Questions about logs

[Feli]

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Dude I will do everything in my power to not do an HP. I haven't picked up a stethoscope in at least 6 years. F that ish

Yeah, but how many times have you scribbled the classic podiatry "AOx3, PEERL, CTA, s1/s2, NT/ND" to get a case started?

 

[DYK343]

I do a fair amount of H&Ps for toe amps and outpatient diabetic stuff that cant wait a month to see PCP for signoff but also dont require admission.
Always under MAC. I also order BMP and EKG morning of surgery.

20yo bunions with no medical history I do my own H&Ps. I feel like sending low risk H&Ps to PCPs might actually anger them as they are already usually pretty busy.

But any moderate/high risk patient gets the boot to PCP without a second thought.

Tangent thought. Why isnt anesthesia more involved with H&Ps? I understand patients have long relationships with PCP. But anesthesia knows anesthesia surgery risks better than anyone. Why dont anesthesia have preop clinics that presurgical patients go to for preop testing?

 

[Feli]

I do a fair amount of H&Ps for toe amps and outpatient diabetic stuff that cant wait a month to see PCP for signoff.
Always under MAC. I also order BMP and EKG morning of surgery.

20yo bunions with no medical history I do my own H&Ps. I feel like sending low risk H&Ps to PCPs might actually anger them as they are already usually pretty busy.

But any moderate/high risk patient gets the boot to PCP without a second thought.

Tangent thought. Why isnt anesthesia more involved with H&Ps? I understand patients have long relationships with PCP. But anesthesia knows anesthesia surgery risks better than anyone. Why dont anesthesia have preop clinics that presurgical patients go to for preop testing?

You are in a bubble as hospital/group FTE, though (they have to refer to you, you work for the facility... will be busy + paid regardless).
When people are paid on collections and have choices for refers/rep (PP - pod or PCPs or other), it is more important to get/keep refer trust and communications. It can burn you pretty bad when PCP just sees pt with a boot or wrap on and has no idea they were doing XYZ surgery. Some PCPs really want to be captain of the ship, some are just looking out for their pts, etc. It's often nothing you've done... but they've likely seen some cowboy DPMs doing dumb stuff prior.

A bunion H&P for healthy or healthy-ish pt is a high level easy visit for the PCC (who may also own lab/ekg/etc), the pt needs PCP anyways... and who cares if they wait a month for elective? It helps to grease the wheels, and you will keep all sides pt/PCP/you happy to let each do what they're good at. If they are overworked hospital PCP who gets money despite production/collect and tries to limit workload, then yeah... maybe that's different.

Also, why not do some/most lesser toe amps in office? (rVu are prob same for your situ either way FAC vs NF/office, but still much more efficient when safe/logical for case/pt). For PP, you get more for toe amp in office, and the pt saves a lot of time. Of course you admit most DM surgery to force the H&P you can't get the outpt route if urgent surg like ray/TMA/I&D/recon/flap/etc. I am way past faking + forcing those H&Ps and trying to keep that stuff outpatient (and a lot of hospitals don't allow it for DPMs' H&P anyways).

...I feel like anesthesia is typically not very involved with pre-op eval as they - and mainly facility - do NOT want same-day cancels (esp elective cases... cxl day of = irritated pt who did npo and took time off and got a driver, wasted OR team $$, lost income, etc). They want that stuff largely done by surgery day. In some places, anesthesia will do pre-op consults a week or so ahead of time for some patients (neck/throat issues, complicated PMH, Rx reaction hx, etc), which is highly useful if available. I have asked for those a few times, explained pt concern or my concern... usually MD/CRNA just calls pt (doesn't actually see them til day of), or I'm just told "that'll be fine, we'll just see them on surgery day." 🙂

 

[DYK343]

You are in a bubble as hospital/group FTE, though (they have to refer to you, you work for the facility... will be busy + paid regardless).
When people are paid on collections and have choices for refers/rep (PP - pod or PCPs or other), it is more important to get/keep refer trust and communications. It can burn you pretty bad when PCP just sees pt with a boot or wrap on and has no idea they were doing XYZ surgery. Some PCPs really want to be captain of the ship, some are just looking out for their pts, etc. It's often nothing you've done... but they've likely seen some cowboy DPMs doing dumb stuff prior.

