By Michael Miller DO, FACOS, FAPWCA, WCC
RAMBLINGS OF AN ITINERANT WOUND CARE GUY, PT. 15
First and foremost, I don't want any of you to think I am a fatalist. I always look for the silver lining while recognizing that a dark cloud at one point may engulf it. Nor do I want the reputation as a harbinger of doom. Like the Monty Python Troupe singing in their movie "The Life of Brian", I always look on the bright side of life. Need there always be a lesser of two evils? Yogi Berra resolved this dilemma by stating, "If you come to a fork in the road, take it."
And yet, when a decision has to be made regarding which side of an argument to take, it always seems like the end result is never as good as I aspire to. Questions that need answers this month include:
Is there something wrong with having a firm grasp of the obvious?
How can trees block your view of the forest?
If two's company and three’s a crowd, then what are four and five?
Cases in point
The 36 year old paraplegic was self-referred (at the strong urging of his astute home health care nurse) for evaluation of "problems with my flap". He had developed a Stage IV ischial decubitus with exposed bone that the plastic surgeon resolved with a fasciocutaneous flap after excising the offending bone. The incision extended to within 1 cm of his anus. Interestingly, his fiancée reported that postoperatively, they discovered an errant suture partially obstructing the anus, which was expeditiously removed. Postoperatively, his prodigious fecal incontinence (three loose uncontrolled bowel movements per day minimum) returned with a vengeance. Moreover, he reported no instructions for offloading the surgical site, had ignored the dieticians recommendations (somebody needs to invent a Dorito, Funnel Cake, and Cheese Fries diet that promotes health, Mary Ellen Posthauer please take note) and had been to several other doctors looking for answers to his problems. In order, the most pressing were: Dehiscence of the distal incision, ongoing fecal contamination of the deep wound, and insipid immaturity. Most concerning to me was that no attention to GI tract function had apparently been entertained. No discussion of a diverting colostomy, no consideration for intravenous, gut-resting, parenteral nutrition. I find it hard to believe that the Plastic Surgeon’s solution to the fecal problem was an errant suture (though in hind site it did solve the problem temporarily). While his fiancée demonstrated support worthy of Madonna's "Material Girl" bustier, the patient wimpedly (MTV and Jersey Shore-ese for "Unmanly") decried his state and advised me that "I got a lot to think about". He did so for about eight more hours accompanied by texts to me from his HHC nurse in teleprompter fashion until he fled to the local Emergency department when his probing fingers found the Jackson Pratt drains pulling out of his skin and nonfunctional. He subsequently returned to the Plastic Surgeon for repair of the flap. And as far as the ongoing fecal problem... it has not yet hit the fan.
Is there anyone of you who have basked in my literary countenance who has not yet recognized my profound aversion to those life-taking, cost-ineffective, mythological curative nostrums called antibiotics (Against Life…perfectly defined)? I sigh each time yet another conference touting efficacy and indications flashes across my screen. For those of you to whom antibiotics are a perpetual additive to your wound care, I refer you to my August 2011 blog, The Intersection of Wound Care, Bacteria, and Shakespeare – Healing, Treatment, and Insight.
The 45 year old half-blind (her words, not mine) diabetic had fractured her ankle weeks before requiring placement of plates and screws to provide some semblance of a functioning joint. Smoking half a pack of cigarettes a day and watching "Hoarders" reruns were interspersed with visits from her next door brother and home health care. To be succinct, my evaluation revealed multiple courses of oral antibiotics with the Asclepian-inspired daily dried gauze. A sudden glint below the thick slough caught my eye wherein, two well machined screws popped up their heads. Her brother who had been watching the evaluation reported that he thought something was wrong but could not make his concerns known to her doctor. A quick phone call to the surgeon on my part led to his treatment of choice to heal difficult wounds on his part… BKA as I heard days later.
Lest I subject you to yet another ongoing, textual harangue regarding my frustration at the all too often encountered, uninspired, illogical, narrow-visioned succor (interestingly pronounced "Sucker") proffered to the willing, trusting but uneducated victims of their care, I choose to stay the course and continue to teach patients verbally, educate colleagues visually and vent my spleen textually each month looking for others who share my passion to help patients, not just treat them. As an Osteopath, I was trained to look at patients in a holistic fashion, a series of interrelated systems and parts where structure and function are interrelated. An effect at one end is manifested at the other. Regardless of where you practice, there will always be those who truly want to do what is best for the patient, be it looking at current evidence, seeking a second, more expert opinion, or more, sending the patient to someone who simply does it better. Eventually, great care will manifest itself in great outcomes which lead to the ability to help those who really need our help. Regardless of antipathy (you are welcome to substitute naïvité, childish egocentrism and/or just generally not caring), we need to fight the good fight and continue to try to help those who need our help…especially our colleagues.
As for a war cry that I proudly proclaim as I ramble from patient to patient, I much prefer Non Illegitimi Carborundum "Don't let the Bastards wear you down" to Veni Vidi Fugi; "I came, I saw, I fled".
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.