It all started with a phone call at close to midnight on a Saturday night from my physician’s phoneline app. It was an established wound care patient calling me to state that his negative pressure therapy device went awry. He was requesting advice to resolve the issue. Out of these growing concerns, he stated that if there was no solution, he would be immediately reporting to our hospital emergency room, which was not his preference in such a situation. In response, I simply informed the patient it was safe to turn off the device and that I would make a home visit to him at 5 o’clock the next morning. With a sigh of relief, he agreed to the plan.

Stepping into the Patient's Shoes

Immediately, after ending the call, I realized I had zero wound care supply inventory for a home wound care visit. Typically, I would keep supplies stocked at my home or car; however, I had never replenished the stock after volunteering services, supplies, and medical expertise at a hospital in Haiti last year.

Principles of Clean Dressing Technique Versus Asepsis

I simply went back to my slumber without worry, believing I would just replenish the supplies at the chain pharmacy that’s open for 24 hours before going to see the patient in the morning. Well, fast forward and it’s 4 a.m. I am now in the pharmacy and staring overwhelmed at the abundance of medical supplies and equipment. Not only did the amount of inventory and disorganization of the items catch me off guard, I was also taken aback by the retail pricing of the items that I prescribe in both inpatient and outpatient settings daily. For perspective, when dressing a medium-size ankle wound, typically a dry sterile dressing consists of a few 4×4cm woven sterile gauze pads (four to five), an abdominal pad, sterile single-ply cotton-rolled gauze (two or three rolls), and paper tape to secure the bandage.

With that in mind, I browsed the wound care section of the store in search of these fundamental items to procure for the dressing change. The first items on the checklist were sterile 4×4cm gauze pads, which took me almost five minutes to find in the overwhelming section of items on top of items in that category. I was able to identify the store brand pack of 20 sterile 4×4cm cotton gauze pads for approximately $8.00. Being that the first item that I selected was almost $10.00, my reaction was this that shouldn’t cost any more than $20.00 total. The next items on the checklist were the abdominal pads. Of course, I had become frustrated with the organization of the store’s shelves, so I stepped back, took a deep breath, and continued my quest, which took me an estimated time of five minutes.

I was able to identify a 12-pack for approximately $5.00. At this point, I was getting slightly more enthusiastic because my checklist was getting filled; however, I had been in the wound care aisle of the store for an elapsed time of fifteen minutes and I was only halfway through my checklist. The third item on the list was sterile single-ply cotton-rolled gauze, which took me another five minutes to identify and narrow down a five-count pack, which had a price point of approximately $10.00. Finally, I was able to procure my fourth and final item in only one minute, which was a pack of paper tape for approximately $5.00. In a matter of 20 minutes and $33.00—before sales tax—I had successfully procured the wound care items needed for my early morning at home dressing change to aid this patient until we resolved the negative pressure therapy device malfunction.

Steps for Helping Patients Acquire Wound Care Supplies

Although I was able to obtain the items needed and resolve the patient’s situation that morning without issue, I was reflecting during my drive back home what had occurred while at the chain retail pharmacy. I thought, “Well, I am a practicing podiatric wound care physician who struggled almost a half hour to identify the correct items needed to perform an optimal dressing change for my patient, and it was above the original target budget of $20.00 total.” The supplies purchased were good for only two to three dressing changes, the typical interval for most weekly dressing changes. If a patient is uninsured or underinsured, they would be paying approximately $33.00 a week on a fixed income, totaling roughly $130.00 per month. Most wounds do not heal until after approximately six to nine months or sometimes a year, thus making it an average cost of $1,300.00 annually for basic dressing supplies.

There have been plenty of occasions when I have informed wound care patients that their insurance plan does not cover supplies and they need to purchase the proper dressing to heal their wound at the retail pharmacy or online, without factoring in the cost per month or year into their already burdened fixed income and copay or out of pocket expenses to be treated at our facilities. This shopping experience was rather enlightening to me as a practitioner because for the first time, I was placed in the patient’s shoes that morning.

Even as a physician, I could simply be reimbursed from the practice for the expenses. Also, given the amount of time it took for me to decipher the products that I needed to purchase that day, I could only imagine the amount of frustration some patients have with me or other practitioners when instructed to purchase these wound care supplies at a local retailer. Since that moment, during inpatient clinical services I first investigate whether the patient’s insurance covers wound care supplies. If their particular plan does cover supplies, I will sit with the patient or their companion to explain each item that the home health nurse will be utilizing. If their particular plan does not cover supplies, I will then sit with my laptop and Google search each item for the patient to find the least expensive price or jot down a list of websites to find bulk pricing. This may seem extremely time-consuming for a busy practitioner, but I would highly recommend either having a pre-printed list of supply recommendations with pricing already prepared or training a staff member to aid the patients.

Conclusion

In closing, there is a quote from Lemony Snicket that seems suited to this moment: “Assumptions are dangerous things to make, and like all dangerous things to make—bombs, for instance, or strawberry shortcake—if you make even the tiniest mistake you can find yourself in terrible trouble.” In the setting of wound care, our mistakes of not taking patient education and finances into consideration when recommending dressing protocols can cost more than time and money; it may cost a limb or even a life.

I would like to dedicate this blog to Carlos “Charlie” Vallejo, MD, who is the father of a longtime friend of mine, Gisselle Vallejo Plasencia. Dr. Vallejo lost his battle to COVID-19 on August 1, 2020. He was a physician who always put his patients first, which is why I found this dedication fitting for this blog post.

About the Author

Alton R. Johnson Jr., DPM is currently an American College of Foot and Ankle Surgeons Podiatric Medicine and Surgery Clinical Research Fellow at the Penn Presbyterian Medical Center in Philadelphia, Pennsylvania. Concurrently, Dr. Johnson is enrolled in the Perelman School of Medicine, University of Pennsylvania Certification in Clinical Research Program with anticipated completion in Spring 2021.