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Dr. Michael Miller is a board certified general surgeon and certified wound care specialist who has practiced wound care exclusively for almost 21 years in Indiana. He is the CEO and medical director of The Miller Care Group, which provides a variety of specialty care services in a variety of care locations, including house calls, skilled, assisted living and independent living facilities. These services include advanced wound care, lymphedema, podiatry, palliative care, pain management, addictionology, mental and behavioral health, and sleep testing.

Dr. Miller was the 2010 American Osteopathic Foundation Physician of the Year, is an honorably discharged Air Force Veteran of Desert Storm, and assistant professor at the Marian University School of Osteopathic Medicine in Indianapolis. He has been a principal investigator on numerous research protocols on cutting-edge wound care technologies, written many articles in peer-reviewed journals and book chapters on wound care topics. He has traveled extensively, teaching wound care and related education on both domestic and international podiums, and provides expert consultations to medicolegal and business/technology organizations.

September 23, 2016

By: Dr. Michael S. Miller, DO

Alternate universes—Einstein’s insanity
I remain absolutely amazed that there are so many people doing the same thing and yet doing it so completely different. Depending on where a patient’s wound care and orders originate from, the care I try to translate from that starting point is always a combination of dressing regimens worthy of computer code in their simplicity. The only thing usually missing is the diagnosis. It’s as though they come from an identical planet in an alternate universe.
The issue is that there is the complete dissociation of what is done for a given wound care problem in one practice setting versus another. Having stayed as far away from hospital-based wound care as possible, I continue to be amazed by hospital wound teams touting their expertise while using two to three times a day dressing changes and therapies that are the antithesis of any identifiable evidence. They actually expect entities receiving their cases (including home healthcare agencies, LTAC, skilled facilities, and others) to copy the identical care scenario regardless of their widely variable situations. In fact, the only constant is the patient and his or her condition.

Another serious delusion is that discharge . . .

April 21, 2015

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Help Me, Help Me, Help Me…next Tuesday

 by Dr. Michael Miller

Health care providers are by nature an altruistic bunch.  I have the honor of interviewing potential entries to my beloved profession as part of the admissions process at the newest Osteopathic Medical School in Indiana, Marian University.  The process is unique in that it does not simply ask the age old questions of “Why you want to be a physician ?”, (“Because I want to do primary care in a rural area”).  No, our probing involves scenarios in which they have to look at a social situation, identify their thoughts, those of the opposing views and then cohesively demonstrate intelligence, confidence, logical thought processes and humanity…all in an 8 minute period repeated 7 times.  Their responses juxtaposed against what I see in my day to day always gives me pause to think about how the practice of medicine has been so perverted by the promotion of self abdication of responsibility.  The “let your government do it for you” mantras and newest politically correct definitions of disabled (encompassing everything from melancholia to dislike of red M and M’s) have resulted in a major paradigm shift in medicine.  Whereas . . .

March 24, 2015

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Don’t Kid Yourself, Amputation Is Unquestionably A Failure
 by Dr. Michael Miller
I recently saw an ad for a pending lecture at a national conference that piqued my interest much like “deflate-gate”.  The title of this lecture horrifically touted that Amputation need not be considered failure.  As a full time wound care doc, I work to identify those conditions that place patients at risk of all consequences both limited and catastrophic.  We use the catchy title of “Limb Preservation”.  We start the process by engaging in the unusual behavior of making definitive diagnoses, then systematically address them in as comprehensive manner as possible.  I am proud to tell you that while there are occasions in which a terminally damaged digit is lost,  that we have rarely sacrificed the greater part of a foot and more, have had only 3 lower extremity amputations in the last 5 years on patients who’s care remained exclusively with us.  Of course, when a patient for whom we have created and implemented a “Limb Pres” care plan is taken out of our system (usually via a hospitalization for a reason other then the lower extremity problem), the facility forces that be unfortunately . . .

February 5, 2015

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Condemning Patients to a Leap of Faith
by Dr. Michael Miller
I have several letters after my name.  The two that say “DO” indicate that I have the training of a physician and the requisite education and responsibilities that uphold those letters.  They should mean to patients that my ultimate goal is to offer (and provide when the fates allow) the entire spectrum of medical care referable to what I am good at and what they came to seek solace for.  Nothing less and if I keep my ego in check, certainly nothing more. Patients run the gamut of their perception of the medical field.  But like the old sales nemesis called “Bait and Switch”, what is offered on the sign all too often does not truly match what is seen on the shelves.  Arrogant people are that way because they are good at what they do and not afraid to tell others.  As a child, we are told to let others brag about us but failing to let people know what we can and can’t do is integral to our patients’ survival and our success.  The problem is that the glitz and glamour of being a healer all . . .

