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Hey everyone, I’m in private practice and newly qualified. A lady who did not speak English attended yesterday evening with her daughter. She was a type II diabetic on insulin and another medicine for her diabetes (but she didn’t know the name). She was on lots of other medication also, but did not know what they were for, or their names. She had a heart op a few years ago, but couldn’t tell me anymore.

She did not know when her last foot screen was, or her last HbA1C.

The lady complained of hot and itchy feet all over, all the time. She also had what I was told was a blood blister that had popped two weeks ago on her little toe. On examination she had a neuropathic ulcer on the base of the left fifth toe. The wound was not infected. Neurological assessment was negative on all tests. Vascular assessment: I did not have a Doppler but both DP pulses were palpable. PT was not palpable. Feet were warm to the touch and she had hair growth on the toes.

I cleaned and dressed the wound, explained the findings, and advised she visit her GP ASAP. I wrote a letter and faxed it to her GP for immediate referral to foot protection team. This morning I contacted GP to find out status – they have no record of the patient. I contacted the patient on the number provided – the number was ‘unavailable’.

My question is: is there anything else I could have done??? I am really concerned about this patient.

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She needs a referal to a high risk foor clinic - now, if not before. Rob

MissB, any idea why a 'blood blister' developed on "the base of (her) left fifth toe".
Did you inspect the inside of the shoe, ask about other shoes, if it had a removable sock liner take it out and examine for irregularities and pressure depressions from the digits?
'Hot and itchy', tinea pedis? there's more than parathesias, all the best and good luck, mark

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LIBERAL small 'l' AND PROUD"

Hi,
Other things I would consider... does the ulcer probe to bone? Duration of the ulcer (hard to illicit sometimes). An XR would be prudent to check for any signs of Osteomyelitis. I would put her into a Darco post op shoe to eliminate the possibility that foot ware contributed to this which is most likely. You also should try and refer into one of the hospital based podiatry clinics, they know how to best handle these sorts of wounds which ofter require multidisciplinary input. Many amputations result with these sorts of presentations.
Good luck!!

Hi Mark,

Obtaining a history was difficult – due to the language barrier and the daughter’s lack of knowledge about her mother’s condition/conditions. I did look at her footwear, she was wearing flip flops. It wasn’t clear whether these were her usual footwear.

There were no signs of tinea pedis.

As for the blood blister – that is what the daughter thought it was. They couldn’t tell me what caused it or if any trauma had occurred, only that it had been there a couple of weeks. Information was limited to say the least!!

I suspect that she is not registered with a GP.

Rob,

I know that she needs to be seen by high risk foot clinic – I just don’t know how to do it seen as she doesn’t seem to be registered with a GP. I did tell them to go to A&E or a walk in centre if unable to visit GP.

Thanks Burke,
I know that the wound should be probed, X rayed, and that offloading is needed… but I’m in a private clinic and we don’t have the equipment or the facilities to provide the care she needs. This is why I faxed GP for immediate referral to foot protection team. I also called the team myself for advice/referral but they were closed. I left a message asking them to contact me, no response as yet.
As I said, I suspect she is not registered with a GP. I’m concerned because I know the risk of amputation with patients such as this. Don’t know what else to do!

MissB

I applaud your integrity- as a newly qualified pod you have done all the right things, it would seem that with lack of co-operation from the patient whether intentional or not, there is nothing more you can do.
Referral, as you have done , is paramount- in the UK in private practise it is most unwise to start probing to bone ! It is up to the specialist team/GP to refer for x ray as appropriate, and the multidisciplinay team have the resources to give the patient the appropriate treatment.
When you are newly qualified in PP it is normal to worry whether you have done the right thing- you seem to be completely on the ball and well able to cope. Dont worry, as time goes on and your experience grows, your confidence in yourself will grow too!

