Foot surgery question...

[chancer]

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Hello,

I have a question. I understand that some DPM's have their own private practice. My question is in regards to out patient surgery that is performed in a clinic and requires the use of a general anesthetic.

What if during the procedure the DPM accidently cuts an artery and there is profuse bleeding. Lets say worse case scenario and the pt has cardiac arrest.

Excuse my ignorance, but would a DPM be able to handle this situation and if so, how?

thx.

 

[Podman]

Hello,

I have a question. I understand that some DPM's have their own private practice. My question is in regards to out patient surgery that is performed in a clinic and requires the use of a general anesthetic.

What if during the procedure the DPM accidently cuts an artery and there is profuse bleeding. Lets say worse case scenario and the pt has cardiac arrest.

Excuse my ignorance, but would a DPM be able to handle this situation and if so, how?

thx.

Hello,

Thank you for the inquiry. To answer your question, I should let you know that you have indirectly made a very common misconception in your inquiry - that is the fact that DPM's are only knowledgeable in the area of the foot...which is in fact, false. The cardiac arrest scenario is a prime reason why DPM's need to have a sound medical background in general medicine and other specialities of medicine. As a matter of fact, during our clinical years and first post graduate residency year, we are expected to rotate through other medical specialities along with DO and MD students.

Now back to your scenario, if the something goes wrong in the OR, the podiatric surgeon is expected to:
1) recognize the problem,
2) limit the adverse effects of the problem within his/her scope of training,
3) if the problem is still persisting, and is beyond the scope of the DPM's training, then seek the expertise of a specialist in the particular area.

Often we forget that as much as we can prepare for a particular Sx, we need also to be prepared for the problems that may happen during the course of a surgery - each patient has his/her own set of pathologies that can alter the procedure and "game plan" sort of speak.

 

[chancer]

^Ok. That's good to know. 👍

I was wondering about that.

2 other question I have if you do not mind answering....


(1) are you guys allowed to prescribe narcotics? I am assuming you are.

and

(2) are there really many jobs available in hospitals? I have heard that DPM's do rotations in the ER. Are they there for foot injuries only?

Thanks.

 

[chancer]

I just saw a response to a similar question about the ER under the residency forum.

Would a DPM actually perform an amputation?

 

[Dr_Feelgood]

1) Yes, podiatrist have an unlimited license to prescribe meds

2) There are some jobs available in hospitals but private practice is still the main employer of pods. Some practices may do call at hospitals but generally those are pods that have an affliation w/ ortho. And yes, pods are only called for foot and ankle disorders. In residency, a pod may work outside that area but that is in residency only.

One other thing to add to the OP is (I'm assuming this is true for other pod schools) at CPMS we are certified in ACLS (advanced cardiac life support). Which plays into podman's excellent answer.

 

[Dr_Feelgood]

I just saw a response to a similar question about the ER under the residency forum.

Would a DPM actually perform an amputation?

I don't know of any state that allows below knee amputations, but in residency you can and will perform the procedure.

 

[Dr_Feelgood]

A pod may perform an amputation up to the tibia in most states.

 

[scpod]

My question is in regards to out patient surgery that is performed in a clinic and requires the use of a general anesthetic....Excuse my ignorance, but would a DPM be able to handle this situation and if so, how?

thx.

The use of general anesthesia is usually legislated by individual states. Most of them have laws that tell you where and how it should be performed and who must be present at the time. In South Carolina, for instance, a DPM must have a CRNA, AA, or Anesthesiologist present to perform general anesthesia, but a Dentist doesn't need that. In Tennessee, performing any surgery under general anesthesia or conscious sedation is limited to a hospital or ambulatory surgical treatment center. Virginia allows a dentist who has the proper training and equipment to do it under certain stipulations in his/her office, but podiatrists are limited to approved hospitals or surgical ambulatory centers. In a not-so-related note Virginia law also permits DPMs to supervise PAs (thought that was interesting).

In any case, pretty much anyone who performs surgery must be ACLS certified because emergencies happen. Most states also stipulate where surgeroies can be performed and what personnel and equipment must be available. Still, I've heard of quite a few cases where minor plastics procedures were being performed in an MDs office and they had to dial 911 because of a cardiac arrest that they couldn't handle. In fact, in any MD or DO or DPM office or clinic where cardiac emergencies can, and do, occur, the procedure is generally to activate EMS-- because even though they may have the knowledge to handle the emergency, they are not equipped to do so.

 

[flypod]

In any case, pretty much anyone who performs surgery must be ACLS certified because emergencies happen.

Scary enough, its not required in all states.

