RAMBLINGS OF AN ITINERANT WOUND CARE GUY, PT. 22
By Michael Miller DO, FACOS, FAPWCA, WCC
The movie, The Horse Whisperer, lavishly showed that taking the time to become one with the subject of your attentions has the greatest potential to provide a symbiosis and subsequently, a healing. In the movie, an injured horse appears to be the primary focus but the astute viewer soon learns that this is but the tip of the tip of the iceberg. In fact, the interactions with the horse itself becomes merely a starting point rather than the focal point for the movie. As the story unfolds, we identify complex cross-current personality patterns, events and human frailties that ultimately becomes a soufflé; something involving significant complexity and skill with the highest risk of a catastrophic outcome, that when all things come together in the perfect proportions at the perfect time in the perfect way rise to become a thing of beauty. In the case of this movie, the horse, its owner and her mother all become transmuted for their own betterment and ultimately leave the horse whisperer to do as he has always done.
Philosophically, do these concepts not transcend to that of healing wounds? Can the quest to become a Wound Whisperer not be an equivalently noble goal? Does not the epithelial rupture from a physiological skin catastrophe channel the psychological trauma that initiates a need for whispered comprehension, comfort and solace so aptly presented in the movie?
The ultimate wound care question is, can even a Dabbler's debauchery be mitigated by simply whispering?
The Dermatologist had spent four months creaming, slathering, foisting, and administering an array of healing condiments worthy of a Chicago hotdog stand to a throng of lower extremity ulcers. Debridements were performed with limited anesthesia in the vain attempt to remove whatever could be removed, in the hope that those things not removed would heal or at the very least, stop the burning pain that occupied the patient's consciousness. Like a quest for infinity itself, the diagnostic considerations encompassed a myriad of inflammatory skin presentations, dystrophic soft tissue conditions, and various dermatologic provocateurs without ever encountering a definitive diagnostic endpoint. Having read that leg ulcers with swelling could be treated with compression, several attempts at uniquely configured wraps reminiscent of Origami were applied with only unaesthetic skin dents as their dermatologic detritus. Ultimately, the now disillusioned patient and her family were allowed a second opinion as they recognized her ministrations had become little more than medical minestrone.
My evaluation of this patient revealed legs that resembled the human incarnation of inflamed Emmenthaler but with little to no edema. The other pathognomonic signs and sequelae of long standing venous disease (mentioned only in passing in the dermatologist's medical record version of Gothe's Faust) were omnipresent. An anxietous, terrified woman accompanied by her equally emotionally traumatized family awaited my foray into Wound Whispering. I wisely chose to spend the needed (and inadequately compensated) time with them all to ascertain the many misstatements, misinterpretations and missteps that had been fed to them like poisoned pablum to a hungry infant. It was only after several visits (sometimes occurring within two days of each other), that the patient finally came to grips with the realization that she was improving, that the lack of pain did not indicate problem and moreover that some pain present, did neither. Ultimately, she was able to go on a much desired trip out of the area for several days by finally accepting that her legs would not auto-amputate if she chose to use the phone as her panacea instead of our office. She heard the whispers and responded as did her wounds.
The Podiatrist had made the diagnosis of venous disease with ulcers and having done so with aplomb, immediately ignored all that is associated with the right treatment. A vascular exam showed sufficient flow to mitigate concern, neurologic and musculoskeletal concerns were quickly trivialized and having identified a ripe target on which to assuage any personal economic concerns (and of course make his wound center management company oversight equally placated), he launched into an inauspicious barrage of weekly ulcer debridements placated by four weekly assaults using the latest, well compensated "Advanced Biologic Wound Dressing." Despite self aggrandizing notes relating an astonishing miracle of healing comparable only to Frankenstein's creation from the dead, the measurements proved only delusion on his part. The self purported key to his success lay in his choice of "evidence-based" compression. In his mind, the key was to assure longevity of treatment by providing the merest fraction of the needed features to control the many facets of of the venous system namely, elastic tubular bandages. As an aside, I have recently seen an avalanche of this particular farcical attempt at primary treatment for venous disease and lymphedema used by far too many Dabblers in my area; a well-blown Razzberry to the manufacturer for pushing sales over successful outcomes. Interestingly, this podiatrist had inherited this patient from his partner who the patient reported spent no more than 30 seconds with her by asking her a few questions, and leaving before she answered. He spent his limited time telling the patient rather than asking and listening. Weeks later in the exam room, she questioned if he even knew her name.
