When Addiction Takes A Health Care Worker

by Dr. Michael Miller

Patients, fellow nurses, even many may docs knew that he was a very good nurse who cared. Of course, not perfect as his supervisors fretted after every visit because his documentation was haphazard at best and nonexistent at worse. But patients loved him, each one waiting expectantly in their homes for this caring ray of nursing sunshine. I am confident the status update phone calls made to other physicians were as informative and clinical as were mine, but he exuded a warm boyishness that was appealing. Yes, there was evidence that something was not quite right. Yes, the documentation may have been a clue, the fact he needed to change jobs every few months, but his reputation as a caring, hard working nurse was never tarnished.

When an opportunity arose to move to health care programming in the home setting, he dove in headfirst with all the exuberance and passion he could muster. But the program oversight mentor manager was unable to demonstrate the skills and honesty my friend craved. Another other life lesson punishing his spirit, he returned home. He briefly worked as a nurse for the only remaining opportunity based on his documentation legacy, a care agency whose practices left him more disillusioned and depressed. Unexplained (or poorly explained) encounters with law enforcement resulted in lawyer fees but nothing rose to the level of permanent damage to that most important to him, his license to care.

We connected off and on for the next few years until I received a text asking me to meet with him, that he had a “need to talk." The 30-minute face-to-face meeting unrolled a long history of substance abuse, heroin, narcotics, other substances he had used for years to assuage his pain of depression and failure when hoped-for panacea antidepressants failed to change his fates.

He asked me to help him with his addictions, noting that he had tried many types of treatments before with some success, albeit limited. Eventually, another blast of reality forced him to swallow or snort his way to relief. He acknowledged he had to have help as he recognized he was ruining his life and that of his family. Like most who live this kind of double life, he had successfully hidden this from them for years until a chance finding of information from an addiction treatment scenario led to his admission of problems. 

Of course, the insurance was poorly chosen, insufficient and hard to navigate, but ultimately, he entered our program. The initial drug screen showed the facts of his two days prior and the pain of his withdrawal was palpable. The recommended treatment program was actually excitedly accepted, mental health appointments were made and he left feeling that he might make it. His accompanying family expressed gratitude that he had found someone to trust and, moreover, had taken advantage of the opportunity.

A text from him a few days later improved my day by telling me he was doing well. The treatments – both medication and counseling – were helping. Meeting attendance was underway and I succumbed to the notion that he might finally have crossed back over to sobriety with some longevity. He was going forward in recreating his life and I had been allowed to participate, a sobering honor.

A few nights later, my physician associate texted me regarding a message from a care agency in another county. They wanted him to know that one of their former nurses that had worked with us had died. He could not remember the name but just some extrinsic minutia, like that the nurse made guitars, was a musician and had worked in Indy. The text ended with the addition that the nurse had a drug problem and my associate was told he had sought care in our program but no one was sure if he got to us for help.

At 11 pm at night, I read that text, but sleep was first on my mind and so I headed to bed. The next morning, another text provided the misspelled name of my nurse-patient-friend as the victim of fate's cruel joke. A late message from the family left the evening before at the office confirmed the truth. Having told the owner of his crash pad that he had a dinner date, he headed to the bathroom on the floor below to enter eternity, and was found a day later.

With each encounter I have with those hoping to reclaim their lives and dignity from this spoiled fruit of the poppy or a bottle of courage, I struggle to understand how each individual differs in how they deal with life, stress, relationships, the good, the bad, and the unknown. I have no answer nor do I ever expect to as even if I think I am getting close, another crack appears in my protective wall. This pervasive addiction crisis will touch someone near and/or dear to us and probably already has, even if you aren’t aware now. Heath care workers like my friend have no immunity to any of the obstacles thrust upon us abruptly or insidiously that overthrow our consciences.

I ponder how to recognize when someone is in real trouble, more when the slightest of clues appears. These fine defects in a veneer of competence and veracity that are a telltale sign something is amiss. But I, like my friend, am human, and so the desire to trust fellow health care workers, my friends, my colleagues seems to be a desperately needed life preserver that gets harder and harder to cling to. The best anyone can do is to trust yourself and hope that is enough to start the rest of the process of helping others.

