Wound Care in Crisis – Why are Dieticians such Big Fat Liars?

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by Michael Miller DO, FACOS, FAPWCA, WCC

Life is 10% reality and 90% perception. There are many conundrums in wound care that may never have an answer. How can one product produce remarkable healing for one caregiver and yet is, in the hands of another, lackluster. Fortunately, one of the unquestionable constants in the vast universe of wound care is that wounds do not heal in the face of abject starvation. For all the hype of the essential nature of nutrition to wound healing, let’s face it, most people pay lip service to the topic and nothing more. Of course, there are entities lurking about in hospitals, long-term care, and high school cafeterias who profess to hold one of the keys to healing. Like many secret societies, their methods and actions are steeped in ancient rituals and secret handshakes passed down from generation to generation. In our society, they are better known by the title, dietician.

They can be seen lurking behind desks in small cloistered rooms, hiding behind trays of mashed potatoes and macaroni and cheese. Sightings are far too numerous to argue their existence but the questions are, what is it they really do and, when they offer to do it, can you trust them? I mean of all the professions to aspire to, theirs is a kind of a pseudo-food occupation. Their knowledge base is something you never see on game shows. Richard Dawson not once ever asked a family to identify the top five reasons why people couldn’t believe it wasn’t butter. You will never see dieticians involved in the Octagon, knuckles bared as they battle over which polysaccharides produce less methane. And yet, every month, Mary Ellen Posthauer blatantly pontificates right here on WoundSource about how she and her colleagues can provide the missing link to improve healing that is not put on or in the wound bed. What unmitigated gall! And so in this month’s Ramblings of an Itinerant Wound Care Guy, I ask the question that no one else has the intestinal fortitude (pun intended) to ask, why are dieticians such big, fat liars?

At first glance, the key to their survival appears to be due to their ability to change nutritional paradigms faster than American Idol changes judges. Even their identifying credentials are shrouded in mystery. The differences in the credentials between an RD (Registered Dietician) and CD (Certified Dietician) are strictly dependent upon which state they work in, however all of them must be an LD (Licensed Dietician). It seems as though everything they do is dedicated toward assuring their own job security. The recommended doses of zinc sulfate swing up and down like a bungee jumper as do the “daily recommended” allowance of vitamin C and multivitamins. When things get desperate, they are prone to making up words. Let's be realistic. Does not the word “kwashiorkor” sound like a Greek appetizer? And I am absolutely sure that I saw an advertisement for the 2013 turbocharged Lamborghini Marasmus.

Do we really need them on wound rounds? Identifying the dietitian on wound rounds is simple; they are the one cowering behind the administrator who is cowering behind the wound cart. Of course, it doesn't help that dieticians are also prone to over simplifying things. Regardless of the location, size, etiology, and appearance of a wound, they brazenly purport to have the solution in one or more of their witches’ brew of powders, juices or liquids. They also are curiously adept at creating the illusion that they are always one step ahead of everybody on the wound team to assure their ongoing compensation. With their trusty sidekicks, the speech pathologist, they provide solutions in ways that no one comprehends. How many of you reading this can truly define what is meant by consistency terms like honey-thick, and nectar-thick? I am confident that if clinicians showed any understanding of this deglutitory enigma, dieticians would pull out another layer of protective terms such as granite-thick or vapor-thick. Of course, they lure us into a false sense of security regarding their omniscience by promoting the subtle siren song that they can resolve any and all dietary problems by adding yet another scoop of protein powder or another can of the oral supplement du jour.

While on one hand, they recommend strict monitoring using advanced scientific methods such as levels of serum-binding pre-albumin, transferrin, retinol-binding pre-albumin, albumin, absolute lymphocyte counts and total protein levels, in their own little world, microscopic changes in pounds and kilograms are enough to send them into a Twinkie-fueled frenzy.

And yet, despite their low key presence, their all-too-frequent “dietary notes” hidden randomly in the patients chart, their unappreciated, under-consulted or under-acknowledged status, these denizens of the healing arts play a crucial role in what we do. It is the simplicity of their purview that makes what they do seem so complex. One might argue that, of all the members of the wound team, they least of all need to look at the mandatorily observed and documented parameters of the wound. However, the specific parameters they view may be different than those that we wound care people look at but are certainly no less important to the cause. In patients with malnutrition, the wound itself have little-to-no affect as the need for nutrition is at least equivalent to and more often than not, supersedes concerns for all other issues in getting it to heal. Pressure reducing a bedsore is of paramount importance but without adequate fuel to heal, even placing the patient in “hover” mode would not produce appreciable healing. Regardless of what type of wound, its specific characteristics, and what dressing company has the facility contract, inadequate nutrition is unquestionably a major limiting factor. In malnourished patients, having a stage III sacral bedsore, a lymphedema-related wound or a diabetic foot ulcer all have their outcomes improved when their nutritional status is evaluated and treated. The simple assumption that looking ‘OK’ means they are eating OK is false bravado. To my mind, one of the biggest mysteries of the universe is still how my most morbidly obese patients have some of the worst nutritional parameters. If they ate to get that big, was it accomplished without protein?