Hopefully the patient will be ok- you have done your best!

regards
CM

Yep, agree with CM here. Sounds like you documented everything and made the appropriate referral. Not your fault that the pt provided misleading/inaccurate information.

Tip for future pts who do not speak English (or indeed vulnerable adults/children); Obtain a contact number of the chaperone who accompanies them for their treatment. You may just need it.

Cheers,
Bel

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Just a rock `n roll refugee.

If...

Realistically there is nothing else you can do.
Don't beat yourself up.

Why?

I think this is your absolute core duty in neuropathic ulcer management, no matter what setting you practice in.

LL

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Remember, it's just a foot.

You did the right thing. Most likely a foreign visitor.

Probing is to determine if the lesion involves bone. To clarify there's osteomyelitis isn't imaging still required. Why not miss the 'invasive' probing and do the scan on all visually suspect lesions? From talking to 'probers' most that look suspect do 'probe to bone', mark

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LIBERAL small 'l' AND PROUD"

Because the true extent of the lesion cannot be determined any other way - perhaps except for where there is good resultion of the sinus tracts on MRI, or opening the lesion for a true I&D. Generally either of these alternatives is overkill for a 5th toe.

Given the sensitivity and specificity of 'probe to bone' compares well to plain x-ray, and its specificity is comparable to TPBS, there is no reason not to use the "5 cent bone scan" in any clinical setting. It provides the mechanism to rapidly instigate antibiotics, whilst awaiting for more definitive confirmation. It is stunningly cheap in contast to MRI.

I cannot think of any instance when I would not do this. It is atraumatic, and a valuable clinical diagnostic tool (though not infallible). Put into context to the rest of the clinical picture, it has a strong role to play.

The gold standard for diagnosis still remains bone biopsy.

LL

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Remember, it's just a foot.

I certainly wouldn't be doing that in a PP in the UK. PPs here just are not equipped to deliver neuropathic ulcer treatment or management, and delivering less than optimum care is leaving the practice wide open to litigation.

Patient needed urgent referral to the GP and footcare team. That's what was delivered.
The fact that the patient didn't arrive was not the pods fault.

To the OP - at worst the patient will go somewhere else. You also got to test the referral pathways for the next time.

Thanks Lucky, are the antibiotics prescribed different for those lesions not probed to those that are?
That is why I have never probed at all, is it really atraumatic, isn't there a chance of damage to the periosteum and / or to 'new' tissue from contact with the probe?
Mark

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LIBERAL small 'l' AND PROUD"

I guess I find this very suprising.

Is diabetic foot care not a basic core practice in private practice in the UK? What is the average private practitioner not equipped in that would leave them unable to manage a straight forward neuropathic ulcer on a 5th toe, or elsewhere.

Genuinely interested...

Ulcer debridement in little different to callus debridement. Poking a sterile blunt instrument into a wound to check its depth is not rocket science. Then pop a basic dressing on, offload with your weapon of choice, review next week? Liaise with GP for adjunctive imaging or antibiotics if necessary.

How does this vary from, say, an ulcerated interdigital corn?

LL

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Remember, it's just a foot.

There is empirical antibiotic therapy, and targeted therapy. Which way you go depends on knoweldge of the common bugs, and whether a deep wound culture is available.

Yes - a blunt sterile probe is atraumatic, and certainly less traumatic than the patient putting on their shoes and taking 5 steps to the reception counter. Periosteum is tough, it takes a 15 blade and a bit of effort to bust through it (generally).

Try dissecting to, cutting through and reflecting back through the periosteum on a raw chicken wing to get a feel for it. Simple 5 minute exercise in comparative anatomy, which is remarkably close to the real thing.

LL

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Remember, it's just a foot.

Hi LL,

Here in the UK we have several problems besetting the PP dealing with anything but routine cases, and acute cases in otherwise healthy patients.