A bunion H&P for healthy or healthy-ish pt is a high level easy visit for the PCC (who may also own lab/ekg/etc), the pt needs PCP anyways... and who cares if they wait a month for elective? It helps to grease the wheels, and you will keep all sides pt/PCP/you happy to let each do what they're good at. If they are overworked hospital PCP who gets money despite production/collect and tries to limit workload, then yeah... maybe that's different.

Also, why not do some/most lesser toe amps in office? (rVu are prob same for your situ either way FAC vs NF/office, but still much more efficient when safe/logical for case/pt). For PP, you get more for toe amp in office, and the pt saves a lot of time. Of course you admit most DM surgery to force the H&P you can't get the outpt route if urgent surg like ray/TMA/I&D/recon/flap/etc. I am way past faking + forcing those H&Ps and trying to keep that stuff outpatient (and a lot of hospitals don't allow it for DPMs' H&P anyways).

...I feel like anesthesia is typically not very involved with pre-op eval as they - and mainly facility - do NOT want same-day cancels (esp elective cases... cxl day of = irritated pt who did npo and took time off and got a driver, wasted OR team $$, lost income, etc). They want that stuff largely done by surgery day. In some places, anesthesia will do pre-op consults a week or so ahead of time for some patients (neck/throat issues, complicated PMH, Rx reaction hx, etc), which is highly useful if available. I have asked for those a few times, explained pt concern or my concern... usually MD/CRNA just calls pt (doesn't actually see them til day of), or I'm just told "that'll be fine, we'll just see them on surgery day." 🙂

I have 1 PCP who refers a lot of wounds to me but absolutely refuses to allow his patients w a chronic ulcer to have a MIS osteotomy, keller osteotomy, etc after failing wound care. He even refused a toe amp once until I sent the patient to vascular first (2ish months at our local university hospital). This particular PCP sends patients to a specialist then tries to override. Drives me nuts.

I recently did a keller local only on one of his patients because I didnt want to clear the patient. Patient with a wound x 2 years. Healed in a week.

Recently had another of his patients who ended up on dialysis because of too many ABX from off and on foot infections (ID was actually the one who over did it - not me). All the patient needed was a MIS 2nd met osteotomy but the PCP refussed. Once the patient was hospitalized for infection and kidney failure I "got a bone biopsy" 2nd met. When I was there I did an MIS elevating osteotomy and the patient healed 1 week later after having the wound for 3 years.

This is more of a rant that anything. It really has nothing to do with what you typed above. Thanks for listening.

 

[dtrack22]

I have 1 PCP who refers a lot of wounds to me but absolutely refuses to allow his patients w a chronic ulcer to have a MIS osteotomy, keller osteotomy, etc after failing wound care. He even refused a toe amp once until I sent the patient to vascular first (2ish months at our local university hospital). This particular PCP sends patients to a specialist then tries to override. Drives me nuts.

I recently did a keller local only on one of his patients because I didnt want to clear the patient. Patient with a wound x 2 years. Healed in a week.

Recently had another of his patients who ended up on dialysis because of too many ABX from off and on foot infections (ID was actually the one who over did it - not me). All the patient needed was a MIS 2nd met osteotomy but the PCP refussed. Once the patient was hospitalized for infection and kidney failure I "got a bone biopsy" 2nd met. When I was there I did an MIS elevating osteotomy and the patient healed 1 week later after having the wound for 3 years.

This is more of a rant that anything. It really has nothing to do with what you typed above. Thanks for listening.

Do them under local in the OR. Then you don’t need permission from their PCP. Though this goes back to the fact that nobody is actually “clearing” your patients for surgery. It’s risk stratification for their ability to tolerate the level of anesthesia you think they need. That’s it.

 

[Adam Smasher]

Medical clearance notes are almost always garbage. Pt goes to NP, NP writes a template note, pt gets one more medical bill, surgery proceeds as it otherwise would have. That's why I clear my own pts. If you can do a TMA on a badly controlled diabetic inpatient, and they generally don't die on the operating table, you can clear virtually anyone else.

