Does podiatry have "soft" cases?

[dr.phoot]

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As a pod, I assume you'll never have to tell someone their dad didn't make it through the surgery. What are the odds someone dies from foot surgery? Maybe massive blood loss?

You'll never face some of the intensive cases in neuro and cardio where it's a matter of life/death. And that creates an overall positive atmosphere, imho. Even primary care might sometimes have to tell people they have life threatening diseases but you don't get that in pod.

Is it wrong to think this way? I'll be putting something similar to this in my p/s. So I just wanted to know if I was wrong before I made a fool of myself to adcoms.

**I used soft in my thread title for a lack of a better term. No disrespect intended, of course***

 

[bobtheweazel]

As a pod, I assume you'll never have to tell someone their dad didn't make it through the surgery. What are the odds someone dies from foot surgery? Maybe massive blood loss?

You'll never face some of the intensive cases in neuro and cardio where it's a matter of life/death. And that creates an overall positive atmosphere, imho. Even primary care might sometimes have to tell people they have life threatening diseases but you don't get that in pod.

Is it wrong to think this way? I'll be putting something similar to this in my p/s. So I just wanted to know if I was wrong before I made a fool of myself to adcoms.

**I used soft in my thread title for a lack of a better term. No disrespect intended, of course***

If you think you can't lose a life:
If you're practicing general podiatry then a large portion of your patient base is probably older with multiple diseases, poor circulation, etc. Basically probably not the greatest surgical candidates, and when you add general anesthesia and other factors into the mix there's always the risk of death. There are checkpoints to prevent it, like maybe their primary doctor will do a preoperative eval, maybe their cardiologist will, the anesthesiologist definitely will, you will, all to make sure that they probably won't die, but the risk is still there.

If you think you can't save a life:
Dr Armstrong (wound care guru) published a study that found that within 5 years of a limb amputation, 68% of people die. That's second to only lung cancer and far worse than the 5 year mortality rates for colorectal cancer (39%), breast cancer (23%), Hodgkin's lymphoma (18%), and prostate cancer (8%). As a podiatrist, when you encounter a diabetic wound, in many cases if you heal that wound, you save a limb, you save a life. It may not be as dramatic as holding a bleeding child in your arms in the ER, but it's certainly a serious contribution.

 

[dr.phoot]

Bob:

Good points, as usual. What I'll add further is that the risk from the surgery--for the demographic mentioned--though present, is probably not something alarming, is it? And you mentioned there's a pre-op stage before the actual surgery so certain things can be picked up on. I went into the OR for a bone spur and it was a pod that performed it. I went through the pre-op process too. So the risk is there but it's not huge. I believe then that you're (mostly) in the green in terms of having to tell someone their father passed away during the surgery. I acknowledge that it's possible but how likely is it?

Bob, I'm in no way saying that podiatrists don't save lives or don't do anything to prevent death immediately. I am rather saying I like podiatry because I don't have to remove a brain tumor or tell someone they have something in their heart that could lead to death. And the surgery is 50/50. I'll rather clip toe nails and shave bunions.
In other words, I really don't want to hold that bleeding child in my arms. I'll rather the soccer athlete that got fouled and needs something done on his ankle. I'll rather detect diabetes and break that news than break the news to someone that they have cancer or AIDS/HIV.

So by soft cases, that's what I meant. You won't be in intense positions. My podiatrist I shadowed told me he was called in to a case where some glass had fallen on a little baby girl's foot. I would rather a case like that than one where there's been a car accident and I have to save some little boy's dad.

Podiatry is important. I'm not saying it isn't. I'm saying being a podiatrist to me means not having to break matters of life/death, not having to perform surgeries on brains, hearts, etc. The worse case scenario is an amputation. Imagine having to separate twins like Dr. Carson and knowing that the twins could die. I just don't want to be in that position. No one dies in podiatry


(Sorry if I'm being naive. I just like podiatry for the reasons listed)

 

[heybrother]

As a pod, I assume you'll never have to tell someone their dad didn't make it through the surgery.

Unfortunately our patients do die during surgery, albeit its the anesthesia and their poor health that usually causes it (insert a comic meme about Blame Anesthesia). I haven't witnessed a fatality in the OR during a podiatry case, but I saw a patient stop breathing for an extended period of time during a case 4th year. The attending was a very talented, young podiatrist and I will remember for a long time the look on his face as he watched intently. The surgery was something very trivial on a young woman. It turned out ok, but there was a moment where it appeared to be going down-hill fast. The fatalities I'm aware of were on Charcot patients.

We give plenty of bad news: you need surgery, you need an amputation, you have necrotizing fasciitis, you have horrible PVD and we can't actually do surgery, you have acute kidney injury and may need dialysis, you have C. Diff, you can't walk on this foot for X+ months. Just because we don't tell people how much longer they have doesn't mean it doesn't get real, real fast.

If you think you can't save a life:
Dr Armstrong (wound care guru) published a study that found that within 5 years of a limb amputation, 68% of people die. That's second to only lung cancer and far worse than the 5 year mortality rates for colorectal cancer (39%), breast cancer (23%), Hodgkin's lymphoma (18%), and prostate cancer (8%). As a podiatrist, when you encounter a diabetic wound, in many cases if you heal that wound, you save a limb, you save a life. It may not be as dramatic as holding a bleeding child in your arms in the ER, but it's certainly a serious contribution.

