MicroDoc Portable Negative Pressure Wound Therapy Units in Final Stages of FDA Approval

The Wound Vac Company seeking surgeons to evaluate new wound care system from Pensar Medical

Fernandina Beach, FL – September 10, 2020 — The Wound Vac Company is pleased to announce that the new MicroDoc – a unique, single-patient-use disposable negative pressure wound therapy system that provides portability and discretion for active patients – is now in the final stages of FDA approval. The units, which are made in the U.S. by Pensar Medical, should be universally available in early 2021.

Compared with larger, traditional negative pressure units, these smaller systems are lightweight, ultra-quiet and small enough to fit into a pocket or purse. Powerful yet simple to operate, the MicroDoc supports uninterrupted negative pressure wound therapy for patients during normal, everyday activities.

The Wound Vac Company CEO and founder Scott Bergquist said, "As the Master Distributor for Pensar Medical, we are very excited about introducing their MicroDoc as the first single-patient use negative pressure wound therapy unit with three pressure settings – 50, 80 and 125 mmHg – to treat a wider range of needs and to help patients heal as quickly as possible.”

The MicroDoc units also feature state-of-the-art Enluxtra Adaptive Dressings, which maintain a moist environment necessary for healing wounds while providing superior absorption. As an added benefit, these dressings can help reduce scarring.

“With FDA trials complete, we are actively reaching out to dermatologists, plastic and general surgeons who are interested in partnering with us for patient applications,” said Bergquist. “In case studies thus far, we have found the unit to eliminate the need for constant dressing changes and to bridge the gap between a traditional negative pressure unit and the final phase of wound healing.” 

For additional information about the MicroDoc or to inquire about a patient case study, please contact The Wound Vac Company at info@thewoundvaccompany.com or visit thewoundvaccompany.com/portable-microdoc-wound-vac.

Negative Pressure Wound Therapy in Veterinary Practice

The following article – written by Bonnie Grambow Campbell, DVM, PhD, DACVS College of Veterinary Medicine at Washington State University and Bryden J. Stanley, BVMS, MACVSc, MVetSc, DACVS College of Veterinary Medicine at Michigan State University – was presented at the NAVC Conference in 2012 (Small Animal). This article discusses the existing literature on the use of negative pressure wound therapy in veterinary practice, highlights successful cases and notes NPWT’s benefits in the management of traumatic open wounds, dehiscences, flaps and more, making a case for additional study and research.

https://www.vetfolio.com/learn/article/negative-pressure-wound-therapy-in-practice

Negative Pressure Wound Therapy for Pets

This article from Petcaresupplies.com outlines the role of negative pressure wound therapy for pet wounds, including the stages of wound healing, how NPWT is used to aid in and promote faster healing, and the types of wounds that are most suitable for negative pressure treatment.

https://www.petcaresupplies.com/blog/the-role-of-negative-pressure-wound-therapy-in-pet-wound-treatment/

How Workers' Compensation & Social Security Disability Interact

The following post outlines how workers’ compensation and social security disability interact. The two benefit systems serve different purposes and are paid for by different entities, but there is often crossover. It’s important to understand how the two work, how they are funded and how to apply, as patients needing negative pressure wound therapy can receive one or both.

https://www.wci360.com/the-interaction-of-workers-compensation-and-social-security-disability/

Case Study: Portable Negative Pressure Wound Therapy

We are pleased to announce the release of the following case study on the use of the Alaira™ negative pressure device to heal a deeper-depth post-surgical wound. Our special thanks go to Dr. Allen Rosen of The Plastic Surgery Group in Montclair, NJ, for his assistance.

Case Study: Unique Application of Portable Negative Pressure Wound Therapy on a Deeper-Depth Wound (pdf)

For a text-only version of this study, please click here.

