Wound Care in Crisis – Ready, Fire, Aim; Moving the Trees to See the Forest
by Michael Miller DO, FACOS, FAPWCA, WCC
As we enter this New Year, I have several resolutions which I hope will act as a sextant for my upcoming wound care voyages. I promise to be less critical of my colleagues who do horrendous, insipid, unprofessional, unethical, unintelligent, profit-motivated things to patients in the name of good care…OK, maybe not. I have promised to continue my Sinbad-like voyage to find my much sought after ball-laden juggler for whom to send my much needed debridements and IV port placements. I understand that surgeons prefer to evaluate patients before elective procedures to assure that they have no potential problems and that they are low risk candidates for the requested procedure. But asking a 300 lb. paraplegic to come in to a poorly accessible office to vet them and then schedule them days later rarely identifies a reason to defer on the procedure but moreover, places the patient, their family and others at high risk and considerable inconvenience. Can you not arrange to see them early and help them later the same day?
In the spirit of the new year, I have some recommended resolutions for others as well. For the hospitals in my area, your resolution should be to communicate with the referring docs. On those occasions when my patients go into the hospital ill and of course, the low hanging fruit cause of the "sepsis" is ruled out (is it ever the wound?), they are treated by the in-house wound care team. Of course, they never call me to see what the wound status was and with the foresight of Curious George, initiate a treatment designed to be difficult and expensive when reproduced by the home health care agency... which I then have to cancel. If they would only call, we could coordinate treatment and reduce at least one consideration for the patient.
For those of you who have not yet considered a New Year's resolution, may I humbly offer one that I guarantee will improve your outcomes and that unfortunately, you may not have previously considered:
This year, my challenge to you all is to adopt a radical concept in medicine called "establishing a diagnosis." Considering a rational, physiologic or anatomical process which is the basic reason for why the wound developed, or why it persists might be a novelty for many. Recognizing that for the Dabblers out there, this concept poses many problems, I nonetheless am going to spot you two basic considerations on which to launch your new year. One, quit worrying about infections. Wounds never fail to heal because of infection, they only get worse and so if the problem is the wound simply isn't getting better, bacteria should be low on your list. Second, the patient is the one with the disease. If you take the time to listen to them, the diagnosis will jump out and bite you on your iPad. After almost 17 years as a full-time wound care doc, I have discovered that what all of my mentors taught me was true, that the solution is always simple if you take the time to evaluate the problem. In wound care, I have realized that we only have nine diagnoses, (YES, I said nine!). The key is to identify which of the nine the patient does or does not have and then treat what is left.
Things that are not diagnoses and therefore are terms that should always be excluded are "cellulitis", gangrene, infection, edema, and the always frightening "bad circulation." I am sure you can think of other "cancer" equivalents that will assuredly frighten your patients into submission.
For the pseudo-altruistic, while you unquestionably get paid more when you debride, the only wounds that need debridement with any routine frequency are neuropathic wounds due to diabetes. Debriding venous ulcers with any regularity means that you are gaming the system but moreover, slowing down the healing and creating pain. Your diagnoses should be based on logic, education and contemplation of the best way to achieve an outcome, not the Dabblers guide to making money while filling holes perpetuated by far too many turn-key wound center creators and their Wound Care Frankensteins. One caveat to all this is that it is not enough to merely identify the diagnosis. A corollary is that the diagnosis should make sense. Pressure ulcers occur over bony prominences, diabetic neuropathic ulcers occur below the ankles and if the wound fails to improve after four weeks based on a given diagnosis and related treatment, then one or both are wrong.
Of course, one of the more basic tenets that will mitigate tunnel vision is "There is no rule that says a patient can only have one diagnosis at a time." It is inconceivable but unfortunately not surprising to me that the patient who presented with an open wound of the Achilles tendon that failed to respond to two months of hyperbaric treatment and expensive penile derived products would be unhealed because the podiatrist failed to look above the malleoli. And of course, the presence of a massively swollen leg and lab studies showing protein levels worthy of Honey Boo Boo's mother were never identified. As will come as no surprise, the next two recommendations from the astute clinician were (in expected order) debridement of the wound to expose the Achilles tendon and then (when the dressing du jour failed to achieve the needed result), BK amputation. You can well understand the sheer terror felt by the patient and her POA. Fortunately, her caring primary doc astutely agreed to a second opinion, resulting in venous compression, nutritional supplementation and a 25% decrease in the wound size in two weeks. Please join me in a rousing "Ta-da."
With the coming of hell on earth better known as ICD-10, you had better know not just a plethora of real diagnoses, but your right from your left. Wound care is more than find a hole, fill the hole. Treat venous disease with real compression, get your diabetics completely off their plantar wounds, pressure sores need pressure relief. Get a firm grasp of the obvious and tighten it up. Know what you are treating as completely as possible before you start treatment. The ready, fire, aim mentality so beloved by our dabbling colleagues may mean better paydays for themselves but the prolonged unsuccessful care they perpetuate will come back to haunt them. To paraphrase Galatians 6:7, "a man reaps what he sows." Even Dabblers get chronic wounds.
Until we ramble together again.
About The Author
Michael Miller DO, FACOS, FAPWCA, WCC 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.