What "The Pitt" Got Right and Wrong About Xylazine Wounds
As a researcher and wound care nurse for people who use drugs, my thoughts on the most recent episode of the Pitt
I am a wound care nurse, PhD prepared researcher focused on xylazine wounds, and proud University of Pittsburgh (Pitt) alum. On Thursday’s episode of “The Pitt” (Season 2, Episode 11), when Dr. Cassie McKay and student doctor James Ogilvie saw a patient for a xylazine wound, my worlds collided. It was my time to shine. Here is my unsolicited opinion on what “The Pitt” got right and wrong about xylazine wounds.
What They Got Right
Dr. McKay said that she met the patient, Kiki, during her time on the street team. People who inject drugs typically avoid traditional medical settings, making low-barrier, highly accessible programs like street teams extremely important to getting more patients to see medical providers.
When they were preparing to go see the patient, Dr. McKay told the student doctor, Ogilvie, to not judge people who suffer from addiction. She said, “We are healers, not judges.” This is the essence of harm reduction, which is about accepting the fact that in our world, people will always use drugs and that it is their autonomous right to do so. Our job as medical providers is to be there for them and offer advice on how to reduce harm associated with use.
When Kiki, the patient, exposed her wound, Ogilvie asked if it was an injection site. When Kiki said no, Dr. McKay correctly noted that xylazine wounds don’t necessarily have to occur at the site of injection. The overall phenomenon is thought to be because xylazine causes low heart rate and vasoconstriction (a constriction of the blood vessels), which leads to reduced oxygen and blood flow to the skin, and, in turn, wounds.
Dr. McKay offered to give Kiki supplies to take care of the wounds herself. This is very common practice. Patients are extremely knowledgeable about what works for them and often prefer to do wound care themselves.
Throughout the dressing change, Ogilvie was staring at the patient. Unfortunately, many patients report stigmatizing and discriminatory practices from health care providers. This is why many people who inject drugs avoid traditional medical care altogether.
What They Got Wrong
Dr. McKay spoke to Kiki about her drug use, asking her if she still uses xylazine. When Kiki said she still does sometimes, Dr. McKay said “Sometimes is not good, Kiki…. meetings [Narcotics Anonymous] are good, not using is even better.” Abstinence is not the only way for patients to recover. In fact, the best way to reduce overdoses from opioids is by taking medications for opioid use disorder like buprenorphine. By telling Kiki that abstinence is the best option, Dr. McKay was 1) failing to offer an evidence-based treatment that could save Kiki’s life and 2) forcing the narrative that the only version of recovery is abstinence, when it doesn’t work for many patients.
Dr. McKay told Kiki that she should change her dressing every day. This is not possible for many patients who live outdoors and frequently have supplies stolen from them. Patients also rightfully prioritize spending their time on things like getting food, somewhere safe to sleep, and avoiding withdrawal. It is our job as providers to recognize that the patient will likely keep the dressing on for many days. Knowing this, we need to choose dressings that can be left on for longer or are easier to change (e.g., keep the base layer the same and just change the outer pad).
There were no nurses in sight during the dressing change. A recent study I led found that almost every low-barrier street team in Pennsylvania had a registered nurse and offered wound care. Wound care is a nursing intervention, and displaying a doctor performing this care further re-emphasizes the narrative so often portrayed on TV that doctors do everything at a hospital.
Lastly (and this is me being picky) the dressing choices that Dr. McKay made were all wrong. She chose to apply Medihoney on July 4—the middle of summer. Medihoney is medical-grade honey that is extremely effective at removing dead tissue, but it can also attract bugs to the wound, especially for patients living outdoors. Second, Dr. McKay chose to apply Xeroform, an occlusive dressing that does not allow for drainage to come out of the wound. This would make the drainage stick to the wound and the skin around it, causing more breakdown. If it were me, I’d have chosen to first ask the patient what works for her, then, with her consent, move forward to apply something non-adhesive that allows drainage to pass through, an easy-to-change absorptive layer, and wrap it.
Overall, I was so happy to see this patient population portrayed on television, bringing light to a problem that has plagued our region for the last 6-7 years. Moving forward, I’d encourage The Pitt and other media programs to get in contact with people on the ground, including people who use drugs themselves, to portray our reality as well as they can.