Podiatric Surgery and General Anethesia

[JEWmongous]

Hello all, I just have a question for those in their podiatric residency, who just finished, or who are familiar with the answer in general.

How often is general anethesia used during podiatric surgery?

I know pods often use local such as when I had my ingrown toenails fixed a few times. For what procedures is general anesthesia used for? Is something like a bunionectomy under local or general? I'm new to the field of podiatry and I was not sure of the answer. Thanks for all of your help!

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[dpmgrad]

Hello all, I just have a question for those in their podiatric residency, who just finished, or who are familiar with the answer in general.

How often is general anethesia used during podiatric surgery?

I know pods often use local such as when I had my ingrown toenails fixed a few times. For what procedures is general anesthesia used for? Is something like a bunionectomy under local or general? I'm new to the field of podiatry and I was not sure of the answer. Thanks for all of your help!

Majority of the forefoot and minor rearfoot elective surgery cases are usually done under local anesthesia or MAC Sedation (IV Sedation) with local anesthesia. These include bunionectomies, hammertoe correction, neuroma excision, EPF, winograd matrixectomy, etc... General anesthesia or regional anesthesia (spinal, popliteal block, etc....) are usually utilize for majority of the midfoot / rearfoot trauma and reconstructive rearfoot surgery cases.

 

[jonwill]

Hello all, I just have a question for those in their podiatric residency, who just finished, or who are familiar with the answer in general.

How often is general anethesia used during podiatric surgery?

I know pods often use local such as when I had my ingrown toenails fixed a few times. For what procedures is general anesthesia used for? Is something like a bunionectomy under local or general? I'm new to the field of podiatry and I was not sure of the answer. Thanks for all of your help!

Like dpmgrad, the majority of general that I've seen used is for rearfoot and ankle trauma (ankle fx, pilons, calc fx, etc). A lot of things we do are easily done under MLA.

 

[doclm]

Like dpmgrad, the majority of general that I've seen used is for rearfoot and ankle trauma (ankle fx, pilons, calc fx, etc). A lot of things we do are easily done under MLA.

Can and do Podiatrists that have a surgery center in their clinic do full Anes. with a CRNA or MD/DO? Is this rare? If so, does the DPM have to be affiliated with a hospital or Ortho group to perform (ankle fx, pilons, calc fx, and rear foot reconstructive surgery)?

Then, whats saying that you get these cases instead of the Ortho taking them? Which is something that I commonly hear about rear foot and ankle trauma.

Also, can DPM's publicly advertise for foot/ ankle trauma and rear foot surgery? Can Pods attract patients without referals?

 

[dpmgrad]

Can and do Podiatrists that have a surgery center in their clinic do full Anes. with a CRNA or MD/DO? Is this rare? If so, does the DPM have to be affiliated with a hospital or Ortho group to perform (ankle fx, pilons, calc fx, and rear foot reconstructive surgery)?

Then, whats saying that you get these cases instead of the Ortho taking them? Which is something that I commonly hear about rear foot and ankle trauma.

I personally know of a few DPMs who are co-owners of free standing surgery centers. There are a few DPMs who have a fully certified surgical suite in the office. These DPMs will have an Anesthesiologist (sometimes CRNA depending on arrangement) come in for the few cases that require MAC Sedation (IV Sedation). I have never seen General Anesthesia or Spinal Anesthesia done in surgical suites of private practice. Of course, General Anesthesia or Spinal Anesthesia can be done in free standing surgery centers.