Referral pathway to GP and the GP Practice. In chronic illness the GP must be involved somewhere down the line. My experience is that referral pathways to and from GP Practices to PP are less than seamless, as illustrated by the OP.
Referral pathway for imaging and Duplex scanning. If an ulcer is not responding to treatment what do you do?
I would want as much information as I could get hold of. I would suggest that looking for blocked and calcified vessels is high on the list of checking things out, and UK PP's do not have the facilities to deal with these. Remember that hand-held doppler readings will often show a bounding pulse (which may be mistaken for a strong pulse) if arteries are calcified.


Lastly there is the question of litigation. I have first-hand experience in dealing with clinical negligence cases, some involving podiatry.
The Gold Standard in diabetes footcare is to work within a multidisciplinary team of expert healthcare professionals. Any podiatrist taking on an ulcer case in a diabetic patient on his or her own is wide open to litigation if the patient subsequently develops a limb-threatening condition.

The type of questions which may be asked after the leg (or portion thereof) has dropped off are:
Was the patient's doctor involved in this case. If not why not?
Did you at any time suggest to the patient that a team approach may be more effective? If not why not?
Were you in possession of the patient's full vascular status before, during and after your treatment plan. If not why not?
Etc, etc, etc.
You can see where this one is going, can't you?

This is not to say that the podiatrist is not the right person to treat a diabetic ulcer, far from it. But simply that the right setting for the podiatrist to do this is within a team.
Excepting that a new patient arrives and turns out to be diabetic with a lesion which may or may not be an ulcer. I that case prompt and urgent referral to the GP is appropriate. The OP acted entirely correctly.

David

Thank you for your comprehensive reply. It is very informative regarding the philosophy of private primary care practice in podiatry within the UK.

Here in the Antipodes, I would say things are a little different. This is not to say that some podiatrists may choose to have very little involvement in neuropathic ulcer care (eg if sports is their game), but I feel there is an expectation amongst many GPs, endocrinologists and the like that the podiatrist is responsible for managing for uncomplicated lesions of this flavour in a primary care or community setting. Naturally a severely septic patient require inpatient care and different needs.

There is certainly still a team approach to primary care here as well. Our system is also geared towards the GP being the 'centre' of the action, but there is a difference between providing the GP with information about the patients' care, and taking responsibility for what I would feel here is a core aspect of podiatry care. A 'team approach' exists here in the private/community setting just as strongly as within a larger hospital. I would argue the outcomes vary little regardless of the setting for uncomplicated neuropathic ulcers.

We too have some barriers to cost-effective advanced vascular imaging, but most neuropathic lesions, in my experience, have very little ischaemic component. Even in a mixed neuro-ischaemic lesion, a correct medical history, careful examination and a thorough non-invasive vascular exam will give you all you need to develop a diagnosis of PAD without Duplex or arteriogram. Again, the majority neuropathic lesion have little PAD component so this is generally not the concern.

I think I am a little suprised that private practitioners refer these things straight to GPs, rather than working with them to manage these simple problems. Our public hospitals would go broke if every one of these ended up being managed by a hospital diabetic foot team.

As an aside. How do private practitioners handle nail surgery then? This is arguably an equivalent procedure in terms of risk (think somewhat ischaemic limb with long standing infection and suspect osteomyelitis). Are these procedures not offered by private practitioners and referred to GPs too? The clinical decision making seems basically the same to me.

Kind regards

LL

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Remember, it's just a foot.

Daivd & LL,

Interesting discussion. I agree with David`s post in that the GP involvement, or referral pathway, in pts presenting with diabetic complications in private practice is not seamless here in the UK. However, I also agree with Lucky here;

Whilst `the Gold Standard in diabetes footcare is to work within a multidisciplinary team of expert healthcare professionals`, I am seeing a marked increase of such ones presenting with ulceration in my practice (often, the pt is unaware that there is ulceration beneath their `corn`). This is a direct result of the NHS discharging patients with `controlled diabetes`. I view it as my responsibility to treat it and send a written descriptive report of the ulcer, which does sometimes include probing to bone, directly to the pts GP. I basically treat patients with uncomplicated ulceration in exactly the same way as I did whilst working for the NHS and expect the GP, or diabetic nurse, to acknowledge receipt of my letter and confirm that the referral has been made the same day. More often than not, I do have to chase up the referral with a couple of phone calls.

