I can't wait to read some of the responses to this one...stuff I'll have to look forward to in 2011
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I was debriding a sacral decubitis ulcer with a general surgeon in the OR. Then the circulator nurse decided to leave and take a coffee break. The patient then proceeded to crap all over the surgical site. It just kept coming. The surgeon kept yelling for the nurse but she was out. She finally came back after about ten minutes.
At one of the residency program that I externed at, I heard of a story where a patient had coded during routine foot care services. Apparently, this resident had gone to the ICU to do a routine foot care consult. For those whom have trimmed nails know that sometimes patients scream when you cut too close to the skin while trimming the nail, which results to patient bleeding. Well, the resident apparently had cut the nail too close and the stimulation must have caused the patient to have coded in the ICU. From that point on, a policy was made by Podiatry that there they will not do any routine foot care consults in the ICU at this particular hospital. In general, I tend to agree with this policy because when a patient is in ICU, the least important thing for the patient to worry about is long toenails.
Since I havent even started pod school yet, this is not a residency story.
However, it is a very funny story from my days in the psych ward (when I worked there...or was it when I stayed there??)
Anyway, had a schizo, totally looney. Thought he was Jesus and was growing his beard out. He had been there for months, so his hair and beard are really long. At this point, he thought he was a monkey.
So, my coworker went into his room to get vitals on him. What is there to greet him?? A big glob of poo right in his grill!
Boy was that funny (for me at least).
I scrubbed my first BKA. Which is not the big of deal but what was weird is the vascular surgeon only cut of the guys feet. Literally just above the feet. I understand why and all of that pooh, but it was weird to see such a distal BKA or should I say AAA (above ankle amputation).
was there and infection in the feet that were cut off? Was it closed primarily?
I saw one of these and thought the same thing. But remember if there is an infection in the feet, the wound should be left open and then closed primarily on a different day after the infection had been successfully treated. During the primary closure more of the leg will be taken off creating a more normal looking stump with at least 4 cm or inches (oh crap I forgot) of leg distal to the tib tub.
They have been moving up the legs. TMA to a Chopart, now the new AAA. Primary closure was performed. The vascular surgeon send gangrene but I didn't see it or smell it. I did look and smell when I dropped the dressings b/c the nurses where guessing on why the BKA. The poor guys is circling the drain b/l BKA, renal failure, and DM.
I also saw a patient like this. had re-vasc of the limb but only to the distal anterior tibial artery but not the dorsalis pedis and the foot turned gangranous. It was amputated above the ankle, left open, the primary closure was during the BKA.
Only wet gangrene really has a smell. dry gangrene is pretty odorless. But I can't smell psudomonas (sp) so what do I know. Really, I was in the OR with a guy whose leg was basically eaten away with psudomonas and everyone else smelled it but me.
How much outside of podiatric medicine exposure do we get in residency? Will I ever be in a position where I'll be doing chest compressions? During our first year, will I ever be called at 3am for a gunshot wound to the chest? When do we start to geographically confine ourselves to the lower extremity? Thanks for the posts guys
Each residency program structures their outside rotations differently. Some schedule their outside rotations throughout the three years; while other residency programs would schedule a large portion of the outside rotations in the first year. The number of outside rotations also varies from residency program to residency program. Some of these outside rotations include, but not limited to, Internal Medicine, General Surgery, Vascular Surgery, Endocrinology, Rheumatology, Infectious Disease, Plastic Surgery, Orthopedic Surgery, Emergency Medicine, Radiology, Pathology, Behavior Science / Psych, Family Practice / Medicine, Sports Medicine, Wound care, Dermatology, Physical Medicine / Rehab, Neurology, Pediatrics / Pediatric Orthopedics, and Trauma service. In certain residency programs, when a resident is on an outside rotation, they are usually on that rotation full time and is not involved with Podiatry (with exception of academic activities) for the length of the rotations. There are other residency programs where the podiatry resident will be on the outside service part time. For example, a podiatry resident on Internal Medicine may scrub on Podiatry cases and do Podiatry rounds part of the day and show up for Internal Medicine for the remainder of the day.
