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Sharp Debridement under LA

Discussion in 'General Issues and Discussion Forum' started by lucas87, Jul 30, 2010.

  1. lucas87

    lucas87 Member


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    Hi room, my first post here!

    Can anyone direct me in the way of literature regarding Sharp debridement using an post tibial block for use on neurovascular corns etc?

    I am trying to bring this into my scope of practice and to develop the department I work for. The only issue is that i have to provide evidence for using such a treatment on patients and to show that there are more pros than cons for my management team to authorise this and to send me for training.

    any help would be gratefully appreciated,


    Lukas
     
  2. Hello and Welcome Lukas.

    I think the question you ask is an impossible one to answer.

    I doubt you will find any inductive evidence showing better outcomes for debriding NV HD's under local. Its sort of an impossible thing to research. Lets face it, if we measured outcomes, they will be entirely dependant on how the patients in the non LA group were able to tolerate the debridement, which in turn would depend on the clinicians manual skill and, in no small part, their psychological skill, and the rapport they established.

    LA is simply a method for making painful proceedures painless. We KNOW it does that. Debriding NV HDs hurts like buggery. We know that too. The inference should be clear.

    I'm a recent convert to the joys of the tibial block. In my experience it is far less painful than the digital blocks all UK pods are familier with and in my private clinic I routinely offer it to patients for anything plantar which is likely to hurt. Ive more or less dropped cryo in favour of needling now, and i've had more than one patient tell me the LA for the needling was far preferable to the pain of the cryo! When I go to the dentist, I expect a choice where LA is concerned. I like to offer that same choice to my patients.

    That said, I sympathise with your problem with your management team. Having played the NHS politics game for 10 years I share your frustration. My advice, for what it's worth, is as follows.

    Re. training, the tib block is part of your undergraduate training so you should only need a refresher. Find someone local who is doing them and adhere yourself to them for a day or two. In my experience most Pods are happy to share their knowledge. Its really not a hard proceedure.

    Re showing more pro's than cons, you may be being too "nice". I've always found in the NHS that it is better to beg forgiveness than ask permission. You are the professional right? Here is your patient. He has an NV HD. You need LA to do it properly. You don't say "please sir may I use LA on this patient" because the answer will always be "how much will it cost?" Try instead, "this patient requires debridement under LA to treat. Unless you want me to refer him to the local pod surgery / ortho team at far greater expense, I'm going to be doing it under LA".

    Failing that, fill in an IR15 (assuming its the same form north of the wall) for a risk to the trusts reputation from the patient going to the local rag complaining that he is having to have an agonising proceedure done without anaesthetic because the trust won't let the pod use the LA they are trained on because it cost too much.

    Or better yet, JFDI. You're the podiatrist. You know what the patient needs and you're trained and equipped to do it. So do it. You don't ask permission to use an insole, or to do nail surgery under LA.

    Shout it with me Lukas, Who da man? YOU DA MAN!!! Get out there, learn you some tib blocks and make it happen. Bend the world to your will.

    WHO DA MAN?!?!

    Regards
    Robert
    (sorry, reading back, possibly should cut back on the caffeine again).
     
  3. Or, I guess, you could just lie.

    Debridment under LA lasts 6 months and costs one appointment at circa £20 for your time (band 6) and about £2 sundries.

    Debridement without LA lasts 4 weeks, therefore 6 * £7 for your time = £42

    Ref to pod surgeon costs circa Loadsamoney.

    LA = cost effective.

    Its probably not going to be that long lasting but it will take them years to figure that out if you know what you're doing, during which time your patient is having pain free and long lasting care.:drinks
     
  4. lucas87

    lucas87 Member

    Lol AM DA MAN!!!

    Thanks for your words of encouragement and for the way to deal with management! i've only been qualified for a year so not wanting to go in gun blazing, I'll get shot down right away.

    Re: money, its even CHEAPER, for them as I'm a band 5 :( but hoping to make this my own niche within the department.

    Unfortunatley I never got the opportunity to do a tib post block during my training, the need for it never occured frequently. However I have found someone who is willing to show me the technique, but it won't happen for a while so just gotta go through these months with regular appointments and good old padding and orthoses in the mean time.

    Thanks again


    Lukas:D
     
  5. blinda

    blinda MVP

    References please, Mr Isaacs?

    Tis true what he says tho, "LA is simply a method for making painful proceedures painless". It`s within our scope of practice so to not use it for a painful procedure could even be seen as negligent. I also use it for NV`s and needling VP`s.

    I wasn`t trained in tib blocks at uni either, so found myself a fabulous mentor, Steve Wells, who let me practice on him! I`ve done the same for a few new graduates in my area too. It`s far more comfortable than Local infiltration.

    Cheers,
    Bel
     
  6. G Flanagan

    G Flanagan Active Member

    here here, i am a great conveyor of all things LA. If anybody in the Lancashire region wants a refresher im quite willing to help.

    I work in surgery so do lots, so you could pop down (or up) anytime.


    George
     
  7. Isaacs R G De Sade M, Torquemada rev. Pilot Study into the effect of scandonest on scream volume and depth of finger imprints on chair armrest. Chains whips and barbed things monthly vol 7 p813 - 821

    I have the full text somewhere.
     
  8. Sarah B

    Sarah B Active Member

    Hello Lukas

    I'm a bit late in on this, I know, but thought I'd share my expererience of getting my own way at work (in the interests of patient care, I hasten to add)!

    If I were you, I wouldn't go for the argumentative approach - it seldom works and tends to upset those senior to you who lack the skills and/or imagination and/or caring to consider a different approach from that which they learned during their training (some time ago).

    I've used essentially the same approach, dressed up with varying degrees of 'officialness' (new word?) over a number of years:

    1. Have the idea (which you've done)
    2. Collect some data to demonstrate the size of the problem - in this case how many patients have NV lesions? Here you have a couple of options: carry out an audit with the participation of colleagues or extrapolate from the patients you see over a period of time. Look at time between visits, treatments used, pain scales, etc, etc. If I were doing this one, I'd pay particular attention to assessing pain during treatment (to justify using LA in the first place).
    3. Look at the costs, risks and benefits of your proposal.
    4. Compile the above information into a written report, and use the evidence you have to justify your stance.

    The only thing I would say is that I'm not sure that making a niche only for yourself is the best way to progress in an NHS career these days. I know people who have done that, and did well out of it, but I personally achieved success at climbing the ladder by demonstrating a commitment to furthering my own skills and using them to work with interedted colleagues. But I guess that's reflective of my own personality and style of working, and maybe also of the departments in which I worked.

    But I have to say that I admire your foresight and desire to develop your own skills, the service you & your colleagues provide and of course your own career. I wish you the very best with it all!

    Do let us know how it goes.

    Sarah
     
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