Now How Did That Happen?

  Have you ever heard of the law of unintended consequences? It says that actions always have an unanticipated or unintended effect.¹ No matter how pure and well-meaning one’s intentions, any action may not turn out exactly how imagined. This can especially true when dealing with governments. One classic example involves the impoverished people of Haiti. The world community has come to the aid of the Haitians even before the hurricane, the cholera epidemic, and the floods. Much of this help has been in the form of food—corn, beans, and other produce. On the surface this looks like a wonderful, generous gesture. Unfortunately, the law of unintended consequences took over. Corn and beans are two of the cash crops grown by the Haitians. When the international community delivered all of this “aid” to the country, the farmers were no longer able to sell their products. Most everyone in the country had all the corn and beans they needed for free! Since the farmers could no longer sell their products, they had no income. The Haitian’s situation was made worse, not better, by this “generosity.”²   Certainly, in wound care we would never do anything without the best of intentions. However, have you ever recommended a treatment that had an unanticipated result? Have you ever recommended a moisturizing cream for a patient’s dry skin only to have them return a few days later with a painful, red, draining leg from an allergic reaction? Have you ever applied a compression bandage to the leg of a patient with a venous ulcer and swollen leg only to have them return complaining of severe pain due to the bandage being too tight? Neither of these instances intended to harm the patient, but the law of unintended consequences was ever present.   Unintended consequences can occur when an inappropriate diagnosis is made. The provider can have good intentions but the outcome will not be what is expected if the appropriate treatment is not used. One of the more frequently misdiagnosed problems we see in our wound center is mistaking a malignant skin lesion for an ulcer. Hardly a month goes by that a patient is not referred to us because of a “wound” on the leg that is not responding to someone’s therapy. It really is not surprising that an unintended consequence occurs when an ulcerated skin cancer is treated with compression therapy!   Unintended consequences can occur when dressings and bandages are not used appropriately despite the best intentions. Most of the wound care products with which we treat our patients require at least a minimum of knowledge to get good results. A compression bandage that is applied with inappropriate tension is one example. Everyone is afraid of wrapping one too tightly and causing problems, but if the bandage is not applied with the appropriate tension (30- to 40-mmHg pressure), the desired outcome will not be achieved. Training and practice are required to acquire the skill of correctly applying compression bandages³ if an unintended outcome is to be avoided.   These are just a few examples of the law of unintended consequences. In wound care we strive to get the best results possible for our patients; that of getting them healed. Unfortunately, if we do not continually study and learn about how to use products and treatments appropriately, we may be the cause of the unintended outcome our patient experiences, that of not healing.   How do we avoid the law of unintended consequences in wound care? Study, learn, and practice, practice, practice. Then, perhaps, you won’t have to ask the question, “Now, how did that happen?” References 1. Norton R. Unintended Consequences. In: The Concise Encyclopedia of Economics. Available at: https://www.econlib.org/library/Enc/UnintendedConsequences.html. Accessed: January 30, 2011. 2. Schwartz TT. Travesty in Haiti: A True Account of Christian Missions, Orphanages, Fraud, Food aid and Drug Trafficking. Lexington, KY: BookSurge Publishing; 2010. 3. Keller A, Müller ML, Calow T, Kern IK, Schumann H. Bandage pressure measurement and training: simple interventions to improve efficacy in compression bandaging. Int Wound J. 2009;6(5):324–330.