Negative Pressure Wound Therapy for Dog Bites

Each year in the United States, more than 350,000 dog bite victims are seen in emergency rooms (totaling about 1% of all ER visits) and approximately 750,000 bite victims receive medical attention. In addition, dog and other animal bites are prone to infection, leading to complications and longer healing times. In this clinical study, medical staff found that when compared with leaving wounds open, negative pressure wound therapy reduced the infection rate and shortened recovery time for dog bite victims.

https://www.sciencedirect.com/science/article/abs/pii/S0735675716001236

Surgical Drains and Negative Pressure Wound Therapy in Veterinary Medicine

This article (Part 1 in a two-part series) from Today’s Veterinary Practice takes a look at surgical drains used for wounds (traumatic or surgical), drains for peritoneal and pleural spaces, and drains used in negative pressure wound therapy. This first article covers indications for drain use, types, benefits & drawbacks, and common complications.

https://todaysveterinarypractice.com/surgical-drains-indications-types-and-complications/?highlight=NPWT

A Study of the Use of Negative Pressure Wound Therapy for Open Wound Management in Dogs

Abstract:

COMPARISON OF NEGATIVE PRESSURE WOUND THERAPY, SILVER COATED FOAM DRESSINGS AND CONVENTIONAL BANDAGES FOR OPEN WOUND MANAGEMENT IN THE DOG

Accepted for publication in Veterinary Comparative Orthopedics and Trauma in November 2014.

Mirja Nolff, Munich, Germany; Michael Fehr, Hannover, Germany; Anika Bolling, Hannover, Germany; Ricarda Dening, Hannover, Germany; Sabine Kramer, Hannover, Germany; Sven Reese, Munich, Germany; Andrea Meyer-Lindenberg, Munich, Germany

Researchers were from: Clinic for Small Animal Surgery and Reproduction; Department for Veterinary Medicine Small Animal Clinic; Department for Basic Veterinary Sciences; Department for Veterinary Medicine; Clinic for Small Animal Surgery and Reproduction

Presented Friday, May 15, 2015
Free Paper Session: Negative Pressure Wound Therapy

Aim: The aim of this study was to evaluate negative pressure wound therapy (NPWT) for treatment of complicated wounds in dogs and to compare it to standard wound therapy.

Method: Dogs (n=50) undergoing open wound treatment in two veterinary centers were classed according to treatment method: bandage (Group A, n= 7), NPWT (Group B, n=18), and foam dressing (Group C, n=25). Pairs of patients matched based on wound conformation, localization and underlying cause were compared between Group A and C (n=7 each) and between groups B and C (n=18 each) in terms of duration of previous treatment, time to closure and complications.

Results / Discussion: Signalment, antibiotic and antiseptic treatment and bacterial status were comparable between groups. The duration of previous treatment was significantly higher in patients assigned to Group B (p=0.04) compared to Group C, while no statistically significant difference was found between groups A and B. Total time to wound closure was significantly shorter in Group C compared to Group A (p=0.02) and in Group B compared to Group C (p = 0.003). NPWT treated wounds suffered significantly less complications (p=0.008) and were significantly less septic during treatment (p=0.016) than wounds treated with a foam dressing.

Conclusion: This study shows that time to healing was halved in NPWT treated animals compared to foam dressing treated patients, which in turn healed faster than patients treated with conventional bandage, underlining the value of NPWT therapy for the treatment of complicated wounds.

Negative Pressure Wound Therapy for Closed Surgical Incisions

This report from Wound Management and Prevention outlines a case study in which negative pressure wound therapy was used on clean, closed surgical wounds in four high-risk patients (two men, two women). All wounds healed well. Learn more about the study, outcomes and implications of the use of NPWT for post-surgical patients.

https://www.o-wm.com/content/use-negative-pressure-therapy-closed-surgical-incisions-a-case-series

Chronic Wounds and Negative Pressure Wound Therapy

This article from The National Center for Biotechnology Information (NCBI) reviews current practices in the management of chronic wounds, including costs and barriers to healing, as well as the role of negative pressure therapy in wound care.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5350204/

Article on Wound Care Basics: Applying NPWT

We’re pleased to share this article from Wound Source, written by Samantha Kuplicki, MSN, about what to do when applying NPWT:

https://www.woundsource.com/blog/basic-training-applying-negative-pressure-wound-therapy

About the Negative Pressure Wound Therapy (NPWT) Process

Negative pressure wound therapy (NPWT) is a medical procedure that uses a vacuum, tubing and dressing to treat a wide variety of burns, acute, chronic and complex wounds. The vacuum, or “wound vac” control unit, is connected to the wound via tubing and a clean dressing that pulls fluid away from the open wound and protects the area from infection.

In this post, we’ll look at the types of wounds NPWT is used for and briefly describe the process.


Uses for NPWT

As described in our recent post on wounds and wound healing, NPWT can be used to help treat and heal:

• Diabetic ulcers

• Bedsores (also known as pressure ulcers)

• First- and second-degree burns

• Trauma and gunshot wounds

• Surgical wounds, especially those with a high risk of infection

• Other complex wounds with large amounts of drainage

Negative pressure therapy is often used in hospitals and clinics but can also be used in homes by visiting home health care providers.

