Maceration is a common clinical complication that poses challenges in chronic wound treatment.1 Excessive moisture can be trapped on the wound surface, especially when occlusive dressings are overused or when nonbreathable cover dressings are applied for extended periods.
By Michael Miller DO, FACOS, FAPWCA
I know we all look forward to the New Year as one of promise, self-evaluation, and a new vision for brotherhood among men. In that spirit, as this is the first of my “ramblings” for 2012, I want to take the time to offer my heartfelt wishes for each of you that read my blog to have a horrifically catastrophic and agonizing condition, something equivalent to what is felt when discovering the first scratch on your new car.
It is not that I wish ill towards any of you that have subverted boredom by yet again reading this blog, but rather it is my hope that you have the opportunity to experience that which so many of our patients do at our mercy, namely pain. Call it schmerz, téngtòng, bol, or sakit, one thing is undeniable - pain hurts! It would seem demented for one to boast that they have significant experience with pain. However, as a medical professional, I have come to the conclusion that having personal experience with moderate to severe pain makes me more compassionate, empathetic, and realistic when dealing with patients who not only profess pain, but have conditions commensurate with the pain they report.
I believe, unquestionably, that experience is the mother of insight. At the risk of exposing what my 23 year-old calls “TMI dad, TMI” (you may add the optional squeaky voice and flapping of the hands), as you read this blog, I am in rehab becoming reacquainted with Number 22 on the Periodic Table of Elements (titanium, for those of you with no chemistry book handy). After minimal deliberation, I have exchanged my degenerate right knee for a shiny new one, which joins the identical twins I received in my hip sockets 5 years ago.
As I was reintroduced to the 5th vital sign in prodigious fashion in the recovery room, I could only pray that my surgeon’s compassion, common sense, and the ink in his pen were all at their maximum as I looked forward once again to the ability to breathe without gritting my teeth. Once my OBQ (One Burning Question) regarding my surviving the procedure had been answered, next in line regarded that most basic of human instincts - avoidance of noxious stimuli, namely pain.
As both my consciousness and pain increased at logarithmic rates, my concerns were monotopical (yes, this is a word) and multifocal. Will I receive enough meds to control the pain? Once controlled, will it last? If I exert myself, will the pain meds be enough? If I need more, what kind of gymnastics or gesticulations will I need to do to get it? Fortunately, John (after three joint replacements, I can call my orthopod by his first name) has shown himself to be an astute caretaker in the Casa del Dolor. I move, I breathe, I eat, I rehab in a maternal-like cocoon of analgesia.
Pain control has become the new slippery slope for health care professionals. We have become the ball in a game of analgesic ping-pong. Unless you have experienced what your patients have (or something pretty darn similar), you really have no way to compare and assess how much pain they have. All that we have is empathy, sympathy, and the SWAG method (Scientific Wild-Ass Guess) from which to launch our Quantum of Solace. Unfortunately, we have all become jaded by lurid tales of abuse by a handful of our dysfunctional health care colleagues, the news media who makes sure that we are kept suspicious and paranoid, and every patient who beats us to the punch by requesting analgesia before we offer it.
Why should taking care of pain be such a pain? One of the problems is that, as health care professionals, we are trained to think objectively. We would like to see things like a rapid pulse, increased respiration, diaphoresis, or elevated blood pressure so that we have sufficient physiologic proof of distress. The problem is that the mantra, “No Sympathetics, No Sympathy” is not appropriate, and makes no one feel better about refusing pain medication or not changing what is obviously an inadequate regimen.
Control of pain is the new, “damned if you do, damned if you don’t.” A few weeks ago, I read that a new, more pure, more powerful version of hydrocodone was to hit the US market. The goal was to give doctors another tool to try on patients in legitimate pain, part of a constant search for better painkillers to treat the aging U.S. population. Of course, the critics say they are troubled because of the dark side that has accompanied the boom in sales of narcotic painkillers: murders, pharmacy robberies, and millions of dollars lost by hospitals that must treat overdose victims.
In the herbal analgesic arena, 16 states allow the use of marijuana for pain relief despite official federal laws to the contrary. In Germany, the Health Ministry has announced a plan to legalize marijuana, and thus officially sanction a practice that pain therapists and palliative health professionals have long administered out of necessity.
Of course, the questions surrounding pain control are myriad and mandatory to answer. However, they need to be asked first of ourselves and not our patients.
