Limb Salvage Program

[ldsrmdude]

I'm curious to hear from those who participate in a limb salvage program (whether you call it that or not) as to what your program looks like and how it works in actuality, not just theory. By limb salvage program I mean a collaborative inter-disciplinary program that focuses on reducing the number of amputations and preserving limbs. Even thoughts on what you think would be the ideal arrangement would be interesting

Edit: I guess I should be more specific. Who is involved in your limb salvage program, how often do you meet to discuss patients/trends/literature/etc, how do you keep track of your results, how do you work inpatient vs outpatient...

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[dyk343]

I'm curious to hear from those who participate in a limb salvage program (whether you call it that or not) as to what your program looks like and how it works in actuality, not just theory. By limb salvage program I mean a collaborative inter-disciplinary program that focuses on reducing the number of amputations and preserving limbs. Even thoughts on what you think would be the ideal arrangement would be interesting

I'm sure we would all agree that the #1 factor in running a limb salvage program is access to skilled vascular surgeons and interventional radiologists.

We lose very few limbs in comparison to the rest of the country (read research and the rate of BKA is very high - at least at what I am used to). Since my residency I would guess we have lost <20 limbs and we see a LOT of wounds. But we also have an all star team of vascular surgeons and interventional radiologists (they have some serious skills). Several of my attendings are also fellowship trained in wound healing and are certified wound care specialists. We run a very busy wound healing clinic. Our infectious disease specialists are probably the smartest doctors in the hospital. We also have a very skilled group of general surgeons that we frequently involve for second opinions and skin grafting. We have a plastic surgeon that we involve for flaps for chronic non-healing "stable" wounds. ...The key is multidisciplinary care

We abide fairly closely to the rule of: After 4 weeks if <50% healing we involve advanced grafts/products. Dermagraft is our usual go-to. We have seen good results with Graffix too but as we know every wound has different needs and we use a wide range of advanced products.

So far, this treatment model has been very effective. Minus a few, almost all of the limbs we have lost are due to frank, outright, non-compliance on the patient's part.

Podiatry students read this article - http://www.ncbi.nlm.nih.gov/pubmed/12766127

 

[SLCpod]

I'm sure we would all agree that the #1 factor in running a limb salvage program is access to skilled vascular surgeons and interventional radiologists.

We lose very few limbs in comparison to the rest of the country (read research and the rate of BKA is very high - at least at what I am used to). Since my residency I would guess we have lost <20 limbs and we see a LOT of wounds. But we also have an all star team of vascular surgeons and interventional radiologists (they have some serious skills). Several of my attendings are also fellowship trained in wound healing and are certified wound care specialists. We run a very busy wound healing clinic. Our infectious disease specialists are probably the smartest doctors in the hospital. We also have a very skilled group of general surgeons that we frequently involve for second opinions and skin grafting. We have a plastic surgeon that we involve for flaps for chronic non-healing "stable" wounds. ...The key is multidisciplinary care

We abide fairly closely to the rule of: After 4 weeks if <50% healing we involve advanced grafts/products. Dermagraft is our usual go-to. We have seen good results with Graffix too but as we know every wound has different needs and we use a wide range of advanced products.

So far, this treatment model has been very effective. Minus a few, almost all of the limbs we have lost are due to frank, outright, non-compliance on the patient's part.

Podiatry students read this article - http://www.ncbi.nlm.nih.gov/pubmed/12766127

Thanks for the article. Good read.

 

[ExperiencedDPM]

It's imperative to have a great communication and relationship between podiatry, infectious disease, vascular surgery and in some hospitals interventional radiologists. I say some hospitals, because there is often a turf war between aggressive vascular surgeons and interventional radiologists.

Our practice has an amazing relationship with infectious disease and vascular. I would agree, that academically the ID docs are very bright, and sometimes a little odd! Vascular surgery is a grueling specialty and attracts a very special breed. At "our" hospital, there is a very strong vascular program with surgical residents and vascular fellows. There is always a vascular fellow in house 24/7. As a result, we get called at all funky hours to perform cases when they call us. The idea is based on Armstrong's model in Arizona, the so-called "toe and flow" team. Often, consults are done together with vascular to decide who goes first. Is the I and D performed first, is the revascularization performed first, is the local foot amp done first, etc. This limits return trips to the OR and addresses the most serious concerns and places things in a priority order to help obtain a game plan.

I would agree that lack of compliance is a huge factor regarding eventual proximal amputations. These are usually the frequent flyers/repeat offenders who leave the hospital AMA and come in through the ER 6 weeks later with gangrenous areas and gas in the soft tissue, and then ask if they can go outside for a minute before they go to xray, so they can have another cigarette.

 

[ldsrmdude]

It's imperative to have a great communication and relationship between podiatry, infectious disease, vascular surgery and in some hospitals interventional radiologists. I say some hospitals, because there is often a turf war between aggressive vascular surgeons and interventional radiologists.

