Honey Remedy Could Save Limbs

[Reasonable Rascal]

Honey Remedy Could Save Limbs

http://www.wired.com/news/technology/medtech/0,71925-0.html?tw=wn_index_3

By Brandon Keim
01:00 AM Oct, 11, 2006

When Jennifer Eddy first saw an ulcer on the left foot of her patient, an elderly diabetic man, it was pink and quarter-sized. Fourteen months later, drug-resistant bacteria had made it an unrecognizable black mess.

Doctors tried everything they knew -- and failed. After five hospitalizations, four surgeries and regimens of antibiotics, the man had lost two toes. Doctors wanted to remove his entire foot.

"He preferred death to amputation, and everybody agreed he was going to die if he didn't get an amputation," said Eddy, a professor at the University of Wisconsin School of Medicine and Public Health.

With standard techniques exhausted, Eddy turned to a treatment used by ancient Sumerian physicians, touted in the Talmud and praised by Hippocrates: honey. Eddy dressed the wounds in honey-soaked gauze. In just two weeks, her patient's ulcers started to heal. Pink flesh replaced black. A year later, he could walk again.

"I've used honey in a dozen cases since then," said Eddy. "I've yet to have one that didn't improve."

Eddy is one of many doctors to recently rediscover honey as medicine. Abandoned with the advent of antibiotics in the 1940s and subsequently disregarded as folk quackery, a growing set of clinical literature and dozens of glowing anecdotes now recommend it.

Most tantalizingly, honey seems capable of combating the growing scourge of drug-resistant wound infections, especially methicillin-resistant Staphylococcus aureus, or MRSA, the infamous flesh-eating strain. These have become alarmingly more common in recent years, with MRSA alone responsible for half of all skin infections treated in U.S. emergency rooms.
So-called superbugs cause thousands of deaths and disfigurements every year, and public health officials are alarmed.

Though the practice is uncommon in the United States, honey is successfully used elsewhere on wounds and burns that are unresponsive to other treatments. Some of the most promising results come from Germany's Bonn University Children's Hospital, where doctors have used honey to treat wounds in 50 children whose normal healing processes were weakened by chemotherapy.

The children, said pediatric oncologist Arne Simon, fared consistently better than those with the usual applications of iodine, antibiotics and silver-coated dressings. The only adverse effects were pain in 2 percent of the children and one incidence of eczema. These risks, he said, compare favorably to iodine's possible thyroid effects and the unknowns of silver -- and honey is also cheaper.

"We're dealing with chronic wounds, and every intervention which heals a chronic wound is cost effective, because most of those patients have medical histories of months or years," he said.

While Eddy bought honey at a supermarket, Simon used Medihoney, one of several varieties made from species of Leptospermum flowers found in New Zealand and Australia.

Honey, formed when bees swallow, digest and regurgitate nectar, contains approximately 600 compounds, depending on the type of flower and bee. Leptospermum honeys are renowned for their efficacy and dominate the commercial market, though scientists aren't totally sure why they work.

"All honey is antibacterial, because the bees add an enzyme that makes hydrogen peroxide," said Peter Molan, director of the Honey Research Unit at the University of Waikato in New Zealand. "But we still haven't managed to identify the active components. All we know is (the honey) works on an extremely broad spectrum."

Attempts in the lab to induce a bacterial resistance to honey have failed, Molan and Simon said. Honey's complex attack, they said, might make adaptation impossible.

Two dozen German hospitals are experimenting with medical honeys, which are also used in the United Kingdom, Australia and New Zealand. In the United States, however, honey as an antibiotic is nearly unknown. American doctors remain skeptical because studies on honey come from abroad and some are imperfectly designed, Molan said.

In a review published this year, Molan collected positive results from more than 20 studies involving 2,000 people. Supported by extensive animal research, he said, the evidence should sway the medical community -- especially when faced by drug-resistant bacteria.

"In some, antibiotics won't work at all," he said. "People are dying from these infections."

Commercial medical honeys are available online in the United States, and one company has applied for Food and Drug Administration approval. In the meantime, more complete clinical research is imminent. The German hospitals are documenting their cases in a database built by Simon's team in Bonn, while Eddy is conducting the first double-blind study.

"The more we keep giving antibiotics, the more we breed these superbugs. Wounds end up being repositories for them," Eddy said. "By eradicating them, honey could do a great job for society and to improve public health."

[WolfBrother]

Any word on the practical application?

