualty collection point by a strike team and treated and released rather than traveling to the hospital and using staff and resources that could be used more judiciously for the more seriously injured.²¹ These teams consist of trained first responders with an experienced HCP (physician, PA, NP) and a nurse and are trained to operate for up to 72 hours in a predetermined location and serve as a “filter” for the hospital. Their role is to treat and release the less severely injured and refer only the more severely injured to the hospital after basic stabilization, thus preserving precious resources necessary for the more seriously injured.

This disaster response training program was offered to the Moroccan military, ministry of health and ministry of tourism, and quickly turned into an Africa-wide interest. A regional training center was proposed. This was assisted with the cooperation of Weber State University in Ogden Utah, Utah Valley University in Orem, and private interests in a public/private/military state partnership. Program supplies and didactic instruction were and will be provided by the UTNG and supplemented through the DoD Africa command. Instruction will be a cooperative effort agreed on between the UTNG and the Moroccan military medical specialists within their specific area of expertise.

Underserved Communities

Finally, from this pool of interested strike team members, a health care provider school will be formed to educate, certify, and service the needs of the underserved communities in Morocco and interested AU countries. This program will be similar to the PA and NP programs in the US and will be geared to those graduates from the previous programs with intense classroom instruction for one year followed by a year of one-on-one preceptorship with an experienced physician. The goal of the program is to prepare individuals with patient care experience to fulfill a bigger role in health care in an underserved (usually austere, rural) area that currently has minimal health care presence. This fills a need identified by the World Bank in 2015 that the Moroccan government needs to respond to the demand for improved access to and quality of health care services—particularly to the rural poor.¹⁷

The Moroccan military has a presence in many medically underserved areas. The logical fit for the HCP program will be drawn from a pool of active-duty military individuals who express an interest and qualify through attendance in all phases of the training.

Conclusion

This program of disaster medical education, strike teams, and HCPs is currently training more than 200 students a year throughout Morocco. The proposed direction of this cooperative program to produce HCPs in rural areas will increase access to health care for the Moroccan people who are now underserved. Morocco, as a health care training hub in Africa, will increase access to health care for interested African countries. The goal politically will be to reduce feelings of government indifference in vulnerable populations and reduce recruitment into radical ideologies.

Environmental disasters can overpower local medical resources. Fortunately, such crises are rare in the U.S. This situation, however, has not always been the case. For example, in 1812, an earthquake along the New Madrid fault of the Mississippi Valley caused the Mississippi River to flow backward for 3 days.¹ Today, in urbanized America, an earthquake of that magnitude would be devastating and severely overwhelm medical systems. All nations, including highly modernized nations, would need help in such disasters.² A response system that is nimble, well-trained, scalable, and rapidly deployable can mitigate disaster sequelae. This article focuses on key aspects of effective rapid response, including speed, appropriate triage, quick-response strike teams, and disaster dynamics.

Why Speed Matters Most

Response time arguably is the most important factor in increasing survival in a disaster. In a 1996 study of earthquake disasters worldwide, Schultz and colleagues found a lower survival rate for victims who received medical care outside a 24-hour window.¹ Studies of earthquakes in China have suggested that unless aid is rendered within 2 to 6 hours, fewer than half the victims will survive.³ Regarding a 1980 earthquake in Italy, de Bruycker and colleagues emphasized the importance of engaging in rescue activities within the first 48 hours.⁴ Safar reviewed mass disasters and reported that 25% to 50% of the injured and dead could have been saved if first aid had been provided immediately.⁵ In 1992 and 1994, Pretto and colleagues wrote that in earthquakes in Armenia and Costa Rica, many deaths could have been prevented had the victims received medical attention within the first 6 hours.^6,7 The question is: How can responses to such crises be improved? Confederate Army Lt. Gen. Nathan Bedford Forrest’s dictum “[Get] there first with the most men” holds true in disaster medicine as well: get there fast with the right people, training, equipment, and supplies.⁸

Deaths in disasters can be described in a 3-phase distribution: immediate, early, and delayed. Stringent building codes and public warnings and evacuations reduce immediate deaths, but victims also die of catastrophic injury soon after an event. Early deaths are preventable with use of rapid interventions, such as tourniquets and airway adjuncts, but these must be administered within minutes or hours. Delayed deaths occur days or weeks after injury secondary to infection or organ system failure—which emphasizes the value of early wound care.