As for being called into the ER for a gunshot wound to the chest area, the chances are highly unlikely unless you are on a trauma rotation or an ER rotation at the hospital. In terms of responding to code blues in the hospital, the policy will vary from hospital to hospital. Some of the podiatry residents may only respond to code blues during their Medicine or General Surgery rotations. In some hospitals, podiatry residents are expected to participate in code blue if available. Of course, there are hospitals where podiatry resident are not responsible for responding to code blues. When I was a resident, I was expected to respond to code blues in my hospital since we were all ACLS certified.
In residency training, you are going to be specializing in the lower extremity. The only time you will venture outside of the lower extremity is when you are on outside rotations. Hopefully, this has answered some of your questions.
As a Practicing Podiatric Physician can you explain the relevance of these outside rotations. I was asked this question by family and friends and ofcourse i also wonder sometimes that if Pods are allowed to do so many things outside the foot during their residency and school then how come they are not allowed to do more than foot in real practice. I mean there are several states that dont even allow them to do ankle yet during school & residency they do A-Z of medicine. I know it gives broad exposure and increases our knowledge of body but is there like a simple answer to this which i can use when someone asks me this question?
How are you going to know who to refer to or call for a consult if you don't really know what other specialties are capable of? How will you even recognize a non-pod pathology and diagnose it if you haven't at least got your feet wet in that area? Maybe most importantly, how will you gain connections and respect in other specialties if you did nothing in your residency but pod cases with fellow DPMs?
Residents learn a lot lot of things they'll never do again in most residencies - esp good PMS-36s, but the goal there is an understanding and appreciation of comprehensive medical and surgical care.
"Only the union of medicine and surgery constitutes the complete doctor. The doctor who lacks knowledge of one of these branches is like a bird with only one wing."
CapCrunch likes this.
yeah tats true. no doubt abt it. But my question was more like why are they then subject to much scrutiny when they are like so much well trained. I mean if we compare a Pod resident to a IM resident or FM resident. He/She has literally same rotations for 1st year. So i mean isnt it so obvious to entire medical community, state govts, federal govts that Pods are doing this and that but still they impose so many restrictions on us. I mean are they missing something here or they just wanna ignore even though they know we are fully capable.
oh that i mean for example if a pod has to take a skin graft from upper part, he needs to call a general surgeon (when infact in his residency he might have practiced serveral of them during his rotation) and then i heard hospitals also (some here in illinois) dont give them priveledges. This just what i heard from others here.
Grafts depend on the scope of practice of the state. Every doctor has a scope of practice. The difference with podiatry is that we don't have a national scope which is as much our fault as anyones. There is still not much talk of it. But just because you did it in residency or feel comfortable doing it doesn't give you the right to do it. If this was the case, hospitals would be a zoo.
A hospital attempting to deny a QUALIFIED podiatrist privileges is a lawsuit waiting to happen. On the other hand, if the podiatrist does not have the proper training for surgical privileges, then he or she should be denied.
There are far too many in our profession with an inferiority complex. Work hard and be confident. We are the best at what we do.
Some places, it's close... many places, not at all.
Not all DPM residencies are carbon copies of one another (not even close), and most are still constantly evolving. You will notice this when you begin to look at the CASPR/CRIP site and see the outlines of each program's rotations. Regardless of where you do residency, you will take at least some pod clinic and consults right from the start (which non-pod PGY-1s obviously would take none or very few of).
In some of the better PMS-36 programs, a PGY-1 pod will do mostly the same schedule as a PGY-1 MD or DO IntMed resident (actually, it's usually more like a PGY-1 MD or DO Surg resident on most I've seen). Some other pod residencies - especially most of the remaining non-PMS-36s - may have you doing mostly pod all along with only sparse attention to external rotations. You really have to do your homework and get the best program for you to get the particular skills and experiences you want from your PG years.
The main goal of doing these external rotations is to further enhance our medical / surgical knowledge (which you had already stated). This extra knowledge would allow us to render better care for our patients. For example, we may be the only physician that our routine foot care patient sees. However, you may recognize some of the pedal manifestation of the systemic disease in this patient and you may then recommend the patient to go see his/her primary care physician for further workup / evaluation.
In addition to expanding our medical / surgical knowledge, you may also learn different approaches to some of the common Podiatric pathology on the outside rotation and may incorporate this into your practice. For example, it would be interesting in learning how a Dermatologist approach a verruca lesion or how a neurologist would approach neuropathy or how a vascular surgeon does a Transmetatarsal amputation.
