Wound Care in Crisis – If the Blind are Leading the Blind, Why Do the Seeing Ones Keep Tripping?
by Michael Miller DO, FACOS, FAPWCA
I have always had a penchant for the ironic. I love a great joke well told, an amusing anecdote well written or a cartoon well drawn. Charles Addams, creator of the Addams family in the New Yorker magazine introduced his “unusual” family by drawing them poised several stories above and looking down upon a group of happy, singing Christmas carolers as they prepared to pour boiling oil on them. I still chuckle when I think about it. I love unusual sayings such as “You have a firm grasp of the obvious”, “You may not be good, but at least you’re slow” or “I can’t see the forest because of the trees.”
With this, my 11th blog, I have to assume that many of you have become repeat offenders at reading my monthly forays meshing irony and sanity. For those keeping score, I sent several more patients to my cadre of jugglers who once again provided my patients with wounds that were metamorphosed (Go ahead and look it up...I know you want to) from chronic caverns to wounds amenable to my healing ministrations. Having the opportunity to work with high quality practitioners who have confidence in me gives me confidence in my own abilities. I recognize that I will make a mistake, miss something, or do the wrong thing. In medicine, one of the integral keys to care is the assumption of responsibility. With so many factors affecting what we do and how we do it, I have learned to avoid the word “fault”, but religiously accept the “responsibility” for my actions and thoughts. However, I must admit that I feel sympathy towards those practicing wound care specifically and medicine in general who just don’t seem to get it right but more, cannot understand that while doing so is not a crime, repeating it is. More, they seem uninterested in doing so even in the face of lack of improvement or worse, worse. Never mind the fact that this type of care (or lack thereof) is cost ineffective, uninspired and potentially detrimental. It seems counterintuitive that they prolong the misdirected agony of the patient while the same treatment continues ad nauseum and believing that it will eventually succeed. Renowned 20th Century businessman Bernard Baruch said it best: "If all you have is a hammer, everything looks like a nail."
For those of you who have wondered from what planet springs my ironic muse, it is the incarnation of the phrase “Truth is stranger than fiction”.
An urgent house call request came from an astute NP case manager who decided that a treatment consisting of six months of lymphedema compression wraps with the only notable change being persistent linear imprints on the leg needed to be changed. The patient had been seen by a “Best Practices” wound care clinic specialist who, despite a history of prolonged standing during her working years, intense purple staining of the lower legs, slow healing wounds that left whitish, thickened scars and diffuse, uniform pitting edema of both legs, astutely identified lymphedema and ordered lymphedema compression and painful manual lymphatic drainage. Interestingly, he also told her to spend as much time as possible with her legs elevated. The outpatient therapists dutifully and blindly followed the ordered care in automaton, rote fashion despite their documentation of little to no improvement time and time again. At no time did they ever have the professional compunction to share their impressions that the treatment (more the diagnosis) was dead wrong and ethically do something about it. And of further interest, the 88-year-old patient was a retired therapist herself who knew the treatment was not working but did not want to insult the doctor nor her younger colleagues. This is a classic case of trying to figure out not just who was blind but more, who was leading who?
In another case, eight weeks of antibiotics had killed the bowel flora and metallicized the taste of her food, plunging the otherwise delightful 72-year-old diabetic patient into a state of malnutrition worthy of Gandhi. Through her PICC line at a local LTAC, the PPN commenced in aggressive fashion as even her best, paltry attempts at gustatory satiation were met with abdominal cramping and nausea. Transferred to a local nursing home out of my immediate purview, the nursing home medical director immediately ignored the labs and the patient’s information, chose to ignore the daughter/POA’s phone calls and commenced an aggressive enteral nutritional repletion plan complete with the cheap and plentiful generic house supplement. Despite an initial agreement between the facility, the patient, himself and the transferring hospital regarding the nutrition (which I was to manage), the PPN was terminated by him, and the patient demonstrated her compliance with a cacophony of nausea, cramping and steadily worsening labs. We attempted to contact the medical director to present (actually re-present) the fundamentals of starvation, gut dysfunction and malabsorption. The nurses were told by him that she needed to eat to get better and that the PPN was dangerous and would not help. Ultimately, we were able to resolve the situation by having him removed from the patient’s care and substituting a wound care NP colleague who had a firmer grasp of the obvious. The PPN resumed and the patient, though now in a much more problematic condition, is at least for now headed in the right direction. Perhaps Bob Frascino, M.D. in his July 10th, 2010 blog at The Body.com (a website dedicated to HIV/AIDS) says it best: "It's important to note that the opposite of evidence-based medicine is not 'alternative medicine,' but rather 'unproven medicine.'"
While I respect the rights of my colleagues to engage in ironic care, I always wonder if they learn from their mistakes. In wound care, I find that the most pervasive thought processes are based on that most fundamental anecdotal missive “I’ve always done it that way”, to which my knee jerk response is, “Then you have been doing it wrong for a helluva long time”. Based on the geometric explosion in the number of patients I am seeing (my second new wound care center will open next month in another medium-sized city), my suspicion is that there are practitioners out there that tend to use irony instead of common sense to achieve their goals.
My condolences lie with those whose lack of knowledge leads them to be unsuccessful though unfortunately, only the patients (and the health care system, and you and I who pay for their experimentation) suffer. The peer review process is supposed to be based on the collegial concept of bringing concerns to the attention of the perpetrator so they can improve, should they choose to improve. Self-induced and perpetuated blindness in the face of problematic care should not be rewarded by allowance of continuation of that care. To those therapists and others who blindly carry out this type of malfeasance, it need not become fait accompli before they recognize not just that it is erroneous, but that the needs of the patient outweighs the ego of and risk of angering the doctor. Patients are starting to recognize that questioning does not demonstrate defiance but rather is the keystone to individualized, best care. It is imperative that bad care be identified as bad care, and that when good care is unsuccessful, it be identified as unsuccessful. More, that when so identified, it be identified to those responsible so they have the opportunity to revise, correct and learn if they so choose. The ability to be intelligent and yet continue to act in an unintelligent manner is true irony.
To quote the most famous sightless person in modern times, Helen Keller, “The most pathetic person in the world is someone who has sight but no vision.”
Until we ramble together again.
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.