Emergency Supplies

What items are most needed? As each disaster is different, it would be presumptuous to provide a one-size-fits-all list, but some common supplies have been suggested. In 2010, Ginzberg and colleagues reported that during the first 24 hours of the Haiti earthquake of 1996, the overwhelming need was for IV hydration, narcotic analgesics, and casting supplies for the splinting of fractures.⁹ During the next 24 hours, IV stabilization was key, along with monitoring by Foley and suprapubic catheters. In the third 24-hour period, providers began to see sepsis-related deaths. In response to this challenge, teams began aggressive treatment with open surgical debridement of wounds, amputation of severely injured limbs, and administration of broad-spectrum IV antibiotics. Regional anesthesia with conscious sedation was mandatory because supplemental oxygen and ventilators were unavailable. By day 4, wound debridement, amputations, and fasciotomies were being provided by newly arrived anesthesiologists and orthopedic surgeons. Ginzberg and colleagues emphasized that rapid response was key in maximizing survival and by day 4, there was a greater need for surgical teams and broad-spectrum antibiotics (eg, piperacillin, tazobactam) to combat sepsis.

Pereira and colleagues reported that in a catastrophe caused by a tropical storm and landslides in Brazil, the most common injuries involved the extremities; the majority of wounds required only cleaning, debridement, and suture; and the most commonly performed operations were for orthopedic injuries.¹⁰ Incidentally, population baseline morbidity and mortality continue during disasters, and rescue personnel invariably sustain injuries, which contribute to the total medical burden. These additional injuries must be anticipated, and plans to manage them must be included in any disaster contingency planning.

U.S. Coast Guard Photo by PO3 Brandyn Hill

Triage

Speed and correct triage are essential building blocks of disaster response. When resources are limited, triage is crucial in providing the right treatment to the right patient. There are numerous triage methods, some more rapid and straightforward; others more effective and cumbersome.¹¹ In 2012, Sasser and colleagues wrote that the purpose of triage is to ensure injured patients are transported to a trauma center or the hospital best equipped to manage their specific injuries in an appropriate and timely manner.¹² Their report focused on prehospital emergent care, not mass-casualty or disaster situations.

Triage is sometimes performed inconsistently. In a 2013 study, Kleber and colleagues found that 24% of providers overtriage and 16% undertriage.¹³ In the U.S., simple triage and rapid treatment (START) is commonly used to sort traumatized patients. All these methods take a “worst gets first treatment” approach. Depending on the magnitude of an event, however, providers may take a reverse-triage approach, in which they better use resources for the least injured patients and provide palliative care to the gravely ill.

During pandemic disasters, trauma triage protocols are ineffective. Instead, these events demand assessments that are sensitive to infectious diseases. Timely, didactic, hands-on training must be conducted before the fact so responders can adapt to react appropriately to a given disaster.¹⁴

Accurate, timely triage in mass-casualty incidents was conceptually demonstrated by Mekel and colleagues who reviewed the medical management of bombing victims in metropolitan Haifa, Israel during the period 2000 to 2006.¹⁵ Providers initiated a predetermined triage system in which patients are assigned to the appropriate echelon of care. Of 342 injured patients, 9.5% had severe injuries, 2.4% had moderate-severe injuries, and 88.9% had mild injuries. Correct and timely triage directed trauma victims to the appropriate medical care. Such action prevents the highest level facility from becoming overcrowded with less severely injured patients and ensures that the more critically injured receive a level of care comparable to that given under nondisaster circumstances.

The handheld ultrasound device, which can be used to correctly diagnose fractures, is an efficient triage resource for prehospital teams. In a 2008 study, McManus and colleagues suggested that ultrasound (vs traditional radiography) could be used to identify fractures in an emergency room.¹⁶ A handheld ultrasound device could be used outside the hospital, in the field, potentially reducing the number of referrals to overwhelmed orthopedic hospitals.

In 2007, Dean and colleagues reported on using ultrasound to rapidly triage disease during an earthquake in Guatemala.¹⁷ In that disaster, 23% of injuries presented within the first 24 hours, and a handheld ultrasound device was used to assess orthopedic injuries—ruling in 12% and ruling out 42%. The handheld ultrasound device is an example of a tool that small medical teams can use to speed triage, enhance patient care, and relieve overcrowded medical centers of the unrelenting pressure.

On-Site vs Hospital

Complicating disaster response is self-triage. Victims with injuries of all severity levels go to the nearest hospital and overwhelm it. In 1991, Waeckerle reported that within the first 30 minutes of a disaster, a wave of victims arrives, usually with minor injuries, and impedes care for the more severely wounded.¹⁸ Correct triage instead would have directed these patients to a hospital other than the overwhelmed level I trauma center.¹⁵ This is not to say that patients with mild or moderate injuries are unimportant—just that their care may take scarce space and resources from the more severely injured.

Mallonee and colleagues reported that of the 759 people injured in the 1996 Oklahoma City bombing, 167 (22%) were fatalities, 83 (11%) were hospitalized, and 509 (67%) were treated on an outpatient basis.¹⁹ Most of the injuries could have been managed by quick-response medical teams operating in the affected area, outside the hospitals. This action would have reduced operational pressure on hospitals and improved severely injured patients’ access to care.

