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/

Latest issue of Negative Pressure Wound Therapy Journal released

The March 2019 issue of the Negative Pressure Wound Therapy Journal is now available. This issue features a case study on NPWT for necrotizing fasciitis, a report on a fistula treated with negative pressure wound therapy, and an article on the role of negative pressure wound therapy in the treatment of pilonidal disease.

A pdf of this issue can be found here: https://www.npwtj.com/index.php/npwtj/issue/view/12

"I'm a certified wound specialist – but don't ask me about wounds"

Wound care certification: Compensable or reprehensible?

by Michael S. Miller, CEO and Medical Director of The Miller Care Group

Universally, regardless of the area of expertise, employment, endeavor or action, there is always some sort of stratification. The best soccer players (that’s “football” for my colleagues across the pond) have the highest profiles and, of course, the highest subsequent annual salaries. They earn these unabashedly because their skills place them well above others. People with extraordinary managerial skills, computer skills, or any other abilities that elevate them to the highest echelons of their endeavor are rewarded based on the initial and ongoing demonstration of skill. 

While in many of these situations some sort of certification is achieved or obtained, it is unquestionably the skill level that they demonstrate ad infinitum that places them in the highest strata. Their real test is simply to do great work that is easily recognized as great.

What does ‘wound care certification’ mean?

Recently, one of the simplest and most basic human skills involving recognizing natural born leaders (such as people who possess superior intelligence or skills) has been obviated by contrived and far-too-often unrelated documentation purporting to prove expertise. For the sake of this diatribe, I am talking about wound care certification. I have previously blogged and spoken about the numerous issues involving the current state of so-called “wound care certification” and based on a series of recent events, the time has once again come to rattle the cages of comfort. Unlike TRUE board certification, which is unfortunately (but for many reasons) limited only to physicians, the zeal to create a “guarantee of expertise” hurdle for which those who can jump it are suddenly granted infinite omniscience and omnipotence has resulted in quite the opposite.

There are presently a myriad of organizations that offer some version of the epithet “Expert in Wound Care and Everything That's Related To It”. The overwhelming majority provide an educational course immediately prior to an examination, which for all but the most daft, virtually assures a passing grade. The driving force behind this mad dash has been that facilities and other entities actually believe that these tests not only confirm wound care knowledge, but directly relate to expertise. 

More intriguing, however, is the fact that with some subtle exceptions, the people taking these “guarantees of expertise” are coming from specialties that certainly are integrated, but overall completely unrelated. Nurses, physical therapists, dietitians, and physicians unquestionably need to have the same, most basic knowledge regarding the infinitely complex world of wounds. But to believe that each of them individually passing the same test means having the same knowledge is ludicrous.

I support those whose passion for wound care and careers have been based on attempting to adhere to Father Hippocrates’ admonition, Primum non nocere (“First, to do no harm”). Not surprisingly, encounters with those waving their wound care expert certificates in front of them (like a shopper during triple coupon value days) have been most unsatisfying. 

As will come as no surprise, my splenic venting is the result of recent verbal interactions with a local BIG hospital wound care therapist spouting wound care gibberish including twice a day dressing changes, “peanut butter and jelly sandwich dressings” (using three and four incompatible products), and advising me that foul odor unquestionably portends gangrene mandating consideration for amputation. 

Of course, the conclusion of the shocking, disgraceful, scandalous, atrocious, appalling, boring, monstrous, heinous but well-intentioned recommendations are always punctuated by their self-congratulatory “And I am certified” as to underpin the validity of their care of their most current sacrificial lamb. Of course, my questions to her regarding the illogic and what evidence she had only resulted in the well-worn "I've been doing this for a long time.” Not a single answer to my questions, but a lot of stuttering.

What is the value of wound care certification?

The question is, of what real value is wound care certification? For those seeking the sought-after economic benefits, then unquestionably having this piece of paper (regardless of what it does or does not portend) solves the problem. 

