Wound Care in Crisis – “How Can You Juggle Patient Care When You Have No Balls?”

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by Michael Miller DO, FACOS, FAPWCA


A house call to a delightful 78-year-old lady revealed a history of a hip prosthesis placed three years earlier that unfortunately had become infected. When the first surgeon could not be found (he had moved out of state just in time), his associate opened the hip, carefully lavaged out the “Root Beer Float” material (per the family, an interesting description if I ever heard one), and then closed the hip primarily.

When the area began draining gross, bloody pus from a sudden opening in the upper incision shortly thereafter, the astute orthopod applied negative pressure directly on the skin to “help pull out the infection”. After two months, when a second hole draining pus developed a few inches below the first, the family sought out the same orthopod who conveniently had headed to the VA system (presumably to wreak more havoc, but now on our sacred veterans). Luckily for these two gentlemen, the patient, despite having been told time and again by family and her primary doctor that the prosthesis was infected and needed to be removed, did not want surgery and decided to wait and see what happened (for two years as of my house call). The family advised me that in the interim, they had consulted several orthopedic surgeons in Indianapolis, only one of whom agreed to even see her. A quick look at her x-ray and his response was the confidence inspiring, “there is no way that I’m going to touch that”. No referral or alternative suggestions were offered. And so, a choice between either making a patient better or allowing them to suffer was made and sealed in infected bone. Was it because of concerns over making her worse (how could you)? Was he concerned about getting sued in the event that the outcome was worse (can a functionless lower extremity become more functionless)? Why would an ethical (and maybe that’s the problem) health care provider who has it in their power to help a patient who has had a bad outcome due to the actions (or lack thereof) of another provider, allow that patient to continue to suffer? I guess the real question is…How can you juggle when you have no balls?

I have never understood the rationale that a patient presenting with a problem caused either indirectly or directly by another health care provider could engender paranoia on the part of our colleagues. It boggles my imagination regarding the conscience of a provider who would allow a patient to suffer needlessly when they have it in their power to alleviate that suffering. I have had many patients over the years who have come to me with wounds and other conditions caused by negligence, stupidity, or simply bad luck who needed the help that I could provide. The problem was that their condition required the assistance of another provider (almost always a surgeon) who could “clean up” the mess and allow the healing process to begin. My quest to find colleagues whose desire to help patients matching their skill level has been a journey worthy of Odysseus. For every miraculous cure that finds its way into the media, a thousand patients suffer from reversible conditions save for finding a juggler with the necessary balls to do what is needed.

I see far too many patients from far too many wound care scenarios in which clinicians juggle their regular practices of 40+ hours per week and then work 4 hours per week in wound care. The result is that they gain the wound care omniscience, panache and outcomes that can only come from working in wound care for...4 hours per week. The conundrum is that these jugglers each have an area of expertise outside of true wound care and so, their balls are tainted by their particular specialty. The plastic surgeon will always recommend the skin graft or flap, the orthopod will threaten amputation, and the family practice doctor, yet another dose of the antibiotic. Regardless of the patients and their conditions for whom they juggle, the clinician's belief is that it best be done with balls you are comfortable with. I know of other clinics where the practioners meet and the wound care decisions are made by committee. Recognizing the polarization of each specialty towards their own definition of “best care” which unquestionably taints the final recommendation, I cannot imagine watching any such group decide on how best to save a limb based on passion rather than the evidence.

As a solo practitioner and wound care expert, I selfishly control the care of my patients. I know what I know and so, use my consultants for their expertise in their fields. Diabetic feet with horrific infected ulcers and osteomyelitis are deftly and expertly sculpted by my colleague, Dr. Kevin Powers, into works of art that require minimal care on my part to restore maximum value. A juggler of the highest rank, his “jones” addictively forces him to help those who need help and I am delighted to enable that habit. When I determine that a vascular problem exists, that particular problem goes to the vascular experts for their input on that problem…only. Osteomyelitis, once cultured and sensitivitied, is the domain of my friendly neighborhood antibiotic guru. But once the patient is well flambéed in antimicrobial brandy, their wound care returns to me. By maintaining sole, expert ownership, the patient has a single point of reference, one number to call, one entity to question. By assuring that each problem is handled by its own expert, I know and make sure that even though there are multiple balls in the air, they all move in the same direction with each juggler in turn responsible for their own balls. It can be a painful experience and difficult to juggle when there are too many hands on the same balls.

As far as trying to figure out how a provider can justify not providing care to those who require their help, the real questions are:

  • When a patient presents with a debilitating problem due to the care of another health care provider, is it ethical to pass on helping them when you have the skills to help?
  • How honest is too honest when a family asks why you won’t help them, especially if you know that the efforts of another colleague resulted in their problem?
  • At what point does paranoia and fear of the unknown usurp that most basic of all medical mantras, Primum non nocere (First, do no harm)? Is doing nothing when something needs to be done not considered harm?
  • Which is worse: to risk helping a patient and being unsuccessful or willingly and blithely allowing them to continue to suffer?
  • Is the Hippocratic Oath more of a negotiation than a credo?

