“Paradigm” derives from the Greek word “paradeigma” and means pattern or example.

Part of one’s challenge as a student, resident or physician is to distinguish between the wheat and the chaff as far as paradigms or dictums are concerned. These judgments apply not only to time honored management practices but also to paradigms or dictums of recent origin. That is, which of these paradigms or dictums mesh with reality and which do not? This chapter is devoted to some of my observations in this regard.

Paradigms in surgery are constantly changing. Some that decades ago were thought to be golden have turned out to be fool’s gold. For example, 60 years ago it was heresy to administer salt containing IV solutions during surgery or for the first three postoperative days. This dictum was the result of teaching by Hans Selye and Francis Moore. This dictum has long since been discarded. When antibiotics first appeared on the civilian scene after World War II, the recommendation was that if you prescribe an antibiotic, the drug should be continued for 10 days to prevent the emergence of resistant organisms. This paradigm has been reversed the past few years and the current rule is that antibiotic usage is best kept to a minimum, for the same reason. In the 1990’s it became popular to administer opioids generously, the thinking being that patients were just experiencing too much pain. Now it is generally conceded that this policy was ill-conceived and has resulted in a significant increase in addiction and fatal accidental overdose. Today there are more deaths from accidental overdose of oxycodone than from gunshot wounds and one half of the latter are self-inflicted!

When the push for more pain control surfaced, I thought the idea was a mistake, would lead to long-term problems and relatively soon would be reversed consequently I never adopted this practice.

Opioids, an addition to their analgesic effect, have for other properties. They are constipating, cause euphoria, are addictive and most importantly decrease one’s ability to tolerate pain. This last property is not widely appreciated.

Just because some individual or group advocates a sizable or title shift in a paradigm obviously does not mean that the recommendation is correct. Time is always the acid test. If the evidence appears to validate the change after passing your experience and common-sense tests, the new approach can be given a try.

The publish or perish culture which prevails at most academic centers may contribute to the spate of new paradigms. Recently, government panels and professional organizations have played key roles in the paradigm shift area. No matter what the source, all such recommendations merit critical scrutiny.

In my experience, current practices and techniques which merit reevaluation include the following:

The taboo regarding the use of adrenaline ln local anesthetics employed about the nose, ears, digits and penis is still extant and widely taught even though it has thoroughly been debunked. In the past when complications arose from the use of local anesthetics containing adrenaline in the areas referenced it was because of the volume of solution injected and not the adrenaline. The volume was so great that it occluded the venous return. It is prudent to avoid digital blocks with adrenaline containing local anesthetics in patients with peripheral vascular disease but in the ordinary patient there is no contraindication. Personally, I have never seen a complication resulting from adrenaline containing local anesthetics. Flaps with tenuous blood supply have blanched temporarily only to regain normal color as the adrenaline dissipated. In all areas, it is wise to avoid excessive amounts of local anesthetic to prevent adverse venous pressure effects.

Sterile technique is a time-honored practice in surgery. However, Vilary Blair pointed out almost a century ago that if one were too obsessive about the dictates of this paradigm one would accomplish little in the field of plastic surgery. For example, rhinoplasties are routinely performed under non-sterile conditions and a postoperative infection is rare indeed. After taking care of scores of wounds heavily contaminated with dirt, gravel, tar, plant material and on occasion horse manure as well as dealing with animal and human bites, and observing uneventful healing with thorough debridement and primary closure followed by two or three days of antibiotics. I began to question some of the implications of sterile technique. It seemed to me that the wounds referenced could not have been sterile at the time of closure and yet they almost routinely did well.

During residency training in the late 1950’s and early 1960’s when open-heart cardiac resuscitation was in vogue, I was impressed by the fact that those patients who survived almost never became infected in spite of the unsterile conditions under which the resuscitation took place. The risk of postoperative infection was appreciably greater for those patients undergoing elective chest surgery.