December 23, 2014

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If All You Have is a Hammer, What Happens When You Run Out of Nails?
by Dr. Michael Miller
Over the years of making house calls for wound care, I found that there was a real need for home based mental health and behavioral care, palliative care, podiatry and lots of other things. We cater to those who are home bound based on the classic definition involving the word “Taxing”. One of the more prevalent problems affecting all patients involves the nebulous but ubiquitous, nerve jangling, aptly named, “5th Vital Sign”, namely pain. As a part of my medical group, we have created a program that provides pain management not just to the home bound but all those whose lives and lifestyles are affected adversely by it. The program is a monument to government bureaucracy involving multiple layers of paperwork, mental health evaluations, testing of bodily fluids for both illegal and legal substances and then, the actual evaluation of the patient commences. After all hurdles are vetted and then jumped, then and only then does a prescription for the appropriate nostrum leave the pad. In wound care, we treat based on the etiology, the location, the related factors, the amounts . . .

November 25, 2014

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Think a Patient Has Rights? They Left.
by Dr. Michael Miller

There are few absolutes in my universe. I know that my youngest daughter will gleefully and with full malice (but humorously presented) find something to torment me about every time I see her; referrals from family practice docs arrive well marinated in multiple antibiotics with nary a diagnosis in sight (save for the ubiquitous “infection”); and that regardless of what I recommend, offer, beg, plead, or cajole, that the patient has the complete and total power to make their decisions regarding their care and who provides it. Unless they are deemed by multiple authorities to be incapable of making a decision, until the appropriate paperwork or an emergency situation exists mandating immediate lifesaving action, the ball bounces squarely in their court…or so I thought.

On a recent long-term care visit, a former patient wheeled up to me, reintroduced herself and requested that I see her for a bedsore. She had been last seen over a year before for another issue but was so pleased to find me at the facility that she wanted to be sure I could see and help her. Feeling honored that she had . . .

November 13, 2014

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Jim Nabors Would Just Cry
by Dr. Michael Miller
For those of you not as familiar with the Hoosier State as you should be, I used to think it was essentially paradise. Jim Nabors of Gomer Pyle fame is our ubiquitous, tuneful icon with his always well-received “Back Home in Indiana” as a mantra to that source of pride.  Our former Governor “My Man” Mitch Daniels was a genius who, using a combination of intelligence, common sense and the persuasive powers of a midwest Svengali, created an economic model that our neighbors can only lust after. Our medicolegal climate is among the best in the US and well it should be. However, while there are some extraordinary caregivers and facilities here, a recent US News and World Report curiously showed that almost none of our hospitals made their “Best of” lists in any category. That is not to say there is bad care but to not have a single facility in an entire state even achieve an honorable mention gives one pause to reflect. The State newspapers were notoriously quiet on this concerning fact despite their trumpeting of who does what well, when and where.

To give an insight . . .

October 30, 2014

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Hole-ier than Thou, Evidence Based Regardless of the Evidence
by Dr. Michael Miller
There are certain phrases that make the hair on the back of my neck stand up.  Someone telling me that they are a good Jew, a good Christian, a good Muslim or the ultimate in self serving lies, “I ONLY practice EVIDENCE BASED MEDICINE”.  People who are what they claim they are do not need to announce it.  A short conversation, watching them work, others opinions about them all answer the question before it is asked.  Like the RN who asked for a recent presentation on the true science behind NPWT (no, you don’t really understand it).  She made sure to tell me not only that she practiced only EVIDENCE BASED MEDICINE but then gave me several examples which incidentally had absolutely no scientific evidence (save for articles from lots of dabblers doing lots of crazy things to people and writing about them).  I am now awaiting her response as she may have to realize that her version of EVIDENCE BASED is no more real than Kim Kardashian’s celebrity.

More humorous to me was finding out the effect of several of the challenges I . . .

July 25, 2012

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BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
The World Health Organization defines palliative care as care that affirms life and views death and dying as part of a normal process, intends neither to speed nor delay death, provides relief from pain and other distressing symptoms, and offers support to the patient and family.