David, I think your statement; is true, but don`t you think it negligent of the practitioner to not perform the appropriate tx, if it is within their clinical expertise? Providing of course, that they also make a referral to the specialist diabetic team and explain why this necessary to the pt. Assessing a patients vascular status and treating neuropathic ulcers is a fundamental part of our training and thus, within our remit in both the private and public sector, IMO.

Unfortunately, more pts are being turned away by the MDT, and GP`s do expect us to manage basic diabetic ulceration and keep them informed of any changes in their foothealth status.

Just my experience and thoughts.

Cheers,
Bel

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Just a rock `n roll refugee.

If...

LL

I think David has covered most of the points regarding diabetic ulcer treatment in PP.

Those of us with experience will know when to treat and know when to refer on- the OP is newly quailified and did the right things with her limited experience of such presentations.

One point that has not been mentioned that in the uk most patients rely on the NHS, they have no medical insurance and may not be in a position to pay for ongoing ulcer treatment if necessary- therefore another reason to get them to the specialist multi disciplinary team within the NHS. I have no problem treating as a first line, and have of course resolved many uncomlicated diabetic ulcers, but as David says, I do not want to open the gates for litigation- life is too short!

Regards
CM

Hi Bel,

In answer to your question (in bold) yes I do (think it negligent). However, by referral back to the GP and specialsit diabetic team and by making sure that the relevant pathways for urgent care, should that need arise, you are working within a team framework.
The onus is then on the NHS if anything goes wrong, you having done everything in your power to ensure seamless care within a team setting.

Bashing on about a "gold standard" in diabetes footcare, as I have, is all well and good, but I recognise, and it is well documented, that many NHS facilities do not employ an adequate footcare team. Your point about early or premature patient discharge is well taken.

Assessment of the lesion, and circulatory and neurological assessment are certainly part of our training, and should be used where appropriate.

miss B Good work. Being a fresher you have done well. i assume you might have off loaded the area. its good to be worried about your patients especially if you cant contact them. You have covered every thing, identified , treated, and referred. Document all this you have done (and that the phone numbers were not reachable).

Probe to Bone test: Miss B you dont have to do it if you are not confident. A sterile, blunt probe is advanced to determine the depth of the ulcer and if the ulcer area includes bone. and if the bone is felt and you include that in your referral to the high risk Team this patient can be fast tracked. Injury of the periosteum is possible if the advancing probe is pushed hard. The idea is to advance the probe not to push it. The fascia that adhers the internal structures is strong enough to resist a blunt instrument. Your knowledge of anatomy and your observations can also guide you. Depth of the ulcer, location (dorsal foot ulcers: The skin is in close proximity to the bone, Compared to plantar aspect) and size of ulcer.
You have done well. Its a pity some patients (or most) underestimate the impact of neuropathy. Or may be they dont have anyone to care. It feels bad but, hey life goes on...

Good Luck

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Regards

David.S

David et al

I have been "banging on" about this for years !!
THERE IS NO REFERRAL PATHWAY TO MULTIDISCIPLINARY TEAMS IN MY AREA

Even the NHS podiatry clinics can only refer via the GP and with the standard of some GP's and Diabetic nurses we have now who don't seem to grasp the urgency of the situation we just have to make do and deal with each individual as best we can ( as Miss B has done)
It is interesting to note

And that is from her local team...really awe inspiring isn't it ?