Specialized Teams

In 2008, Barillo and colleagues suggested that having standardized medic bags would allow a small detachment of medical professionals to provide care nimbly—and doing so would represent a leap forward in access to care.²⁰

Because of their unique ability to understand the culture and coordinate military assets with local authorities, DoD international health specialists are crucial interfaces for any population, foreign or domestic. Seyedin and colleagues and Merin and colleagues suggested that in both the Bam earthquake in 2003 and the Nepal earthquake in 2015, understanding the culture played a vital role in health care delivery and in adhering to cultural norms in deciding when to perform surgery, making end-of-life decisions, communicating with family, establishing trust with local and regional leaders, and other matters.^21,22

Strike teams are small groups of variably trained health care providers who are dispatched to underserved, outlying, or overwhelmed areas to deliver precached basic medical care and triage significant injuries to medical centers. The handheld ultrasound device is an example of a strike team tool. During a local emergency, it is understood or assumed that response is inundated and that people are going untreated.

Crucially, strike teams must be trained, prepared, and readily dispatched ahead of larger response elements. Though quickly deployable, disaster medical assistance teams (DMATs) and National Guard Chemical, Biological, Radiological, Nuclear and High-Yield Explosive Enhanced Response Force Package units, take time to mobilize. Therefore, strike teams should consist of community citizens or local National Guard assets, the latter being particularly suited to rapid response given their training, effective command and control, and intrinsic logistics.

The efficacy of strike teams was demonstrated during the 2011 earthquake in Japan.²³ Disaster medical assistance teams were invaluable in triaging and treating patients during the first 3 days. A team left 34 minutes after the event to render aid to people caught in a roof collapse. During triage, 17% of the injuries were classified urgent, 22% intermediate, and 61% minor. On day 7, a DMAT was dispatched to assist with emergency medicine and primary care; 3% of the injuries were severe and required urgent care, 50% required intermediate care, and 47% required minor care.

The value of strike teams is 3-fold: It provides rapid, professional care at a crucial place and critical time; it correctly triages patients and thus allow hospitals to maintain resources for the more severely injured; and augments overwhelmed providers at crucial sites. The roles of strike teams were echoed in 2006 by Campos-Outcalt, who reported that DMATs deployed to austere locations had the flexibility to augment existing medical staff and to rapidly deploy, self-sustain, and treat patients until a situation was resolved.²⁴ This nimble strike team mentality could become a rapid and flexible model to save more lives, relieve significant suffering, and offload pressure from local hospitals by treating the less critically injured.

What Comes Next?

After a disaster, space is at a premium, and nonmedical residents who make up 40% to 70% of the shelter population require resources as well.²⁵ Family members and the lightly injured may be conscripted to augment the overwhelmed medical staff. In 1988, Halbert and colleagues described how Afghan volunteers with minimal medical experience were given training and supplies and served as advanced emergency medics, delivering medical care and performing well under austere conditions.^26,27 Strike teams thus may provide on-scene training in addition to medical care.

In 2012, Kirsch and colleaguesfound that Haiti earthquake victims who received treatment and remained in camps showed no improvement in income, employment, or food access 1 year after the disaster compared with victims who remained outside the camps and in their own neighborhoods.²⁸ This finding underscores the need for accurate and timely triage by strike teams outside hospitals and quick treatment and return of patients to their homes.

Conceptually, strike teams need not be confined to medical response. Team members also might be specialists in epidemiology, disease surveillance, public health, culinary water protection, municipal security, and civil engineering. Noji reported that malnutrition, diarrheal diseases, measles, acute respiratory infections, and malaria consistently accounted for 60% to 95% of reported deaths among refugees and displaced populations.²⁹ In 2005, Spiegel found that the potential for epidemics of communicable diseases was increased by overcrowding and poor sanitation in both natural disasters and complex emergencies.³⁰ In 2007, Watson and colleagues suggested that communicable diseases may account for two-thirds of the deaths in conflict areas, and malnutrition significantly increases the risk of these diseases.³¹ Effective disaster care may be better accomplished through decentralized strike team interventions, which avoid the pitfalls of displacement and overcrowding.

Conclusion

Crises of all magnitudes can be greatly eased by well-trained, quick-response, all-hazards medical detachments—small teams that can be rapidly mobilized and deployed to establish casualty collection points, provide accurate triage, and render emergency care. These highly mobile teams can bridge the gap between the occurrence of a disaster and the arrival of substantial assistance from state, federal, and nongovernmental organizations—a most vulnerable time. These competent, flexible teams then can be absorbed by the larger force when it arrives for sustained disaster operations. Predisaster planning must take into account the possibility of long-term care for casualties and the displaced. Careful attention should be given to the potential for epidemics—immunizations should be administered quickly to achieve herd immunity—and a program that will provide food, water, shelter, sanitation, and security should be established.
 

Acknowledgments
The authors thank Sarah M. Paulsen and members of the Utah Air National Guard and Morrocan military for their friendship and help in preparing the manuscript.

