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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