RAMBLINGS OF AN ITINERANT WOUND CARE GUY, PT. 21
By Michael Miller DO, FACOS, FAPWCA, WCC
For those of you who cannot remember the now deceased comedian Chris Farley, did not find his humor funny or simply cannot remember any of his memorable performances; I suggest you move on to another, less controversial, "here's how to use scissors" type of blog.
Chris Farley was a genius. His insights covered many, many topics but their pertinence, I have found, is particularly suited to wound care. Those of you who work in the vicinity of a wound care dabbler, I invite you to cut this blog out and surreptitiously leave it where they cannot miss it or send them the link. I am betting that one or two of the following will strike home but even if not, at least they will get the message that someone (probably many-one) wants them to reconsider their current as-yet-unrecognized (you may substitute the words barbaric, substandard, fraudulent or wasteful) practices. Recently, the shenanigans of several 4-hour-per-week wound management company puppets have led a handful of patients to file complaints with their clinics, hospitals and in two cases, demand that they not be charged (believe it or not, with no coercion, suggestion or turbo charging and actually with a second or two of feigned disbelief on my part).
The basics are simple, so let’s get them out on the table. The keys to success are not just avoiding making mistakes but recognizing that one was made and avoiding making it again. While Mr. Farley inadvertently but repeatedly insults Sir Paul McCartney during an adoration-fueled interview, he rewards each faux pas he commits with a smack to his forehead accompanied by his self-acknowledged cry of "Stupid, Stupid, Stupid." The resultant laughter from the audience and his embarrassment should result in Chris’ reminding himself not to act stupidly again. Of course, the key to the comedic bit is his ability to say the wrong thing again and again and punish himself for the wrong thing again and again. If only Chris had a check list on which to remind himself what things were safe to ask and what questions or actions would take him into treacherous territory. Fortunately for his audience, he just never got it right.
In stark contrast is the hapless wound care dilettante who perpetuates bad care without ever hearing the whispered "Stupid, Stupid, Stupid" from those who recognize their folly. We are all looking for the magical panacea for medical errors and, for better or worse, the simple checklist seems to fit the bill. They are a way to organize, systematize and deputize and they require no advanced training, no coursework and can be done in the absence of a pseudo-wound care management company. The airline industry does so for a considerable number of their processes and purports to have dramatically reduced errors. Why not us?
The trick to using checklists is that they represent common sense but applied logically. Knowing how many gauze sponges were used in a surgery is a fact. If the right lung needs surgery, then operating on a healthy left one is wrong, the checklist mandates you know which lung is which. The ideal dressing for a wound with certain characteristics is another easily identified use offered by many dressing manufacturers.
And so, a common sense checklist can be created for wound care in multiple aspects. The infamous dabbler credo, "I've always done it this way" or afflicting a patient with your treatment choice du jour based on ignorance, bravado or misdirected passion and not science is simply "Stupid, Stupid, Stupid."
Cases in point
While it is not my goal to teach venous disease versus lymphedema identification in a few paragraphs, it is a safe bet that a few seconds on the differences would get you to a 70% success rate in diagnoses and treatment. Yes, there is some overlap but the haphazard flipping of a coin to establish the diagnosis at least in my area has resulted in far too many long-term treatment failures and even a recently encountered "No one knows how to treat it" mentality foisted on patients by several area primary care physicians. Venous disease makes pitting edema, lymphedema usually does not. Venous edema makes the whole extremity swell somewhat uniformly. Lymphedema causes irregularities, giant lobules and sharp "cutoffs" at joint areas. Venous disease causes purple, brown or black staining (hemosiderin deposition). Lymphedema involves little to no discoloration. Redness in venous disease rarely means infection and is almost always dermatitis due to inflammation. In lymphedema, the same redness mandates a further investigation due to the catastrophic effects of infection. If you can pinch the skin at the base of the second toe, they have venous disease, if not, lymphedema. Since the anatomy and physiology of these are entirely unrelated (though yes, there may be some overlap), there are major differences in treatment. Those well-intentioned automaton therapists who blindly accept erroneous diagnoses and treat based on them are as guilty of "Chris Farley-ism" as their referring charlatans. A few cases of amnesia-fueled anecdotal success is nothing compared to the evidence that exists... give it up! Or better, make up a checklist of identifying features of both diseases, their differences, and similarities as well as their treatment using modern evidence and look at it once in a while.