A couple of years ago I went to a diabetic conference laid on by Diabetes UK. I sat and dutifully listened to presentations from somewhat eccentric nurses who "loved feet" and spoke utter bovine excrement . But the whole theme o it was made abundantly clear they do not recognise IPP's exist !!
Several tried to interject and get answers but the speakers just didn't understand the volume of practitioners that are working outside of the NHS and struggling to cope with Diabetic neuropathetic ulceration that is necrotic with nowhere to refer to.

Having had a patients father brought to me ( origin India) who could not speak English and the son had limited understanding a couple of months ago who, on examination had bilateral ulceration to the bone under callus on the plantar aspect of the Hallux Ipj's. I decided to call the Sons GP to ask for an immediate referral to the MDT at the local hospital. I can only say the response I received was nothing short of disgusting. The GP screamed at me down the phone so loud even the patient and relative could hear "never mind what you want what does the Son want" wouldn't listen to anything I said so I asked if he wanted to speak to the Son who was standing next to me who made an appointment with the GP for the following day in the evening.

I was livid the Son was bemused and the patient totally bewildered

I dressed the area's aplogised I was unable to take it further and asked to be informed....I'm still waiting...but then I'm used to that so MissB don't feel bad Hun there are a lot of us about with the same problems that would appear to be beyond resolution
Cheers
Derek

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"Political Correctness" is a doctrine, fostered by a delusional, illogical minority, and rabidly promoted by an unscrupulous mainstream media, which holds forth the proposition that it is entirely possible to pick up a turd by the clean end

I'm not sure how relevant this is, but surely these problems with referral pathways is just asking for trouble with private practitioners being able undertake nhs work with the new healthcare reforms? from my very limited experience (being a student) either attitudes towards private practitioners needs to change or there needs to be a better understanding of how many pp's there are and the kind of patient's they are getting through there door.

Incidents like DTT's are not only unhelpful to the patient's but there bad for future working between pp's and nhs

Hi Del,

Agreed - that's the way it is in many areas in the UK. Thats why the practitioner involved needs to stay one step ahead of the game - because if something does go wrong they are first in the firing line.

My concern is when the GP's have to pay for it out of their own budget which is starting to happen now under the new government NHS reforms, if we have the described current situation at present whats it going to be like when that is fully in motion ???

I was speaking to a GP on monday who informs me he cannot send patients for MRI scans direct anymore. They have to be referred to a consultant who sends the pt for MRI which is reported back to the consultant and then back to the GP. The GP practice then gets charged for it.

So my question is, what chance have we now getting ANY referrals to specialist care when the GP practices are running out of money ??

Very interesting times ahead I fear, and hopefully the courts will recognise that difficulty and you as an expert witness will build that into your submissions .
Cheers
D

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My location

http://www.surreyfootcare.co.uk

"Political Correctness" is a doctrine, fostered by a delusional, illogical minority, and rabidly promoted by an unscrupulous mainstream media, which holds forth the proposition that it is entirely possible to pick up a turd by the clean end

Hi Blumley

Well Ive been trying to improve things for the last 25 years, I'll hand the mantle to you and yours that are just coming into the profession

I wish you all the luck in the world for the future, I think your going to need it

Cheers
D

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My location

http://www.surreyfootcare.co.uk

"Political Correctness" is a doctrine, fostered by a delusional, illogical minority, and rabidly promoted by an unscrupulous mainstream media, which holds forth the proposition that it is entirely possible to pick up a turd by the clean end

with 25 years of this its nothing short of a miracle that you haven't gone a bit mad :). Ah well nothing like a touch of optimism to keep you going through revision

ben

Hi Ben
Not a bit mad????

Errr wot makes you arrive at that conclusion???

I'm revising myself for an exam believe it or not so dont ever think you can give up learning in this profession

Just ENJOY
Cheers
D

__________________
My location

http://www.surreyfootcare.co.uk

"Political Correctness" is a doctrine, fostered by a delusional, illogical minority, and rabidly promoted by an unscrupulous mainstream media, which holds forth the proposition that it is entirely possible to pick up a turd by the clean end