In my own practice, recognizing the need for the help only a trained protein/calorie maven can provide, we have partnered with nutritional experts who assist in evaluation, identifying the most appropriate means of repletion, creating the scenario in which repletion will occur and ongoing monitoring. While my experience has shown that far too many dieticians are inextricably linked only with the enteral route (likely due to those self-professed, patient-centered overlords called insurance companies and facility administrators), the literature provides ample support that enteral feedings may actually have more risks than via the parenteral route (A.S.P.E.N. is the pot of gold on this). Of course, it is much easier for the misinformed, uneducated, or simply dabbling clinician to depute the dietician to order up a few cans of this or a few scoops of that and spray it down a silicone tube rather than have them work with the pharmacy to calculate precise electrolytes, fluid volumes and acid base balances. I bring up this point because there seems to be a widespread pushback against parenteral access. Lurid tales of past experiences with infections, blood clots and fungal infections are used to ward off common sense when the bowels are catatonic. For the well-informed, the new techniques for PICC placement and care, and the TPN formulas themselves are light years ahead of the Neanderthal technologies of even 10 years ago. Those dieticians I know and respect maintain an even-handedness on the best choice, even when it may be the more costly, inconvenient and complex one.

Physicians diagnose and order, nurses evaluate and provide treatment, therapists identify and create solutions. The dieticians’ job is to make sure there is enough glue in the mix so the whole team has symbiosis in purpose, not merely to correct years of bad eating habits or a newly diagnosed nutritional anathema. It is not that our dietary compatriots are out to assure themselves ongoing employment. Who they are and what they can do to make a wound care specialist successful is something no clinician or patient can take for granted. As is my usual custom as I draw to a close, I propose yet another simple addition to our compendium of common sense. Instead of the dabblers mantra of “see the hole, fill the hole”, I propose a new shibboleth for the nutritionally astute, courtesy of our imperative dietary partners in healing, namely “see the hole, feed the hole.”

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.

WoundSource ENEWS


Well, now that we have that anger out of the way let's clarify a few points.
The Registration is a NATIONAL process; Certification and Licensure are state processes. The knowledge base of an RD (aka required course work to qualify for the national registration exam) includes BOTH clinical and food service knowledge bases - this is a generalist's registration process and intended to provide entry level competencies only. Just as in a physician, nursing, accounting and legal field the base knowledge is required as is mentoring and knowledge development. A dietiTian who works with wounds is a specialty area - and one of my specialties with more wound healing successes than I can count. My expertise is the piece of wound healing that is frequently overlooked because of the complexity of the medical care. And of course we all know that everyone knows how to eat well and meet their needs (that went the way of the home ec courses several generations ago).
As far as the dogging of enteral I would suggest you take a look at the data on dysbiosis with TPN and the end result of multisystem organ failure. (Aka: microbiome) You may have improved technology to deliver the PN (new name by the way- TPN is no longer the correct terminology) however you still have thousands of years of evolution that, by Grade A evidence based research that says the enteral route trumps the parenteral route soundly. Does this require a full nutrition plan of care and an occasional use of PN - absolutely. All tools are used when the situation indicates. PN carries with it a much greater cost to the health care world which includes infections and at times impeded wound healing due to lipid driven inflamation and hyperglycemia. Someone who diverts to PN use routinely, in my experience does not have an understanding of how to use enteral nutrition or does not like the tube placement conversation that has to occur with the patient.
As a professional who routinely sees scurvy, vitamin A deficiency in addition to protein calorie malnutrition your rant would seem to indicate that you do not fully understand the complexity of nutrition and how it boils down to a nutrition care plan. Nutrition care plans that also become more efficient with experience. Much like any other profession, including yours.

1.lack of knowledge or information

This article proves that even well educated individuals can be ignorant beyond belief. As Martin Luther King Jr. stated "Nothing in the world is more dangerous than sincere ignorance and conscientious stupidity". I would hope that in the 2 years since that was published you reevaluated your position on this topic. Also, if you are going to insult an entire profession, please use the correct spelling; it's Dietitian.

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