As for DPMs doing reconstructive rearfoot surgery and foot / ankle trauma, they are usually done in hospital ORs or surgery centers that have arrangements with hospital for admission, since these cases require the patient to be admitted to hospital for pain management. You do NOT need to be affiliated or be part of an Ortho group to do reconstructive rearfoot surgery or foot / ankle trauma surgery. As long as the DPM have the hospital privilege to perform the reconstructive rearfoot surgery and foot / ankle trauma surgery, the DPM can perform these surgeries in the hospital OR and Surgery centers. As for DPMs getting foot and ankle trauma from the hospital ER, it really depends on the arrangement that the DPMs have with the hospital ER and the covering ortho groups. Obviously, DPMs in an ortho group would be getting the foot and ankle trauma from the ER when the ortho group takes call at the hospital. Majority of the DPMs that take foot and ankle trauma call in the ER are NOT part of an ortho group and have some sort of an arrangement with the ER and Ortho groups. For example, at Temple University Hospital (Level 1 trauma) and UMDNJ University Hospital (Level 1 trauma), DPMs and Ortho take alternating primary Foot and Ankle trauma call (eg. DPMs take call on even days and Ortho take call on odd days, etc....). In smaller communtiy hospitals, many of the DPMs take primary call for Foot and Ankle trauma call every day since the Ortho groups are usually tied up with other Orthopedic trauma (hip fractures, femur fractures, pelvic fractures, upper extremity fractures, etc....). This is the case for me, my Podiatry group takes primary foot and ankle trauma call from the hospital ER every day since the on call Ortho group are tied up with hip fractures (my hospital is surrounded by a bunch of nursing homes). In other hospitals, DPM only get the forefoot trauma cases only, while the Ortho groups get the rearfoot and ankle trauma cases. On the other hand, there are some hospitals where the on call Ortho group or the ER physician would make a decision as to what cases will go to the DPM and what goes to Ortho. Of course, there are some DPMs that do not want to take primary foot and ankle trauma call from the hospital.

 

[dpmgrad]

Also, can DPM's publicly advertise for foot/ ankle trauma and rear foot surgery? Can Pods attract patients without referals?

If you have hospital privileges and appropriate training / board certification to do foot / ankle trauma and reconstructive rearfoot surgery, you can definitely publically advertise this.

As for Podiatrist attracting patients without any referrals is rather difficult because we are specialists. You may attract some of your patients through advertisements. However, majority of your patients are usually through various referral sources (Primary Care Physicians, Hospital / ER, Orthopedic Surgeons, other DPMs, hospital ancillary staff such as nurses, etc...). Your own patients can also be a great referral source. If you do a good job and build up a good reputation, the patients will send their family and friends to you. For example, I recently performed routine foot care on a 97 years old patient and she sent me her grand daughter who needed bunion surgery. If you or your group have a great reputation, you will also get a lot of the second opinions, etc... More prominent DPMs such as Dr. Gary Jolly, Dr. Michael Downey, and Dr. John Schuberth get tons of second opinions or get referrals for more complicated foot / ankle cases.

 

[doclm]

If you have hospital privileges and appropriate training / board certification to do foot / ankle trauma and reconstructive rearfoot surgery, you can definitely publically advertise this.

As for Podiatrist attracting patients without any referrals is rather difficult because we are specialists. You may attract some of your patients through advertisements. However, majority of your patients are usually through various referral sources (Primary Care Physicians, Hospital / ER, Orthopedic Surgeons, other DPMs, hospital ancillary staff such as nurses, etc...). Your own patients can also be a great referral source. If you do a good job and build up a good reputation, the patients will send their family and friends to you. For example, I recently performed routine foot care on a 97 years old patient and she sent me her grand daughter who needed bunion surgery. If you or your group have a great reputation, you will also get a lot of the second opinions, etc... More prominent DPMs such as Dr. Gary Jolly, Dr. Michael Downey, and Dr. John Schuberth get tons of second opinions or get referrals for more complicated foot / ankle cases.

Thanks a lot!!!

 

[Dr_Feelgood]

Also, can DPM's publicly advertise for foot/ ankle trauma and rear foot surgery? Can Pods attract patients without referals?

You can advertise just about anything you want if you have the training, certification/qualification, and skill to do what you are advertising. Where any and all docs get into trouble is where they push the envelope into areas that they have little if any training. Such as a pod advertising as a knee expert; yes the leg bone is connect to the ankle bone, but if you haven't scoped about a 1000 knees (you did 1 or 2 in residency but you feel you did them well) you are not qualified to say you are an expert. And should not go there even if the law allowed it.

 

[doclm]

You can advertise just about anything you want if you have the training, certification/qualification, and skill to do what you are advertising. Where any and all docs get into trouble is where they push the envelope into areas that they have little if any training. Such as a pod advertising as a knee expert; yes the leg bone is connect to the ankle bone, but if you haven't scoped about a 1000 knees (you did 1 or 2 in residency but you feel you did them well) you are not qualified to say you are an expert. And should not go there even if the law allowed it.