Soak a 4x4 in the Honey then apply to wound and cover?

In a austere environment this could be a serious life saver.

[FlightERDoc]

Any word on the practical application?

Soak a 4x4 in the Honey then apply to wound and cover?

In a austere environment this could be a serious life saver.


Before I did that, I'd heat (pasturize) the honey (even if previously done) and let it cool. Plain granular sugar works too.

You can also just pour it on. It works by pulling the water out of the bacteria (and the tissue, got to keep the patients fluids up). Bees make peroxide, but so does every other animal, it's one of the ways the immune system kills foreign cells.

BTW, hyperbaric oxygen therapy would probably have helped the original patient, too. It's great for diabetic ulcers.

[DrBaboon]

Dr. Silvetti was a controversial figure in malpractice lawsuits related to wound care. IOW - he served as the expert witness in such lawsuits. I am not going to get into the intricacies of the controversies or what different people have said about his track record as an expert witness, as that would distract from this question AND potentially puts me in legal conflict.

http://www.juryverdicts.com/experts/si.html

http://www.macleodpharma.com/Content/Multimex.htm

He made use of his patented products in wound care with seemingly good effects.

However, I would have liked to see more fully developed research prior to going to market. Yes, there is published material on these products.

My reasons for posting are to add to what FlightERDoc said, and to agree that hypertonic sugars/polysaccharides are not new ideas in wound care. I also wanted to point out some of the pitfalls of less thorough research or other distractions (such as becoming a controversial expert witness). I can't help but think that had other choices been made, approaches like this type of product might be more widespread.

PPPPPPP

Proper research. Study design.

As has been said: "The pleural of annecdote is *not* data."

Basically, I am sympathetic to the idea of applying such substances to wounds.

Which doesn't in any way excuse people from the need to go further and do things correctly.

[tangent]

Int J Low Extrem Wounds. 2006 Mar;5(1):40-54.Click here to read Links

Erratum in:
Int J Low Extrem Wounds. 2006 Jun;5(2):122.

Comment in:
Int J Low Extrem Wounds. 2006 Mar;5(1):55.

The evidence supporting the use of honey as a wound dressing.

* Molan PC.

Department of Biological Sciences, University of Waikato, Hamilton, New Zealand. pmolan@waikato.ac.nz

Some clinicians are under the impression that there is little or no evidence to support the use of honey as a wound dressing. To allow sound decisions to be made, this seminar article has covered the various reports that have been published on the clinical usage of honey. Positive findings on honey in wound care have been reported from 17 randomized controlled trials involving a total of 1965 participants, and 5 clinical trials of other forms involving 97 participants treated with honey. The effectiveness of honey in assisting wound healing has also been demonstrated in 16 trials on a total of 533 wounds on experimental animals. There is also a large amount of evidence in the form of case studies that have been reported. It has been shown to give good results on a very wide range of types of wound. It is therefore mystifying that there appears to be a lack of universal acceptance of honey as a wound dressing. It is recommended that clinicians should look for the clinical evidence that exists to support the use of other wound care products to compare with the evidence that exists for honey.

PMID: 16543212 [PubMed - indexed for MEDLINE]

J Wound Care. 2004 Oct;13(9):353-6. Links
Clinical usage of honey as a wound dressing: an update.

* Molan PC,
* Betts JA.

Honey Research Unit, Department of Biological Sciences, University of Waikato, Hamilton, New Zealand. pmolan@waikato.ac.nz

PMID: 15517742 [PubMed - indexed for MEDLINE]


Ostomy Wound Manage. 2002 Nov;48(11):28-40. Links
Re-introducing honey in the management of wounds and ulcers - theory and practice.

* Molan PC.

Department of Biological Sciences, University of Waikato, Private Bag 3105, Hamilton, New Zealand. pmolan@waikato.ac.nz.

Dressing wounds with honey, a standard practice in past times, went out of fashion when antibiotics came into use. Because antibiotic-resistant bacteria have become a widespread clinical problem, a renaissance in honey use has occurred. Laboratory studies and clinical trials have shown that honey is an effective broad-spectrum antibacterial agent that has no adverse effects on wound tissues. As well as having an antibacterial action, honey also provides rapid autolytic debridement, deodorizes wounds, and stimulates the growth of wound tissues to hasten healing and start the healing process in dormant wounds. Its anti-inflammatory activity rapidly reduces pain, edema, and exudate and minimizes hypertrophic scarring. It also provides a moist healing environment for wound tissues with no risk of maceration of surrounding skin and completely prevents adherence of dressings to the wound bed so no pain or tissue damage is associated with dressing changes. Using appropriate dressing practice overcomes potential messiness and handling problems.