Environmental disasters can overpower local medical resources. Fortunately, such crises are rare in the U.S. This situation, however, has not always been the case. For example, in 1812, an earthquake along the New Madrid fault of the Mississippi Valley caused the Mississippi River to flow backward for 3 days.¹ Today, in urbanized America, an earthquake of that magnitude would be devastating and severely overwhelm medical systems. All nations, including highly modernized nations, would need help in such disasters.² A response system that is nimble, well-trained, scalable, and rapidly deployable can mitigate disaster sequelae. This article focuses on key aspects of effective rapid response, including speed, appropriate triage, quick-response strike teams, and disaster dynamics.

Why Speed Matters Most

Response time arguably is the most important factor in increasing survival in a disaster. In a 1996 study of earthquake disasters worldwide, Schultz and colleagues found a lower survival rate for victims who received medical care outside a 24-hour window.¹ Studies of earthquakes in China have suggested that unless aid is rendered within 2 to 6 hours, fewer than half the victims will survive.³ Regarding a 1980 earthquake in Italy, de Bruycker and colleagues emphasized the importance of engaging in rescue activities within the first 48 hours.⁴ Safar reviewed mass disasters and reported that 25% to 50% of the injured and dead could have been saved if first aid had been provided immediately.⁵ In 1992 and 1994, Pretto and colleagues wrote that in earthquakes in Armenia and Costa Rica, many deaths could have been prevented had the victims received medical attention within the first 6 hours.^6,7 The question is: How can responses to such crises be improved? Confederate Army Lt. Gen. Nathan Bedford Forrest’s dictum “[Get] there first with the most men” holds true in disaster medicine as well: get there fast with the right people, training, equipment, and supplies.⁸

Deaths in disasters can be described in a 3-phase distribution: immediate, early, and delayed. Stringent building codes and public warnings and evacuations reduce immediate deaths, but victims also die of catastrophic injury soon after an event. Early deaths are preventable with use of rapid interventions, such as tourniquets and airway adjuncts, but these must be administered within minutes or hours. Delayed deaths occur days or weeks after injury secondary to infection or organ system failure—which emphasizes the value of early wound care.

Emergency Supplies

What items are most needed? As each disaster is different, it would be presumptuous to provide a one-size-fits-all list, but some common supplies have been suggested. In 2010, Ginzberg and colleagues reported that during the first 24 hours of the Haiti earthquake of 1996, the overwhelming need was for IV hydration, narcotic analgesics, and casting supplies for the splinting of fractures.⁹ During the next 24 hours, IV stabilization was key, along with monitoring by Foley and suprapubic catheters. In the third 24-hour period, providers began to see sepsis-related deaths. In response to this challenge, teams began aggressive treatment with open surgical debridement of wounds, amputation of severely injured limbs, and administration of broad-spectrum IV antibiotics. Regional anesthesia with conscious sedation was mandatory because supplemental oxygen and ventilators were unavailable. By day 4, wound debridement, amputations, and fasciotomies were being provided by newly arrived anesthesiologists and orthopedic surgeons. Ginzberg and colleagues emphasized that rapid response was key in maximizing survival and by day 4, there was a greater need for surgical teams and broad-spectrum antibiotics (eg, piperacillin, tazobactam) to combat sepsis.

Pereira and colleagues reported that in a catastrophe caused by a tropical storm and landslides in Brazil, the most common injuries involved the extremities; the majority of wounds required only cleaning, debridement, and suture; and the most commonly performed operations were for orthopedic injuries.¹⁰ Incidentally, population baseline morbidity and mortality continue during disasters, and rescue personnel invariably sustain injuries, which contribute to the total medical burden. These additional injuries must be anticipated, and plans to manage them must be included in any disaster contingency planning.

U.S. Coast Guard Photo by PO3 Brandyn Hill

Triage

Speed and correct triage are essential building blocks of disaster response. When resources are limited, triage is crucial in providing the right treatment to the right patient. There are numerous triage methods, some more rapid and straightforward; others more effective and cumbersome.¹¹ In 2012, Sasser and colleagues wrote that the purpose of triage is to ensure injured patients are transported to a trauma center or the hospital best equipped to manage their specific injuries in an appropriate and timely manner.¹² Their report focused on prehospital emergent care, not mass-casualty or disaster situations.

Triage is sometimes performed inconsistently. In a 2013 study, Kleber and colleagues found that 24% of providers overtriage and 16% undertriage.¹³ In the U.S., simple triage and rapid treatment (START) is commonly used to sort traumatized patients. All these methods take a “worst gets first treatment” approach. Depending on the magnitude of an event, however, providers may take a reverse-triage approach, in which they better use resources for the least injured patients and provide palliative care to the gravely ill.