As a Board-Certified General Surgeon, I was tormented by three different board examinations: a written test, an oral examination of six hours, and lastly, having two surgeons observe me performing several major surgeries and reviewing case charts. While I am by no means recommending this version of the Spanish Inquisition for wound care expertise, there is no question in my mind that the ability to answer questions whose answers were presented mere hours before is highly problematic in terms of identifying true expertise. I recognize that certification must start somewhere and having been involved in test question creation, verification and more for numerous written certification examinations, I understand that the investment of time and energy is nothing to be taken lightly. However, since wound care is a “boots on the ground” practice, then those boots need to be examined.

I have proposed (with mixed reception) that an additional level of verification of expertise must be initiated. I recognize that economics play an important role in both ends of the quest for achieving a higher strata by paying for certification resulting in access to higher compensation. However, the investment to demonstrate expertise must be met with higher compensation only when this expertise is defined and unquestionably recognized and demonstrated. 

Insurance companies routinely request mandatory chart reviews to assure that standards of care are met and more, that the documentation exists so that compensation is commensurate with the documented care provided. 

Why should the certification of a wound care specialist be any different?

In the myriad of turn-key wound care operations in almost every hospital, they have a cookbook and quota system, so why even force certification on anyone since these wound care dabbling automatons simply follow the code written into their ports?

So, the time has come to take a critical look at how to create a hurdle and what it must be made of. What will it take for the wound care certifying bodies to recognize that it is the practice of wound care that demonstrates expertise, not the ability to answer a bland, factual conundrum? 

To create a new paradigm requires courage; but more, true altruism. I propose that so-called “wound care certifying entities” take their certification to the next level by mandating submission of redacted charts from candidates looking to truly demonstrate wound care expertise. A minimum number (3 or 4) redacted charts would be required from each of the major wound categories: pressure-based tissue injuries, Venous based, diabetic neuropathic (which arguably would include arterial/ischemic), and then an additional eight or so other wound or related cases for an approximate total of 20. I think this is a very reasonable number considering the myriad number of cases that a true wound care expert should be seeing and participating in over a defined period. 

Using specific criteria and a point system based on accepted for evidence-based or best practice criteria, a panel of three experts (yes, I know that this circles back but you have to start somewhere) would score these cases and then identify whether or not this particular candidate met the minimum standards to be truly called a certified wound specialist or whatever title that entity purports to proclaim. To paraphrase Associate Justice Potter Stewart of the United States Supreme Court, I cannot define great wound care, but I can recognize it when I see it. 

Compensation based on a spoon-fed examination, self-proclaimed expertise, and substandard care masquerading as the end result of certification have had their time in the sun. The new mandate is to do what the insurance companies and other bureaucratic oversight entities are unquestionably moving toward. Where I grew up, we call it “Put up or shut up.” If you want to get paid for providing true wound care expertise, then waving a printed e-mail from an organization stating: Veni didici, tradidi vobis praecepta mea (I came, I learned, I passed) may be a good start, but until you treat more than a piece of paper in that bed, it's not wound care – or at least not what I would want for myself, my family or my patients.

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

Standardizing Wound Care Dressings For Cost Savings & Better Results

This article by Randall Wolcott, MD, and Vicki Fischenich, RN, MSN, GNP-BC, WCC, outlines how a Texas wound care clinic achieved significant cost savings while improving outcomes, staff productivity, and patient and clinician satisfaction by adopting a new method of standardization.

We would like to thank Vicki Fischenich, RN, for allowing us to share this article. 

http://www.todayswoundclinic.com/files/TWC_April2014_Wolcott.pdf

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.

Copy of Lidocaine and Wound Management

The Use of Lidocaine in Managing Wounds

by Aletha Tippett, MD

What is Lidocaine?

Aletha Tippett, MD

Lidocaine is typically used to reduce sensation in tissue in a specific area. Lidocaine can be either injected or applied topically, depending on need. This topical anesthetic is popular because of its low cost and minimal side effects. Once applied, lidocaine typically takes about four minutes to begin affecting sensation, and effects can last for between a half hour and three hours, depending on dosage. One of the main benefits of lidocaine is its rapid onset of action; while stronger or longer-acting substances may be preferred for surgical procedures, lidocaine’s fast-acting nature makes it perfect for reducing pain in a wound.

