By Michael Miller DO, FACOS, FAPWCA
“IMPOSSIBLE, for a plain yellow pumpkin to become a golden carriage… But the world is full of zanies and fools, who don’t believe in sensible rules, and who won’t believe what sensible people say. And because these daft and dewy-eyed dopes keep building up impossible hopes, impossible, things are happening every day” (Rodgers and Hammerstein’s Cinderella).
I can remember my children singing these words along with the Fairy Godmother as the bright colored cartoon flickered across the TV screen. I hummed it to myself as I went to work, thinking “what a cute, meaningless song.”
The word “impossible” now holds special promise for me. My time in the wound care arena has led me to believe that the word “impossible” means only that right here and right now, the solution does not exist, but ultimately it will. Like the concept of the Gold Standard not being the same as “perfect,” (the best available right now, though it may have drawbacks and leaves a lot of room for improvement) impossible means that it will never, ever, ever happen…at least for the time being.
Encountering “impossible” should compel us to look backwards in time to see where we were and what was previously impossible. The Wright Brothers flew, man walked on the Moon and for now, the 27% pay cut from Medicare is pushed back one whole month. Having watched “impossible” become “old news,” what then does “impossible” portend for the future? I recently read of the discovery of what may be the cancer vaccine, scientists believe they may have found the most basic key to life in the “God Particle,” and the Indianapolis Colts won their first game this season. “Impossible” things still on my bucket list include dramatic reduction or elimination of lower extremity amputations (a quest for which my Buckeye colleague, Aletha Tippett MD, has become Don Quixote incarnate), hospital Emergency Departments stopping their habit of a shot of antibiotics for every red leg, and wound conferences without the same speakers every other conference has. Will the amputation rate ever decrease? Can the knee jerk administration of antibiotics “just in case,” or worse “to prevent infection,” ever be realized? Impossible need not, and should not, represent the unattainable. Instead, it simply offers the realization that what is needed may not be available just yet, but can be.
I saw an 18-month old child in the office recently. This adorable tyke who admirably performed the perfunctory “High Five” was referred from the local dermatologist after consultation with the plastic surgeon and pediatrician. Having been born with a benign nevus of the scalp, it’s removal left a defect that had failed to heal. The parents were frustrated at the lack of any improvement and were advised to consider subjecting the child to scalp expanders and flap flipping to cover this otherwise benign defect, since it was universally decided that the wound would never heal on its own. Impossible.
Looking at the past, everything I knew about healing in little children told me unless there is some catastrophic condition present, they heal the worst injuries in a matter of minutes using peanut butter and Skittles. Yet, this animated crib denizen had a persistent, quarter-sized hole in his head. Impossible.
The history revealed nothing untoward (his identical twin brother was just that, with the exception of no nevus - an interesting conundrum regarding the concepts of how identical twins form). Grasping at straws, I asked for the treatment history. Three times a day, wound ointments of varying companies, all of which were allowed to cure in the ambient air. The resultant scabs were not only tolerated, but also welcomed by all who assured the family that this was a necessary component of healing. Impossible?
The scab (eschar sounds so impersonal) gently removed, a drop of hydrogel applied, and an all too common Band-Aid “spot,” changed every three days, was my foray into “Impossible.” A week later, a completely healed scalp greeted me. His mother was grateful, while the patient remained appropriately more impressed with his SpongeBob stickers.
A 54 year-old man had been hospitalized for 8 months. He had been gainfully employed until one morning when his blood pressure reached a level that left him vegetative. He developed a Stage 4 sacral pressure-based tissue injury, which had been treated by the wound care specialist at the facility. Despite 8 months of negative pressure therapy, the wound responded minimally. Multiple bone biopsies by the same specialist demonstrated osteomyelitis, which never seemed to respond to either the antibiotics or the treatment.
In frustration, the family requested a second opinion - which fell to me. They had been told by the same wound care specialist that the wound would never heal due to his catastrophic condition. Impossible. The attending hospitalist pleasantly advised me that, based on the other group’s failure despite aggressive therapy (8 months of the same treatment isn’t failure, it’s insanity), it would never heal. Impossible. As I entered the room, his radio was on softly, and there in the background was Mantovani playing a song from The Man of La Mancha.
Not surprisingly, I was not able to identify the exposed bone that was featured so prominently and repeatedly in the wound notes, but did identify epibole, necrotic tissue, and granulation tissue the consistency of wet Charmin. Impossible?
I promised the wife no miracles, but explained that the tissues present would never heal and that an aggressive, 100% bleeding wound to assure a healthy base was the only chance for any hope of healing. Impossible? A signed consent and 24 hours later, I found myself with my trusty curette and the impossible. 5 minutes later, I left the room to write my note with the strains of “To Dream the Impossible Dream” stuck in my head.
One week later, the wound had diminished by 20% with another 20% decrease the following week, a trend that continued to the delight of the family, and the surprise of the attending.
There is no magic to taking a history, evaluating the patient and their wound, having to mull, ponder, consider, ruminate, and cogitate until deciding why the previous treatments failed, and then deciding what to do to make the impossible possible.
As a wound care specialist, I know what I know, and that is when to say when. The key to success is to stick to the things you know, learn the things you don’t, and get help when you need help. This is what we do, and so, it is no surprise that we tend to get positive results when others cannot. I am not interested in treating heart disease, weird endocrinopathies, or bizarre skin rashes. I have no problem leaving those “impossibles” to others. As far as non-healing wounds that present as “impossible,” I look at them as the chance to catch lightning in a bottle, winning the Publisher’s Clearinghouse Sweepstakes, or Medicare making a decision that benefits patients and doctors without adding yet another form to submit.
Impossible need not be an impenetrable barrier, or the beginning of the end where we throw up our hands, cry out in anguish, and try to drown our sorrows in a box full of Boston Cream donuts. Our abilities to see in patients and wounds what others miss, find what others lose, and heal what others merely treat assures that we will ultimately reach the unreachable. Like Tom Cruise as Ethan Hunt, my philosophy in life has been, is, and will probably always be…Mission Impossible.
Until next time…
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.