During pandemic disasters, trauma triage protocols are ineffective. Instead, these events demand assessments that are sensitive to infectious diseases. Timely, didactic, hands-on training must be conducted before the fact so responders can adapt to react appropriately to a given disaster.¹⁴

Accurate, timely triage in mass-casualty incidents was conceptually demonstrated by Mekel and colleagues who reviewed the medical management of bombing victims in metropolitan Haifa, Israel during the period 2000 to 2006.¹⁵ Providers initiated a predetermined triage system in which patients are assigned to the appropriate echelon of care. Of 342 injured patients, 9.5% had severe injuries, 2.4% had moderate-severe injuries, and 88.9% had mild injuries. Correct and timely triage directed trauma victims to the appropriate medical care. Such action prevents the highest level facility from becoming overcrowded with less severely injured patients and ensures that the more critically injured receive a level of care comparable to that given under nondisaster circumstances.

The handheld ultrasound device, which can be used to correctly diagnose fractures, is an efficient triage resource for prehospital teams. In a 2008 study, McManus and colleagues suggested that ultrasound (vs traditional radiography) could be used to identify fractures in an emergency room.¹⁶ A handheld ultrasound device could be used outside the hospital, in the field, potentially reducing the number of referrals to overwhelmed orthopedic hospitals.

In 2007, Dean and colleagues reported on using ultrasound to rapidly triage disease during an earthquake in Guatemala.¹⁷ In that disaster, 23% of injuries presented within the first 24 hours, and a handheld ultrasound device was used to assess orthopedic injuries—ruling in 12% and ruling out 42%. The handheld ultrasound device is an example of a tool that small medical teams can use to speed triage, enhance patient care, and relieve overcrowded medical centers of the unrelenting pressure.

On-Site vs Hospital

Complicating disaster response is self-triage. Victims with injuries of all severity levels go to the nearest hospital and overwhelm it. In 1991, Waeckerle reported that within the first 30 minutes of a disaster, a wave of victims arrives, usually with minor injuries, and impedes care for the more severely wounded.¹⁸ Correct triage instead would have directed these patients to a hospital other than the overwhelmed level I trauma center.¹⁵ This is not to say that patients with mild or moderate injuries are unimportant—just that their care may take scarce space and resources from the more severely injured.

Mallonee and colleagues reported that of the 759 people injured in the 1996 Oklahoma City bombing, 167 (22%) were fatalities, 83 (11%) were hospitalized, and 509 (67%) were treated on an outpatient basis.¹⁹ Most of the injuries could have been managed by quick-response medical teams operating in the affected area, outside the hospitals. This action would have reduced operational pressure on hospitals and improved severely injured patients’ access to care.

Specialized Teams

In 2008, Barillo and colleagues suggested that having standardized medic bags would allow a small detachment of medical professionals to provide care nimbly—and doing so would represent a leap forward in access to care.²⁰

Because of their unique ability to understand the culture and coordinate military assets with local authorities, DoD international health specialists are crucial interfaces for any population, foreign or domestic. Seyedin and colleagues and Merin and colleagues suggested that in both the Bam earthquake in 2003 and the Nepal earthquake in 2015, understanding the culture played a vital role in health care delivery and in adhering to cultural norms in deciding when to perform surgery, making end-of-life decisions, communicating with family, establishing trust with local and regional leaders, and other matters.^21,22

Strike teams are small groups of variably trained health care providers who are dispatched to underserved, outlying, or overwhelmed areas to deliver precached basic medical care and triage significant injuries to medical centers. The handheld ultrasound device is an example of a strike team tool. During a local emergency, it is understood or assumed that response is inundated and that people are going untreated.

Crucially, strike teams must be trained, prepared, and readily dispatched ahead of larger response elements. Though quickly deployable, disaster medical assistance teams (DMATs) and National Guard Chemical, Biological, Radiological, Nuclear and High-Yield Explosive Enhanced Response Force Package units, take time to mobilize. Therefore, strike teams should consist of community citizens or local National Guard assets, the latter being particularly suited to rapid response given their training, effective command and control, and intrinsic logistics.

The efficacy of strike teams was demonstrated during the 2011 earthquake in Japan.²³ Disaster medical assistance teams were invaluable in triaging and treating patients during the first 3 days. A team left 34 minutes after the event to render aid to people caught in a roof collapse. During triage, 17% of the injuries were classified urgent, 22% intermediate, and 61% minor. On day 7, a DMAT was dispatched to assist with emergency medicine and primary care; 3% of the injuries were severe and required urgent care, 50% required intermediate care, and 47% required minor care.

The value of strike teams is 3-fold: It provides rapid, professional care at a crucial place and critical time; it correctly triages patients and thus allow hospitals to maintain resources for the more severely injured; and augments overwhelmed providers at crucial sites. The roles of strike teams were echoed in 2006 by Campos-Outcalt, who reported that DMATs deployed to austere locations had the flexibility to augment existing medical staff and to rapidly deploy, self-sustain, and treat patients until a situation was resolved.²⁴ This nimble strike team mentality could become a rapid and flexible model to save more lives, relieve significant suffering, and offload pressure from local hospitals by treating the less critically injured.

What Comes Next?