Lidocaine has been my go-to product for wound care for over 20 years. I always use viscous lidocaine applied to any dressing. A patient might need systemic pain relief also, but the application of topical lidocaine is very effective to help alleviate local pain of wounds. Since I have used lidocaine so long for thousands of wounds I can say it definitely helps the healing of wounds. Having a nearly 100% healing rate speaks to that.

The newest thing that I found out about lidocaine was recently published in Wounds regarding lidocaine's bacteriostatic properties. A study was conducted with surgical wounds, some had lidocaine applied, others had saline applied. The post-surgical infection rate with the lidocaine wounds was much less than the wounds with saline application. This tells me why I rarely had wound infections in all the years treating wounds with lidocaine.

Tips for the Application of Lidocaine

To use lidocaine to treat pain in a wound, just apply a small amount, about 1-2 grams, of oral viscous lidocaine to the dressing. then apply this side to the wound. Because of its viscous nature, lidocaine can be used on any type of dressing. Apply the side of the dressing with the lidocaine to the wound. The affects should begin within a few minutes, providing pain relief to your patient. Change daily or as needed and provide further systemic pain relief if necessary.

So, if you have not used lidocaine for wound care, consider starting to use it. You will be very happy with the outcome.

Note: Aletha Tippett, MD, is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, a family physician, and international speaker on wound care.  This article was originally published as part of the WoundSource Trending Topics series; permission for its use on this blog was provided by the author. 
 

References

1. Lidocaine Hydrochloride (Local)". The American Society of Health-System Pharmacists. Archived from the original on 2015-09-06. Retrieved Aug 26, 2015.
2. WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Archived (PDF) from the original on 13 December 2016. Retrieved 8 December 2016.
3. "Lidocaine HCL". International Drug Price Indicator Guide. Retrieved 27 August 2015.
4. J. P. Nolan & P. J. F. Baskett (1997). "Analgesia and anaesthesia". In David Skinner, Andrew Swain, Rodney Peyton & Colin Robertson. Cambridge Textbook of Accident and Emergency Medicine. Project co-ordinator, Fiona Whinster. Cambridge, UK: Cambridge University Press. p. 194. ISBN 9780521433792. Archivedfrom the original on 2017-09-08.

Lidocaine and Wound Management

The Use of Lidocaine in Managing Wounds

by Aletha Tippett, MD

What is Lidocaine?

Aletha Tippett, MD

Lidocaine is typically used to reduce sensation in tissue in a specific area. Lidocaine can be either injected or applied topically, depending on need. This topical anesthetic is popular because of its low cost and minimal side effects. Once applied, lidocaine typically takes about four minutes to begin affecting sensation, and effects can last for between a half hour and three hours, depending on dosage. One of the main benefits of lidocaine is its rapid onset of action; while stronger or longer-acting substances may be preferred for surgical procedures, lidocaine’s fast-acting nature makes it perfect for reducing pain in a wound.

Lidocaine has been my go-to product for wound care for over 20 years. I always use viscous lidocaine applied to any dressing. A patient might need systemic pain relief also, but the application of topical lidocaine is very effective to help alleviate local pain of wounds. Since I have used lidocaine so long for thousands of wounds I can say it definitely helps the healing of wounds. Having a nearly 100% healing rate speaks to that.

The newest thing that I found out about lidocaine was recently published in Wounds regarding lidocaine's bacteriostatic properties. A study was conducted with surgical wounds, some had lidocaine applied, others had saline applied. The post-surgical infection rate with the lidocaine wounds was much less than the wounds with saline application. This tells me why I rarely had wound infections in all the years treating wounds with lidocaine.

Tips for the Application of Lidocaine

To use lidocaine to treat pain in a wound, just apply a small amount, about 1-2 grams, of oral viscous lidocaine to the dressing. then apply this side to the wound. Because of its viscous nature, lidocaine can be used on any type of dressing. Apply the side of the dressing with the lidocaine to the wound. The affects should begin within a few minutes, providing pain relief to your patient. Change daily or as needed and provide further systemic pain relief if necessary.