Pain is a mix of perception, chutzpah, experience, and psychology. How does one decide what medicine to prescribe? What dose to start with? How much autonomy do you allow the patient to have in controlling their own pain? Does the patient having pain serve a purpose? If not, then why should they have it? Is this patient trustworthy or will someone profit from my blue paper on the black market? Can this patient manage their pain themselves or do they need closer observation and more assistance? Is the method of dosing appropriate? Who should manage patients’ pain, the primary care doc who controls so many medications for them, or we who see the visual analog of pain in their wounds? Are pain management specialists necessary, or are they there merely to CYA?
In trying to completely mitigate the issue, there are other considerations. However, many of the purported analgesic substitutes offer no improvement on the safety and efficacy profiles of narcotics. Acetaminophen is all but off the market, as this once innocuous panacea has now been implicated in causing liver failure, and soon will be a blank page in the PDR. Even the most neophytic wound care specialist understands that inflammation is an integral part of wound healing, and that patient use of medications countering this - such as any of the available NSAID’s - while infinitely less likely to have the DEA knock at your door, conceivably provides inadequate pain relief and more potentially interferes with and slows down healing.
And so, we delude ourselves and our patients by allowing them to have pain in the name of false pride and paranoia. Most of you have probably forgotten your pharmacokinetics course in school, wherein you learned that the overwhelming majority of oral pain medications have a half-life of about 4 hours. What this means is that ½ of the pain medication is gone (metabolized, used up, etc.) at the 4 hour mark. Further, oral medications take about ½ hour to become effective. Using simple arithmetic, the equation means that a patient must take their oral pain medication every 3 ½ hours in order to keep pain controlled (remember it is easier to control pain than to get rid of it after it has recurred). And yet, (time for the self guilt), the vast majority of pain prescriptions are written for every 6 hours (if you don’t believe me, just ask your friendly neighborhood pharmacist). This means that the patient has a period of 2 ½ hours in pain before they are allowed relief, which will yet again be inadequate and short lived. Is it any wonder that patients in pain will do what is needed to control their pain? And yet, their reports to us regarding their pain situation are met with doubt, disbelief, or pseudo-intellectual statements like “well, pain is a sign of healing” or “I would not have expected that removing that foam dressing would cause you to turn into the Hulk.” Is it any wonder that our patients press us so hard for more pain relief? They seem to recognize more than us that pain is detrimental to our bodies and that it, in effect, slows down the healing process.
As health care professionals, we need to be honest and ask why so much time, energy, effort, and money is devoted to what has unquestionably and unequivocally been the definition of abysmal failure, namely, interdiction of the otherwise lucrative illegal pain medicine market. Why must we, who train to heal those who truly want to be healed, act as gatekeepers for wannabe Euphorics?
And so, at the risk of creating a cacophony of self-righteous indignation, I offer the simplistic consideration that analgesics no longer need prescriptions. Yes, I understand that legislated removal of this jocular jurisprudence would be celebrated by thousands of screaming denizens attacking pain pill purveyors like a bunch of preteen ingénues to a free Justin Beiber concert. However, I pose to you the undeniable realization that patients, or others that want access to pain medications, legal or otherwise, can get them even with draconian regulations in place, and yet the medical profession is forced to take the lead on spitting into a tornado. Would complete and total legalization and unmitigated availability lead to more rampant drug use with an increase in criminal behavior? Maybe the crime rate would drop, due to the lack of effort needed to satiate craving, or potential sociopaths simply being too high to do anything untoward.
Of course, we then get into the issues of what happens when these people are unable or unwilling to care for themselves, or get themselves into a physical state where they cannot care for themselves. Who (or what governmental, religious, or social entities) will then provide the care needed for these now legally obtunded, analgesic-fueled miscreants? Is this societal babysitting service sounding familiar to anyone else? It looks like legal or illegal, we wind up in the same place but with potential for less stress, less paperwork, and less failure on the part of ourselves when the prescriptive handcuffs are unlocked. But since realistically those former pot-smoking members of Congress have forgotten or refuse to admit their herbal foibles (how do you smoke without inhaling?), such legislation is merely the ramblings of an itinerant wound care guy. And so, in closing I offer you the sage advice of a recuperating former athlete, a victim of great muscle, great bone, but lousy cartilage, whose zeal to be pain-free himself led me to ponder the perplexities of pain. Use your training, your education, and your compassion to decide who, what, where, when, how much, and how to give your patients relief from the pain that they do not deserve, do not want, and do not need.
Legal or illegal, prescriptive or normative, ideal health care comes when pain control is based on the provider-patient understanding of mutual concern and open communication - an analgesic work-in-progress. The current status quo where we adversarially punish patients, either inadvertently or purposefully, for daring to have pain is unacceptable. Primum non nocere is as pertinent now as it was to the ancient Greek healers.
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.
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