These considerations and the fact that minor breaks in technique had no effect on wound healing caused me to ponder over what other factors besides bacterial contamination played significant roles in wound infection such as inadequate debridement, rough handling of tissues, excessive sponging and use of the suction, leaving excess necrotic tissue in the wound from poorly placed ligatures, ischemia from retractors, particularly self-retaining retractors, overzealous use of the Bovie, closure using excessive tension as well as poor postoperative care. Many studies have shown a positive correlation between operative time and infection rate. This relationship should not be viewed as entirely due to increased bacterial air fallout but also to increased insult to tissues from the trauma of the surgery itself.

During my career, I took care of hundreds of lip lacerations. These wounds involved a contaminated area and yet they almost never became infected following a thorough debridement careful repair and sound pre-and postoperative management. I received a telephone call from a local ER one day, the nurse stating that one of my lip repairs had returned because of wound infection. I recall my reply was, “Lady my lip wounds don’t get infected. Check the chart again to see whose patient this is.” She did and it wasn’t my patient!

My brazenness and confidence in replying to the nurse in the manner I did was based on long experience with such wounds.

To my mind, to think that any wound is sterile borders on fantasy. The first break in technique comes when the skin is violated. The adnexal glands contain bacteria. In addition, the wound is contaminated from bacterial fallout from the air.

There would appear to be at least five factors involved as to whether a particular wound becomes infected: the type or types of contaminating organisms, the quantity of same, the milieu into which the organisms are introduced, the immune competence of the patient and the antibiotic coverage.

My peeve or problem with the sterile technique paradigm is not that we should be cavalier about possible breaks in sterility but rather that the emphasis on avoiding contamination has overshadowed other significant factors involved in infection. Some of these factors are referenced above. Pattern the operative strategies to not only minimize contamination but also to manage the wound in such a fashion as to decrease the chances of the bacteria present to gain a foothold. In my opinion, it is prudent to treat the tissue as if it were yours and only lightly anesthetized. The old adage of gentle ways our best is an excellent guide as far as surgical technique is concerned.

Along the same vein, the highly regarded and by some rigidly adhered to initial 10-minute scrub of the day warrants comment. If one has been scattering manure or has just come in from the autopsy room, there could be justification for such fastidious. Assuming the surgeon exercises a reasonable amount of personal hygiene, launching into a 10-minute scrub with brushes and usually rather potent anti-septic soap, seems a little excessive. My questioning this widespread practice is not based on an aversion to cleanliness but rather on the belief that this routine is credited for being far more important to infection prophylaxis than it really is. Furthermore, especially for individuals with dry skin, a 10-minute scrub can be quite irritating. As pointed out above, it is easy to blame infection on a break in sterile technique when the real culprit may not have been such a break. Rather, rough handling of tissue, self-retaining retractors, etc.

Cleanliness is next to godliness as far as surgery is concerned but sterile technique is only one of multiple factors affecting suppuration.

Theoretically, if one dons a gown and gloves in a correct manner and one’s gown and gloves are not compromised, there is no need to scrub at all!

Most, if not all, medical students and surgical residents are familiar with the old dictum that the “solution to pollution is dilution.” When the offending substance is plus, urine, bile, blood or saliva or some other liquid, copious irrigation and suction is usually an appropriate remedy. However, if foreign material is embedded in tissue, as is almost always the case with contaminated wounds resulting from blunt force, irrigation and suction alone will not provide adequate cleansing. Overzealous irrigation with saline may even be deleterious. Saline is isotonic but not isoionic. Cushing showed in 1901 on nerve-muscle preparations that saline had an adverse effect. Meticulous sharp excision, removing as little normal tissue as necessary, is the only way to accomplish adequate cleansing of the wound when foreign material is either adherent or ground into the tissue. This debridement should be carried out with magnification.