The NPWT process has become increasingly popular over the past 20 years, in part because it is non-invasive, can be administered in many settings and provides just the right amount of moisture necessary for healing while also protecting wounds from outside contaminants, such as dirt and bacteria.

The Process

After cleaning (a process also known as debridement), a sterile, open-cell foam or gauze is cut to fit the size of the wound and packed into the opening. Next, the wound is covered with a clear, thin dressing that creates an airtight seal around the wound.

A vacuum pump, or control unit, is attached to the dressing with tubing, which pulls fluid and dead tissue away from the wound and into a collection canister. The vacuum can be adjusted to regulate the strength of the suction (from -125 to -75 mmHg, depending on the patient and the wound being treated) and the length of time.

Dressings must be changed regularly during treatment. Removal and changing of dressings is usually pain-free and minimizes damage to any new skin forming around the healing wound; however, patients can experience varying of levels of pain during NPWT, depending on the location and type of wound, so pain medications are often used alongside this therapy.
 

Important considerations

Negative pressure therapy can be a highly effective, efficient and economical way of treating complex and chronic wounds IF:

• Healthcare providers are properly trained on procedures and use of all equipment

• The wound is routinely checked for any signs of infection or change

• The dressing around the wound remains clean and is regularly changed

• The drainage tubes are connected properly to the collection canister

• Drainage is flowing correctly into the canister (e.g., the tubes are not clogged, bent or blocked in any way) and the negative pressure seal is intact

• The collection canister is monitored and changed regularly
  

For more information about negative pressure wound therapy and continuing education courses on NPWT for healthcare and insurance professionals, please contact The Wound Vac Company.

Wounds & Wound Healing – Part III

In Part II of our short series on wound types and wound healing, we looked at the complications that can occur in open wounds, including infections.

In this final post in our three-part series, we’ll take a brief look at NPWT – negative pressure wound therapy – and how it can be used to treat complex open wounds.
 

Open Wounds and Negative Pressure Wound Therapy (NPWT)

As we noted in Part II of our wound care series, in open wounds, the skin is broken or damaged in some way, leaving the underlying area open to the air. This leaves the body exposed to potential contaminants such as dirt and bacteria, which can result in infection. Left untreated – or treated incorrectly – these infections can lead to life-threatening complications.

Over the past 20 years, negative pressure wound therapy (NPWT) has become a leading technology in the treatment of open wounds. To heal properly, open wounds need just the right amount of moisture, to be protected from infection, and – in larger, more complex wounds – help in bringing tissues back together while the skin closes. NPWT, when used properly, does all of these things.

Negative pressure wound therapy works by applying carefully controlled suction to an open wound using a special vacuum pump, hence the name “wound vac” for the control unit. The suction delivers negative pressure evenly through a dressing, such as foam or gauze.

Drainage from the wound is removed using tubing, which adheres to the dressing and is deposited into a collection canister. The dressing, suction and fluid removal also help protect the area from outside contaminants, pulling them away from the wound.

During this process, NWPT increases blood flow to the wound area and provides oxygen to the wound while removing excess fluid, so that the wound has just the right amount of moisture and can close and heal properly.

Use of NPWT

Negative pressure wound therapy can be used for a wide variety of complex open wounds, including:

• Traumatic wounds, such as combat or gunshot wounds

• Post-surgical wounds

• Pressure ulcers (bedsores)

• Diabetic ulcers

• Skin grafts

When used correctly, negative pressure wound therapy serves as a powerful wound healing tool. However, it is not the right choice for every patient and it is imperative that medical staff be carefully and properly trained in the use of NPWT equipment and procedures.

Even an incorrect application of NPWT dressing can put patients at risk. Healthcare staff must ensure that when NPWT is used, the appropriate dressing and correct suction settings are in place and that they are frequently monitoring both the patient and the wound.
 

For more information on the proper use of NPWT and licensed training for medical staff, please contact us.  

Wound Types & Wound Healing: Part I

Note: Key primary material for this article came from woundcarecenters.org.
 

Wound vacs – and negative pressure wound therapy, or NPWT – are used to treat a variety of different wounds in patients. But what exactly is a wound? What are the different types and how are they treated using a wound vac?