On arrival at our office, her immediate outcries regarded her now economically crippling bills which her insurance had only partially covered as well as weeks of twice weekly visits with a hole in her finances joining those on her legs. Like a beaten dog cringing every time a hand is raised near it, she surreptitiously eyed my staff and I. The history and the limited materials she could wrest from her prior captors were reviewed, and we discussed my impressions, her feelings regarding what did happen (akin to a nuclear explosion from a can of soup), what should have happened, and what could, if she and her family so desired. Her only response...disbelief. Fortunately, the way we addressed her concerns, allowing her the chance to vent anguish and concern, express her needs and ask pointed, potentially inflammatory questions gave us the merest toehold to start her on the climb to healing something that as of the time of this blog, is unquestionably progressing, not without the occasional paranoia-fueled concern but always answered with support via a genuinely proffered whisper.
I do not purport to have achieved a black belt in Wound Whispering but recognize the universality of the beneficial effects of creating a psychological umbilicus to start the entire healing process. For example, sometimes, all four layers of compression wraps are not used to allow for inadequate but tolerated compression short term to allow for some modicum of success by acting as a salve for a previous insult. Occasionally, planned failure is indicated to a certain extent such as applying compression wraps loosely so that when they fall, the patient can be told that they fell due to successful reduction of the swelling by the wraps. Allowing patients a short period of tolerated, potentially intrusive easy access to personnel to have questions answered, even when inopportune (such as at 9 pm or more than five times in a single day) may be vexing, but more often than not creates an atmosphere through which whispers are heard.
In stark contrast is the Wound Shrieker, who terrorizes the hapless wound via a cacophony of all too frequent, or inadequate debridements, smothering it with an illogical hodgepodge of contradictory toxic substances, blindly ignoring the blaringly omnipresent proximal swelling, forgetting the concepts of interrelations and interactions, assuming that patients have access to the funding of Bill Gates, the personnel of Beijing, and care worthy of Tutankhamen. The attitude of omniscience, expertise and success so boldly foisted is based solely on recollection and fawning devotion by those who support the psychosis and not outcomes. Placing your needs above those of the patient or moreover, substituting your interpretation of their problem for their perception only creates a din of discord. Not taking the time to recognize that wounds and related conditions are super-multi-factorial; that bad care can result occasionally in good outcomes (and the converse); and that the patient is the one with the disease is a hysterical cry in the wilderness, not a soft comforting whisper of competence. By whispering, you allow the patient a chance for acclimation to you, your staff and your style. Wound whispering allows the patient to be heard by simply having their uniqueness a modicum louder than yours.
The keys to becoming a Wound Whisperer:
- Let go of the ego - The goal is to best help the patient regardless of who does so. If you find yourself wondering why you can't get them better, it is time for you to end your involvement. Better collegiality than embarrassment.
- Money may make the world go round and while financial concerns are all too often tenuous conversations, it must be considered first and last. First, be sure the patient can economically bear the burden of your intended care. Last, profits come from successful outcomes, not meeting the management company's quota. Do what is right, best and most importantly, ethical.
- Remember the patient has the disease but it never exists in a vacuum. It is imperative that no stone lay unturned, no sight be unseen and no whisper be unheard. Only the patient can decide what things impact them.
- Be honest and logical in your evaluations of how your care is doing. Having case after case eventually going elsewhere after months of care may still provide a robust bottom line but clearly indicates some introspective (or external oversight) review is warranted. If your colleagues won't tell you that you have a problem, then they probably have the same problem.
The railroads have it right. Stop, look and listen. And when things seem to be turning into a confusing miasma of contradictory histories, confusing findings, and unmitigated noncompliance, there's nothing wrong with the occasional, anguished scream of outrage, but whispering may work just as well.
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.