Our practice has an amazing relationship with infectious disease and vascular. I would agree, that academically the ID docs are very bright, and sometimes a little odd! Vascular surgery is a grueling specialty and attracts a very special breed. At "our" hospital, there is a very strong vascular program with surgical residents and vascular fellows. There is always a vascular fellow in house 24/7. As a result, we get called at all funky hours to perform cases when they call us. The idea is based on Armstrong's model in Arizona, the so-called "toe and flow" team. Often, consults are done together with vascular to decide who goes first. Is the I and D performed first, is the revascularization performed first, is the local foot amp done first, etc. This limits return trips to the OR and addresses the most serious concerns and places things in a priority order to help obtain a game plan.

I would agree that lack of compliance is a huge factor regarding eventual proximal amputations. These are usually the frequent flyers/repeat offenders who leave the hospital AMA and come in through the ER 6 weeks later with gangrenous areas and gas in the soft tissue, and then ask if they can go outside for a minute before they go to xray, so they can have another cigarette.

I really wish we had vascular surgery always in house. Our vascular surgery doctors are based at another hospital and come to our hospital a few days a week. I also wish we had ID, but we don't.

 

[ExperiencedDPM]

I really wish we had vascular surgery always in house. Our vascular surgery doctors are based at another hospital and come to our hospital a few days a week. I also wish we had ID, but we don't.

Your hospital has no infectious disease docs? That's really unusual. Most hospitals now encourage ID consults to assure greater efficacy with antibiotic coverage. I've been on staff at major university teaching hospitals and small community hospitals and they all had ID docs.

 

[dtrack22]

I really wish we had vascular surgery always in house. Our vascular surgery doctors are based at another hospital and come to our hospital a few days a week. I also wish we had ID, but we don't.

The vascular issue you bring up is our biggest problem with limb salvage. Of course I say that knowing that none of us at my program have any desire to actually do limb salvage, our proximal amp recommendation threshold is therefore low. So maybe blaming vascular is just a convenient excuse? It's not quite a few days a week bad, but it's a group that takes turns covering call for the hospital and the general surgery residents and the vascular group's PA handle the consults and in house folks. The general surgery residents are the gen surg/trauma surg service and have little understanding or desire to actually take care of these vasculopaths. Sometimes getting our vascular service to do intervention on patients while in house is difficult (the attending on call has a full schedule of patients that actually pay well and so they recommend outpatient angio and get to our guy in a month), and then when they do revasc you're lucky if they open up anything distal to the TP trunk. Nobody is recanalizing vessels in the foot here. They are good vascular surgeons, just spread too thin.

Our ID docs on the other hand are great. They provide the medical treatment of our wound patients who have OM and they do it well. We involve them on any patient with suspected/proven OM, otherwise we make our own abx recs to the hospitalists.

We probably average 1-2 BKA v AKA per month? Not sure if that's good or bad for a 700 bed county hospital. Vascular surgeons and podiatrist who really want to pull out all the stops to save limbs is what we are admittedly lacking.

 

[ldsrmdude]

Your hospital has no infectious disease docs? That's really unusual. Most hospitals now encourage ID consults to assure greater efficacy with antibiotic coverage. I've been on staff at major university teaching hospitals and small community hospitals and they all had ID docs.

I'm on staff at 2 hospitals here. Both are county hospitals in small rural counties. We have 1 ID doc at the bigger of the 2 hospitals, but not at the smaller of the 2. There are ID docs that are in neighboring counties that I can send patients to as an outpatient but nobody on staff at the hospital. The hospitalists typically manage a lot of that with input from the surgeons, nephrologists, etc.

 

[ldsrmdude]

The vascular issue you bring up is our biggest problem with limb salvage. Of course I say that knowing that none of us at my program have any desire to actually do limb salvage, our proximal amp recommendation threshold is therefore low. So maybe blaming vascular is just a convenient excuse? It's not quite a few days a week bad, but it's a group that takes turns covering call for the hospital and the general surgery residents and the vascular group's PA handle the consults and in house folks. The general surgery residents are the gen surg/trauma surg service and have little understanding or desire to actually take care of these vasculopaths. Sometimes getting our vascular service to do intervention on patients while in house is difficult (the attending on call has a full schedule of patients that actually pay well and so they recommend outpatient angio and get to our guy in a month), and then when they do revasc you're lucky if they open up anything distal to the TP trunk. Nobody is recanalizing vessels in the foot here. They are good vascular surgeons, just spread too thin.

Our ID docs on the other hand are great. They provide the medical treatment of our wound patients who have OM and they do it well. We involve them on any patient with suspected/proven OM, otherwise we make our own abx recs to the hospitalists.

We probably average 1-2 BKA v AKA per month? Not sure if that's good or bad for a 700 bed county hospital. Vascular surgeons and podiatrist who really want to pull out all the stops to save limbs is what we are admittedly lacking.

Yeah, as you note, it takes commitment from all sides to make the limb salvage thing really work. The funny thing is, I actually have the buy-in from vascular here, and they do the best they can to see inpatient consults within a day and my outpatient referrals within a week or so. I can get in touch with one of them via text at about anytime if I need to. The system is sort of set up against us. I'm not sure if some of the other surgeons here share my interpretation of "limb salvage."