Using electrocautery instead of a scalpel or scissors for dissection is a common practice these days. Dividing tissue with heat may be appropriate in some areas but it violates the principle of gentle handling of tissue. The expert technicians of the past honed their skills with scalpel or scissors rather than with the Bovie. One obvious advantage with Bovie dissection is that coagulation current is available on the same instrument one is using to divide tissue. Whether this benefit overshadows the disadvantages of heat dissection is questionable, to my mind.

Following destruction of a skin lesion either by heat or cold, the patient experiences more pain postoperatively as compared to removing the lesion by shaving or excision and leaving the wound open. The increased pain associated with heat or cold destruction appears to be secondary to the zone of injured tissue at the margins of the wound. My views concerning sharp versus cautery dissection are no doubt a reflection of the way I was trained. Nevertheless, I think that the hemostatic advantages of using heat to divide tissue have been exaggerated, particularly in some areas such as the scalp.

It is widely believed, written and taught that there is a so-called golden period within which traumatic wounds may be safely repaired. Many authors specify rather rigid time limits in this regard. In my experience, primary closure can be delayed for 48 hours for wounds in the head and neck area, and often in other areas as well, especially if three conditions are met: antibiotics, elevation of the wound higher than the heart and application of cool, moist compresses to the wound. Almost routinely, wounds two days old can be the debrided and closed primarily as long as these conditions are met and frequently even when they do not apply. Lacerations of the lips are often associated with mandibular and/or maxillary fractures. These wounds should not be repaired until the fractures are taken care of. Debridement and repair the lip wounds after such delays, often for two days, rarely results in infection. If the wounds are closed prior to the fracture surgery they almost routinely will be disrupted during the latter.

Many of the arbitrary time limits regarding primary wound closure do not interface with reality. Obviously, each defect must be evaluated individually and if invasive infection is present, delayed primary closure is indicated. The skill and experience of the surgeon factor into the length of time following injury that primary closure is feasible. Even the novice can safely manage a wound or day or two old, assuming the proper protocol is followed. This includes thorough cleansing of the defect, meticulous debridement and appropriate antibiotic coverage.

Eyelid wounds are peculiar in that they often show purulent exudate within a few hours post injury. This purulence is no contraindication to primary closure.

Students and residents are instructed to close small defects resulting from excision of skin lesions, converting the wounds to ellipses, the long axes of which parallel the natural skin wrinkles, and suturing. The scar which results from such treatment almost always is much more conspicuous than if the wound is allowed to heal by secondary intention. This situation pertains almost universally to defects of the trunk and extremities in all age groups and applies especially to the face and neck in children and young adults. Suturing a few millimeters in diameter wound of the face and neck in the latter age categories almost always results in the scar which looks exactly like what it is - a postsurgical scar. On the other hand, the scar which follows spontaneous healing usually has the appearance of a minor blemish secondary to an infected coma dome or small chickenpox scar. The difference between the scar resulting from suturing and the one secondary to spontaneous healing is usually striking. This phenomenon is another example of where less is better.

Emergency room physicians often advise removal of skin sutures from extremity and trunk wounds in seven days. In most instances, the wounds will disrupt if this advice is followed, unless closure has been meticulous in the deeper tissues, which is usually not the case. As a general rule, skin sutures should be left in the trunk and extremity wounds for two weeks. As will be pointed out later one should avoid placing external skin sutures in the trunk and extremities except in the hands and feet, if one aspires to create the least conspicuous scar.

A major drawback in being an emergency room physician is that one is almost routinely denied the follow-up and insight that ensues from observing results. Having been taught by their mentors to advise certain time intervals for suture removal, the ER physician tends to follow these protocols. The problem here is that their mentors, as a general rule, were also not exposed to follow up. This quandary has resulted in the handing down of incorrect paradigms from one generation to the next. This problem even pervades textbooks written by ER physicians.

