Where do you draw the line?

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Client presents for "routine" appointment.

Developed an ulcer on lateral aspect of leg 6/52 ago. The ulcer is 4x2cm, dried sloughy surface,shallow with reddened border.

"My doctor said it's not an ulcer, he wants me to keep it nice and dry" states patient. Ulcer has been treated with betadine and gauze twice a week.

I know I can do a better job of it and get the bugger healed within a few months with dressings that are conducive to healing (moist dressings - unless aforementioned GP has some research he hasn't shared with international wound care community)


However - ulcer is halfway between the knee and ankle, and is a leg ulcer.


Would you perceive this as being in the realm of Podiatrist's responsibility?

Where do you draw the imaginary line of "too high" and being out of "our area?"



(I've referred her to the RDNS for wound care, but would love to get at the ulcer for some serious debridment.)

 

Hi One F.I.G

If you're not insured for treating a leg then it's definitely out of your area whether we would like it to be or not (!) so check with your professional body and/or med insurance company. I think 'Podiatry' scope of practice varies around the world and I don't know what country you're in.
If you are insured: determine the cause of the ulcer then liaise with the nurse and the Doctor, suggest whatever you think is right for the current wound stage and back your suggestions with the evidence.
By the way the evidence around the 'best' wound dressing to use is by no means conclusive- check the evidence base within the NICE Guidelines



Cheers
John

 

Unfortunately I d have to say steer clear.

 

\
That's a great reference - thanks for that.

(No mention of betadine solution, dry gauze and no debridement being the treatment of choice though!! The nurses at RDNS will sort the doctor out! )

 

This is really a scope of practice issue isnt it?

Here in Queensland we have a liberal scop of practice, with no real "definition" for podiatry. Hence we treat surgically below the knee, and many practitioners prescribe orthotics and physical therapy for conditions proximal to the knee.

Where does podiatry start and stop? Who knows. Although I think an anatomical basis for scope of practice has had its day. We have moved along as a profession and many podiatrists have tentacles into different pathologies affecting the knee, hip and spine.

I for one would have NO PROBLEM treating that ulcer here in Queensland, and regularly do. But you need to consult your state registration board for clarification me thinks?

 

Just my thoughts!

I don't think this is a scope of practice issue, rather an approach issue.

What is causing the ulcer? Ischaemia, venous insufficiency, malignancy, warfarin therapy? Without identifying the cause of the ulcer, your dressing choice will remain irrational.

I this was my patient, I would try to identify the cause of the ulcer via Doppler ABPI and a good medical history and then contact the GP suggesting a treatment plan including onward referral to e.g. nurses/vascular surgeon/dermatology. I would then re-dress itas per my 'diagnosis'.

What I would say is that betadine solution is a poor choice in commparison to inadine dressings and that a dressing that prevents further bacterial infection by being less 'porous' such as any foam dressing, would be better than sterile gauze, but it really is impossible to decide what your dressing should be unless you know what is causing the wound and what you are trying to acheive.

Scope of practice-wise, I think it is fine to make suggestions about further care of this wound to the appropriate bodies, but it would be remiss to treat this in isolation.

If you're looking for info on dressings, www.worldwidewounds.com has about as much info as you'll ever need!

Hope this helps!?

 

Have done this - hopefully with the RDNS support we will get the GP to make the necessary referrals.

Unfortunately this isn't the first patient of this particular doctor who has had an ulcer not being treated in this manner. I write my letters summarising Ax results, (ABI's etc) and suggesting a treatment plan, but he fobs them off and tells the patient "we don't really need to bother".

I make the referrals myself now.

The question for me is how high up the leg do we go with our wound care?

 

This is the point I made before...fixing ulcers is a relatively straightforward task, just deal with the causative pathology.

You need to contact your state registration board to seek clarification!

If you are well read and competent in wound care, then you should have no hesitation in providing optimal venous ulcer care to the leg. Your patients, and ultimate the medical staff you deal with, will ultimately gain your appreciation and respect.

Happy ulcer debridement and a merry Xmas,

 

Scope of practice is state and country dependent.A suggestion:Get a good nurse and have her/him take care of debridement,dressing changes,etc.