Just to muddy the waters - that the mortality is high after a limb amputation is easily demonstrated. That our interventions will safe a life is unfortunately more tenuous. That is the dominant thought process that is taught in school and it has its merits. My personal variant opinion is that a BKA is not the tipping point (though it doesn't help and our patients are short on reserve), but just an indicator of the patient's already poor underlying health status. Start inquiring to your PVD patients about strokes and heart attacks. Its all part of the same system and we have a tendency to decondition our patient's with long periods of non-weight bearing. I'm somehow missing my drive of articles, but I think this is discussed here: https://www.ncbi.nlm.nih.gov/pubmed/25601358 in an article by Shibuya (apologies if it isn't - I met Thorud and this was a topic of interest of his from what I recall).

 

[bobtheweazel]

To sum up the systematic review that heybrother is referring to in case y'all can't access the full article:
-For diabetic patients with foot ulcers, 5 year mortality rate was about 40%.
-For diabetic patients with foot ulcers who subsequently had amputations, 5 year mortality rate rose to about 63%.
-One of the studies reviewed reduced the 5 year mortality rate of diabetic patients with foot ulcers (with and without amputations) from 48% down to 26.8% employing an aggressive cardiovascular risk management program in a multidisciplinary diabetic foot clinic.

 

[ldsrmdude]

Although I agree with you to a certain point, @dr.phoot - if I ever feel a bit self-important, I read some of the threads from the general/vascular/neuro/etc surgeons and I feel quite humbled - but I don't know that it's something I would focus a lot on in my personal statement. It comes across similar to saying that you are pursuing podiatry because you'll be able to work less hours and still call yourself a doctor. It may be true, but it's not something you focus your personal statement on. I'm not saying that you should lie and say you want to pursue podiatry because you love working on the really sick patients we work with. I think you're fine if you have a sentence about it, but it isn't something I would spend a lot of space on. Just my thoughts

Just as an aside, we had a patient die in PACU while I was a 3rd year resident. I've had a few scary moments intra-operatively, but overall, as @heybrother said, it's been the anesthesia or something else that almost does them in. The hard ones to deal with are the long-term patients that get septic from a new wound and die suddenly or something similar. If your residency keeps you in the same wound center or clinic for the 3 years, I can almost guarantee you that there will be patients that you will take care of that will die while under your care. It's a sad fact about the patient population that we deal with. So the statement you made "No one dies in podiatry" may be a bit short-sighted and misleading, even though I certainly understand the point you are trying to make

 

[dr.phoot]

Although I agree with you to a certain point, @dr.phoot - if I ever feel a bit self-important, I read some of the threads from the general/vascular/neuro/etc surgeons and I feel quite humbled - but I don't know that it's something I would focus a lot on in my personal statement. It comes across similar to saying that you are pursuing podiatry because you'll be able to work less hours and still call yourself a doctor. It may be true, but it's not something you focus your personal statement on. I'm not saying that you should lie and say you want to pursue podiatry because you love working on the really sick patients we work with. I think you're fine if you have a sentence about it, but it isn't something I would spend a lot of space on. Just my thoughts

Just as an aside, we had a patient die in PACU while I was a 3rd year resident. I've had a few scary moments intra-operatively, but overall, as @heybrother said, it's been the anesthesia or something else that almost does them in. The hard ones to deal with are the long-term patients that get septic from a new wound and die suddenly or something similar. If your residency keeps you in the same wound center or clinic for the 3 years, I can almost guarantee you that there will be patients that you will take care of that will die while under your care. It's a sad fact about the patient population that we deal with. So the statement you made "No one dies in podiatry" may be a bit short-sighted and misleading, even though I certainly understand the point you are trying to make

Thank you! This is the kind of stuff I was hoping to read. I really needed a perspective like this

 

[dr.phoot]

Unfortunately our patients do die during surgery, albeit its the anesthesia and their poor health that usually causes it (insert a comic meme about Blame Anesthesia). I haven't witnessed a fatality in the OR during a podiatry case, but I saw a patient stop breathing for an extended period of time during a case 4th year. The attending was a very talented, young podiatrist and I will remember for a long time the look on his face as he watched intently. The surgery was something very trivial on a young woman. It turned out ok, but there was a moment where it appeared to be going down-hill fast. The fatalities I'm aware of were on Charcot patients.

We give plenty of bad news: you need surgery, you need an amputation, you have necrotizing fasciitis, you have horrible PVD and we can't actually do surgery, you have acute kidney injury and may need dialysis, you have C. Diff, you can't walk on this foot for X+ months. Just because we don't tell people how much longer they have doesn't mean it doesn't get real, real fast.



Just to muddy the waters - that the mortality is high after a limb amputation is easily demonstrated. That our interventions will safe a life is unfortunately more tenuous. That is the dominant thought process that is taught in school and it has its merits. My personal variant opinion is that a BKA is not the tipping point (though it doesn't help and our patients are short on reserve), but just an indicator of the patient's already poor underlying health status. Start inquiring to your PVD patients about strokes and heart attacks. Its all part of the same system and we have a tendency to decondition our patient's with long periods of non-weight bearing. I'm somehow missing my drive of articles, but I think this is discussed here: https://www.ncbi.nlm.nih.gov/pubmed/25601358 in an article by Shibuya (apologies if it isn't - I met Thorud and this was a topic of interest of his from what I recall).

Thank you!