Written by Anita Kilroy Findley - Tissue Viability Nurse, Mental Health, Leicestershire Partnership NHS Trust
Sally was admitted to a low secure facility for forensic service users at Leicestershire Partnership NHS Trust in February 2011. She had a history of institutionalised care from the age of 9 following emotional, physical and sexual abuse. From the age of 15 she was placed in secure facilities for arson, theft and actual bodily harm. As a result of her upbringing, her diagnoses were of post traumatic stress disorder, mild learning disability and emotionally unstable personality disorder.
February 26th - Sally used the metal strip of a CD case to cause lacerations to her arms and legs after her leave was suspended. These were reviewed by a medic and antibiotics commenced. Sally's concordance was variable and she would reopen the wounds to insert foreign objects such as blue tack and food.
March 2nd - on redressing the wound on her left leg staff found it inflamed, swollen and painful with a 10cm laceration to the medial aspect with purulent exudate. A swab result indicated staphylococcus aureus that was sensitive to flucloxacillin.
March 3rd - Sally was refusing antibiotics and reopened the wound on her right leg.
March 4th Both Sally's wounds had toiletries sprayed in them and were brushed with toothpaste. A further cut to the left leg was then made with videotape casing.
March 5th - Both her leg wounds had purulent discharge and were malodorous. Sally was refusing antibiotics, removing dressings and inserting lip balm. Her room was stripped of anything she could use the put in the wounds.
March 7th - Sally was referred to a Tissue Viability Nurse. She had a 15cm wound to the right leg and 8cm to the left leg, suturing not an option as she would remove them. Sally was deemed as having the capacity to know the risk of not taking antibiotics, "it's my legs and I'll do whatever I want."
A cut to her right leg was at least 2cm deep and the base could not be seen but was measured with a sterile probe. The left leg showed gross contamination and slough. Sally said she wanted to feel pain and wanted to die. She was advised on the significant risks, but she said she deserved to be punished. A discussion with Sally about antimicrobial options for dressings took place to see what she may find acceptable Sally had been opening wounds up and pushing faeces in. She then agreed to apply Activon Tube (Advancis Medical) a topical ointment containing 100% Medical Grade Manuka honey, as she liked the idea of something natural "squirting in".
March 9th - Sally informed us that she was hearing voices of the devil and mafia telling her to interfere with her wounds. Distraction techniques were tried, but they only have a short term effect and the wounds then had shower gel and faces inserted into them. Staf removed contaminants and Sally had them redressed with Activon Tube and an absorbent secondary dressing. She continues to refuse antibiotics.
March 10th - A multidisciplinary review restores Sally's escorted leave, the loss of which triggered these episodes of self harm.
Dressings were changed on daily basis to allow Sally to see the wounds as this is what she wants.
March 17th - Lacerations healed to both calves but Sally reopens them in response to the emotional distress of her friend falling out with her. Staff initiate Activon Tube again, as Sally has accepted tis and it has the desired antimicrobial effects.
Deliberate self harm wounds are at high risk from contamination, either from the implement itself or from items 'added'. The prolific use of antibiotics in these cases are now discourage and antimicrobial dressings are the preferred option. Leicestershire Partnership NHS Trust has a care pathway for wounds of this type, aimed at ensuring the service user gets the right treatment for their wound and that they are involved in their treatment options. All self harm wounds known to be grossly contaminated are treated for 14 days with a topical antimicrobial as they have significantly higher risk of developing an infection than those caused by 'clean' instruments. The Best Practice Statement for the use of topical antimicrobials (2011) argues that a consensus should be reached for wounds that fall into this parameter.
In this case honey was utilised for its debriding abilities and antimicrobial properties. The format chosen enabled good surface contact without the trauma that may have occurred had any type of packing been attempted. Bacteria within the wounds had caused malodour. The release of glucose into the wounds provided an alternative fuel source for these bacteria enabling rapid deodorising (White and Molan 2005, cited Betts 2009).
March 28th - Sally has discontinued treatment and her wounds are progressing to healing with no sign of infection.
Deliberate self harm wounds by their nature should heal as an acute wound, however many are subject to repeat trauma, as in Sally's case, which can lead to the wound becoming chronic. The anti-inflammatory effects of 100% Medical Grade Manuka honey on excess pro inflammatory cytokines and proteases fund in chronic wounds are well documented (Molan 2009, Dunford 2000, Gethin 2004) leading to honey being the first choice for wounds of this type.
In Sally's words "honey was great, really helped my legs, best thing I ever had for them...honest"
Best Practice Statement; the use of topical antiseptic/antimicrobial agents in wound management. 2nd edition. Wounds UK, London, 2011
Dunford C (2000) Using honey as a dressing for infected skin lesions. NT plus 96 (14):7-9
Gethin G (2004) Is there enough clinical evidence to use honey to manage wounds? Journal of Wound Care 13 (7):275-78
Molan P (2009) Why honey works. In White R, Cooper R, Molan P ed: Honey: a modern wound management product. Cromwell Press. Wiltshire: 2-21
White R and Molan P (2005) cited Betts J (2009) Guidelines for the clinical use of honey in woundcare. In White R, Cooper R, Molan P ed: Honey: a modern wound management product. Cromwell Press. Wiltshire:24-32