 

[dpmgrad]

2) There are some jobs available in hospitals but private practice is still the main employer of pods. Some practices may do call at hospitals but generally those are pods that have an affliation w/ ortho. And yes, pods are only called for foot and ankle disorders. In residency, a pod may work outside that area but that is in residency only.

Actually, majority of the Podiatrists that take primary Foot and Ankle call in the hospital ER are NOT affiliated with ortho.

 

[Dr_Feelgood]

In any case, pretty much anyone who performs surgery must be ACLS certified because emergencies happen. Most states also stipulate where surgeroies can be performed and what personnel and equipment must be available. Still, I've heard of quite a few cases where minor plastics procedures were being performed in an MDs office and they had to dial 911 because of a cardiac arrest that they couldn't handle. In fact, in any MD or DO or DPM office or clinic where cardiac emergencies can, and do, occur, the procedure is generally to activate EMS-- because even though they may have the knowledge to handle the emergency, they are not equipped to do so.

I don't know of any law that states a surgeon must be ACLS certified for DPMs, DOs, or MDs. I'd strongly suggest it but may surgeons recieve ACLS and then they let the certification lapse.

 

[Podman]

I don't know of any law that states a surgeon must be ACLS certified for DPMs, DOs, or MDs. I'd strongly suggest it but may surgeons recieve ACLS and then they let the certification lapse.

I agree. I'm unaware of state laws requiring ACLS perse but I do know that the 3 year residency programs require both CPR and ACLS certification.

 

[cool_vkb]

The use of general anesthesia is usually legislated by individual states. Most of them have laws that tell you where and how it should be performed and who must be present at the time. In South Carolina, for instance, a DPM must have a CRNA, AA, or Anesthesiologist present to perform general anesthesia, but a Dentist doesn't need that. In Tennessee, performing any surgery under general anesthesia or conscious sedation is limited to a hospital or ambulatory surgical treatment center. Virginia allows a dentist who has the proper training and equipment to do it under certain stipulations in his/her office, but podiatrists are limited to approved hospitals or surgical ambulatory centers. In a not-so-related note Virginia law also permits DPMs to supervise PAs (thought that was interesting).

In any case, pretty much anyone who performs surgery must be ACLS certified because emergencies happen. Most states also stipulate where surgeroies can be performed and what personnel and equipment must be available. Still, I've heard of quite a few cases where minor plastics procedures were being performed in an MDs office and they had to dial 911 because of a cardiac arrest that they couldn't handle. In fact, in any MD or DO or DPM office or clinic where cardiac emergencies can, and do, occur, the procedure is generally to activate EMS-- because even though they may have the knowledge to handle the emergency, they are not equipped to do so.

I wonder why r dentists given more priveledges than us. i mean common, we do 3yrs of residency and are more closer to Allopathic medicine then Dentists. We deal with orthopedic or Internists every single day. we have training just like MDs. and i guess we even have a whole clerkship in Anesthesiolgy right?

then why this discrimination for us😕 . everytime i see, in scholarships, in armed forces, and now even in General Aneshthesia.

 

[scpod]

I don't know of any law that states a surgeon must be ACLS certified for DPMs, DOs, or MDs. I'd strongly suggest it but may surgeons recieve ACLS and then they let the certification lapse.

They may not specifically state that the "surgeon" has to be ACLS certified, but there are states that have laws that say an Ambulatory Surgical Center, for instance, must have "someone" who is ACLS certified on duty any time a patient is in the facility. Virginia passed a law in June that requires a dentist giving anesthesia to be ACLS certified. New York has the same requirement, but they also both have a requirement for some post-doctoral education as well. It would be nice if there was some kind of consensus.

 

[Dr_Feelgood]

I agree with this statement. That is why most surgeries are done in a surgical center or the OR.

 

[flypod]

Dr. Feelgood,

We both put our pants on one leg at a time the difference is when I put these pants on I make gold records.

I need more cowbell. 😀

 

[fpr85]

A pod may perform an amputation up to the tibia in most states.

Are many DPMs actually peforming amputations? I thought for the most part, it was vascular docs doing these.

 

[Podman]

Are many DPMs actually peforming amputations? I thought for the most part, it was vascular docs doing these.

as feelgood said, all PM&S-36 trained pods do perform those procedures during their residencies, but not all of them apply this in their practices - usually due to state restrictions. Some states will allow amputations up to and not including the tibia, some will have have upto the digits only (i believe that is the case for Ohio), while others will not allow amputations by a DPM.

 

[flypod]

Are many DPMs actually peforming amputations? I thought for the most part, it was vascular docs doing these.

You wont find many DPMs doing these procedures as it is my understanding.

 

[jonwill]

You wont find many DPMs doing these procedures as it is my understanding.