After a disaster, space is at a premium, and nonmedical residents who make up 40% to 70% of the shelter population require resources as well.²⁵ Family members and the lightly injured may be conscripted to augment the overwhelmed medical staff. In 1988, Halbert and colleagues described how Afghan volunteers with minimal medical experience were given training and supplies and served as advanced emergency medics, delivering medical care and performing well under austere conditions.^26,27 Strike teams thus may provide on-scene training in addition to medical care.

In 2012, Kirsch and colleaguesfound that Haiti earthquake victims who received treatment and remained in camps showed no improvement in income, employment, or food access 1 year after the disaster compared with victims who remained outside the camps and in their own neighborhoods.²⁸ This finding underscores the need for accurate and timely triage by strike teams outside hospitals and quick treatment and return of patients to their homes.

Conceptually, strike teams need not be confined to medical response. Team members also might be specialists in epidemiology, disease surveillance, public health, culinary water protection, municipal security, and civil engineering. Noji reported that malnutrition, diarrheal diseases, measles, acute respiratory infections, and malaria consistently accounted for 60% to 95% of reported deaths among refugees and displaced populations.²⁹ In 2005, Spiegel found that the potential for epidemics of communicable diseases was increased by overcrowding and poor sanitation in both natural disasters and complex emergencies.³⁰ In 2007, Watson and colleagues suggested that communicable diseases may account for two-thirds of the deaths in conflict areas, and malnutrition significantly increases the risk of these diseases.³¹ Effective disaster care may be better accomplished through decentralized strike team interventions, which avoid the pitfalls of displacement and overcrowding.

Conclusion

Crises of all magnitudes can be greatly eased by well-trained, quick-response, all-hazards medical detachments—small teams that can be rapidly mobilized and deployed to establish casualty collection points, provide accurate triage, and render emergency care. These highly mobile teams can bridge the gap between the occurrence of a disaster and the arrival of substantial assistance from state, federal, and nongovernmental organizations—a most vulnerable time. These competent, flexible teams then can be absorbed by the larger force when it arrives for sustained disaster operations. Predisaster planning must take into account the possibility of long-term care for casualties and the displaced. Careful attention should be given to the potential for epidemics—immunizations should be administered quickly to achieve herd immunity—and a program that will provide food, water, shelter, sanitation, and security should be established.
 

Acknowledgments
The authors thank Sarah M. Paulsen and members of the Utah Air National Guard and Morrocan military for their friendship and help in preparing the manuscript.

Environmental disasters can overpower local medical resources. Fortunately, such crises are rare in the U.S. This situation, however, has not always been the case. For example, in 1812, an earthquake along the New Madrid fault of the Mississippi Valley caused the Mississippi River to flow backward for 3 days.¹ Today, in urbanized America, an earthquake of that magnitude would be devastating and severely overwhelm medical systems. All nations, including highly modernized nations, would need help in such disasters.² A response system that is nimble, well-trained, scalable, and rapidly deployable can mitigate disaster sequelae. This article focuses on key aspects of effective rapid response, including speed, appropriate triage, quick-response strike teams, and disaster dynamics.

Why Speed Matters Most

Response time arguably is the most important factor in increasing survival in a disaster. In a 1996 study of earthquake disasters worldwide, Schultz and colleagues found a lower survival rate for victims who received medical care outside a 24-hour window.¹ Studies of earthquakes in China have suggested that unless aid is rendered within 2 to 6 hours, fewer than half the victims will survive.³ Regarding a 1980 earthquake in Italy, de Bruycker and colleagues emphasized the importance of engaging in rescue activities within the first 48 hours.⁴ Safar reviewed mass disasters and reported that 25% to 50% of the injured and dead could have been saved if first aid had been provided immediately.⁵ In 1992 and 1994, Pretto and colleagues wrote that in earthquakes in Armenia and Costa Rica, many deaths could have been prevented had the victims received medical attention within the first 6 hours.^6,7 The question is: How can responses to such crises be improved? Confederate Army Lt. Gen. Nathan Bedford Forrest’s dictum “[Get] there first with the most men” holds true in disaster medicine as well: get there fast with the right people, training, equipment, and supplies.⁸

Deaths in disasters can be described in a 3-phase distribution: immediate, early, and delayed. Stringent building codes and public warnings and evacuations reduce immediate deaths, but victims also die of catastrophic injury soon after an event. Early deaths are preventable with use of rapid interventions, such as tourniquets and airway adjuncts, but these must be administered within minutes or hours. Delayed deaths occur days or weeks after injury secondary to infection or organ system failure—which emphasizes the value of early wound care.