This epidemic and all the proposed cures depend on one thing: the individual's ability to help themselves. You cannot legislate stupidity nor mandate people accept the help they seek and then swerve away from at the last second. At its most basic, the determination of how we live and die seems to be impacted mostly by fate, the wrong person at the wrong place at the right time for what becomes the inevitable. Articles and news stores in which uneducated lay experts and legislators purport to have to key through mandates, and program creation are well-intentioned but misguided.

Flinging money and resources at this problem through haphazard program creation like our ongoing efforts at drug interdiction are futile. No program, counseling, medications or other can have an effect on an addict who has not yet rediscovered their soul and that happens suddenly. The moment in which they realize they need help is fleeting, and occurs like a thunderclap. Like a child earning to crawl, it happens in a haphazard, uncoordinated fashion and then can disappear just as quickly. Wrong place, wrong time is how they start their journey and how it almost always seems to end. Our job is to hope we are there just as the lighting strikes.

A friend of mine was a good nurse. He died, and nothing anyone could do could prevent it. Nor could he.

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.

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, we have rarely sacrificed the greater part of a foot and more, and have had only 3 lower extremity amputations in the last 5 years on patients whose 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 but infrequently demonstrate their inadequacy and paranoia by gang-haranguing the patient and family.  They are lambasted with lurid tales of the condition marching up the leg engulfing the foot, knee, torso, and brains much like a flesh-eating PacMan.  The patient’s confidence, now neutered, has little chance against this persistent onslaught of inadequacy and so, much like the Queen song, “Another One Bites The Dust."

I do not know who will be presenting this attempt to mitigate abject failure of care nor do I really care.   The mere consideration that the performance of an elective amputation is acceptable an that all is right with the world seem to me to be an admission of technological impotence.  I am not talking about a traumatic event in which the extremity has become a high risk gam no more functional than a flesh colored Lego.  I am talking about the loss of a limb, a major, integral part of ones self taken blithely through what was unquestionably a series of unrecognized but correctible events; a perverse falling domino affect further amplifying the inadequacy of one or many to correct the aberrant conditions. The final curtain comes down culminating in extremity Gotterdammerung.

I cannot recall a patient with any condition coming to me and asking for a catastrophic outcome.  Rather, they come to me with that sword of Damocles hanging over their heads from far to many under-confident wound care dabblers. The mantra of need for amputation is repeated ad nauseum in Hare Krishna fashion.   Never a mention of what they would or could to prevent it, rather a litany of proposed attempts, none of which presented with any conviction regarding the “If this fails, then…”

It is not so much that the occurrence of this tragic outcome is unacceptable, as there are things done wrong that have good outcomes and things done well that have undesirable endpoints.

The 54-year-old diabetic with poor vascular supply escaped the “Hospital Wound Care Team” by signing out AMA.  They had apparently failed to convince him of the beneficial novelty of being a one-legged Homo Sapien.  He appeared at our clinic fresh from his great escape, terrified but hopeful.  His wife of 35 years had convinced him that even the smallest chance of salvation was worth the trip.  A quick evaluation and off he went to a colleague who quickly obtained a vascular intervention, wherein blood was soon discovered in areas previously barren of it.  Debridement skills reincarnated tissues declared post-mortem with healthy tissues now substituting for the previously surface.  Antibiotics soon floated leisurely to angry soft tissues which responded in kind.  Much like 1960s action figures, he now talked and walked on two essentially identical legs.

Is Limb Salvage a miracle akin to manna from heaven or simple, logical evaluation and diagnoses smothered in a healthy dose of confidence and expertise?  Probably equal arts of both.  The medical notes we sent to his would-be ampu-cutioners will probably not make them happy, but they may yet think differently the next time they are faced with what they perceive as a firm grasp of the obvious.  In the meantime, the patient has sworn to visit them all, doc by doc and nurse by nurse, to demonstrate perhaps a little too proudly that what they willingly and knowingly were willing to abdicate.

As far as that pending lecture, I lament the premise but more, the presenter who would knowingly and willingly bare their soul regarding their catharsis of inability.  Demonstration of expertise…I think not.