PMID: 12426450 [PubMed - indexed for MEDLINE]


Gen Dent. 2001 Nov-Dec;49(6):584-9. Links
The potential of honey to promote oral wellness.

* Molan PC.

Honey Research Unit, University of Waikato, Hamilton, New Zealand.

Honey has been used as a medicine throughout the ages and in more recent times has been "rediscovered" by the medical profession for treatment of burns, infected wounds, and skin ulcers. The large volume of literature reporting its effectiveness indicates that honey has potential for the treatment of periodontal disease, mouth ulcers, and other problems of oral health.

PMID: 12024746 [PubMed - indexed for MEDLINE]


Nurs Times. 2000 Dec 7-13;96(49):36-7. Links
Using honey dressings: the practical considerations.

* Molan P,
* Betts J.

Honey Research Unit, University of Waikato, Hamilton, New Zealand.

PMID: 11965957 [PubMed - indexed for MEDLINE]

Am J Clin Dermatol. 2001;2(1):13-9. Links
Potential of honey in the treatment of wounds and burns.

* Molan PC.

Honey Research Unit, University of Waikato, Hamilton, New Zealand. pmolan@waikato.ac.nz

There has been a renaissance in recent times in the use of honey, an ancient and traditional wound dressing, for the treatment of wounds, burns, and skin ulcers. In the past decade there have been many reports of case studies, experiments using animal models, and randomized controlled clinical trials that provide a large body of very convincing evidence for its effectiveness, and biomedical research that explains how honey produces such good results. As a dressing on wounds, honey provides a moist healing environment, rapidly clears infection, deodorizes, and reduces inflammation, edema, and exudation. Also, it increases the rate of healing by stimulation of angiogenesis, granulation, and epithelialization, making skin grafting unnecessary and giving excellent cosmetic results.

PMID: 11702616 [PubMed - indexed for MEDLINE]


Trop Doct. 2000 Oct;30(4):249-50. Links

Comment on:
Trop Doct. 2000 Jan;30(1):1.
Trop Doct. 2000 Jan;30(1):54.

Honey and sugar as a dressing for wounds and ulcers.

* Molan PC,
* Cooper RA.

PMID: 11075670 [PubMed - indexed for MEDLINE]


J Wound Care. 1999 Sep;8(8):415-8. Links
The role of honey in the management of wounds.

* Molan PC.

Honey Research Unit, University of Waikato, Hamilton, New Zealand.

PMID: 10808853 [PubMed - indexed for MEDLINE]


J Wound Care. 1999 Jul;8(7):340. Links

Comment on:
J Wound Care. 1999 Apr;8(4):155.

Honey in wound care.

* Cooper RA,
* Molan PC.

PMID: 10776224 [PubMed - indexed for MEDLINE]


J Int Acad Periodontol. 2004 Apr;6(2):63-7. Links
The effects of manuka honey on plaque and gingivitis: a pilot study.

* English HK,
* Pack AR,
* Molan PC.

Discipline of Periodontology, School of Dentistry, University of Otago, Dunedin, New Zealand.

Research has shown that manuka honey has superior antimicrobial properties that can be used with success in the treatment of wound healing, peptic ulcers and bacterial gastro-enteritis. Studies have already shown that manuka honey with a high antibacterial activity is likely to be non-cariogenic. The current pilot study investigated whether or not manuka honey with an antibacterial activity rated UMF 15 could be used to reduce dental plaque and clinical levels of gingivitis. A chewable "honey leather" was produced for this trial. Thirty volunteers were randomly allocated to chew or suck either the manuka honey product, or sugarless chewing gum, for 10 minutes, three times a day, after each meal. Plaque and gingival bleeding scores were recorded before and after the 21-day trial period. Analysis of the results indicated that there were statistically highly significant reductions in the mean plaque scores (0.99 reduced to 0.65; p=0.001), and the percentage of bleeding sites (48% reduced to 17%; p=0.001), in the manuka honey group, with no significant changes in the control group. Conclusion: These results suggest that there may be a potential therapeutic role for manuka honey confectionery in the treatment of gingivitis and periodontal disease.