Emergency Supplies

What items are most needed? As each disaster is different, it would be presumptuous to provide a one-size-fits-all list, but some common supplies have been suggested. In 2010, Ginzberg and colleagues reported that during the first 24 hours of the Haiti earthquake of 1996, the overwhelming need was for IV hydration, narcotic analgesics, and casting supplies for the splinting of fractures.⁹ During the next 24 hours, IV stabilization was key, along with monitoring by Foley and suprapubic catheters. In the third 24-hour period, providers began to see sepsis-related deaths. In response to this challenge, teams began aggressive treatment with open surgical debridement of wounds, amputation of severely injured limbs, and administration of broad-spectrum IV antibiotics. Regional anesthesia with conscious sedation was mandatory because supplemental oxygen and ventilators were unavailable. By day 4, wound debridement, amputations, and fasciotomies were being provided by newly arrived anesthesiologists and orthopedic surgeons. Ginzberg and colleagues emphasized that rapid response was key in maximizing survival and by day 4, there was a greater need for surgical teams and broad-spectrum antibiotics (eg, piperacillin, tazobactam) to combat sepsis.

Pereira and colleagues reported that in a catastrophe caused by a tropical storm and landslides in Brazil, the most common injuries involved the extremities; the majority of wounds required only cleaning, debridement, and suture; and the most commonly performed operations were for orthopedic injuries.¹⁰ Incidentally, population baseline morbidity and mortality continue during disasters, and rescue personnel invariably sustain injuries, which contribute to the total medical burden. These additional injuries must be anticipated, and plans to manage them must be included in any disaster contingency planning.

U.S. Coast Guard Photo by PO3 Brandyn Hill

Triage

Speed and correct triage are essential building blocks of disaster response. When resources are limited, triage is crucial in providing the right treatment to the right patient. There are numerous triage methods, some more rapid and straightforward; others more effective and cumbersome.¹¹ In 2012, Sasser and colleagues wrote that the purpose of triage is to ensure injured patients are transported to a trauma center or the hospital best equipped to manage their specific injuries in an appropriate and timely manner.¹² Their report focused on prehospital emergent care, not mass-casualty or disaster situations.

Triage is sometimes performed inconsistently. In a 2013 study, Kleber and colleagues found that 24% of providers overtriage and 16% undertriage.¹³ In the U.S., simple triage and rapid treatment (START) is commonly used to sort traumatized patients. All these methods take a “worst gets first treatment” approach. Depending on the magnitude of an event, however, providers may take a reverse-triage approach, in which they better use resources for the least injured patients and provide palliative care to the gravely ill.

During pandemic disasters, trauma triage protocols are ineffective. Instead, these events demand assessments that are sensitive to infectious diseases. Timely, didactic, hands-on training must be conducted before the fact so responders can adapt to react appropriately to a given disaster.¹⁴

Accurate, timely triage in mass-casualty incidents was conceptually demonstrated by Mekel and colleagues who reviewed the medical management of bombing victims in metropolitan Haifa, Israel during the period 2000 to 2006.¹⁵ Providers initiated a predetermined triage system in which patients are assigned to the appropriate echelon of care. Of 342 injured patients, 9.5% had severe injuries, 2.4% had moderate-severe injuries, and 88.9% had mild injuries. Correct and timely triage directed trauma victims to the appropriate medical care. Such action prevents the highest level facility from becoming overcrowded with less severely injured patients and ensures that the more critically injured receive a level of care comparable to that given under nondisaster circumstances.

The handheld ultrasound device, which can be used to correctly diagnose fractures, is an efficient triage resource for prehospital teams. In a 2008 study, McManus and colleagues suggested that ultrasound (vs traditional radiography) could be used to identify fractures in an emergency room.¹⁶ A handheld ultrasound device could be used outside the hospital, in the field, potentially reducing the number of referrals to overwhelmed orthopedic hospitals.

In 2007, Dean and colleagues reported on using ultrasound to rapidly triage disease during an earthquake in Guatemala.¹⁷ In that disaster, 23% of injuries presented within the first 24 hours, and a handheld ultrasound device was used to assess orthopedic injuries—ruling in 12% and ruling out 42%. The handheld ultrasound device is an example of a tool that small medical teams can use to speed triage, enhance patient care, and relieve overcrowded medical centers of the unrelenting pressure.

On-Site vs Hospital

Complicating disaster response is self-triage. Victims with injuries of all severity levels go to the nearest hospital and overwhelm it. In 1991, Waeckerle reported that within the first 30 minutes of a disaster, a wave of victims arrives, usually with minor injuries, and impedes care for the more severely wounded.¹⁸ Correct triage instead would have directed these patients to a hospital other than the overwhelmed level I trauma center.¹⁵ This is not to say that patients with mild or moderate injuries are unimportant—just that their care may take scarce space and resources from the more severely injured.

Mallonee and colleagues reported that of the 759 people injured in the 1996 Oklahoma City bombing, 167 (22%) were fatalities, 83 (11%) were hospitalized, and 509 (67%) were treated on an outpatient basis.¹⁹ Most of the injuries could have been managed by quick-response medical teams operating in the affected area, outside the hospitals. This action would have reduced operational pressure on hospitals and improved severely injured patients’ access to care.

