APMA News - September/October 2017 - S3

SUPPLEMENT TO APMA NEWS

YOUR APMA / PAGE 3

WHEN TIME MATTERS, DON'T DELAY
By Barbara Bellione, RN, CPHRM, ARM, director of Risk Management, PICA

Your patient presents for her first post-operative appointment. Three days
earlier, you performed a hallux varus repair, arthroplasty of the second
digit, and an open partial ostectomy of the second metatarsal, all of the
right foot, and repair of the peroneal brevis tendon in the right foot and
ankle. Following surgery, you applied a cold therapy unit (CTU) within the
bandages to control swelling and pain.
Upon examination, you note a cyanotic appearance of all five toes of
the right foot, which you attribute to the CTU. What would you do?
A. Remove the CTU and instruct the
patient and her husband how to monitor the capillary refill time between
visits to monitor return of the circulation and ask the patient to return the
following day.
B. Remove the CTU and refer the patient
to a vascular surgeon for a vascular
evaluation the following day.
C. Remove the CTU and call the vascular surgeon to arrange an immediate
appointment for a vascular evaluation.
The scenario above was
at the heart of a podiatric
malpractice lawsuit. The
defendant podiatrist in this
case opted for choice A. He
removed the CTU, instructed
the patient and her husband
how to monitor the capillary
refill time between visits, and
instructed her to return the following day.
When the patient returned the next
day, color had returned to toes 3, 4, and
5, but toes 1 and 2 were still cyanotic.
The podiatrist removed the K-wire from
the second toe, which seemed to improve
circulation, and made arrangements for
the patient to see a vascular surgeon the
following day.
The patient admitted to the vascular
surgeon that she had utilized the CTU
continuously overnight the night prior
to her initial post-op visit (against the
instructions that had been provided
by the podiatrist), and the toe issues
became apparent the next morning.
The vascular surgeon diagnosed a vasospasm and felt it was intensified by the
prolonged use of cooling. An angiogram
showed a complete loss of blood flow to

the first and second toes of the right foot.
He treated the patient with intra-arterial
TPA and nitroglycerin. A sympathetic
block was performed two days later. The
patient was also treated with hyperbaric
oxygen, nitroglycerin paste, and local
debridement. Her condition worsened,
necessitating amputation of the first and
second toes of her right foot.
The allegations in the lawsuit against
the podiatrist included that a delay
in obtaining a vascular consultation
created a window of lost
opportunity for the vascular
surgeon to salvage the toes.
Unfortunately, podiatric and
vascular surgery experts for
the defense could not support the podiatrist's three-day
delay in obtaining a vascular
consultation. They felt the
podiatrist should have opted for choice C
above-arrange an immediate appointment for a vascular evaluation. Had the
patient received immediate treatment,
there was a good chance the toes could
have been saved. The case was ultimately resolved through mediation.
This case illustrates the importance
of making timely referrals, especially in
situations where there may be a short
window of time to prevent an unfortunate
outcome. When time matters, be proactive
and call the appropriate consultant to
provide a synopsis of the situation and
obtain an immediate appointment for
the patient.
For more information, contact Barbara
Bellione at 800-251-5727, ext. 2052,
or visit www.picagroup.com.

FELLOWSHIP
OPPORTUNITY AT
THE UNIVERSITY
OF MICHIGAN
By Michael E. Munson, DPM, assistant
professor of Internal Medicine and fellowship program director

Fellowship applications due:
November 1, 2017

A

s more podiatrists are considering
careers at universities and academic
health centers, or simply want to expand
their knowledge and acquire the skills to
conduct high-quality research, the profession has seen a corresponding increased
interest in podiatric fellowships. This article
focuses on a research fellowship in limb
preservation, wound care, and diabetic lower
extremity complications at the University of
Michigan, department of Internal Medicine,
division of Metabolism, Endocrinology, and
Diabetes (MEND) in Ann Arbor, MI. This
CPME-approved fellowship is a two-year program designed to train podiatrists interested
in a career in research, teaching, and clinical
medicine/surgery, and it covers all areas of
podiatric medicine. Two positions are available, one in each year of training.
The educational opportunities in this
fellowship program are quite rare. We are
aware of only a few training programs of
this kind that seek to produce highly trained
wound care and limb preservation experts in
Continued on Page 4
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Table of Contents for the Digital Edition of APMA News - September/October 2017