PMID: 15125017 [PubMed - indexed for MEDLINE]


J Pharm Pharmacol. 1991 Dec;43(12):817-22. Links
A survey of the antibacterial activity of some New Zealand honeys.

* Allen KL,
* Molan PC,
* Reid GM.

Department of Biological Sciences, University of Waikato, Hamilton, New Zealand.

To assess the variation in antibacterial activity of honey a survey was carried out on 345 samples of unpasteurized honey obtained from commercial apiarists throughout New Zealand. Most of the honeys were considered to be monofloral, from 26 different floral sources. The honeys were tested against Staphylococcus aureus in an agar well diffusion assay, with reference to phenol as a standard. Antibacterial activity was found to range from the equivalent of less than 2% (w/v) phenol to 58% (w/v) phenol, with a median of 13.6 and a standard deviation of 12.5. Neither the age of the honey samples nor whether they had been processed by the apiarist was associated with lower activity. However, the difference between floral sources in the antibacterial activity was very highly significant. Kanuka (Kunzea ericoides (A. Rich.) J. Thompson. Family: Myrtaceae), manuka (Leptospermum scoparium J. R. et G. Forst. Family: Myrtaceae), ling heather (Calluna vulgaris (L.) Hull. Family: Ericaceae) and kamahi (Weinmannia racemosa Linn. f. Family: Cunoniaceae) were shown to be sources likely to give honey with high antibacterial activity. When antibacterial activity was assayed with catalase added to remove hydrogen peroxide, most of the honeys showed no detectable antibacterial activity. Only manuka and vipers bugloss (Echium vulgare L. Family: Boraginaceae) honeys showed this type of activity in a significant proportion of the samples. The high antibacterial activity of manuka honey was in many cases due entirely to this non-peroxide component.

PMID: 1687577 [PubMed - indexed for MEDLINE]


[Note: there are others, but they tend to be more specific to particular types of infections or discovering the anti-biotic mechanism]

-t

[Jonas Parker]

Honey might be a good item to add to a family's survival supplies. I wonder if the honey from the local grocery store would work, as I have no idea what flowers it came from.

[WolfBrother]

Wasn't there a treatment using sugar on open wounds?

Sugar tone dressing?

I've googled a couple of variants and didn't have much luck. I don't think my search fu is good today.

[Reasonable Rascal]

Sugardyne, a 50/50 mix (as I recall) of sugar and Betadyne. Worked pretty well for it's day though there are more effective remedies now. But push come to shove it has been shown to work. As recently as the 70's it was arguably the best we had for certain types of wounds, pressure sores (decubiti) being one I often saw it used on with good effect.

RR

[FlightERDoc]

Sugardyne, a 50/50 mix (as I recall) of sugar and Betadyne. Worked pretty well for it's day though there are more effective remedies now. But push come to shove it has been shown to work. As recently as the 70's it was arguably the best we had for certain types of wounds, pressure sores (decubiti) being one I often saw it used on with good effect.

RR

Unfortunately, it seems the company making sugardyne was having problems with the FDA and it's no longer being manufactured. But, it's pretty easy for the pharmacy to whip it up: Granular sugar and betadine solution, to wet.

It's still a good treatment for hard to heal sores...

[Buffalomary]

Back when I was in the Army and stationed at Tripler Army Medical Center in Honolulu, working on the general surgical ward, I remember a vet who came in with a serious sacrococcygeal decubitus ulcer (if memory serves me right, approximately 3-4 inches in diameter and down to the bone). After approximately a week of treatments each shift, the ulcer was only getting worse. Two of the civilian nurses convinced the doctors to allow them to treat the ulcer with honey and aloe. The doctors agreed. It worked!! The wound started to show regranulation and healing. And this was within approximately two weeks! It was such a drastic change when compared with the previous treatment.

Even though it was obviously successful, that was the only patient they allowed that treatment on while I was there, and we saw many patients with similar wounds. I never did get the whole story as to why, but I was very impressed how that treatment worked much better than the "standard" for that day of cleaning with betadine scrub, heat lamps, and then coating with Silvadene each shift.

It was far from a scientific research project, just a veteran, paralyzed due to his injuries from Vietnam, needing assistance. But I know what I saw and I know it worked!