So let’s cut to the chase.  Amputations are never considered acceptable as an endpoint.   The emotional, psychological, financial, social, physical, circulatory, cardiac, musculoskeletal, neurologic, and human effects are so heinous, abhorrent, repulsive, vile, and execrable that the mere consideration of this as acceptable questions anyone’s humanity.   In short, the casual suggestion that lower extremity amputation is an acceptable outcome is simply unacceptable.

Until we ramble together next time.

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.

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 question 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&M’s) have resulted in a major paradigm shift in medicine.  Whereas the hospitals once touted their ability to heal all manner of maladies, they now recognize their cost ineffectiveness, more detrimental than beneficial care (just check the nutritional parameters of anyone pre- and post-hospitalization) and the downright danger of going to one, unless you are a burgeoning superbug.

So the shift is to the home, the place where the heart is, to where you bring the bacon and where the cows may yet arrive.  House call medicine, once relegated to Marcus Welby, MD (a TV show from the 60s that dripped of altruistic, medical honey), is now the hot new medical paradigm.  Reimbursement is actually a touch better recognizing that these visits involve the doctor on the move with what instrumentation can be carried in the standard car and a trusty assistant sidekick.  Much like the US Post Office, “Neither snow nor rain nor heat nor gloom of night stays these couriers from the swift completion of their appointed rounds” – EXCEPT for patient compliance.  The official definition of someone being homebound and thus eligible to receive home-based services is that their leaving home must be a “taxing” effort.  They are allowed to leave for church, certain specific personal issues and, most interestingly, for medical care. 

And so to home we go, the place where the infirm lay in wait for their scheduled visits done so at their convenience.  While I recognize the basic human rights of privacy and the ability to be respected for one’s personal issues, having patients delineate the exact timing of their visits seems a bit out of sorts.  I mean, they are “homebound," right?  More, there are those who watch the clock like a mission control countdown in which coming 10 minutes before or after the “scheduled" time means risking their wrath.  How many times have I contacted the patient days before with confirmation and then reconfirmation of the visit, only to be told it is now inconvenient, that they have company, they have another doctor's appointment, that they are too sick to have the visit, or they are not dressed (always an interesting conversation with my truncal bedsore patients).  Of course, the real risk of the house call is that the house is something from a hoarders episode, has the ubiquitous GIANT friendly dog, or family members reminiscent of Uncle Fester and Lurch.

The underlying problem is the now-so-pervasive entitlement mentality that a house call visit, once done with the utmost humanity, compassion and at huge inconvenience to the providers, has become little more than a game of flashlight tag in which the patients have all the batteries.  And so the question is, how do we solve this? 

Unquestionably, many home bound patients are truly and solely homebound and their ability to get out of the house without a trained ambulance crew or other equal transport is onerous at best.  To these patients, I am delighted to offer that which I have pledged in the name of Hippocrates.  The key, however, is that not enough of them show either simple appreciation or preparation for what we house-calling Medicare indentured servants do.  The acknowledgement that our goal is to provide the highest quality medical care in locations far too often unsuitable seems far too alien far too often.  But have no fear, the powers that be are looking at the documentation and starting to examine those all too powerful words “taxing effort." 

My plea is they not question someone’s need for homebased services and their provision.  Rather, the goal should be to make patients responsible for them, that the definition of home bound means that you are so.  Being too ill to have someone provide medical care in your home is ludicrous.  Mandating rigid schedule adherence is something that only pizza delivery boys can attain.  Scheduling a home visit with all the attendant preparation of making the schedule, mapping a logical route, arranging to meet their home health care nurse and the attendant costs of time and money there means planning worthy of Bruce Jenner’s pending surgery.  And finding no one home or the patient “unavailable” means more than simply an earlier lunch.

House call medicine, the ultimate in patient centered medical service.  On demand care … of the patient, by the patient, for the patient, but at whose convenience?

Until we ramble together next time…

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.

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.

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.

Wound Care in Crisis – Chris Farley Wound Care

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by Michael Miller, DO, FACOS, FAPWCA, WCC

For those of you who cannot remember the now-deceased comedian Chris Farley, did not find his humor funny or simply cannot remember any of his memorable performances; I suggest you move on to another, less controversial, "here's how to use scissors" type of blog.