On these outside rotations, you will also have an opportunity to work with other residents and different attendings of various specialities. Sometimes, we do have the opportunity to educate our fellow colleagues as to what we do as Podiatric Surgeon. In addition, it will also allow you to work with these people and allow them to get to know you. Once they do get to know you, they will be more incline to refer patients to you. For example, I work with Family Practice residents at my hospital on my Internal Medicine rotation and in the ER rotation. Since I got to know the Family Practice residents well, the few that stayed in the local area are now refering patients to me since they know me well.
You do need to understand that when we do these outside rotations, it does not make us an expert in that area nor does it make us qualify to treat patients beyond our scope of practice.
Even though we may do similiar rotations that the IM / FP in the first year, it does not mean that adequately trained to treat the patient beyond our scope of practice. These IM / FP residents get additional training in their area of specialty during the next few years beyond PGY-1.
As jonwill stated, I am not aware of any restrictions that medical community places on the Podiatry community beyond the scope of practice. As jonwill said, it is unfortunate that Podiatry does not have a national scope of practice. Hence, what a Podiatrist can do will vary from state to state.
Jonwill already answered your question on this subject matter. However, I wanted to add a few words to it. Just because you did a few skin graft from the upper part on your one month rotation and you feel comfortable doing it, it does not qualify you to do this procedure. General Surgeons do get additional training in this area in the next couple of years of residency training. Based on what you said, a general surgeon who did a one month rotation in Podiatry Surgery and did couple of bunion surgery in the rotation and is comfortable doing them, should be qualified to do bunion surgery.
Actually, that is NOT what I meant in my post. I was just trying to illustrate a point. To my knowledge, General Surgery residents do not do Podiatric Surgery rotation in general. However, there are Family Practice residents that actually do an elective rotation with Podiatry in some residency programs.
I would just like to add that the other rotations are highly valuable especially general surgery and orthopedic surgery. Bone is bone, skin is skin, and soft tissue is soft tissue. You may not get to do every possible podiatric procedure in residency. But if you have strong surgical skills and you know your anatomy you can do anything on your own. Drilling a screw into an elbow is the same thing as drilling it through a foot.
Back to the topic.... Well, I'm not a resident, but when I was shadowing residents, one DPM described TO the patient --no joke-- her ankle pain/condition as: "It's like putting Volkswagen tires on a Mack truck." I almost died laughing. And I hope to grow up to be just like him!
In my Residency when in another service's rotation, we were expected to perform to the best of our abilities all of the duties of any Resident on that service, but I always had a Resident from that other service to whom I could turn if I didn't know what to do. As long as we put in a hard effort and didn't try to do things that we really did not know how to do, we meshed well (in other words, "Don't be frontin'!").
During my Internal Medicine month I recall being paged out of sleep by the Floor nurses at about 2am to read an abnormal EKG: "Hmmmm...doesn't match anything in Dubin. Not even if I turn the strip upside down...D'oh."
I personally had no GSW's, no codes, no chest compressions. I did do several non-podiatric procedures though. My running thought was, "What can I take from this rotation to apply to my own practice?" It was not so much that I was trying to be a [fill-in-the-blank] doctor, but rather I was trying to pick up a few pearls each rotation to use in Podiatry.
I got called into the ER last night. The patient was getting into his car when a car coming the other way came too close to his car and hit his door. His foot was crushed in the door. It looked horrible on x-ray so I ordered a CT. The guy sustained a fracture dislocation with 1 displaced medially and 2-5 displaced laterally. There was quite a bit of comminution. I threw a posterior mold on him and wrote him for some pain pills. We'll probably do the case early this week. Nice!
3yo F vs. automobile - her foot got run over by the car. She had some abrasions and on x-ray no fractures but a foreign body at the same location as on of the abrasions. No laceration.
We cleaned her up bandaged her - she said thank you after screeming like a lunatic. Sent her on her way.
That is the exciting trauma so far at the Level one INOVA.
There is an orthopedic trauma team that gets most calls - we cover the cases though. I'd rather cover the cases than get called to the ER.
I can't wait to get to get to Kauai. One month of private practice in an ortho group during the day and sipping mai tais on the beach in the evening. I am jealous that you started out your fourth year with a trip to paradise and I have to wait. Where are you at this month anyway?
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