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I got a 76 yo lady came in for general nail management She is a diabetic and presented with involuted nails on both hallux. She was admitted to the hospital for cellulitis on the big toe on the 3rd week after the last visit with me.
She informed the doc that it was the podiatrist's fault for causing this infection as I've cut the nail way too deep.
No pus noted on the nail sulcus. All I can see is general swelling and redness of hallux.

What's worst, the doc thinks I'm totally at fault too.

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Miss Gangrene

Thos is from the Diabetes manual I use with our 3rd yr students:

“There are some vascular surgeons who tell their ischaemic patients never to seek treatment from a Podiatrist because such treatment could be harmful; indeed, at the first Malvern Conference on the management of the diabetic foot (UK), a vascular surgeon listed Podiatry as one of the causes of gangrene.” (Foster A: Should Podiatrists Treat Patients With CLI? Critical Ischaemia 3(4)120-124 1992)

Some of these concerns are addressed by Foster (Foster A: Should Podiatrists Treat Patients With CLI? Critical Ischaemia 3(4)120-124 1992)
 It is true that Podiatrist sometimes accidentally cut their patients – this is inevitable
 Unfair accusations are made against Podiatrists when the Podiatrist was simply the last person to see a patients or detects an ulcer, which the patient then blames the Podiatrist for causing
 The Catch 22 – “If the Podiatrist does not clear out the nail sulcus the pressure of accumulated onychophosis on the flesh may cause ulceration, which in turn become infected and necrotic. Conversely, if the sulcus is cleared out, this may set up inflammation, ulceration, infection and necrosis. Either way, the podiatrist can potentially be blamed.”


Common problems caused by lack of podiatry for the CLI patient: (Foster A: Should Podiatrists Treat Patients With CLI? Critical Ischaemia 3(4)120-124 1992)
 Nails may be cut by amateurs with catastrophic consequences. Many patients with CLI are elderly and frail. Their eyesight may be poor and associated neuropathy may be present. It is dangerous for such patients to provide self-care.
 Lay care for the patient with CLI is definitely contraindicated. Nails in the ischaemic foot are often thickened, curved or involuted and it is easy to cause trauma to the nail plate or sulci when using improper instruments.
 Without a podiatrist nails may be neglected and left to grow overly long. If the feet are painful or the nails are gryphotc, the patient may be afraid that podiatrist treatment to reduce the nails will be painful and they will not voluntarily seek treatment. Thickened nails and pressure from the shoe may lead to ulceration of the nail bed.
 Although the feet of patients with CLI rarely develop heavy callosities, they will sometimes form plaques of thin, glassy and very hard callus. Such callus, if neglected, may split and crack, leading to ulceration.
 Shoes are very important for these patients, so will benefit from Podiatric advice.
 Without podiatric intervention, the detection and treatment of ischaemic lesions may be delayed.
 Without access to regular Podiatry, patients may use the unsuitable proprietary remedies or “trim corns with razor blades”.


Guidelines for establishing protocols for the podiatric management of CLI (Foster A: Should Podiatrists Treat Patients With CLI? Critical Ischaemia 3(4)120-124 1992)
 Podiatrists should always palpate pedal pulses before treating to ensure CLI is detected
 Patients and relatives should be carefully educated and informed about how to avoid trauma to the CLI foot, the danger signs of deterioration and necessary action to be taken if this occurs
 When removing callus or corns on the ischaemic foot, Podiatrists should be inclined to underoperate and should handle the foot very gently.
 Podiatrists should cut nails with great care and never clear out the sulcus or dig under the eponichium of the ischaemic foot if this can be avoided
 Podiatrist should … take further courses in the management of the high risk foot
 If pulses are impalpable, the PI is low and the foot is painful or ulcerated or gangrenous  emergency referral
 Podiatrist should never use caustics or chemical debriding agents on the critically ischaemic foot
 Podiatrist should always follow national guidelines
 Podiatrists must remember that there is no such thing as mild diabetes or a trivial lesion on a diabetic foot or a CLI foot.
 Podiatrists should always tell the patient exactly what is going to be done to them during treatment
 Podiatrists should always keep very precise notes, recording all lesions and treatment offered together with follow-up arrangements and emergency advice in case the foot deteriorates. If accidental trauma is caused to the foot it is essential for the Podiatrist to record exactly what happened.

