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Health & Safety during domicillary visits

Discussion in 'Practice Management' started by Nicki Allen, Apr 11, 2006.

  1. Nicki Allen

    Nicki Allen Welcome New Poster

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    Has anyone got any good ideas to prevent back and neck problems for podiatrists carrying out treatment in patients homes?
  2. Donna

    Donna Active Member

    Dear Nicki,

    In my previous employment, I was required to do home visits, and unfortunately found it particularly difficult to maintain correct spine posture in this situation. :rolleyes:

    I was visited by an occupational therapist (OT), who took a fairly thorough background history, and she made a couple of “constructive” comments regarding behaviour modification when performing home/hospital/nursing visits.

    I personally didn’t find any of these suggestions to improve my comfort, but perhaps they may benefit you:

    - Where possible, place the patient’s leg on a small chair or footrest, or if the patient has a recliner chair, ask them to fully recline the chair to (comfortably) raise their feet as high as possible from the ground. This may prove difficult with some patients as hip/knee problems can make it difficult for them to sit for any length of time like this.

    - Don’t sit on the floor. Instead use a low chair, and bend forward from the hips. I was also advised to try kneeling on a single knee with the other leg bent in front (a bit like the “will you marry me?” pose) and bending forward from the hips while in this position. (I was actually advised against kneeling by my physio, who also said that those ergonomic kneeling chairs are particularly bad :eek: )

    - Carry as little gear with you as possible, a small bag with 1 packet of instruments, 1 pair of gloves, dressings, scalpels, etc, which saves your back from lifting large loads into and out of the car.

    It is best if you consult a reputable OT yourself, to see if they can make any other changes to your home visit set up. This is just a basic summary of what I was told to do, but I'm not sure of the quality of the advice I received… When I relayed this info back to my physio, he was quite unimpressed with the advice given, considering the presence of an L4/L5 disc bulge :eek: . So I don’t know if this was just the OT on a bad day :confused: , or if there are more experienced or better OT’s around that can offer more useful advice?

    I hope this has helped a little bit, or at least pointed you in the right direction with where to get more help ;)


  3. Nicki Allen

    Nicki Allen Welcome New Poster

    Thanks Donna
    Its pretty much what I thought but its a difficult problem to solve, especially if an individual has underlying back problems.

    Thanks again :)
  4. davidh

    davidh Podiatry Arena Veteran


    My advice (and you may not find this at all helpful) is to give up the domiciliary work, and carry out your treatments in a surgery-based environment in which you have control over a) the patient's height. and b) your height.

    Back poblems, and RSD, are the inevitable eventual consequences of domiciliary work.
    A decent standard of living is not.

  5. Donna

    Donna Active Member

    Hi david :p

    That's exactly the advice that I was given by both the physio and the orthopaedic surgeon regarding my crooked back, to avoid forward flexed postures...and surprise surprise, within 2 months of leaving that type of work my level of pain had dropped by 90% :D


    Donna :)
  6. trudi powell

    trudi powell Active Member

    Give up home visits...yes we should as a profession ignore the housebound and disabled. It looks alot more professional to greet people from behind your fancy waiting room desk, than walk into their homes carrying your tools ?!

    I know this thread was a while ago but there are some people who make a very good living out of domicilliary practices. I would gross $400-$600 a day. The rent is cheap too !

    Realistically, there are some very basic rules for your health and wellbeing while doing a home visit. These guidelines generally don't get passed down from podiatry 'elders' to our newer generation since we don't get to work side by side on a home visit.

    I have had the large busy, ground floor clinic and employees but due to my 3 beautiful young daughters find it more flexible to do home visits. I work 4 days a week in school hours and only give my patients a guess-timate of appointment time. Usually a 2 hour window, say 10am - 12 noon. ( after all most of my patients are home all day anyway )

    Your posture is critically important. Firstly to prevent future laminectomies and secondly to position yourself to control and see the feet well.

    I prefer to sit on a kitchen style chair in front of their most comfortable and well-lit easy chair. [/B]Your knees should be lower than your pelvis. This way your ASIS are level and you're not twisting. I place a blueys ( plastic backed disposable absorbent sheet - used often in hospitals for dressings and incontinence ) on my lap and get the patient to put 1 foot up on my lap at a time. I work with very ill, housebound ,high risk patients and only one lady was unable to place her leg up due to her spinal fixation. Ensure the patient relaxes their leg so they don't end up cramping in their quad.