A wet-to-dry dressing is commonly used to care for a granulating wound. Many physicians have been taught that the removal of such a dressing has a beneficial debridement affect. Personally, I have never observed such a phenomenon but have seen many patients experiencing excruciating pain from such a practice. A single layer of greasy gauze as the initial layer of a wet to dry dressing prevents this unnecessary pain by keeping the dressing from adhering to the wound. It is important to use only a single layer of greasy gauze. Multiple layers prevent the wet portion of the dressing from keeping the wound moist and also interfere with drainage. Unless one stresses that a single layer only should be applied, it is likely that some well-meaning nurse or technician will use multiple layers, thinking that if one layer is good, multiple layers should be better.

The efficacy of a single layer of greasy gauze and converting an agonizing experience into an essentially painless one is spectacular. I have been both amazed and dismayed over the years by the fact that most physicians are not aware of the necessity of incorporating greasy gauze in a wet to dry dressing. As I once heard a wise and experienced orthopedic surgeon advised his residents, “If you can’t be a doctor, be a humanitarian.”

What are the advantages of a wet to dry dressing over a dry dressing on a granulating wound? A wet-to-dry dressing keeps the wound moist, conforms better to irregularities in the contour of the wound and may absorb drainage better by increased capillary attraction. The dry component of the dressing impedes drying out of the wet part.

Culturing of chronic wounds is a common practice, whether they appear infected or not. In interpreting the results, it is important to distinguish between colonization and invasive infection. If the wound is merely colonized, and this is a clinical judgment, antibiotics are not only contraindicated but may be deleterious. Infectious disease specialists, and my experience, are almost routinely overzealous in prescribing antibiotics for colonized wounds. It is a truism that almost every wound which is been open for 48 hours will be colonized.

Many physicians do not distinguish between prophylactic and therapeutic antibiotics. Prophylactic antibiotic therapy, by definition, is directed toward preventing an infection and generally should be limited to a single dose or administration for one or two days only, depending on the circumstances. Therapeutic antibiotics are employed to destroy organisms causing infection and routinely are given for five days or longer. It is not uncommon for a prolonged course of antibiotic therapy to be prescribed for prophylaxis, leading to unnecessary expense, gastrointestinal problems and increased risk of developing resistant organisms. In dealing with open wounds resulting from trauma, a two-day course of postoperative antibiotic prophylactic therapy has proved most effective for me.

Most of us were taught that for antibiotics to be efficacious they must be given preoperatively. Obviously, this doctrine is false, as any physician dealing with trauma is well aware. With elective procedures, when antibiotics are appropriate, it is wise to administer them preoperatively. But to expand this line of thinking to the conclusion that antibiotics are not worthwhile if given after wound has been incurred is fallacious.

Some wounds require rather elaborate dressings, such as those following certain types of hand surgery. On the other hand, many surgeons appear to be more enamored with various dressing protocols than evidence suggests they should be. For example, neurosurgeons as a group, appear to be rather compulsive in this regard and apply intricate, multilayered and expensive wound coverings that to my mind represent significant overkill. The dressings not only increase the patient’s bill from the cost of the material involved but add to the OR expense because of the time consumed in applying the dressing. My routine coverage for scalp and facial wounds is a cool, moist washcloth, changed frequently. The moist cloth helps keep the wound clean, the coolness provides some degree of pain control and vasoconstriction, the latter leading to less edema. Usually there is no extra charge for the washcloth so the dressing is free!

Medicating patients prior to dressing change appears to be an increasingly common practice. One of my former mentors often remarked that if one needs to premeditate for most dressing changes he or she probably is not very well-versed in what they’re doing. By applying a single layer of greasy gauze as the first layer of the dressing, as previously recommended for wet to dry dressings, the pain is associated with removal of a dressing can essentially be eliminated. Most fresh wounds tend to ooze a slight amount of serosanguineous material for a day or so and this sticks to a dry dressing. A single layer of greasy gauze resolves the problem. Cleansing of the wound should involve warm water. If a cleansing agent beyond water is used, it should be diluted and rinsed away before reapplying the dressing. Avoid using compound tincture of benzoin in elderly patients. Also, use tape that is not overly adherent in the same age group. Most elderly people have rather fragile skin and skin may be removed when tape is loosened if it is too adherent. In addition, apply as little tape is necessary to secure the dressing and, if possible, secure the dressing largely with roller gauze, using tape only at the margin of the gauze.