DPM's do a ton of foot amputations. I've seen a lot of digit, transmet, Lis Franc, Choparts, and even Symes. But I've never seen a DPM do anything close to a BK. That's vascular or general usually.

 

[IlizaRob]

I wonder why r dentists given more priveledges than us. i mean common, we do 3yrs of residency and are more closer to Allopathic medicine then Dentists. We deal with orthopedic or Internists every single day. we have training just like MDs. and i guess we even have a whole clerkship in Anesthesiolgy right?

then why this discrimination for us😕 . everytime i see, in scholarships, in armed forces, and now even in General Aneshthesia.

It all comes down to politics. Dentists have been established and defined in the medical community much longer than pods. There is no question what dentists do or what their training consists of. Pods on the other hand have been contually evolving. So there is still question on what we really do and what our training is to those who are not recently familiar with the profession. Dont worry, it will come with time.

 

[doclm]

DPM's do a ton of foot amputations. I've seen a lot of digit, transmet, Lis Franc, Choparts, and even Symes. But I've never seen a DPM do anything close to a BK. That's vascular or general usually.

Can DPM's work with the patient after an amputation to fit a Prosthetic foot? The Pods are the biomechanic experts, so I don't see why they could help the patient use a new tool in place of their foot.

Is there prosthetics avaliable to replace parts of the foot versus the whole foot?

 

[krabmas]

Can DPM's work with the patient after an amputation to fit a Prosthetic foot? The Pods are the biomechanic experts, so I don't see why they could help the patient use a new tool in place of their foot.

Is there prosthetics avaliable to replace parts of the foot versus the whole foot?

the pod can cast for the prosthetic foot and then send out to a lab, but usually the patient is sent to an orthotist (prothsetics specialist) to get casted and fitted to the prosthetic.

for Chopart's, Lis Franc's, Syme's, and TMAs there is usually not a prosthetic just a butress used in the shoe and sometimes a shorter custom shoe. there is also a company that makes a prosthetic for all foot amputations that looks like a real foot. If you read the literature on all of these amputations it says over and over again how these limb salvage proceedures are based on the fact that they rarely need a prosthetic for minimal ambulation for small tasks.

For BKA's and higher the Orthotist will cast and fit the patient to the prosthetic.

 

[doclm]

the pod can cast for the prosthetic foot and then send out to a lab, but usually the patient is sent to an orthotist (prothsetics specialist) to get casted and fitted to the prosthetic.

for Chopart's, Lis Franc's, Syme's, and TMAs there is usually not a prosthetic just a butress used in the shoe and sometimes a shorter custom shoe. there is also a company that makes a prosthetic for all foot amputations that looks like a real foot. If you read the literature on all of these amputations it says over and over again how these limb salvage proceedures are based on the fact that they rarely need a prosthetic for minimal ambulation for small tasks.

For BKA's and higher the Orthotist will cast and fit the patient to the prosthetic.

Thanks for the reply 👍

Is it possible to use partial prosthetics to increase the quality of lives for patients with partial amputations? Or is there not a market for this?

What kind of education does an Orthotist have? Also, have you ever heard of a Podiatrists obtaining that education separately just to take all of this into their own hands?

 

[chancer]

Wow.

Really good repsonses from everyone.

ONE LAST QUESTION....More than likely...

Ok, so how do you guys make your money?? I know you have to build a client base ect. But is most of it from walk-ins off the street? Do some MD's refer patients to DPM's w/out knowing one individually?

I once went to a MD for my flat feet. Basically, they kill me. I can only buy one brand of shoes (brooks) and they still ache at the end of the day. All the doc did was give me those ortho pad things, and they felt to wierd for me to continue to wear them. He didn't mention anything about a DPM🙁

I am just curious.

Thanks!

 

[Dr_Feelgood]

As with any private practice you must build a relationship w/ PCPs. Many PCPs don't know enough about podiatry. That is why I'm a big fan of Broadlawn's FP residency which has a podiatric rotation.

 

[funfeet]

I once went to a MD for my flat feet. Basically, they kill me. I can only buy one brand of shoes (brooks) and they still ache at the end of the day. All the doc did was give me those ortho pad things, and they felt to wierd for me to continue to wear them. He didn't mention anything about a DPM🙁
QUOTE]

I had flat feet too, and went to a chiropracter. But that was high school soccer, and he was our athletic trainer. He never mentioned a DPM either, which i think is strange now. He was also the trainer for the Chicago Fire, so I'm assuming he's trained a bit more in the lower extremity.

 

[dpmgrad]

As with any private practice you must build a relationship w/ PCPs. Many PCPs don't know enough about podiatry. That is why I'm a big fan of Broadlawn's FP residency which has a podiatric rotation.