[FlightERDoc]

Back when I was in the Army and stationed at Tripler Army Medical Center in Honolulu, working on the general surgical ward, I remember a vet who came in with a serious sacrococcygeal decubitus ulcer (if memory serves me right, approximately 3-4 inches in diameter and down to the bone). After approximately a week of treatments each shift, the ulcer was only getting worse. Two of the civilian nurses convinced the doctors to allow them to treat the ulcer with honey and aloe. The doctors agreed. It worked!! The wound started to show regranulation and healing. And this was within approximately two weeks! It was such a drastic change when compared with the previous treatment.

Even though it was obviously successful, that was the only patient they allowed that treatment on while I was there, and we saw many patients with similar wounds. I never did get the whole story as to why, but I was very impressed how that treatment worked much better than the "standard" for that day of cleaning with betadine scrub, heat lamps, and then coating with Silvadene each shift.

It was far from a scientific research project, just a veteran, paralyzed due to his injuries from Vietnam, needing assistance. But I know what I saw and I know it worked!

I've seen it work too. I just don't believe the antibacterial claims, with or without H2O2. I've done a pubmed search and asked our librarian to get me some more recent papers.

[DrBaboon]

Actually, while dextrans, sugar or other agents pop up in wound healing, povidone iodine has ended up being contraindicated in wound care, as well as other antiseptics. There are numerous people who continue to use it, in many cases because it's what they learned to do, and because they attribute good outcomes to it.

The problem has been that products like povidone iodine have toxic effects, and prevent wound healing.

I don't recall that there has been a major revision to the pressure ulcer guideline that the AHCPR put out around 1994, but this was one of it's points.

http://www.ahrq.gov/

http://www.medicaledu.com/ahcpr.htm



As we continue to discuss whether/when there might be revisions to "the book," and what those revisions might involve, I'd like to vote again (vote early, vote often :D ) in favor of going further with the pressure ulcer/wound care section.

[Reasonable Rascal]

I'll agree, Dr. B. I'd like to see more on this subject.

Like it or not, should TSHTF there is going to be an increase in such wounds amongst otherwise healthy people to whom bad things have happened. Without the niceties of qualified PT, a working ortho dept, etc there is going to be a return to the days of spending time on your back while mother nature does the rest. No more rods for femurs, just traction and time. I doubt there is a person here with any time on the wards who has not seen what happens to anything resembling a bony prominance when that happens.

RR

[tangent]

I remember one that got infected and turned into gangreen. we scraped the bone and applied a seaweed based compound that we were only able to get through the suply chain by ordering, IIRC, clostomy bags/sets

think it started w/ a che* or cha* - anyone know what this seeweed based compound is and how effective it is?

also, what would be other austere treatments for gangreen? It was on the womans pelvis so amputation was not an option.

thanks,

-t

[DrBaboon]

To clarify, there are different processes that need to occur with complicated wounds. They can be simplified into debriding and healing.

The gangrenous portion of a wound that Tangent mentioned, isn't healed by putting on the product he saw. It is debrided in some manner or another, leaving whatever tissue(s) under it, and then hopefully going on to the healing process.

Debriding can occur using a wide variety of mechanisms.

Sharp debriding is the most obivous method - using surgical techniques.

Other processes or methods of debriding include: Autolysis (aka autolytic debriding) - which can be encouraged by substances applied to the wound or particular dressings. It can also be enhanced with enzymes. It's commonly combined with mechanical debriding (typically, by removing a dressing to which junk has become adherent), or by various means of irrigation. Maggots also are a method of debridement (however, there are some logistical and "other" issues involved when they are used - intentionally or unintentionally).

Wound healing follows a process that begins with (and approximates) growing a monolayer of cells in tissue culture. That (hopefully) goes on to granulation. Eventually, epithelial tissue may be able to grow over the wound. Epithelial tissues, epithelialization does not equal normal skin.

I believe the ingredient that you are looking for is alginate -- one of its salts -- such as calcium alginate, sodium alginate. It's been incorporated into a wide variety of products, from dressings, to volume (cavity) filling items such as ropes or "spaghetti," or whatever.

Alginates:

http://www.lsbu.ac.uk/water/hyalg.html

http://en.wikipedia.org/wiki/Alginate

Wound Care Product Examples:

http://www.polymem.com/

http://www.southwestmedical.com/Woundcare_Products/Specialty_Woundcare/CollagenSilicone/Fibracol_Plus_Collagen_Wound_Dressing_with_Alginat e_-_Rope/2677p0

The product list is long, so I will not make any effort to be comprehensive.



FWIW - I have found it helpful to simplify discussions of dressing choices and frequency of changing the dressing along these lines....