With palliative care patients who have wounds, we change our focus from what may be best for the wound to what’s best for our patient. We view the patient in a holistic manner. Our goal is to give the patient control, facilitating the highest level of independence, dignity, and comfort. Or secondary goals may include healing the wound, preventing decline of the wound, preventing infection, managing odor, controlling exudate, and providing adequate pain control.

As wound care clinicians, we want to disrupt these patients as little as possible. Selecting appropriate dressings to heal the wound or prevent further decline are vital. Managing odor and exudate helps our patients maintain dignity, and using dressings that help control odor, such as charcoal dressings or even a wound management device, can be very helpful. If the odor comes from a high bacterial level causing necrotic tissue . . .

July 18, 2012

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BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
You’ve identified your patient’s lower extremity ulcer as a venous ulcer. It has irregular edges, a ruddy wound base, and a moderate amount of drainage. The patient’s bilateral lower extremities are edematous. As a wound care clinician, you know sustained graduated compression is key to healing stasis ulcers and preventing their recurrence.

So are you ready to wrap? Not yet. As wound care clinicians, we always put our patients’ safety first. We need to be sure that compression won’t harm our patients and that there’s no underlying arterial component. Obtaining the ankle brachial index (ABI) gives us the information we need.

Obtain an ABI when pulses aren’t clearly palpable, on patients with lower extremity ulcers, and before starting compression therapy. The ABI rules out significant arterial disease and determines the amount of compression (if any) that can be applied safely. The normal ABI is ≥ 1.0 to 1.3.  An ABI of ≤ 0.9 indicates lower extremity arterial disease. An ABI of 0.6 to 0.8 signals borderline ischemia; ≤ 0.5 signifies severe ischemia.

For high-pressure compression (40 to 50 mm Hg . . .

July 11, 2012

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BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
An essential part of weekly wound assessment is measuring the wound. It’s vitally important to use a consistent technique every time you measure. The most common type of measurement is linear measurement, also known as the “clock” method. In this technique, you measure the longest length, greatest width, and greatest depth of the wound, using the body as the face of an imaginary clock. Document the longest length using the face of the clock over the wound bed, and then measure the greatest width. On the feet, the heels are always at 12 o’clock and the toes are always 6 o’clock. Document all measurements in centimeters, as L x W x D. Remember—sometimes length is smaller than width.

When measuring length, keep in mind that:

the head is always at 12 o’clock
the feet are always at 6 o’clock
your ruler should be placed over the wound on the longest length using the clock face.

When measuring width:

measure perpendicular to the length, using the widest width
place your ruler over the widest aspect of the wound and measure from 3 o’clock to . . .

July 3, 2012

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BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
Lower extremity ulcers are often referred as the “big three”—arterial ulcers, venous ulcers, and diabetic foot ulcers. Are you able to properly identify them based on their characteristics? Sometimes, it’s a challenge to differentiate them.

Arterial ulcers tend occur the tips of toes, over phalangeal heads, around the lateral malleolus, on the middle portion of the tibia, and on areas subject to trauma. These ulcers are deep, pale, and often necrotic, with minimal granulation tissue. Surrounding skin commonly is pale, cool, thin, and hairless; toenails tend to be thick. Arterial ulcers tend to be dry with minimal drainage, and often are associated with significant pain. The patient usually has diminished or absent pulses.
Venous ulcers are located on the medial lower leg, medial malleolus, and superior to the medial malleolus. You rarely see them on the foot or above the knee. They have irregular wound margins and tend to be shallow and ruddy red, although slough may be present. Venous ulcers tend to have moderate to large drainage amounts. Although they don’t usually cause a lot of pain, patients may complain of “achy” legs. Surrounding skin is . . .

June 27, 2012

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BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
We’ve talked about types of exudate (drainage). Now let’s consider the amount of exudate in wounds, which is a key part of our assessment.

No exudate present: The wound is too dry.
Scant amount of exudate present: The wound is moist, even though no measurable amount of exudate appears on the dressing.
Small or minimal amount of exudate on the dressing: Exudate covers less than 25% of the bandage.
Moderate amount of drainage: Wound tissues are wet, and drainage involves 25% to 75% of the bandage.
Large or copious amount of drainage: Wound tissue is filled with fluid, and exudate covers more than 75% of the bandage.

Always take into account the amount of exudate when selecting the dressing. We want to promote moist wound healing, with a moist wound and no adverse effects of moisture, such as maceration of the periwound.

Do you always document the amount of drainage by using the terms none, scant, small, moderate or large? Or does your clinical setting use percentages instead? Is a certain level of drainage needed before you can institute a moisture barrier or skin sealant for periwound protection . . .