    Some Pods swear by the little foot stool, but this requires you to lean forward placing a great strain on the lower back, and it can make it difficult to get a easy steady view of the dorsum of the foot.

    I suffer from more cervical straining but the lower back is protected from the flexing. A quick look up to talk and make eye contact with your patient is enough to protect your neck. Obviously good symmetrical posture is best for us all.

    There are great advantages of a domicilliary practice, flexibility of working hours being the most obvious. If I need to pop in to see the Easter bonnet parade at school, it doesn't mean cancelling patients . The main disadvantage is going home and still needing to wash and sterilise all your sets of tools each night. Buy an ultrasonic cleaner.

    Doing home visits usually means we need to be even more diligent with sterile techniques, and an obsessive organisation of your 'kit'.

    On another note for personal safety, when attending a new client and you're not entirely sure they are a legitimate well-intentioned patient, just send a text msg to a friend with the address you are visiting, so someone knows where you are, or ask your friend to call you in 20 mins. Especially in the rural areas, a text is cheap and reassuring.

    Generally a home visiting Pod will see more ulcers and lesions than the clinically based Pod. We are amongst the top wound care practitioners around. We still do orthotics and to people with little room for error. You can be a real Pod and be professional while still appreciating we have been invited in to our patients' homes and respect that.

    Happy Treating
  7. Anne McLean

    Anne McLean Active Member

    Hi Nick,

    A very good question.

    No one has suggested looking at the design of our dom bags. Try as we might to keep weight to a minimum, this is not always possible and a laden case can be heavy. I use a trolley type case which I can pull along. The handle zips into the top of the case for occasions when I have to carry it. I have had severe lordosis of the spine since I was a child and I find that this greatly reduces strain on my back.

    The height of most footstools available to the profession is too high for the average housebound patient. I have at long last found a stool that is not too high and this makes a big difference.

    The size and weight of a portable dust extraction drill is another problem.

    Why do manufacturers continue to ignore our professional needs? As a profession we seem to accept equipment which is made for other professions and modified for our purposes. Why do we not demand items that are fit to serve their purpose and designed to serve the needs of the podiatry profession rather than just 'to make do'?

    I would agree with David's view of keeping dom visits to a minimum, but don't feel that we can cut them out altogether. I limit visits to those who are genuinely housebound.

    I find that the majority of seats are too high to be of any use. Where patients have prayer stools or similar very low stools, these are helpful. Failing that, I sit on the floor.

    Not having to keep to a tight schedule is also helpful. I too give an approximate time of arrival. This reduces a lot of the strain whilst driving in heavy traffic, etc. Mobile phones have also reduced these pressures, as it's always possible to contact the patient and notify them of severe delays.


  8. trudi powell

    trudi powell Active Member

    The other good thing about the mobile phone on home visits is you can phone your patient after you have been tapping and knocking and ringing at their front door for 2 mins, to tell them you are standing on their front doorstep and get them to open the door !!

    I even have a lady who I park right up to her locked screen door and blast my car horn for a ridiculous 3 sec , sometimes 5 secs, and she still doesn't hear me !! Don't you just love 'em !! No wonder I have nodules on my larynx.
  9. casanach

    casanach Welcome New Poster

    Hi all,

    Any one with a problem with doms could do worse than read Donna's response on 12 April 2006. I agree 100% with her suggestions.

    I am 56 and have been working in Chiropody/Podiatry for 30 years with much of my work being Domiciliary in nature. Whilst I will not say I never have back and neck pain is is seldom acute and never long lasting.

    The kitchen/dining chair for the operator is ESSENTIAL. This puts you in a sensible working position with your thighs parallel to the ground.

    The next trick is to get the patient HIGHER than you. Add 1 or 2 squab cushions to their chair if possible. Failing that the least worst option is to sit them on the same size chair as yourself. The no-no option is to have them lower than yourself; you will then spend the whole session bending forward. If you follow what I am saying you will realise that recling chairs are not a lot of use, hence the fact that I never allow my patients to use them. If I add that I am 1.8 metres tall this advice may have some resonance to newly qualified members.