Topical antibiotics are often applied to recently sutured wounds or abraded areas. In my experience, these preparations contribute nothing to the eventual outcome, are expensive, greasy and water immiscible. In addition, they soil personal and bed clothing. As noted above, most wounds drain a small amount of serosanguineous material for a day or so and the topical antibiotic tends to prevent drainage from escaping, leading to wound maceration. Topical antibiotics are worthless as far as cleaning contaminated abrasions. A moist dressing may remove a very slight amount of foreign material from a dirty abrasion but active debridement is really required to cleanse the wound.

A drain will not prevent a hematoma but it may alert one to the presence of bleeding. The same device can prevent a seroma or a liquid serosanguineous collection, the latter being not uncommon these days with so many people on blood thinners.

Many physicians harbor the illusion that surgery is key to management of pressure ulcers. Nothing could be farther from the truth. The reason the patient developed the ulcer needs to be addressed prior to surgery. Otherwise, the lesion will promptly recur.

Pressure ulcers, as the name implies, result from prolonged pressure between the skin and an underlying bony prominence, leading to ischemia, hypoxia and necrosis. The term decubitus is often employed instead of pressure ulcer but should be avoided. Decubitus implies a horizontal position. The second most common pressure ulcer is an ischial one and results from prolonged sitting. Individuals confined to bed and unable to turn themselves should be turned every two hours or placed on an alternating pressure mattress or some other appropriate bed designed to minimize pressure. Patients in wheelchairs who are unable to elevate their buttocks from the seat of the chair for 30 seconds or so every one-half hour, need a wheelchair with a reclining back so that they can lie down for a brief period every one-half hour and relieve the pressure on their ischial areas. It is not uncommon to obtain a history of a long automotive drive by a paraplegic prior to development of ischial pressure ulcers.

Some pressure ulcer patients will not be compliant as far as prophylactic measures to prevent ulcers are concerned and their wounds should be managed conservatively.

A colostomy is often recommended for ischial ulcer patients. Such surgery in most cases is unnecessary, in my experience. Careful dressing routines and pharmacological management of the G.I. tract can avoid significant fecal contamination. Also, the peroneal area usually has appreciable resistance to infection from G.I. organisms.

As an aside, when debriding pressure ulcers, and usually this can be done at the bedside, it is important to stop when bleeding occurs. Otherwise, a lot of time will be required to obtain hemostasis.

Patients are often advised to use hydrogen peroxide or alcohol to cleanse wounds. Both of these substances are protoplasmic poisons and should not be applied to open wounds. They will delay or prevent wound healing. ½% hydrogen peroxide is efficacious as a preoperative mouthwash when treating lip, buccal mucosa or tongue wounds, because of its effect on anaerobic bacteria. 3% hydrogen peroxide is helpful in removing blood from hair but it should be kept out of wounds as much as possible.

One of the latest fads in most emergency rooms these days is not to have razors available because of the increased risk of infection following preoperative shaving. However, razors are frequently necessary to shave hairy abraded areas, except eyebrows. In non-or sparsely hairy areas the crust which forms following an abrasion separates with minimal friction, such as that associated with routine bathing. In hairy areas, the crust adheres to the hair and makes removal difficult and painful. As a consequence, the crust usually remains in place following epithelial separation of the abrasion and the sebaceous material and perspiration which accumulates beneath the crust leads to ulceration. The area requires frequent dressing changes in shaving of the surrounding skin to provide for tape adherence. Healing may require several weeks and involves a lot of wound care. These ulcers can be prevented by shaving the abraded hairy areas. Shaving may require topical or infiltrated local anesthesia. Following healing of the abrasions, the crust can be separated with minimal discomfort using a curved or straight mosquito hemostat. If hairy abraded areas are not shaved at the time they are debrided, later timely removal of the crusts can be a nightmare both for the patient and the surgeon.