I'm just talking about advertising for everything a pod has been certified to do through their education and residency training.

Is there education and certifications that Podiatrists have in which they cannot practice or advertise in society? (besides state regulations)

I hear that DPMs are allowed to do more things during their residency, versus being out in the real world practicing. Why is that?

 

[efs]

I hear that DPMs are allowed to do more things during their residency, versus being out in the real world practicing. Why is that?

During residency you may rotate with MDs/DOs and perform procedures under their supervision. These may be things that would ordinarily be outside our scope. I.e. during general surgery rotation performing appendectomies or with orthopaedics doing knee scopes, carpal tunnel releases, ACL reconstructions, etc. While these are good at helping round out the educational experience by no means would these be things you might want to take on yourself.

 

[mdocd]

Have noted previous discussion on general anesthesia in podiatry surgery- would like to know your opinion on this: Is it at all excessive to perform correction of right and left foot bunions, neuromas, and hammertoes (more than 4) all in one surgical appointment in a free standing podiatric surgical office? And just as important, is it standard to administer general anesthesia for this plan? What, if anything would be the alternatives?

 

[krabmas]

what do you consider a free standing podiatric surgical office? is the anesthesia provided by an anesthesiologist?

what is the patient's medical history?

sometimes it is the patient's choice to go under general.

I have seen many cases especially neuromas that go general (some local too).

there are many factors that go into whether to do bunions or other foot surgeries B/L.

If the patient is going to be in a wheel chair and ther house is set up for wheel chair use then it is fine.

Also it depends on the bunionectomy performed. some procedures can be WB immediatley post-op in a surgical shoe.

 

[dawg44]

Have noted previous discussion on general anesthesia in podiatry surgery- would like to know your opinion on this: Is it at all excessive to perform correction of right and left foot bunions, neuromas, and hammertoes (more than 4) all in one surgical appointment in a free standing podiatric surgical office? And just as important, is it standard to administer general anesthesia for this plan? What, if anything would be the alternatives?

Excessive- yes. I would never do that many procedures on bilateral extremities. PEs and DVTs do happen.

 

[dawg44]

I personally know of a few DPMs who are co-owners of free standing surgery centers. There are a few DPMs who have a fully certified surgical suite in the office. These DPMs will have an Anesthesiologist (sometimes CRNA depending on arrangement) come in for the few cases that require MAC Sedation (IV Sedation). I have never seen General Anesthesia or Spinal Anesthesia done in surgical suites of private practice. Of course, General Anesthesia or Spinal Anesthesia can be done in free standing surgery centers.

As for DPMs doing reconstructive rearfoot surgery and foot / ankle trauma, they are usually done in hospital ORs or surgery centers that have arrangements with hospital for admission, since these cases require the patient to be admitted to hospital for pain management. You do NOT need to be affiliated or be part of an Ortho group to do reconstructive rearfoot surgery or foot / ankle trauma surgery. As long as the DPM have the hospital privilege to perform the reconstructive rearfoot surgery and foot / ankle trauma surgery, the DPM can perform these surgeries in the hospital OR and Surgery centers. As for DPMs getting foot and ankle trauma from the hospital ER, it really depends on the arrangement that the DPMs have with the hospital ER and the covering ortho groups. Obviously, DPMs in an ortho group would be getting the foot and ankle trauma from the ER when the ortho group takes call at the hospital. Majority of the DPMs that take foot and ankle trauma call in the ER are NOT part of an ortho group and have some sort of an arrangement with the ER and Ortho groups. For example, at Temple University Hospital (Level 1 trauma) and UMDNJ University Hospital (Level 1 trauma), DPMs and Ortho take alternating primary Foot and Ankle trauma call (eg. DPMs take call on even days and Ortho take call on odd days, etc....). In smaller communtiy hospitals, many of the DPMs take primary call for Foot and Ankle trauma call every day since the Ortho groups are usually tied up with other Orthopedic trauma (hip fractures, femur fractures, pelvic fractures, upper extremity fractures, etc....). This is the case for me, my Podiatry group takes primary foot and ankle trauma call from the hospital ER every day since the on call Ortho group are tied up with hip fractures (my hospital is surrounded by a bunch of nursing homes). In other hospitals, DPM only get the forefoot trauma cases only, while the Ortho groups get the rearfoot and ankle trauma cases. On the other hand, there are some hospitals where the on call Ortho group or the ER physician would make a decision as to what cases will go to the DPM and what goes to Ortho. Of course, there are some DPMs that do not want to take primary foot and ankle trauma call from the hospital.