June 20, 2012

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BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
What exactly is wound exudate? Also known as drainage, exudate is a liquid produced by the body in response to tissue damage. We want our patients’ wounds to be moist, but not overly moist. The type of drainage can tell us what’s going on in a wound.

Let’s look at the types of exudates commonly seen with wounds.

Serous drainage is clear, thin, watery plasma. It’s normal during the inflammatory stage of wound healing and smaller amounts is considered normal wound drainage. However, a moderate to heavy amount may indicate a high bioburden.
Sanguinous exudate is fresh bleeding, seen in deep partial-thickness and full-thickness wounds. A small amount may be normal during the inflammatory stage, but we don’t want to see blood in the wound exudate, as this may indicate trauma to the wound bed.
Next we have the famous serosanguineous exudate, which is thin, watery, and pale red to pink in color. It seems to be everyone’s favorite type of drainage to document, but unfortunately, it’s not what we want to see in a wound. The pink tinge, which comes from . . .

June 13, 2012

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By Nancy Morgan, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
Staging pressure ulcers can get tricky, especially when we’re dealing with a suspected deep-tissue injury (SDTI). The National Pressure Ulcer Advisory Panel defines an SDTI as a “purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue… Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.”

The key difference between this type of ulcer and an unstageable pressure ulcer is that SDTI involves intact skin, whereas an unstageable ulcer involves a breakdown into at least the subcutaneous tissue. An unstageable ulcer is covered with necrotic tissue, such as slough or eschar, formed from remnants of the collagen matrix of subcutaneous tissue. So it’s always a full-thickness ulcer—either stage III . . .

June 6, 2012

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BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
Support surfaces are geared for managing our patients’ tissue load and redistributing it to prevent skin breakdown. There are three types of pressure redistribution mattresses available, classified as group 1, group 2, and group 3.  Group 1 mattresses lack a power source and maintain a constant state of inflation.  They include foam mattresses, gel mattresses, and air mattresses.  Group 2 support surfaces, such as powered, low-air-loss, and alternating pressure mattresses use inflation and deflation to spread the tissue load over a large surface area. Group 3 mattresses include the air-fluidized mattress, a special type of powered mattress that provides the highest-pressure redistribution via a fluid-like medium created by forcing air through beads, as characterized by immersion and envelopment.

We need to consider many factors when choosing a support surface, such as the patient’s medical status, risk assessment score, wound stage, environment, and (one of the most important factors) who’s paying for the support surface. Depending on your work setting, you may face many challenges getting your resident on the appropriate support surface. Do you know that experts recommend any patient at risk for . . .

May 30, 2012

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BY: NANCY MORGAN, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
Wound healing and nutrition go hand in hand. Without adequate fluids, calories, and protein, wound healing can be delayed.

Protein is extremely important in wound healing. Patients with wounds require almost double the protein intake (1.2 to 1.5 g/kg/day) of those without wounds. All stages of wound healing require adequate protein. The basis of the human body structure, protein is responsible for making enzymes involved in wound healing, cell multiplication, and collagen and connective-tissue building.

Protein also promotes a positive nitrogen balance—and it’s the only nutrient that does this. Our patients need a positive nitrogen balance so new tissue can be made. When this occurs, the body is in an anabolic state, or a state of overall protein gain. If our patients don’t consume enough protein and negative nitrogen balance occurs, a catabolic state may develop in which no new tissue growth occurs, leading to a delay or halt in wound healing.

But getting the healthy individual to consume enough protein is a challenge. So how can you get your patients with wounds to consume an adequate amount? Are your dietitians giving . . .

May 9, 2012

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By: Nancy Morgan, RN, BSN, MBA, WOCN, WCC, CWCMS, DWC
I was thrilled to be asked to write a blog for Wound Care Advisor. They asked me to come up with a name for the blog. I thought it would be easy… NOT ! I found myself doing all this research on how to make up a good name that would be catchy and memorable. I reached out to all my wound care friends for ideas and started a long list of names. Every morning I would look at this list and add more. Then I said I had to STOP THE INSANITY! I had to refocus and asked myself… who are you writing the blog for? It’s for people like me! I am a nurse that is in love with wound care, I have been in this field for almost two decades—ouch! that just dated me. I started at bedside then moved to an educator role co-founding the Wound Care Education Institute where we have taught over 16,000 clinicians, spreading the knowledge of Wound Care so they can make a difference in their patients’ lives. I am that person that “gets the rush” every time I . . .

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