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Apologies if this has been posted elsewhere but did anyone see this last week?

A young girl, must have been early/mid twenties, with really rather disgusting OG/OM/OX great nails that needing avulsing.

Apart from her being a tad minging, I mean come on love, do you not have a bath in your house!!? I was intrigued as to why the heck she was referred to an orthopaedic foot and ankle surgeon for the procedure. It was even done under a general anaesthesia which seemed daft to me!

2 questions.

1. Under what circumstances would a fit, healthy individual be referred to secondary care for a simple avulsion, under general.

2. Why did the surgeon also administer Local to the area as you would do normally? Baffled by that.

Oh and she obviously had some real issues with looking after herself given the terrible state of her toes post op. I don't think she'd changed the dressing for 2 weeks or something. Dirty girl .

This episode can be viewed on Channel 4 OD

1. Because this is routinely done in orthopaedics. There is little that is done under local anaesthesia alone. Also can be patient preference.

2. To lower the dose of IV sedation required, so that a quicker recovery can occur in recovery. All foot surgery is done with adjunctive regional blocks, including digital surgery. Also for pre-emptive analgesia (esp. bupivacaine).

LL

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Remember, it's just a foot.

Well you learn something new every day.

Seems a ridiculous waste of resources to me but I suppose if she had a genuine needle phobia then it's the only option. She definately had a soap phobia, that's for sure!

Also the chap was using cotton bud type devices to apply the phenol. Are those EZswabs? I also noted an application of what looked like vaseline around the PNF/sulcus to protect the skin which seems sensible. Do you still scarify with a blacks file using that system or just apply with the swab end, and how do they compare to just dropping the phenol in with a dropper? I must admit to occasionally getting phenol where we didn't want it, very occasional though and never caused a problem. the EZswabs look neater and given we dispose of our phenol after one use (and only use a few drops) it would probably work out no more expensive.

I would urge everyone to track it down on 4OD as posted previously. Always interesting to see foot based things on the telly.

To DGRoberts,

Your 2 questions are both excellent points!

It is ridiculous that a pod was not involved in the first place.

Hamish,

How expensive is it for a patient to have this procedure done by an orthopaedic surgeon, compared to a pod?

I would imagine the insurance tariff is the same for the surgery, the sedation will have been an additional cost over a pod with LA - but maybe the telly show got a special rate for dropping the name of the hospital into the piece.

I dont think it fair to say this girl was minging! She obviously had a phobia about her feet, and there would have been no way she could have endured a local infiltration alone- I imagine that although young, the decision was taken to phenolise once and for all so that the problem was never an issue again. Even her follow up protocol was difficult for her as we saw by the subsequent post op infections.
In this instance I do believe the correct referral pathway was taken, but more post op care should have been in place.

Cornmerchant

Unfortunately I can't access this video from Canada, so can't comment on the buds they used. Were they pre-filled? I do wish I could see it, the body equivalent of "How clean is your House?" I'm guessing. That show has aired on our specialty networks, I'm sure we have just as many grotty houses, as they've also created a spin-off for the US tv market.

As for the buds, we used cotton tipped applicators that we manually saturated in Phenol when I was in school. A friend who was trained at Brighton and leapt the pond tried it herself a few times when she moved here but didn't have as good results; anecdotally higher rates of regrowth (though statistically insignificant as she stopped shortly thereafter and reverted to her old successful ways).

I use a few drops and work it in with a blacksfile, as she was influential in my training, and I find it works quite well. I saw quite a bit of regrowth with the buds myself as evidenced by the number of patients either needing or seeking revision of the procedures. They dry up quickly and get saturated with blood/drainage, decreasing the effectiveness of the phenol. I have never had a failure since graduating and switching to her (and apparently your) technique.

Stick with the tried and true, and just take care not to spill that phenol.

Sarah

The reason many nails surgeries are performed by Gen Surg and Ortho units is to give the new interns some surgical experience. They are considered to be simple procedures, so they let the newbies have a go.

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Stephen Tucker
Eastern Health
Podiatry Manager

My location

I fully agree with this. I dont believe in turf wars. There are many areas of overlap between various health disciplines. The most important thing is getting the best patient outcomes and utilisation of limited resources.

Colin Thomson in Edinburgh did a study on the success rates and costs of Orthopaedic surgeons v Podiatrists and the Podiatrists won hands down for success rates and costs.

Why didnt her parents FORCE her to wash? It must have been really minging living with such a smelly daughter!

Also those nails did look as if a partial nail removal could have been done and a bit of conservative nail drilling rather than leaving the girl with a cosmetically unattractive pair of toes for the rest of her life. But total nail removal was probably decided upon for paranoia reasons.

Jacqui

Lets be a bit realistic about this, the reason that an orthopaedic surgeon done the procedure and not a Pod is simple he wanted !!5 Minutes of TV fame!!

You might be right Joseph. I also think her apparent psychosis may have played a part too. I may be wrong but it may well have been the case she was assessed by a community Pod and then passed into secondary care as she may have presented as a tad complicated.

Either way she WAS minging, no 2 ways about that. All her lesser nails were full of muck and bullets, I just hope she's snapped out of it and had a bath since.

dgroberts

In one sentence you say that she apparently has psychosis, the next you say she is minging, as you pointed out in your original post.
I wouldnt like to hear your views on someone with real mental health issues.

Cornmerchant

Get off your high horse man, very condescending tone there sir.

I used the term psychosis in its loosest sense; the TV program was edited in such a way to give the impression she was flaky and unwilling to look after herself. It makes better telly.

I deal with people that have genuine, debilitating mental health issues regularly so know exactly how to behave around, and manage this patient group.

Time for a between cleaning brew and to find a fascinating thread regarding a programme that highlights a national fascination for boobs, bums, boys bits and feet.

At the start of this young ladies 5 minutes of fame she explains she keeps her socks on in the shower, removes them and puts a clean pair on. This would explain the build up of tut and gubbins. Also highlights an irrational fear rather than anything more serious.

Its such a shame this 19 year old did not get a referral to a podiatric team that could have managed the patient's fear, managed the damaged toenail during regrowth at the same time as managing the other "worse" nail. Finally a referal to Pod surgeon for bilateral PNAs under general would have completed the care.

Seen worse, dealt with worse with a bit of time, understanding, trust and patience most fears can be overcome. Wonder if this is what some of our colleagues mean when they promote themselves with the words "all foot problems treated sympathetically"?

I wonder if her irrational fear was "cured"? Maybe the fee she received for appearing on Embarrassing Bodies did the trick.

GB

dgroberts

I have dismounted my high horse.

However, I take exception to the description of a young girl who could actually be my daughter , as minging. I do think on a publc site, that it is not in the interest of the profession to refer to patients in such derogatory terms. Call me old fasioned, just how i was dragged up!
I am sure you are very sympathetic to your patients with mental issues.

Cornmerchant

Maybe they have a pre arranged medical team for the show/series and therefore have no need to venture beyond these professionals as they probably cover all areas of practice.