    I am astonished Domiciliary working practice is not now taught in the colleges. I left in 1976, not sure how much things have improved in terms of chiropody. Further, I suspect that the generation before me using fixed bladed scalpels and sewing together appliances were better technicians and provided just as good if not a much better service than that offered nowadays. I am talking here about good honest chiropody, not podiatry. Both have their place.

    Best wishes,


    Maybe I am lucky as I have never had RSI or major lumbar problems despite my dom bag not being particularly light; I often carry 6 sets of instruments in plastic boxes. I am not a muscle man being 73kg on average but I do keep my self fit and use sound manual handling technques. I would recommend T'ai Chi as a sound example of how to use your posture efficiently.
  10. Anne McLean

    Anne McLean Active Member

    I agree with both Trudi and Howard. Mobile phones are very useful for contacting patients when you cannot gain access or for informing them that you are held up. If you are running a solely domiciliary practice, they also enable patients to contact you when you are out on visits.

    Whilst Donna's and Howard's advice is spot on in an ideal world, I find it impossible to transfer many of the genuinely housebound, who are the only patients I visit, to dining room/kitchen chairs. Many of them live in sheltered housing and don't possess such furniture in their houses. The majority are too immobile to move safely on my own and the time taken to do so would render my fees for treatment unviable.

    Unlike Howard, I am only 5'2", so I am probably more suited to the patient who is welded to an armchair, whether or not it reclines.

    I have been working in chiropody/podiatry for 37 years and must confess to back problems, although it is difficult to tell whether or not this is posture related, as I had a bad car crash on my way to work when I was in my twenties.

    This is another possible consequence of domiciliary visits that no one has considered. I wonder how many others have had accidents in the course of carrying out domiciliary visits or travelling to work? Mine made me reconsider the viability of providing domiciliary treatments to all and sundry, in all weather and is the reason that I now limit such visits to the genuinely housebound or very frail/elderly.

    My accident occurred on black ice, because I was too 'professional' to cancel an appointment in inclement weather. Sadly, I still abhor having to cancel appointments and have never done so, but I like to think that if the weather was really bad and possibly unsafe to travel in, that I would now have enough sense to do so.

    I also have problems with bilateral arthritic arms and hands, which is why I now use a trolley type domiciliary case. There is no way to prove that this is work-related, but if I had my time over again, I would certainly avail of any equipment that might reduce the risk of such an outcome in any type of work situation.

    And all of this despite being a proponent of Tai-Chi!


  11. One Foot In The Grave

    One Foot In The Grave Active Member

    Firstly home visits because of the toll they take on a Podiatrist's spine should be limited to those who are totally and completely housebound -those who do not leave the house for ANY other reason. Anyone who can leave their home should attend a clinic.

    We are fortunate our council provides a transport service which brings isolated clients to us so they can receive their treatments in an optimal clinical environment. We do one homevisit per week which is rotated between 3 pods - not too much of a physical demand.

    In our practise we do not take drills on homevisits. Their bulk and the OH&S issues associated with debris from their use prohibits this in our opinion.

    A trolley is ideal, but this still needs to be lifted in and out of a car so it's weight should be kept to a minimum. the homevisit case needs to be able to be wiped clean, so our choice is a fishing tackle box - the compartments are ideal for separating dressings and blades etc.

    Seating preferable near a window, with overhead lights on in a room without carpet. The client either on an adjustable height bed or in an armchair with foot able to be raised onto footstool.

    What rot! It's about me wanting to be mobile when I am an aged person myself.
  12. Anne McLean

    Anne McLean Active Member

    Unfortunately, I am nearing old age myself and appreciate the value of domiciliary visits more as I embrace this stage of life.

    I would agree that we need to preserve mobility in the elderly, but I am also aware that I give far superior service to my patients in the surgery, as opposed to in their homes. It is also more cost effective and takes less out of the practicing podiatrist. This is not what patients see however and, they are quite happy to be treated in front of their 'home fires'.

    I have always limited my domiciliary visits to those who are genuinely housebound for whatever reason and shall continue to do so.

