Wound Care in Crisis – Getting a Firm Grasp on the Obvious
by Michael Miller DO, FACOS, FAPWCA, WCC
Is there some feature, mark or other identification that assures a patient that caveat emptor is not a concern? Perhaps wearing a scarlet letter “W” identifying oneself as a wound care specialist. In Mel Brooks' 1974 Western, Blazing Saddles, the bad guys, when offered the sine qua non of a do-gooder respond acidly "Badges? We don't need no stinking badges." How then can patients identify helpers versus harmers? Why does the desire to be all things to all people as health care providers so easily usurp common sense? While the specific origin is murky, there is no question that somebody created the credo we all purport to adhere to, "First do no harm". Can ignorance, stupidity, greed or malicious intent for profit mitigate this?
Cases in point
My staff identified two fairly benign appearing venous insufficiency ulcers on the right leg of a lady that two nights prior had called the office searching for solace. Purplish staining, mild periwound redness accompanied her ulcers. During that prior call she had grilled me like a pork chop regarding what my thoughts were on her prior and ongoing treatments. She reported a history of 10 applications (5 per wound) of very expensive biologic dressings applied in the operating room with all the mandatory accouterments of labs, paperwork and concurrent exorbitant hospital bills. Her treating orthopedic surgeon had debrided, cauterized and tormented her legs in a manner only slightly less altruistic than the Spanish Inquisition.
After each application and the mandatory chargeable time in a recovery room, she was immediately sent to the hospital physical therapist for layers of foam and short stretch bandages weekly. As we spoke she reported that she was scheduled for two additional applications in the next week. She was told that "even though it has not worked yet, I want to try it one more time." When neither of the perpetrators of this charade could provide a salient argument to continue, she decided to seek a second opinion. Most interestingly, she could not identify a specific medical diagnosis of what was being treated from either the Orthopod or his therapy lackey. What she was told was that the failure to heal was due to "old age and poor skin." For his part, the Orthopod had made his caring demeanor evident by speaking to the patient only when on the operating room table, never before or after.
When asked why she had gone to the facility and more continued despite obvious persistent and unmitigated failure (and rapidly increasing concern on her/her husbands part regarding wound care competence), she told me that when she called the hospital, she was told "we do wound care." Fortunately, her change in venue and practitioners resulted in complete healing in 4 weeks using 4 layer compression and simple foam dressings changed weekly. As will come as no surprise, she was called by the hospital and told that because she had canceled the two additional surgical windfalls, she was responsible for all costs. She defiantly stated "I dared them to charge me." I have yet to personally encounter the biologic product representative that allowed this unmitigated abuse to proceed unquestionably in the name of profit. If you are reading this, please pass on scheduling lunchtime education. The patient did meet him once and is eager to do so again (preferably in a dark alley) and demonstrate her appreciation. With 10 failures, I cannot imagine the Orthopod ever using it again (though the profit motive can be a powerful panacea to failure).
I have the pleasure of working as a medicolegal consultant for several plaintiff's firms in Indiana. I get to see the extent that providers will go to to avoid responsibility or semblance of expertise. I thought I had seen it all until a recent deposition of the Medical Director of a Wound Management Company's "Best Practices Wound Clinic" crossed my desk. In the vain attempt to avoid admitting that the treatment he was trying to defend was the antithesis of correct, this self proclaimed "hyperbaric expert who did wound care" boldly reported that he rarely established a diagnosis when he started treatment and in fact, it might be 10 to 12 weeks of evaluation of a given patient before he finally decided on one. I can only imagine the delight his patients would feel if they read of his Stephen Hawking-like intelligence. I don't know about the rest of you but with only 9 diagnoses to work with (Ask me and I will happily send them out to you), even on my worst day, it should take a little less than that. Do any of you treat patients with no idea what you are treating? Is this what they are teaching at those "guaranteed certification" dabbler's courses? Compression to pressure-based tissue injuries, offloading venous insufficiency ulcers and weekly debridements of Pyoderma Gangrenosum are a blind man's darts game. On that note, unbelievably he reported that since his experience showed that only a low percentage of definitively diagnosed PG wounds demonstrated Pathergy, he had no problem sharply debriding them weekly. Of course, he also had no problem favorably adjudicating the performance of an aggressive debridement of all wounds weekly to make sure they had healthy tissue to heal. God bless the quota system to measure success in wound care. The only thing obvious to not just the plaintiff's attorney but to the defendant's was his gross incompetence and the prostitutional pandering he engaged in. I am hard pressed to believe that he will have much future in either wound care or expert testimony as vocations.
Later that week, a previously respected colleague stopped me at a meeting to advise me that since she could not work in hospice due to a "non-compete" clause (are we really so hard up to prevent competition for treatment of the dying?), her hospital was paying for her to take the hyperbaric course so she could do a few hours in their hodge-podge-staffed wound care center (interesting that she did not say a wound care course). She figured she could make some money and kill some time until the "non-compete" ended. I was tempted to see if the hospice would hire me to "kill a few hours" (puns intended) without having any expertise in doing so. My gently proffered suggestion to her that she might want to work with my organization to gain some real experience and skill was graciously accepted "if I'm not comfortable with what they teach me at that course."
And what of the bored plastic surgeon who, while walking the halls of the LTAC, received a hearty "Hello" from one of my patients that he had operated on years before. When told that he was there to get his wounds healed, the surgeon graciously offered to look at them and did so before the paraplegic patient could respond. When his attention was caught by some exposed tendon fibers in an otherwise healing ankle wound, he left the room only to return with a scalpel blade and gauze with which he debrided the tendon. NO consent, no time out and no ethics. His note was found a few days later (after being written a few days later) which listed in simple terms a story of falsification worthy of Anthony Weiner’s diary. His dictation said all the right things with one small exception...the patient had no idea what he had done.
If you look at a forest, you will see trees. They do not block it, they are it. When someone vomits, it means that the meal they ate did not agree with them. When a baby is born, there is no question on whose uterus carried it. Something obvious is just that. Getting a firm grasp is not double speak. It is a simple restatement of what we already should do persistently and consistently. It is making sure that what you think you know is, in fact, what you know. Being wrong is not a crime. Wounds change, factors that affect their healing arise and resolve. But launching into an expensive cacophony of cross-current treatments in the vain hope that something you throw at the wound will ultimately stick is sheer lunacy. It is not so much can you but should you treat without even the slightest hint of a presumptive diagnosis? Is it ethical to disinterestedly treat patients with potentially significant, life- or limb-threatening problems because there is nothing better on television? Does familiarity mandate battery?
The Ready, Fire, Aim method of patient care may be the dabblers mainstay but let me assure you, our patients are getting more savvy and eager to respond. Be it from burgeoning expertise by googling, and/or the mandate to become more responsible for one's health care; thinly veiled incompetence, whether purposeful or insipid should not, and will not be tolerated. Medicare is now providing unique EOB's with the admonition for patients to identify any care they deem questionable, concerning or questionably given. The next time you see a new patient, take a good history, perform an appropriate physical, and pick the most likely etiology(ies). My list of nine diagnoses keeps my devotees and I on the straight and narrow. Regarding the patient with the now healed venous ulcers, the Physical Therapist contacted her and (I have to assume he thought I would not be successful) in Don Quixote fashion, offered to resume treatment in the event that she was not happy nor getting better. Interestingly, he did not mention the Orthopedic Sancho Panza. Common decency precludes me from repeating her conversation with him but it did involve splenic venting worthy of Mike Tyson. As will come as no surprise, my requests for their records remains unrequited and she has yet to receive that bill.
Until we ramble together next time.
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.