Chris Farley was a genius. His insights covered many, many topics but their pertinence, I have found, is particularly suited to wound care. Those of you who work in the vicinity of a wound care dabbler, I invite you to cut this blog out and surreptitiously leave it where they cannot miss it or send them the link. I am betting that one or two of the following will strike home, but even if not, at least they will get the message that someone (probably many-one) wants them to reconsider their current as-yet-unrecognized (you may substitute the words barbaric, substandard, fraudulent or wasteful) practices. Recently, the shenanigans of several 4-hour-per-week wound management company puppets have led a handful of patients to file complaints with their clinics, hospitals and in two cases, demand that they not be charged (believe it or not, with no coercion, suggestion or turbo charging and actually with a second or two of feigned disbelief on my part).

The basics are simple, so let’s get them out on the table. The keys to success are not just avoiding making mistakes but recognizing that one was made and avoiding making it again. While Mr. Farley inadvertently but repeatedly insults Sir Paul McCartney during an adoration-fueled interview, he rewards each faux pas he commits with a smack to his forehead accompanied by his self-acknowledged cry of "Stupid, stupid, stupid." The resultant laughter from the audience and his embarrassment should result in Chris’ reminding himself not to act stupidly again. Of course, the key to the comedic bit is his ability to say the wrong thing again and again and punish himself for the wrong thing again and again. If only Chris had a checklist on which to remind himself what things were safe to ask and what questions or actions would take him into treacherous territory.

Fortunately for his audience, he just never got it right. 

In stark contrast is the hapless wound care dilettante who perpetuates bad care without ever hearing the whispered "Stupid, stupid, stupid" from those who recognize their folly. We are all looking for the magical panacea for medical errors and, for better or worse, the simple checklist seems to fit the bill. They are a way to organize, systematize and deputize and they require no advanced training, no coursework and can be done in the absence of a pseudo-wound care management company. The airline industry does so for a considerable number of their processes and purports to have dramatically reduced errors. Why not us?

The trick to using checklists is that they represent common sense but applied logically. Knowing how many gauze sponges were used in a surgery is a fact. If the right lung needs surgery, then operating on a healthy left one is wrong, the checklist mandates you know which lung is which. The ideal dressing for a wound with certain characteristics is another easily identified use offered by many dressing manufacturers.

And so, a common sense checklist can be created for wound care in multiple aspects. The infamous dabbler credo, "I've always done it this way" or afflicting a patient with your treatment choice du jour based on ignorance, bravado or misdirected passion and not science is simply "Stupid, Stupid, Stupid."

Cases in point
While it is not my goal to teach venous disease versus lymphedema identification in a few paragraphs, it is a safe bet that a few seconds on the differences would get you to a 70% success rate in diagnoses and treatment. Yes, there is some overlap, but the haphazard flipping of a coin to establish the diagnosis at least in my area has resulted in far too many long-term treatment failures and even a recently-encountered "No one knows how to treat it" mentality foisted on patients by several area primary care physicians. Venous disease makes pitting edema, lymphedema usually does not. Venous edema makes the whole extremity swell somewhat uniformly. Lymphedema causes irregularities, giant lobules and sharp "cutoffs" at joint areas. Venous disease causes purple, brown or black staining (hemosiderin deposition). Lymphedema involves little to no discoloration. Redness in venous disease rarely means infection and is almost always dermatitis due to inflammation. In lymphedema, the same redness mandates a further investigation due to the catastrophic effects of infection. If you can pinch the skin at the base of the second toe, they have venous disease – if not, lymphedema. Since the anatomy and physiology of these are entirely unrelated (though yes, there may be some overlap), there are major differences in treatment. Those well-intentioned automaton therapists who blindly accept erroneous diagnoses and treat based on them are as guilty of "Chris Farley-ism" as their referring charlatans. A few cases of amnesia-fueled anecdotal success is nothing compared to the evidence that exists... give it up! Or better, make up a checklist of identifying features of both diseases, their differences, and similarities as well as their treatment using modern evidence and look at it once in a while. 

I am looking for a treatment for some podiatrists in my area who are afflicted with a pattern of practice that precludes them from looking above the patients' ankles. Whether the patient has venous disease or lymphedema, regardless of what is going on distally, if it can't get blood flow out proximally, it won't get better. You can contact cast, apply all the growth factors you want and it will simply stay stagnant. That is, unless you use the omniscient wisdom gained as a member of a dabbler's wound center and then, a debridement done frequently is guaranteed to get bigger since without adequate venous return, the tissues will never leave their state of senescence.

