September 23, 2016

By: Dr. Michael S. Miller, DO

Ramblings of an Itinerant Wound Care Guy

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 from one care setting to another is a simple extension of identical personnel availability and services. It is bad enough to slather a wound in silver cream and then scrape it out later that day with a hospital-based captive, but to expect more, to order the same dressing changes in the home care setting because that’s what’s been done in the inpatient setting, is simply a manifestation of too much LSD (Loss of Sense Disorder). And of course, the dressings are never a simple wound filler and a topper. Going from or to an LTAC, a skilled facility, a home setting and vice versa for all is equally a conundrum of translation and reproducibility.

One area hospital physical therapist has earned the title of The Peanut Butter and Jelly Man as he artfully maneuvers into any given wound his mixture of amorphous hydrogel, calcium alginate, and other dressings du jour all covered with something containing Silver…and done two to three times a day. The reaction from the home healthcare agency receiving his orders is always a combination of anger, derision, and authoritativeness as the URGENT call they make to me results in the much-appreciated translation into common sense. He can probably be forgiven as he has no wound initials after his name save for the DPT, but the costs perpetrated by his wound care charade cannot be justified nor tolerated, nor do they translate into any viable home care.

Unfortunately, despite an infinite universe of available training courses and conferences, the most common visible manifestation of far too many dabblers’ interventions are ineptitude and inefficiency with no understanding of what happens when there is a change of care venue. In my universe called Indianapolis, there is a myriad of “wound care doers” for whom the simplest of wound care tasks are universally inconsistent from day to day and patient to patient. If routine activities such as staging a pressure-based tissue injury are so fraught with errors and inconsistencies (more on this issue coming up in future blogs), then how can the untrained or pseudo-trained be expected to identify the why’s, how’s, and what’s of a given patient condition and how to treat it in a given care scenario? The inconsistency of care from provider to provider, facility to facility, and then within a given wound care management entity suggests that care concepts embody “Whisper Down The Lane” (a child’s game in which a retold story changes radically by the end of the line) and are rampant in wound care.

If the mantra of wound care is “evidence based,” then knowing the evidence is mandatory and the evidence considered universal and applicable. I cannot imagine any dabbler admitting to themselves or a patient that their care is based only on experience. More, that they scrupulously refrain from reading articles and going to lectures and conferences to avoid diluting their encyclopedic wound care knowledge.

If we agree that there must be acceptable uniformity in wound care (also known as the standards of care), then there must be universality of treatment across all spectrums of wound care. If twice-a-day dressings are bad in the home setting, then how can they be good in the hospital? If marinating a wound in a dilute bleach solution is not supported by evidence, then how does that status change from acceptable in the hospital to below standard of care in the home healthcare setting?

Albert Einstein is credited with stating, “The definition of insanity is doing the same thing over and over again, but expecting different results.” The key is knowing the results of your treatment and that the outcome you desired was or was not achieved using your current methodology. If your patients are not healing after they leave your care, you deserve to know why. No one likes criticism, so finding subtle, acceptable ways to tell someone that their care is Neanderthal, catastrophic, disastrous, calamitous, apocalyptic, and cataclysmic may be a tightrope walk.

One of the most basic concepts of medical care is to make a diagnosis, treat using the best evidence, evaluate the outcome, correct if needed, and then repeat all of the above if necessary. Universality means that the properties of a class of systems are independent of the details of the system. A venous ulcer in the hospital is just like a venous ulcer in the home. Pressure ulcers are categorized by their location on the body not the location of the patient. If great care is to be great, then where it is delivered is the least important concept, as long as what is delivered is universally great.

Until we ramble together next time.

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.

 

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