differing views on how to treat

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Hi

whilst on placement I cam across something new and I was wondering if I could get your views on this.

The patient is a male late 30's who has a neuropathic ulcer to the heel. This has been on going for best part of a year, with it showing signs of improvement then deteriorating again. The patient, is a smoker and type 2 diabetic, with not the best self control with regards to diet etc.

He has been in for debridement twice a week and re dressings, but is also under the care of a local orthopaedic consultant. Now this consultant has decided they do not want the wound debrided at all, until their next appointment with them (around 7 weeks). The podiatrist has gone along with this, despite not being happy with the decision. I saw the patient again more recently and his ulcer seems to have gotten a lot worse, with bleeding under the callus as well as the area being very dry.

The podiatrist at this point offered debridement, but the patient has refused as he wants to go with his consultants advice. The consultant has also failed to reply to emails or any other form of contact.

Now from what I have read, debridement seems to be a major part of neuropathic ulcer management, so im intrigued by the consultants decision.

Has anyone experienced this before, if so could you shed light on their decision and how you would manage this situation.

kind regards

ben

 

Sounds odd to me, all literature and experience indicates frequent debridement and offloading of the affected area plus consideration of the consequences of infection and the appropriate action to be taken. I.E. leaving the wound undebrided would increase the potential for critical colonisation and infection by contaminating microbes.

Dave

 

I would have a few issues this. Mainly regarding the issue of doing as the co sultant says even if it goes against evidence, Knowledge, Experience and pofessional skills. If all goes wrong the podiatrist will be required to prove their reasoning for not debriding. If it is the correct choice for the wound and they can explain their reasonings then fine, but if debridement was required and leaving the callous led to deterioration and further complications then the podiatrist is potentially able to be held responsible. Just because the othopod may have said no to debridement does not mean that it is the correct decision or that the pod would be free of blame for any resulting problems. As a health professional they would be expected to fully support their own reasoning for treating or not treating. Simply stating that 'the orthopod said No' would be no defence in a negligence case.
Personally I would do what I thought appropriate with the patients consent, document fully what had been done and why, document if patient declines debridement stating why and get the patient to record/sign this decision. If consultant not responding to contact then also recording times and dates of calls and copies of letters or emails.

In my 16 or so years of experience within the world of Diabetic wound care I have frequently gone against consultants requests/demands when I have felt that it is in my patients best interst, I have always ensured that the patient knows what I'm doing and why, and is able to consent to treatment. I have also in difficult cases made sure that the GP is kept informed and if there is a specialist nurse affiliated to the consultant I have also contacted them(they are generally amazingly knowledgable about the condition they deal with, very approachable and a fantastic link when technology fails!).


Basically, the podiatrist should do what they consider best for the patients longterm outcome, with the patients consent, with fully documented records and the confidence to know that they are a qualified professional able to make educated decisions regarding their patient's care






Basically, need to do what is best for the patient and their
wound. If you carry out appropriate treatment, record everyhing and are able to provide good reasoning fir your treatment then the outcomes should be the best possible for all involved!!

 

first off thank you dave for the articles, very informative! I think your points about documenting everything and discussing these things with the gp are very relevant and something I will maybe suggest depending on how things develop. Have these situations occurred with any of you in the past?

 

The patient, is a smoker and type 2 diabetic, with not the best self control with regards to diet etc.

hmmmm I guess the orthopedic decided he had enough with him lol