Junky wounds that need material removed need to have dressings that stick to the wound relatively more, and need to be changed more often.

Clean wounds inevitably still have the dressing stick to them, and unfortunately have some healthy tissue removed when the dressing is changed. The goal is to make that as small an amount of healthy tissue as possible. That is accomplished by changing dressings LESS often, and using dressing materials that are a little bit like "sticky notes" - that is, adhesive enough to stay put, but not particularly sticky/adherent - just like the way we move certain paper products around. The other property of a dressing that needs to be present for the dressing to be left in place for several days (or more) is that the dressing can't be expected to dry out, along with the wound surface under it.

Gauze is not ultimately a material that leads to wound healing.

While it's usually OK to start out with gauze, the open weave of it allows tissue to work through the fibers, and gets trapped in the gauze. It also dries out. Traditional wet-to-dry dresssings have to be changed every so many hours, or they dry out and end up being more toxic, even if it's OK to debride the wound by having the wound surface to work its way into the gauze weave prior to gauze removal.

In any kind of on-going treatment of a wound, we need to think of gauze as a debriding tool that will not encourage healing AFTER we reach the point of successful debriding. Since many wounds are not in a binary state (that is - they are not either junky or clean - they are often a mixture of both extremes, with one or more intermediate states in some region(s) of the wound), it is often helpful to go to dressing materials that can encourage autoloysis while being able to minimize disruption of the cleaner/healthier portions of the wound.

[FlightERDoc]

I remember one that got infected and turned into gangreen. we scraped the bone and applied a seaweed based compound that we were only able to get through the suply chain by ordering, IIRC, clostomy bags/sets

think it started w/ a che* or cha* - anyone know what this seeweed based compound is and how effective it is?

also, what would be other austere treatments for gangreen? It was on the womans pelvis so amputation was not an option.

thanks,

-t

Some sort of alginate....

Gangrene without abx? debride and hope for the best, but order a body bag.

[Jonas Parker]

...While it's usually OK to start out with gauze, the open weave of it allows tissue to work through the fibers, and gets trapped in the gauze. It also dries out. Traditional wet-to-dry dresssings have to be changed every so many hours, or they dry out and end up being more toxic, even if it's OK to debride the wound by having the wound surface to work its way into the gauze weave prior to gauze removal.

In any kind of on-going treatment of a wound, we need to think of gauze as a debriding tool that will not encourage healing AFTER we reach the point of successful debriding. Since many wounds are not in a binary state (that is - they are not either junky or clean - they are often a mixture of both extremes, with one or more intermediate states in some region(s) of the wound), it is often helpful to go to dressing materials that can encourage autoloysis while being able to minimize disruption of the cleaner/healthier portions of the wound.

OK. Then wouldn't Telfa be the answer to the problem? Use gauze as a bandage but Telfa (perhaps with Bacitracin) as the dressing?

[DrBaboon]

Sure -- Telfa is a reasonable answer when combined with a petrolatum based ointment (such as bacitracin) - if the wound is reasonably clean.

Rationale: Telfa dressings don't stick very much, nor does the petrolatum based ointment (bacitracin), which are desireable features. By itself, telfa would let the wound dry out unacceptably, which is countered by the bacitracin.

It would probably need to be changed more often than one of the more modern dressings. Since we're probably not going to end up with a situation during "normal" times where we'd choose to use telfa/bacitracin in favor of the modern products, I'm not sure what to suggest for how often to change the telfa/bacitracin. Deciding on wound assessment techniques would be the first step in guiding how to determine optimal frequency of changing the dressing.

Telfa/bacitracin would also require tape or other means of holding it in place, and that may require more attention to minimise skin damage (compared to one of the more modern dressings). Tape adhesives are more likely to cause trouble than "sticky note" adhesives on more modern dressings.

Trade offs: Higher cost per dressing for one of the fancy items, but considerably fewer of them used. Some ability to cut a telfa dressing to size. Depending on the fancier modern dressing obtained, you may or may not be able to cut it to size or to stretch the supply by doing so if the wound is small enough. Storage requirements vary - stocking a larger quantity of fewer different items, a wider variety of items, etc. Any of us could calculate that in different ways.

Personnel costs for care probably are not a dollar-cost expense, but are a time expense (particularly if caring for other patients and/or training any apprentices we might have in our practice), and would be higher with the telfa/bacitracin idea.

All in all, I think it's a reasonable plan.