    The suggestion of a trust, which is forward thinking enough to provide transport and assistance to ferry people to a clinic, has to be commended. It would be great to think that others might follow suit. Unfortunately, with current cutbacks, we are unlikely to see the realisation of this. What a pity, as it answers so many other social needs as well.


  13. Hi everyone,
    This is my first posting on this site. I left my 45hr per week practice after 17 years, when baby number 2 in 14 months was due. The choice was go insane with ever demanding patients for 7pm appointments and no long day care due to wait list. Unable to sell practice as prospective buyers who checked out workload just opened up down the road.

    My choice walk out and convert to home visiting. I was back to work when no. 2 was 3 weeks old,starting at 3 days now after 5 yrs working 5 days but during school hours. I stiil spend 3 days in my old area and converted double garage into new podiatry rooms with the biggest waiting room in Sydney which doubles as our entertainment room leading onto deck and pool!

    I shared rooms with chiropractors and massage therapist when in full time practice, which was just as well as I was their best customer with numerous problems ranging from a disc block to constant neck and shoulder muscle pain and spasm, dislocated ribs and the list continues. All neck and shoulder symptoms resolved since change of pace and only 2 low back disc block episodes in 5 years.

    I use a trolley case but had to change to a smaller lighter bag as I caused shoulder blade problems with larger bag. I also use a portable chair on wheels with built in footstool available from the beauty industry suppliers. This has solved my problem of varied chair heights at each home. I use disposable file and leave the drill at the office. My domicillary practice has grown but I control it with strict limitations on my time and distance I will travel.

    At the end of the week I am in front financially as no more rent, and I don't have to work all those crazy hours. I have quality family time. Next year plan to work 2 longer days by working around other half's shifts and claw back 1 free day a week for house cleaning and gym.

    Life's pretty good and Podiatry is such a great flexible profession.
    Regards Maryann
  14. Anne McLean

    Anne McLean Active Member

    Hi Maryann,

    Welcome to the forum. Let's hope that this is the first of many posts from you.

    My apologies for the tardy reply, but I have just returned from a well-earned holiday.

    Your input proves that it is not just domiciliary visits that need to be considered when we think of work related injuries. Back, neck, breathing and a plethora of other problems, affect general podiatric work as well.

    All areas of podiatry therefore merit much greater consideration in respect of health and safety.

    Instead of using equipment adapted for dentists, we should be looking at some that is ergonomically built especially with the podiatrist in mind, taking into consideration our work positions, which are very different to those of our dental colleagues.

    I presume that your garage conversion suggests that you would prefer to work from premises, rather than continue visiting patients at home. This appears to be the general consensus with the majority of podiatrists. However, as you point out, podiatry is a wonderfully versatile profession. Having had two children myself, I am testament to that.

    I have moved from teaching to domiciliary, industrial, NHS, commercial and now private practice and have enjoyed all areas of work at particular stages of my life.

    Being totally sexist here, I feel that domiciliary podiatry is ideal for females who are bringing up a family, yet still want to continue working.

    The one tenet that we should not lose sight of at such times, is the fact that we are all professionals and, should charge professional fees for our services. Whilst it may be helpful for female podiatrists to be able to keep their hands in and earn pin money for a few years alongside rearing their families, we should always be mindful of the fact that our male colleagues are doing the same job to make a living for themselves and their families. It is only fair therefore that we all charge realistic rates for a job well done.

    I am glad to hear that life is pretty good for you at present and wish you every success in your latest venture.


  15. Hi Anne,

    Thanks for the reply, sorry for the late response, I don't get on the computer too often.

    I agree that there needs to be more thought put into designing suitable equipment to prevent our injuries. We were recently holidaying in Noosa and as usual my son took sick and needed to see a doctor. We saw a very relaxed guy who used a fitball as his office chair. I think not suitable for domicillary visits!

    I'm also not winding down home visits they are forever increasing. I wanted my home office to generate new patients in the local area, as my house calls are 20 mins away. It is a good balance but I still only want to work 4 days not 5. My dust is mounting around the home.

    I agree that we should all be earning a living, I know I need too, I like too spend it too much.

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