Specialized Teams

In 2008, Barillo and colleagues suggested that having standardized medic bags would allow a small detachment of medical professionals to provide care nimbly—and doing so would represent a leap forward in access to care.²⁰

Because of their unique ability to understand the culture and coordinate military assets with local authorities, DoD international health specialists are crucial interfaces for any population, foreign or domestic. Seyedin and colleagues and Merin and colleagues suggested that in both the Bam earthquake in 2003 and the Nepal earthquake in 2015, understanding the culture played a vital role in health care delivery and in adhering to cultural norms in deciding when to perform surgery, making end-of-life decisions, communicating with family, establishing trust with local and regional leaders, and other matters.^21,22

Strike teams are small groups of variably trained health care providers who are dispatched to underserved, outlying, or overwhelmed areas to deliver precached basic medical care and triage significant injuries to medical centers. The handheld ultrasound device is an example of a strike team tool. During a local emergency, it is understood or assumed that response is inundated and that people are going untreated.

Crucially, strike teams must be trained, prepared, and readily dispatched ahead of larger response elements. Though quickly deployable, disaster medical assistance teams (DMATs) and National Guard Chemical, Biological, Radiological, Nuclear and High-Yield Explosive Enhanced Response Force Package units, take time to mobilize. Therefore, strike teams should consist of community citizens or local National Guard assets, the latter being particularly suited to rapid response given their training, effective command and control, and intrinsic logistics.

The efficacy of strike teams was demonstrated during the 2011 earthquake in Japan.²³ Disaster medical assistance teams were invaluable in triaging and treating patients during the first 3 days. A team left 34 minutes after the event to render aid to people caught in a roof collapse. During triage, 17% of the injuries were classified urgent, 22% intermediate, and 61% minor. On day 7, a DMAT was dispatched to assist with emergency medicine and primary care; 3% of the injuries were severe and required urgent care, 50% required intermediate care, and 47% required minor care.

The value of strike teams is 3-fold: It provides rapid, professional care at a crucial place and critical time; it correctly triages patients and thus allow hospitals to maintain resources for the more severely injured; and augments overwhelmed providers at crucial sites. The roles of strike teams were echoed in 2006 by Campos-Outcalt, who reported that DMATs deployed to austere locations had the flexibility to augment existing medical staff and to rapidly deploy, self-sustain, and treat patients until a situation was resolved.²⁴ This nimble strike team mentality could become a rapid and flexible model to save more lives, relieve significant suffering, and offload pressure from local hospitals by treating the less critically injured.

What Comes Next?

After a disaster, space is at a premium, and nonmedical residents who make up 40% to 70% of the shelter population require resources as well.²⁵ Family members and the lightly injured may be conscripted to augment the overwhelmed medical staff. In 1988, Halbert and colleagues described how Afghan volunteers with minimal medical experience were given training and supplies and served as advanced emergency medics, delivering medical care and performing well under austere conditions.^26,27 Strike teams thus may provide on-scene training in addition to medical care.

In 2012, Kirsch and colleaguesfound that Haiti earthquake victims who received treatment and remained in camps showed no improvement in income, employment, or food access 1 year after the disaster compared with victims who remained outside the camps and in their own neighborhoods.²⁸ This finding underscores the need for accurate and timely triage by strike teams outside hospitals and quick treatment and return of patients to their homes.

Conceptually, strike teams need not be confined to medical response. Team members also might be specialists in epidemiology, disease surveillance, public health, culinary water protection, municipal security, and civil engineering. Noji reported that malnutrition, diarrheal diseases, measles, acute respiratory infections, and malaria consistently accounted for 60% to 95% of reported deaths among refugees and displaced populations.²⁹ In 2005, Spiegel found that the potential for epidemics of communicable diseases was increased by overcrowding and poor sanitation in both natural disasters and complex emergencies.³⁰ In 2007, Watson and colleagues suggested that communicable diseases may account for two-thirds of the deaths in conflict areas, and malnutrition significantly increases the risk of these diseases.³¹ Effective disaster care may be better accomplished through decentralized strike team interventions, which avoid the pitfalls of displacement and overcrowding.

Conclusion

Crises of all magnitudes can be greatly eased by well-trained, quick-response, all-hazards medical detachments—small teams that can be rapidly mobilized and deployed to establish casualty collection points, provide accurate triage, and render emergency care. These highly mobile teams can bridge the gap between the occurrence of a disaster and the arrival of substantial assistance from state, federal, and nongovernmental organizations—a most vulnerable time. These competent, flexible teams then can be absorbed by the larger force when it arrives for sustained disaster operations. Predisaster planning must take into account the possibility of long-term care for casualties and the displaced. Careful attention should be given to the potential for epidemics—immunizations should be administered quickly to achieve herd immunity—and a program that will provide food, water, shelter, sanitation, and security should be established.
 

Acknowledgments
The authors thank Sarah M. Paulsen and members of the Utah Air National Guard and Morrocan military for their friendship and help in preparing the manuscript.