My solution has been long in coming and at first blush may seem unseemly. If medical costs include repeated visits to multiple, contemplative (you may substitute the words “paranoid and wimpy”) consultants, endless phone calls trying to convince a recalcitrant colleague to do the right thing only to have them back out at the last moment, or worse, allow the patient to get ”outside your sphere of influence (wherein they disappear into a black hole only to reappear much later well cultured, drugged, with new problems and the original one either unchanged or worse), then my plan of attack unquestionably saves money in the long run. The key is to get them the right help from the right person...now! I recently had a patient require care I knew might be arranged if I could play and win the crap shoot with the numerous health care options available to me. I chose to efficiently place my bet on an ambulance ride to a facility well outside Indianapolis so he could receive the care he needed from a physician who was more than happy to provide it. He had done so for patients of mine several times before. I was told by the ambulance driver that insurance would not consider this ride an emergency because I was bypassing “about 20 hospitals”. In response, I told him that it was cheaper to do the right thing the first time than the wrong thing multiple times regardless of the travel time.

To paraphrase the Mastercard commercials:
Cost of the ambulance ride beyond the “usual area”…expensive;
Inconvenience to the patient by making him travel … significant;
Having the ability to get the patient the care needed without doing the indecisive tango with colleagues with one phone call and our mutual genuine satisfaction with the desired outcome …PRICELESS.

Medical costs go down when the right care is offered, accepted and given in a timely fashion. If not offered, then the others do not follow. Sick people remain sick until they get better. Patients with wounds can heal only when offered the chance to heal. We wound care specialists are not the only ones whose care starts with the need to fill a void in the health of their patient. Regardless of the severity, the cause and/or whoever else has dabbled with their problem, I am confident that the vast majority of us willingly, happily and determinedly have, do and will use (and have used) all our skills and resources to help those we can. In the event we are unsuccessful, then the hope is that time will bring a new trick, a new wound dressing, a new drug to heal what we currently cannot. Unfortunately, when the reason for failure to improve is due to provider frailties such as fear of being sued, fear of a worse outcome or simple need to “never meet failure”, then even time will not provide the solution. As health care providers, our job is to provide care of the highest quality in a timely fashion in as cost-effective manner as possible, nothing more and certainly nothing less. Failing to meet this standard equates to overall increased costs without improved outcomes.

As far as the patient with the infected hip prosthesis, a call to another of my favorite jugglers took under 3 minutes before he interrupted me and simply stated, “I will probably need some help, but send her as soon as you can”. I could hear the balls as he hung up the phone.

Until next time when we ramble together…

About The Author
Michael Miller DO, FACOS, FAPWCA is the Founder and Medical Director of The Wound Healing Centers of Indiana and IndyLymphedema, as well as a clinical consultant, teacher, inventor, and published author.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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Yes, Dr. Miller, you are intelligent and a great wound doctor for healing many before my eyes. Wound care, much like other areas of medicine, is a practice. How can you improve without research, evidence-based care and a passion to do what is right? Wound care is not a part-time hobby or a way to make extra money. Wound care, like other areas of medicine is a specialty. A doctor that specializes in cardiovascular treatment would not do gastro-intestinal. General practitioners have a wonderful place in medicine, but an intelligent doctor knows when the patient needs to see a specialist that has a greater knowledge base. It is an intelligent person who realizes when he/she needs to seek advice from someone who has more knowledge on the subject. It is not a weakness, but strength of character when he/she is aware of their limits of knowledge.

I have known wound care doctors in wound clinics that did specialize outside of the clinic as well as in the clinic. These are the doctors that continue their education and strive to be better on how patients are healed. These doctors attend wound education, write research, and strive to learn the newest advances in care. Much like Dr. Miller, evidence-based care is what guides his/her practice.

Yes, Dr. Miller, I agree that part-time wound care doctors work in wound clinics, but there are some full-time wound care doctors that work in wound clinics also. Though these doctors are far and few between, I only dream of the day the public wakes up to realize and accept wound care as a specialty and seek out those specialists who treat the whole person and not just the wound. There is more to healing than just the dressing. The proper dressing is very important, but if you do not look at nutrition, hydration and off-loading, the expensive dressing is not going to work.The next comment of that patient assessment is mind, body and spirit. An upset, uneducated patient will not heal as quickly as a patient who feels confident and comfortable with the care he/she is receiving.

Nurses need to specialize in wound care, in all areas of healthcare facilities. The nurses have an oath, though many do not use it, to do no harm. This is going to become more important as healthcare evolves and more educated patients require evidence-based care. Though mistakes happen—we are human—it is the nurse/doctor that has educated the patient that will be doing no harm. By specializing nurses, they are allowed the chance to learn, explore and research the information. Nurses that know their limits will seek the advice of others who specialize.

There are wound care nurse and have been present for years. They are called Wound, Ostomy, Continence Nurses WOCNs or Enterostomal Therapy nurses. They can and do fix what most others wouldn't dream of touching. A good doctor knows this. I work in a hospital where all the hospitalists are keen to the fact that the WOCNs are the specialists and so, they allow us to do what we do best. Am I that good? Yes, and I say that knowing that I spend an equal amount of time honing my craft while learning everything I can.

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