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Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
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God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

I read a few years back that Lloyds of London does not offer medical malpractice insurance in Pennsylvania and Australia- but does cover the rest of the world. So, we have this in common (since I practice in Pennsylvania), as well as getting accused from time to time for causing an infection.

Here are some things that I commonly document on diabetics and vasculopaths...

1) Nails were debrided without bleeding or trauma to the soft tissue
2) Care was taken not to violate the nail folds
3) Antiseptic was applied prophylactically before and after the debridement
4) Patient tolerated the procedure very well and without pain
5) Patient was informed to seek immediate medical attention if any changes occur not matter how minor, even if this means going to the emergency room
6) I reviewed the warning signs of infection

What a strange world we live in when podiatrists cutting nails have to document more than brain surgeons???

This my friends is a world wide issue. Not just the vascular surgeons dealing the dirt from ''on high'' but other medical professionals like to point the accusing finger at us too. I was treating a diabetic patient who was also under the care of the practice nurse for ulcer dressings to his right pma. The nurse had seen the man the previous day & announced that it had healed. Yes you guessed it , healed NO, roofed YES. After checking circulation was not an issue I debrided the area & rebooked the chap in with the nurse for regular dressing changes. On his next visit the patient told me that the nurse doesnt want you (me) to ''mess with it anymore!'' as she told the patient that I had caused his ulcer to re occur. I have since had a friendly chat with the nurse in question. I think many of these misunderstandings happen because we tend to work in isolation, very few of the GPs or nurses actually understand what we as podiatrists do. Indeed one GP was very scathing & was quite amazed that Podiatry was actually a degree course!! Dont ya just love em.

Thank you all for the wonderful replies! And I do agree with Mr Scorpio that proper documentation will be the best way to go if anything should happen.

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Miss Gangrene

The git probably can't see past his ego to consider all possibilities.

I've had similar incidents happen to me too - you know,the 60-odd yo woman who has refused to change her footwear for years, despite being told by every POd who has seen her. You enucleate her H/D and surprise! Pus oozes out. You inform the client that she has an ulcer under her corn and her automatic reply is "you've caused an ulcer!" My reply is "I'm good, but not that good. An ulcer takes weeks and weeks of pressure to develop. This is why we've been asking you to change your shoes for 5 years. "


All we can do is document, document, document.

I tell every patient that has a corn with the remote possibility of an underlying ulcer that they definitely have an ulcer prior to debridement. If wrong, I still tell them that it is "pre-ulcerative" (which is the truth) and they are lucky- I document that the shoes caused the problem (which is the truth) and that they are non-compliant (which is the truth) - they leave the office happy and perhaps wise up- they typically come back with the same shoes - and the beat goes on...

When it is ulcerated after debridement, and I told them before-hand, I have never been accused of causing the ulcer.

This is pretty much the same spiel I use now (although I might steal your "pre-ulcerative") - that one client telling me I caused an ulcer once 10 years ago was enough.

We live & learn.

It is all the same over the world. Some doctors claim podiatrists for infections and necrosis after treatment. But sometimes it is for insurance reasons, bringing in attorneys to have some money.

Podologicus Schliersee Germany

Let me set another example from another colleague of mine.

A diabetic patient claimed that the podiatrist had caused an ulcer unncessarily on the plantar aspect of left hallux.On the last visit, the podiatrist did give her a nic during callus debridement. The pod did everything she could with dressing and wound care advice before letting the patient go.
She got admitted with swelling and redness around the hallux 3 weeks later. Upon hospitalisation, her blood sugar is high. Toe brachial index demonstrated 0.2 /0.3 reading ( I think). She also had other multiple medical problems.
Now the patient's daughter wants the hospital to pay for all the costs involved. She claimed that if the cut doesn't happen in the first place, she wouldn't have to pay for for the bills in the first place.

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Miss Gangrene

I think there needs to be some some clear statements in things such as the Australian Podiatric Guidelines for Diabetes etc that say:

"Inadvertant skin penetration is a potential side effect of any podiatric treatments that require the use of surgical instrumentation. Appropriate management of any skin trauma should be performed to minimise the risk of secondary infection"

This type of thing would go a long way to helping Registration Boards and Courts to knock this issue on the head.

This *no* different to some minor bleeding when getting a "scale and clean" at the dentist, and needs to be put in perspective.

LL

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Remember, it's just a foot.

we have such a statement in our new patient information brochure, and all pod clinics could do likewise

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Stephen Tucker
Eastern Health
Podiatry Manager

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