Be very cautious about advising heating pads or ice bags. The single biggest cause of malpractice litigation 60 years ago was hot water bottle misadventures. Cold can be as noxious as heat. I recall saying a young man who had been advised by emergency room personnel to apply ice packs to first and 2nd° burns of his upper eyelids. He was very conscientious in following directions and his upper eyelid skin died from the extreme cold, necessitating grafting of the defects.

A cold compress, which involves immersing a washcloth or similar material in ice water, ringing it out and applying it in a single layer to the wound and reapplying the washcloth only after it has warmed up, will never lead to such a complication.

A towel or similar protective device should always be placed between an ice bag and the underlying skin. If a heating pad is recommended, a low setting should be used and the patient and family thoroughly briefed regarding problems associated with excessive heat.

Iodoform gauze is a reasonable packing material following incision and drainage of an infected sebaceous cyst or similar purulent collection. The packing should be changed within a day or so and replaced with plain gauze packing moistened with saline or water. Iodoform gauze used initially as packing helps control the odor and has some antibacterial effect. Employing it for follow-up dressing changes causes discomfort and impedes healing.

Many surgeons appear to believe that discontinuing NSAIDS five days prior to surgery is sufficient to avoid increased bleeding time. I am aware of the theoretical arguments why a five-day prohibition should be adequate. The reality is, however, a three-week NSAID abstinence is necessary, and even that period frequently will not return the bleeding time to normal. As noted previously, about one half the patients seen in the emergency room for repair of lacerations will have ingested an NSAID during the previous three weeks and will display increased bleeding, edema and discoloration.

Instructors often emphasize the proper way to remove sutures so that contamination of the suture tract can be avoided. I have never observed a problem from contamination of a suture tract resulting from an appropriate technique. The important thing is to completely remove the sutures, as painlessly as possible. By the time the sutures are removed there are protective immune mechanisms in place so that infection from casual contamination is exceedingly unlikely.

Every student is taught to use the surgeon’s knot on the first throw of a suture whether there is excess tension on the wound margins or not. Unless overcoming tension is involved a surgeon’s knot should not be used. It requires more time and motion, and the suture, if deep to the skin, leaves more foreign material in the wound. In addition, it is also a waste of suture.

Almost all students are warned not to get a running suture too tight. As a result, almost every novice routinely gets his or her running suture too loose!

The latest catch phrase in medical jargon is “evidence based.” The term was coined by Gordon Guijett and appeared in print in 1992 in JAMA. Its genesis was an outgrowth of what were obvious deficiencies in so-called expert based medicine, in which the subjects covered were true because the experts said they were true. To my knowledge, there is no difference between conclusions arrived at by the scientific method, first promulgated by Francis Bacon centuries ago, and the evidence based approach. The way the term “evidence-based” is battered around one would assume that this new evaluation paradigm is significantly superior to methods employed in the past. In reality, as referenced above, it arose because of antagonism against authoritarianism. I suspect that most of the public, the majority of students and many of my colleagues believe there is a critical distinction between conclusions arrived at by the scientific method compared to the “evidence-based” approach. The expression “evidence-based” obviously for me comes under the pet peeve category. However, I do think that the point made above is valid and worth mentioning. The implication in the term is, as pointed out above that the scientific community has discovered a new, more exacting, and precise way to evaluate data and that the results far overshadow those of the previous methods. The seduction of new, cool phraseology is obviously strong. Language is a powerful tool as any politician or trial lawyer will affirm.

My goal in commenting on the topics above was not to compete for the iconoclast award of the year. Rather, it was to elaborate on some of the current medical routines which are, in my opinion, are over emphasized or do not mesh with reality.

If experience indicates that some traditional teaching is off the mark, one should entertain alternate approaches. Some current practices seem to have more in common with a Japanese tea ceremony than sound approaches.