Why Give Up on MIST Treatment and Crow Boot? Jack Kegley's Story

UPDATDJack Kegley, USMC

UPDATED: 5/18/2013:
Mr. Kegley reports that he is now getting treatment that is satisfactory to him. Thanks for everyone's help!
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ORIGINAL STORY:

Jack Kegley USMC is a 100% disabled Veteran (Vietnam) currently receiving treatment at the Seattle VA.

With the use of treatment such as MIST therapy, skin grafts, negative pressure therapy and specialized boots to offload the wound, his wound shrunk to the size of a pencil lead and was continuing to heal. Then the VA decided to give up on him. Why?

In 2007 Jack sought treatment of a diabetic ulcer about the size of a quarter, on his right big toe. Elderly diabetics are frequently at risk for injuries of this sort and, if not properly treated, they can grow to the size of a nickel or quarter, and compromise the patient's health generally.  For two years he was treated weekly at the dermatology clinic where a nurse practitioner would debride the foot (that is, scrap off any dead tissue), wrap it in a bandage and send him on his way. This did not result in healing.

Typical "Crow Boot"

In 2009, a new approach was tried: instead of treating Jack as an ulcer with a patient to be managed, he was treated as a patient with an ulcer to be healed.. The more aggressive and holistic approach went after not just the dead tissue of the toe, but the entire patient's nutrition (vitamins and minerals), blood sugar, bio mechanics of walking and so forth. This included the use of a Celleration Corporation “MIST Treatment” (which is also approved at other VA facilities and at Madigan Hospital). Plans were made for a "crow Boot" made to offload the foot even further and perhaps a skin graft to close the wound completely. The ulcer began to shrink and reached the size of a pencil lead.

However toward the end of 2012 that treatment was terminated. The Mist Treatment device was taken away and the previous, ineffectual treatment of scraping the wound was resumed. What does this mean to Jack?

He wrote to the VA several times:

"Let me start this conversation by stating that I am pleased with the level of care that has been provided to me, under most circumstances, by those I have worked with at the VA Seattle and that the following is not reflective of the entire staff and facility.

I am now back at the position I was a year ago with no indications to what type of progress they expect to make, how they expect to offload the weight on my toes (I now have wounds of both large toes) or give me any indication as to the future plans.  They are even talking about taking the scooter away at some point in the future.  I will not tolerate going backwards, I will get out of the VA system and seek private care before I let this return to a point it was a year ago.
Now that they have cancelled the crow boot which was suppose to offload my right foot, and made other changes that do not give me confidence, there are no indications as to when they expect to do anything other than debride the foot.
It has now been 8 weeks since Podiatry took over care of the wound, I am no better than I was when they started, my second toe is healing as expected (but no indication as to why the foot blistered in the first place) and secondary wound has occurred on the side of the original injury.  When I was receiving the Mist treatments, infections were non existent ( I am now under antibiotic care for an additional 6 week to fight a new infection) and an explanation was never given as to why I only received 3 of 27 mist treatments authorized by fee services and why the treatments were cancelled. No plans have been discussed as to future offloading of the wounds or future treatments other than a weekly debridement.  That treatment has now been denied for the future with no explanation to me as to why.
As a Marine I learned the difficult we did right away and that the impossible took a little longer.  I will not stop this type of correspondence until my status returns to a satisfactory state or this issue is resolved.
Sincerely
John M Kegley
USMC"

Lest you think that MIST Technology is some strange, new-age things, see the Bibliography of studies proving its effectiveness. It's not as cheap in the short run as debridement but, on the other hand, it was fixing the problem. The crow boot is not exotic either.
The VA system is not a privilege or a nice-to-have; it is a right that was earned by service to our nation. It is not a place to mess around; it is a place to implement effective treatment. Why was the treatment that was working ended and the treatment that was not working resumed?
Why the change?
Who benefited from stopping the treatment that worked?
So far, Jack has written several times to the VA and not received any response giving him a satisfactory response as to why the Seattle VA Hospital decided it didn't like MIST treatments and the crow boot. What will it take to get these questions answered and effective treatment resumed?

Saluting The Speechless

This week at the VA Hospital on Columbian, I was working with a client. He was there with two family members, I was with another volunteer from Veterans And Friends of Puget Sound, and jointly we were shepherding this elderly veteran through the process of getting the basic exam necessary for medical assistance there.

He was certainly deserving; he was a member of The Greatest Generation and I won't go into the details, for the point of my story was this: he could no longer speak or write. Communication was difficult. It seemed as if he had lost mental function, and it's hard to tell whether he had, for his hearing was not the best either. People around him typically spoke of him in the third person; there seemed little point in speaking to him since he could not respond and it was not clear that he understood anyway.
This changed when one doctor was told that the client was hard of hearing. The doctor started giving directions in a loud voice: "Can you raise your right hand? Can you give me a thumbs' up with your left hand?" and so forth. The client did all that, subject to some restrictions obviously of a physical nature. It became apparent to me that he was mentally alert to a significant extent.
I didn't know what to do about that. I made an effort thereafter to speak loudly into his ear where we were going next, "We need to get a blood draw, is that all right?" But it is hard to keep this in mind, when the responses are minimal. The responses were there, but they were purely physical and difficult to feel as communication.
Then it happened. We were in a waiting area and, as often happens, struck up a minor conversation with another waiting person. When that person left, he looked straight at the client and gave him a salute. The client gave him a relatively sharp salute right back.
This nonverbal message communicated a lot: respect, presence, interaction, normalcy. It is a part of the military culture that was important to him. It was something he could do and feel good doing, and in the process receive the respect he merited.
For the rest of the visit, I made a point of encouraging those present to give him the salute. He always responded. After we loaded him into his vehicle to be taken home, I faced him and did what I have not done since the Boy Scouts: gave my best salute. He returned it with firmness.
There is nothing more to say.