If All You Have is a Hammer, What Do You Do 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 homebound 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 homebound, 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 of drainage, the surrounding tissues and so on, ad nauseum. Not surprisingly, in pain management, the scenario is much different. In wound care the mantra of the dabbler is see the hole, fill the hole. In pain management, the goal is to minimize pain to maximize functionality but the overriding questions are how this is accomplished.

If the ends justify the means, then why not use explosives to kill flies? A recent conversation with a local healer points out that same mentality that has made millions for Bud Light. Their now-famous slogan, “It’s only weird if it doesn’t work,” demonstrates the relationships assumed by disillusioned sports fanatics whose bizarre actions, foods, etc., seem to provide a direct correlation to touchdowns and field goals. Our discussion regarded a quadriplegic patient with no sensation below C5. The “Healer” had kept him on oral narcotics for years because of his “pain." The spirited but limited discussion ended up with his telling me that he had been using narcotics as his main source of pain control for years, that he had a relative with pain management experience whom he consulted “when needed," and that his many years of training included that of pain management.

His reason for the consult to my pain service was that he recognized that in today’s cause célèbre pain management climate, that one single narcotic slip might result in a major fall. I elected to press the issue by asking him why he didn’t just give all his hypertensives one medicine, his infected denizens one antibiotic and why he did not simply write for morphine across the analgesic board since they all worked and that was much easier than actually making a diagnosis regarding specificity. He responded by simply stating that his training provided him sufficient impetus to do as he had been. My thought was that the incomprehensible and confused logic he promoted regarding the differences between nociceptive and neuropathic pain may have been because both start with the letter “N” rather than any actual physiologic differences.

I accepted the consult on behalf of the group and he was genuinely appreciative. The fact that he requested the consult when he was perfectly able to do so himself (at least in his mind) suggests that a schism of major proportions had erupted in his cranium – namely, that of doing what worked versus doing what was physiologically correct but more appropriate.

The indiscriminate, unguided, “I have done it this way for years” mentality does not demonstrate expertise but rather the insipid, pseudo-intellectual detritus of a wound care or pain management Jonathan Gruber.

What I use to treat a patient for their wounds or their pain is based on a myriad of factors – the least of which is “I’ve always done it that way." In my mind, the real question to be considered is, “If one size fits all, then what size is 'ALL?' ”

Until we ramble again.


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Dr. Michael Miller is Board Certified in General Surgery by the American Osteopathic Association and initially received his 10-year certification in wound care by the American Academy of Wound Management in 2000 and the American Professional Wound Care Association in 2005.
His practice has been devoted exclusively to wound care and related issues since 1998. He is one of very few full-time physician wound care specialists in the State of Indiana, as well as the U.S. He has published numerous articles in peer-reviewed journals, written chapters in wound care texts, and presented poster exhibits and podium presentations at numerous domestic and international conferences.
Dr. Miller is also a consultant to numerous companies in the wound care industry and provides expert consultations to professionals in the investment and legal industries. In addition to his clinical practice, he owns several patents on wound care devices. Dr. Miller was named the American Osteopathic Foundation's 2010 Physician of the Year.