In this first post in our short series on wounds and healing, we’ll start by taking a look at wound types and explore some of the most common ways they’re caused.
 

Wound categories

There are two basic types, or classifications, of wounds: Open and closed.

Closed wounds are those where the skin is not broken. Closed wounds include simple injuries like basic bruises, where you bump into something and later experience redness, bleeding and/or discoloration underneath the surface of the skin at the site.

More serious closed wounds take place when someone is violently hit by an object. A direct blow can cause more severe internal bleeding, tissue damage and even muscle damage. However, the damage in these closed wounds is still below the surface of the skin.

In open wounds, the skin is split, cut or cracked open in some way. Open wounds leave underlying tissue – and sometimes bone and muscle – exposed to the air, as well as to dirt and bacteria.

Many people think that open wounds need air to heal; however, what’s most important is that wounds get just the right amount of moisture they need to heal and that they’re protected from infection while closing.

Wound vacs and NPWT are used exclusively for open wounds, where they’re used to help close the skin while providing moisture and protection from harmful bacteria.
 

Types of open wounds

Open wounds fall into several major categories, including:

·       Abrasions: These are shallow, irregular wounds on the upper layers of skin, due to contact with a rough or smooth surface, such as when you scrape your knee or fall off a bicycle and get “road rash.” There’s usually minor bleeding and little pain with these wounds.

·       Punctures: Punctures are small and usually round. They’re caused by objects like needles, nails or teeth, such as in the case of a human or animal bite. They’re sometimes caused intentionally – for instance, when you get a flu shot – but are often accidental. The wound size, depth, bleeding and pain are directly related to the size and force of the object.

·       Penetrations: This type of wound takes place when an object or force breaks through the skin and damages underlying tissue, muscle or organs. Penetrations have different sizes, shapes and levels of severity depending on the cause, and can be life-threatening.

·       Lacerations: Lacerations are tears in the skin with irregular, torn edges. They’re usually deeper than abrasions and cause more pain and bleeding, and they’re often caused by trauma or are the result of an accident.

·       Incisions: Incisions generally result from surgical procedures or from the skin being cut with a sharp object like a scalpel, knife or scissors. Incisions usually have sharp, smooth edges and lines.

·       Gunshot wounds: These are penetrating wounds caused by bullets from a firearm. Entrance wounds may have burn marks or soot on the edges and surrounding tissue. If a bullet goes completely through the body, the exit wound will be larger and more irregular than the entrance wound. The fast, spinning movement of a bullet can cause serious damage to tissue, vital organs and blood vessels as it passes through the body.

In our next post in this short series, we’ll take a look at the complications that can occur with open wounds and begin to explore how wound vacs can be used to treat them.

Interested in learning more about wound vacs and NPWT? Contact The Wound Vac Company today.

Bedsores, pressure ulcers & wound therapy

Among the problems that negative pressure wound therapy is regularly used to treat, bedsores are one of the most common.  But what are bedsores? How do they develop, how are they treated and how and why is NPWT used to heal them?

In this article, we’ll take a brief look at these injuries, explain how they develop, explore possible complications, and discuss how and why wound vacs are used in healing them.
 

What are bedsores?

Bedsores – also known as pressure ulcers, pressure sores, pressure injuries or decubitus ulcers – are essentially skin, soft tissue and bone injuries that develop due to prolonged pressure on an area of the body. They’re called “bedsores” because they’re often seen in patients who have limited mobility and are confined for long periods of time to a bed or a chair.

Pressure ulcers can also evolve due to friction – for instance, if a patient is lying in bed and the skin has become fragile and moist, it can be rubbed and damaged by sheets or other fabric.

Pressure ulcers can develop quickly, and they appear most often in places where the bone is near the surface of the skin, such as:

• On the lower back or at the base of the spine (tailbone)

• Around the heels or ankles

• On the elbows

• On the hip

• Around shoulder blades

• On the back of the skull

Unfortunately, pressure sores may look small on the surface, but the damage beneath the skin is often much worse. The blood vessels next to the bone get squeezed, so the muscles and the tissues near the bone usually suffer the most. 

Bedsores are common, especially in hospitals and nursing homes, where patients remain in bed for extended periods of time.  In fact, according to a recent report by the National Pressure Ulcer Advisory Panel (NPUAP), approximately 2.5 million patients develop pressure injuries each year, leading to 60,000 deaths per year due to these injuries and related complications.
 