I am looking for a treatment for some podiatrists in my area who are afflicted with a pattern of practice that precludes them from looking above the patients' ankles. Whether the patient has venous disease or lymphedema, regardless of what is going on distally, if it can't get blood flow out proximally, it won't get better. You can contact cast, apply all the growth factors you want and it will simply stay stagnant. That is, unless you use the omniscient wisdom gained as a member of a dabbler's wound center and then, a debridement done frequently is guaranteed to get bigger since without adequate venous return, the tissues will never leave their state of senescence. Of course, those many repeat visits will help the bottom line of the wound management companies... and statistics can always be manipulated... just ask the State of Indiana's Pressure Ulcer initiative. How about a simple checklist that asks those difficult questions like, 'Is there good blood flow to the area? Is the blood getting out of the area? Have I established a definitive diagnosis for why the ulcer started and exists?'... etc. Of course, simply closing your eyes and throwing a dart at the diagnosis dartboard does add some intrigue to the scenario. The firmly held belief that the function of the heart is to keep the feet alive and that anything above the feet is irrelevant guarantees treatment failure and is simply “Stupid, Stupid, Stupid.”
Like small children learning simple phrases, dabblers learn negative pressure wound therapy (NPWT) in simple terms. It has become a punch line to an expensive and grossly overused joke. Why understand anything regarding the physiology, the tissue considerations or the laws of physics that govern its effects when learning three simple words takes out all of the guesswork. Three words to order an expensive, potentially cumbersome treatment regardless of where the wound is located, the amount of drainage, pain, dimensions, type of tissue being treated, etc. Three words that have become the sine qua non for guaranteed healing regardless of any other factors one might need to consider. If successful (rarely), the doc is a knowledgeable, omniscient hero. If wrong, they have gotten 3 months to avoid seeing the patient and wound hopefully able to identify another 3-month delaying tactic as they vainly look for some semblance of healing. Repeat after me... Foam, Continuous, 125; Foam, Continuous, 125; Foam, Continuous, 125... "Stupid, Stupid, Stupid." And dare the reps actually throw them a curve ball like gauze, or lower pressures or that other setting...intermittent (and now the newest and most interesting concept of variable intermittent which is much more physiologic), they play the "need a white paper" or, "who else is doing that" mantra. Let's be realistic. Other than cases where the drainage is massive and ongoing, continuous is "Stupid, Stupid, Stupid."
Recognizing that NPWT is basically giving the wound a hickey, how many of you really want your significant other to suck on your neck for periods exceeding 48 hours with no break; forget going to the bathroom or getting a snack. The sheer action of that on your skin (or an open wound for that matter) would be torture and yet, dabblers do it all the time and proclaim their random successes. I like to ask those who purport to have healed wounds using passion, and the SWAG method (Scientific Wild-Ass Guess). Did the wound heal because of what you did or IN SPITE of what you did? Using a checklist with the wound parameters and based on the available evidence is a simple way to remember that every patient is different and every wound on every patient is different, and so the "one size fits all" mentality is truly "Stupid, Stupid, Stupid."
The last diatribe is the expected one on establishing a diagnosis before you treat. I have finally realized that there are only 9 diagnoses in wound care and that simply identifying which of them best defines the wound or related condition keeps me on track as we evaluate patients. (Feel free to contact me for the list or to give me your thoughts on this seemingly simplistic but guaranteed method of staying on track). My colleagues and those who come to work and study with me have learned that when I say "Run your 9", it means that they missed the diagnosis and need to logically re-evaluate their work up. It is too easy to knee-jerk a diagnosis and the dabblers credo of "see the hole, fill the hole" is an easy trap to fall into. By having a checklist, something that forces us to consider numerous options and then rule them in and out in a logical fashion is no less worthy a task than that of the airline industry. It need not be complex to be comprehensive. Diagnoses, diagnostic tests, and treatment choices can all be juxtaposed on a checklist. With the coming of the sequester, reimbursements will be reduced. The key is not to do more unnecessary procedures or prolong the agony by dabbling from one unsuccessful passion fueled treatment to another, but to create an atmosphere of competent, successful, logical care. Chris Farley had it right when he was astute enough to realize when he was acting "Stupid, Stupid, Stupid." The ability to identify specific data points and juxtapose them virtually guarantees cost-effective, successful outcomes. You can choose to use simple effective tools to do a better job at what you do or, like his motivational speaker persona, Matt Foley "You'll end up living in a van, down by the river.”
Until next time when we ramble together…
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.