So, if you have not used lidocaine for wound care, consider starting to use it. You will be very happy with the outcome.

Note: Aletha Tippett, MD, is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, a family physician, and international speaker on wound care.  This article was originally published as part of the WoundSource Trending Topics series; permission for its use on this blog was provided by the author. 
 

References

1. Lidocaine Hydrochloride (Local)". The American Society of Health-System Pharmacists. Archived from the original on 2015-09-06. Retrieved Aug 26, 2015.
2. WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Archived (PDF) from the original on 13 December 2016. Retrieved 8 December 2016.
3. "Lidocaine HCL". International Drug Price Indicator Guide. Retrieved 27 August 2015.
4. J. P. Nolan & P. J. F. Baskett (1997). "Analgesia and anaesthesia". In David Skinner, Andrew Swain, Rodney Peyton & Colin Robertson. Cambridge Textbook of Accident and Emergency Medicine. Project co-ordinator, Fiona Whinster. Cambridge, UK: Cambridge University Press. p. 194. ISBN 9780521433792. Archivedfrom the original on 2017-09-08.

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 II

In Part I of our short series on wound types and wound healing, we looked at the two main types of wounds, open and closed, and the main categories of open wounds.

Since closed wounds are not treated using wound vacs – or negative pressure wound therapy – we’ll focus in this article on the types of complications that can occur with open wounds.
 

Open Wound Complications

In open wounds, the skin is broken, cut or split in some way. This leaves the underlying tissue – and potentially bone, muscle and organs – open to the air, which can result in problems with overall healing.

Most small, minor wounds can be treated at home by washing the area carefully with soap and water, using a mild disinfectant to remove dirt and debris, and applying a sterile dressing or bandage to cover the area. Depending on the cause and severity, many small wounds will heal on their own in a few days or weeks.

However, even small wounds can develop serious problems. Let’s take a look at some signs of open wound complications.

Infections

Many open wounds happen due to accidents and are caused by objects that puncture or break the skin, such as metal nails or edges, knives, broken glass, teeth, wooden splinters, etc. These objects are often dirty and can carry bacteria or other organisms that get under the skin and enter the surrounding blood or tissue.

However, it’s possible for infection to occur in any open wounds, including surgical incisions.

If an open wound becomes infected, symptoms can include:

·      Redness, red streaks or swelling – Initially, there may be some redness and swelling around the opening of the wound, which is normal, but if the color worsens, streaks develop (also known as lymphangitis), or swelling increases, it usually means that infection is present.

·      Fluid, pus or draining from the wound – Again, it’s normal to have some clear or slightly yellow drainage, especially from surgical wounds, but if the color turns cloudy, greenish or dark, or if the area has a strong odor, this indicates a problem.

·      Heat or warmth – If infection is present, the body will send additional blood cells to the surrounding area to help fight it. This can make the skin feel warm.

·      Increased pain – There is often mild to severe pain at a wound site when an injury, accident or surgery takes place. However, this pain should decrease over time. Sudden or worsening pain at the site usually indicates a problem.

·      Feeling sluggish, tired or feverish – A fever of over 100° for several hours, or an ongoing feeling of malaise, usually indicates that the body is trying to fight off infection.

In addition, if a wound is not healing and improving over time, this usually indicates that there may be infection present.

Severe infections in an open wound can result in problems such as lockjaw (caused by tetanus bacteria), gangrene (caused by a variety of bacteria, including Clostridium and Streptococcus), and sepsis.
 

Wound closing and healing

To heal properly, open wounds need just the right amount of moisture and to be protected from infection while closing.

Small wounds can be covered or closed with small adhesive strips or sterile bandages. Larger wounds, however, may require stitches, staples or other treatments to help them close and to prevent infection. Closing the wound brings separated tissue together to promote the healing process.

When treating complex open wounds, there are a variety of treatments that may be used to help the area heal. In the final post of our short series on wound types and healing, we’ll take a look at how negative pressure (NPWT) can be used to help treat and close complex open wounds.

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

Note: Important material for this article came from woundcarecenters.org.

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.

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.

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.