Early warning signs and complications

One of the first signs of bedsores is a change in skin color.  The skin in the affected area usually starts to look red, purple or blue, and then develops an open sore as the wound develops through the skin and tissue below.

As the sore worsens, dead tissue can lead to drainage and fluid leakage, as well as strong odors, and the patient may develop fever. In the worst cases, deep tissue injury, muscle and bone infection, necrosis and even sepsis can result if sores are left untreated.
 

Treatment options

During early stages, it’s important to move the patient and release pressure from the affected area. The infected area should be kept clean and dry, and patients should increase their intake of water and protein to help with blood flow and healing.

Dead tissue must be removed (this process is called debridement) and regular inspection of the area must be completed. Antibiotics – either topical or oral – are often used to help treat infection while the wound is healing, and dressings should be applied and regularly changed.

Treatment of more serious injuries is challenging. If treated quickly and properly with a process such as negative pressure wound therapy, bedsores can heal within a few weeks, but more serious wounds can require surgery.
 

Negative pressure wound therapy (NPWT) and bedsores

The use of negative pressure wound therapy (NPWT) with a wound “vac” (or vacuum-assisted therapy) has proven to be a highly effective option for the treatment of pressure ulcers. During this process, a suction tube is attached over the wound, along with dressings, to:

• Release pressure

• Draw away moisture and remove drainage

• Help close the wound

• Reduce the risk of infection

In short, after the removal of dead tissue, this process takes care of all the necessary requirements for helping the wound heal.

When used properly, negative pressure helps wounds heal within 4-6 weeks at half the cost of surgery. In addition, it removes all surgical risks and potential complications, which is especially important given that nursing home and hospital patients are often poor candidates for pressure injury reconstruction surgeries in the first place.

Have more questions about healing bedsores with wound vacs or NPWT? Contact us today.

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 medico-legal 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 into why this may have happened, I offer the following. Several years ago, our Department of Health created a pressure ulcer task force initiative designed to establish guidelines, which were intended to improve prevention, treatment and reporting. There was a great hullabaloo from the department and the many entities invited to participate regarded the creation of this work as a pressure ulcer paper messiah.

Of course, you must remember that development of pressure-based tissue injuries that are currently called Stage 3 and Stage 4 are to be reported to CMS as they are now considered NEVER EVENTS.  (Dare I use this moment to prognosticate my next blog discussing the complex, stupid and illogical systems currently used to “Stage” these?) And more, these numbers are to be reported as part of a medical errors reporting system.

There is a generally acknowledged fact that for better or worse, despite the very rare “unpreventable” pressure-based tissue injuries, the development of a pressure ulcer in a hospital is as ubiquitous as Facebook lurkers.  With approximately 200 acute care facilities, even the most optimistic (and deluded) health care professionals I have spoken with offer numbers anywhere from five (5) Stage 3 and 4 pressure-based tissue injuries up to 200 per month. Nobody has suggested fewer and there have actually been some who thought there were more. Simple mathematics, using even the low number, would result in approximately 12,000 bedsores developing right here in the Hoosier State (5 bedsores x 200 hospitals x 12 months). 

And so, to cut to the chase, the most recent report from our Indiana Department of Health for medical errors in 2013 was recently published.  It identified the names and numbers regarding the facilities that honestly disclosed their medical errors (based on mandates with severe, punitive actions for failing to do so). Forty-five bedsores were reported!!  Moreover, the officials in charge of this program were outraged because the prior year, there had been 30 reported, which demonstrated a 50% increase!

At this point, I will pause and allow you to re-hinge your jaw from the unquestionable drop it took. 45 bedsores, a 50% increase from a year prior and a national report on health care performance demonstrating that there may be health care here, but it is probably better almost anywhere else? And so, regardless of the veracity of these numbers, they still mandated action.

Of course, the powers that be plodded explosively into action announcing new programs to improve care. When my children were naughty, they were punished. When they lied about being naughty, the punishment increased. Closing my eyes, plugging my ears and telling my wife that I will be creating initiatives to improve their behavior sounds good, but trying to put a patch on a badly broken and dysfunctional wheel is simple bureaucratic buffoonery.

IS the grass greener on your side of the wound dressing? What is your state up to in terms of pressure ulcer prevention, treatment and reporting? As far as our state song sung with such vim and vigor by Jim …perhaps the title needs to be, “Back home anywhere but Indiana.”

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.