February 5, 2015

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Ramblings of an Itinerant Wound Care Guy

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 too often clouds our success.  Some time ago, I blogged about the pseudo-utilitarianism of all those so-called “Wound Certification” Exams.  At first blush, these seem to be the key to health, wealth, omniscience and outcomes equaled only by those wound care management companies.

Even now, LinkedIn wound related groups blare the need to pass the test to “Get Certified” as the key to higher pay, more prestige, and joining an elite group which hold the keys to immortality.  I have searched in vain through my trifocals looking for some form of altruism hidden in each posting.  Nowhere does it ever say the basic facts…If you really want to learn what you are doing and not hurt patients, not dramatically increase costs, and really improve outcomes instead of causing irreparable financial, emotional and physical damage to unsuspecting patients, then take this course.  Let there be no doubt that the hot new medical gimmick is wound care and everybody can do it.  Getting certified mitigates the concerns that you may or may not know what you are really doing.

A story comes to mind of the wound certified PA who treated a profusely leaking G tube site by wallpapering the patients abdomen with absorbent pads and sealing the edges with adhesive border.  I guess she passed the “Out of sight, out of mind” part of her certification exam as his macerated abdomen cried out for mercy upon removal of these 4 days later.  Her goal was apparently to absorb the profuse acidic magma and allow the gastrostomy to simply heal.  Rather than admit that she did not truly have a good solution and get a second opinion, her treatment resulted in several days in the hospital.

Or the Wound Care Department at the local county facility (a magnificent edifice so modern that 114 computers grew legs and walked out without anyone knowing).  This wound department is run by an unsupervised Therapist who, despite having the mandatory three wound related initials behind his primary degree, never uses less than three products on a given wound and then changes them at least twice daily.  As you might surmise, his popularity with the home health care agencies borders on that of Bill Cosby. Recently I saw a robust 36 year old male patient of his whose only physical defect was the obvious termination of his body at both knees.  His story can be summarized in three simple phrases.  He went, they saw, they cut off.  The same hideous poem repeated twice.  The star of the show was a diabetic foot ulcer which failed to heal after no offloading, topical antibiotics and debridements akin to grating parmesan.  He had been told at the start of treatment to expect this and so no one was surprised when their Nostradamic forecast arrived.  The PT never referred to a wound physician, never sought a second opinion nor recognized the limitation of his own education and training.  I am sure in his mind, he did the best he could and I would agree emphatically except his best was not nearly The Best.  Insult to injury was the dehisced BKA flap of 3 months duration that begged for a more modern treatment than dry gauze.

Patients come to us with trust that we recognize not just our skills, but our limitations.  I have no intention of doing open-heart surgery or even attempting physical therapy.  A sign over a door that says “Wound Care” should mean just that.  When you come to us, we will care for your wound and you here to the best of our ability and if that is not enough, the care will continue wherever is needed until you are healed or our best efforts on your behalf are exhausted.  The abdication of the duty of looking for help, recognizing that a better idea, a better treatment, or simply someone better exists need not be foreign.  The leap of faith we ask our patients to take need not be into the pool of ego and stupidity.   Experience means recognizing that losing provides the opportunity to win the next time the situation presents itself.  Winning does not mean the search to improve stops.  A wound that fails to heal, a leg that is removed means that there exists a “more”.  The leap of faith we ask our patients to take is one we need to as well.  And best of all, it is almost always a hop, skip or a jump away.

Until we ramble next time.

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