Of course, those many repeat visits will help the bottom line of the wound management companies... and statistics can always be manipulated... just ask the State of Indiana's Pressure Ulcer initiative. How about a simple checklist that asks those difficult questions like, 'Is there good blood flow to the area? Is the blood getting out of the area? Have I established a definitive diagnosis for why the ulcer started and exists?'... etc. Of course, simply closing your eyes and throwing a dart at the diagnosis dartboard does add some intrigue to the scenario. The firmly held belief that the function of the heart is to keep the feet alive and that anything above the feet is irrelevant guarantees treatment failure and is simply “Stupid, Stupid, Stupid.”

Like small children learning simple phrases, dabblers learn negative pressure wound therapy (NPWT) in simple terms. It has become a punch line to an expensive and grossly overused joke. Why understand anything regarding the physiology, the tissue considerations or the laws of physics that govern its effects when learning three simple words takes out all of the guesswork. Three words to order an expensive, potentially cumbersome treatment regardless of where the wound is located, the amount of drainage, pain, dimensions, type of tissue being treated, etc. Three words that have become the sine qua non for guaranteed healing regardless of any other factors one might need to consider. If successful (rarely), the doc is a knowledgeable, omniscient hero. If wrong, they have gotten 3 months to avoid seeing the patient and wound hopefully able to identify another 3-month delaying tactic as they vainly look for some semblance of healing.

Repeat after me ... Foam, Continuous, 125; Foam, Continuous, 125; Foam, Continuous, 125... "Stupid, stupid, stupid." And dare the reps actually throw them a curve ball like gauze, or lower pressures or that other setting...intermittent (and now the newest and most interesting concept of variable intermittent which is much more physiologic), they play the "need a white paper" or, "who else is doing that" mantra. Let's be realistic. Other than cases where the drainage is massive and ongoing, continuous is "Stupid, stupid, stupid." 

Recognizing that NPWT is basically giving the wound a hickey, how many of you really want your significant other to suck on your neck for periods exceeding 48 hours with no break? Forget going to the bathroom or getting a snack. The sheer action of that on your skin (or an open wound for that matter) would be torture, and yet, dabblers do it all the time and proclaim their random successes. I like to ask those who purport to have healed wounds using passion, and the SWAG method (Scientific Wild-Ass Guess). Did the wound heal because of what you did or IN SPITE of what you did? Using a checklist with the wound parameters and based on the available evidence is a simple way to remember that every patient is different and every wound on every patient is different, and so the "one size fits all" mentality is truly "Stupid, Stupid, Stupid."

The last diatribe is the expected one on establishing a diagnosis before you treat. I have finally realized that there are only 9 diagnoses in wound care and that simply identifying which of them best defines the wound or related condition keeps me on track as we evaluate patients. (Feel free to contact me for the list or to give me your thoughts on this seemingly simplistic but guaranteed method of staying on track). My colleagues and those who come to work and study with me have learned that when I say "Run your 9," it means that they missed the diagnosis and need to logically re-evaluate their work up. It is too easy to knee-jerk a diagnosis and the dabblers credo of "see the hole, fill the hole" is an easy trap to fall into.

By having a checklist, something that forces us to consider numerous options and then rule them in and out in a logical fashion is no less worthy a task than that of the airline industry. It need not be complex to be comprehensive. Diagnoses, diagnostic tests and treatment choices can all be juxtaposed on a checklist. With the coming of the sequester, reimbursements will be reduced. The key is not to do more unnecessary procedures or prolong the agony by dabbling from one unsuccessful passion fueled treatment to another, but to create an atmosphere of competent, successful, logical care. Chris Farley had it right when he was astute enough to realize when he was acting "Stupid, stupid, stupid." The ability to identify specific data points and juxtapose them virtually guarantees cost-effective, successful outcomes. You can choose to use simple effective tools to do a better job at what you do or, like his motivational speaker persona, Matt Foley, "You'll end up living in a van, down by the river.”

Until next time when we ramble together…

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About The Author
Michael Miller DO, FACOS, FAPWCA, WCC 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.