It is good to get to know the other residents at the hospital where one is doing his/her Podiatry residency training. Two of the family practice residents that graduate with me from my hospital are now referring all of the non HMO patients to me since they know me well. I also have a General Surgery surgeon referring some of the patients to me since I had worked with him on my General Surgery rotation and he was the Chief resident at the time.

 

[chancer]

It is good to get to know the other residents at the hospital where one is doing his/her Podiatry residency training. Two of the family practice residents that graduate with me from my hospital are now referring all of the non HMO patients to me since they know me well. I also have a General Surgery surgeon referring some of the patients to me since I had worked with him on my General Surgery rotation and he was the Chief resident at the time.

Smart.

And that can be fairly lucrative? I am genuinely curious. Being a DPM doesn't sound like it would be too bad of a job. I just don't really know that much about it.


Thx.

 

[fpr85]

Is there prosthetics avaliable to replace parts of the foot versus the whole foot?

In this case you would just make a custom foot orthotic and add either a morton's extension or full extension plate (depending on site of amputation) to increase the biomechanical leverage. In place of the missing digits, etc. a toe filler would be added.

This is of course depends what the patient is after -- something that will actually work for them, or something merely for aesthetics.

I find this extremely fascinating and have read a few articles about it in my O&P magazines, it has been out for a while, just not approved of by whatever organization in the US yet:
Osseointegration:

Osseointegration is a method of attaching prostheses directly into the bone, I've seen a few pictures of fingers too.

the pod can cast for the prosthetic foot and then send out to a lab, but usually the patient is sent to an orthotist (prothsetics specialist) to get casted and fitted to the prosthetic.

Someone who specializes in prosthetics would be known as a prosthetist. Orthotist in regards to orthotics. Or if specialized in both, a CPO, Certified Prosthetist Orthotist.

What kind of education does an Orthotist have? Also, have you ever heard of a Podiatrists obtaining that education separately just to take all of this into their own hands?

Taking on the responsibilty of fabricating prostheses is both time-consuming and expensive. There are several ways that one can become a CP, CO, or CPO -- www.abcop.org, www.bocusa.org. There are universities that you actually attend (2 years I believe) to become qualified, one being Northwestern. You can also apply to be one after X amount of years of training under a CP or CO.
As a podiatrist, you can definitely handle the fabrication of a prosthesis for missing toes. It becomes trickier when dealing with chopart amputations etc -- that would revolve more around the fabrication of a custom-made AFO with forefoot filler.
Symes, BK amputations, definitely out of your scope without proper training. AND DON'T FORGET EQUIPMENT!
Grinders, bandsaws, ovens, plastics, etc... of course you could always send it out... but what do you do for adjustments? Send the item out everytime? That would become very frustrating for both you and the patient.

Parts also cost a fortune, prosthetic feet (e.g. carbon feet made by companies like Ossur, Ottobock, etc.) can sell for HUNDREDS of dollars, we just purchased one that was $700 -- and that was our discounted rate.

Hope this helped.

 

[doclm]

In this case you would just make a custom foot orthotic and add either a morton's extension or full extension plate (depending on site of amputation) to increase the biomechanical leverage. In place of the missing digits, etc. a toe filler would be added.

This is of course depends what the patient is after -- something that will actually work for them, or something merely for aesthetics.

I find this extremely fascinating and have read a few articles about it in my O&P magazines, it has been out for a while, just not approved of by whatever organization in the US yet:
Osseointegration:

Osseointegration is a method of attaching prostheses directly into the bone, I've seen a few pictures of fingers too.




Someone who specializes in prosthetics would be known as a prosthetist. Orthotist in regards to orthotics. Or if specialized in both, a CPO, Certified Prosthetist Orthotist.



Taking on the responsibilty of fabricating prostheses is both time-consuming and expensive. There are several ways that one can become a CP, CO, or CPO -- www.abcop.org, www.bocusa.org. There are universities that you actually attend (2 years I believe) to become qualified, one being Northwestern. You can also apply to be one after X amount of years of training under a CP or CO.
As a podiatrist, you can definitely handle the fabrication of a prosthesis for missing toes. It becomes trickier when dealing with chopart amputations etc -- that would revolve more around the fabrication of a custom-made AFO with forefoot filler.
Symes, BK amputations, definitely out of your scope without proper training. AND DON'T FORGET EQUIPMENT!
Grinders, bandsaws, ovens, plastics, etc... of course you could always send it out... but what do you do for adjustments? Send the item out everytime? That would become very frustrating for both you and the patient.

Parts also cost a fortune, prosthetic feet (e.g. carbon feet made by companies like Ossur, Ottobock, etc.) can sell for HUNDREDS of dollars, we just purchased one that was $700 -- and that was our discounted rate.

Hope this helped.

Thanks for the reply👍