Interesting to read. I've taken call at 5 different level 1 centers in 3 different states during my training and a bunch of level 2s and its all ortho all the time.

 

[jonwill]

Interesting to read. I've taken call at 5 different level 1 centers in 3 different states during my training and a bunch of level 2s and its all ortho all the time.

I've been at 5 different podiatry programs in 4 states and podiatry did most of the foot and ankle call at all of them. I guess it is just hospital dependent, as well as training dependent. Many hospitals and ortho residencies have no faculity member dedicated to foot and ankle (Pinzer, FAI). Many of the programs that I have been at have ortho departments that fall under this category.

I think a lot of it may depend on whether there is a podiatric surgical residency at the hospital. At the majority of these hospitals, podiatry is usually in the ortho department and covers the foot and ankle stuff. That has been the case in my travels. But there are a ton more hospitals than there are podiatric surgical residencies (I think there are only about 215 podiatric surgical residencies with just over 500 slots in the nation).

Dawg, have you ever been at a hospital that had a podiatric surgical residency (3 year)? And if so, what role did it play?

 

[dawg44]

I've been at 5 different podiatry programs in 4 states and podiatry did most of the foot and ankle call at all of them. I guess it is just hospital dependent, as well as training dependent. Many hospitals and ortho residencies have no faculity member dedicated to foot and ankle (Pinzer, FAI). Many of the programs that I have been at have ortho departments that fall under this category.

I think a lot of it may depend on whether there is a podiatric surgical residency at the hospital. At the majority of these hospitals, podiatry is usually in the ortho department and covers the foot and ankle stuff. That has been the case in my travels. But there are a ton more hospitals than there are podiatric surgical residencies (I think there are only about 215 podiatric surgical residencies with just over 500 slots in the nation).

Dawg, have you ever been at a hospital that had a podiatric surgical residency (3 year)? And if so, what role did it play?

No I haven't had any exposure. We had 2 F&A orthopods in our residency program. Like I said every hospital I've been at has been all ortho all the time. The place I am at now is a tertiary referral center for foot and ankle for about 4 million people with a MLB and NFL team. The only exposure I get is either a complication or a referral from a podiatrist, and oh yeah this website.

 

[dpmgrad]

Interesting to read. I've taken call at 5 different level 1 centers in 3 different states during my training and a bunch of level 2s and its all ortho all the time.

As jonwill alluded to, many of the level 1 and level 2 trauma centers that have a three years Podiatric Surgery Residency programs usually have some sort of arrangement to take primary call for foot and ankle trauma. I know that Orthopedics and Podiatric Surgery alternative primary call for Foot and Ankle trauma at Temple University Hospital (Level 1 trauma) and UMDNJ University Hospital (Level 1 trauma). Podiatric Surgery takes daily primary call for foot and ankle trauma at Morristown Memorial Hospital (Level 2 trauma). All of these hospitals have Podiatric Surgery Residency programs. Of course, there are Level 1 trauma center where only Orthopedics take primary call for foot and ankle trauma. For example, only Orthopedics take foot and ankle trauma call at Jeffersom University Hospital (Level 1 trauma), which has no Podiatric Surgery Residency program but it does have a Orthopedic Foot and Ankle Fellowship. As you said, all of the level 1 and 2 trauma centers where you have rotated at, did not have a Podiatric Surgery Residency programs. This would probably explain why you have not seen any DPMs taking primary foot and ankle trauma call at a trauma center. You also have to realize that an Orthopedic group may be on call for all Orthopedic trauma from the ER. However, some of these Orthopedic groups may have DPMs handling all of the foot and ankle pathology. Hence, these DPMs will take primary foot and ankle trauma call when their Orthopedic group is on call at the hospital.