3 important exceptions:
1) any cardiac hx more serious than htn/hld = cardiology referral. Not pcp, cards.
2) bad asthma/copd I suppose would be pcp clearance but then again I wouldn't bother scheduling this person.
3) pt is crazy = pcp can clear because I don't trust them, and again I probably shouldn't be scheduling this kind of person.

Apart from the logistical advantages of getting the pt to surgery with fewer speed bumps, it gives you a reason to understand the whole person. For example, a diabetic pt with hga1c in the 8s or 9s or beyond shouldn't even be scheduled for surgery. No clearance necessary because they're not a surgical candidate to begin with. Control or sugar or find a stupider surgeon.

Lastly, it's never truly "medical clearance" but rather the pcp/cardiologist offering their consultation as to the patient's level of risk stratification, and the onus falls on the surgeon (podiatrist, ortho, ent, whoever) to decide if the benefits of surgery justify the risks.

 

[Retrograde_Nail]

I’m hospital employed and would never do an H&P on any of my patients ever. I have had quite a bit who ended up having cardiac issues that were not previously identified before (not sure what PCP was doing before). I think it’s worth having another set of eyes see the patient. Where I practice anesthesia also does their own pre operative screening as well and will try and block cases if they still have a concern with the clearance. So there is no way I would ever consider clearing the patient myself. Never. No way.

Also it is worth knowing that you are feeding your fellow PCPs with easy RVUs. Everyone wins. I’ve never had a PCP refuse.

 

[Adam Smasher]

I have had quite a bit who ended up having cardiac issues that were not previously identified before (not sure what PCP was doing before).

This doesn't make sense. The same PCP who hadn't diagnosed cardiac issues before finds something as soon as your patient is indicated for elective surgery?!

Where I practice, PCPs are booked solid for weeks, so it's not so simple as getting clearance without scheduling the surgery around it. Plus they were already treating me like I'm interchangeable with anyone else before I started clearing my own people, so it's not like I'm depriving them RVUs.

 

[DYK343]

I’m hospital employed and would never do an H&P on any of my patients ever. I have had quite a bit who ended up having cardiac issues that were not previously identified before (not sure what PCP was doing before). I think it’s worth having another set of eyes see the patient. Where I practice anesthesia also does their own pre operative screening as well and will try and block cases if they still have a concern with the clearance. So there is no way I would ever consider clearing the patient myself. Never. No way.

Also it is worth knowing that you are feeding your fellow PCPs with easy RVUs. Everyone wins. I’ve never had a PCP refuse.

My issue is when I need to amp a toe in a week or less and a PCP appointment is 2-3+ weeks. I either have to clear them or admit them. Hospitalists dont want to admit a non septic toe amp. In that situation what do you/I do?

I clear them. MAC. EKG/BMP preop. MAC anesthesia has minimal risks. Never zero. But minimal.

A real doctor (anesthesia) will review it the morning of surgery anyway. Its bad to look at it that way. I get it. But admitting every toe amp because a PCP preop appointment is weeks out isnt logical.

Do them under local in the OR. Then you don’t need permission from their PCP. Though this goes back to the fact that nobody is actually “clearing” your patients for surgery. It’s risk stratification for their ability to tolerate the level of anesthesia you think they need. That’s it.

Yeah thats why I did one of his local only. But piggybacking off Felis post about involving PCPs and not cutting them out of the process. It can piss them off. But this PCP pisses me off so I dont care. Dont send me patients for my expertise if you are going to micromanage what I do.

Dude is a crap PCP and hurts his patients with his ego.

Guy sucks.

Thanks again for listening.

 

[DYK343]

Lastly, it's never truly "medical clearance" but rather the pcp/cardiologist offering their consultation as to the patient's level of risk stratification, and the onus falls on the surgeon (podiatrist, ortho, ent, whoever) to decide if the benefits of surgery justify the risks.

I love it when they say "Clear for surgery" in their note because now im off the hook.
They should always say minimal risk/low risk/moderate risk/optimized/etc.

In reality though were not taking deaths door grandmas to surgery to fix bunions. If youre sick and going to surgery its because its not elective anymore. Has anyone ever had a bunion patient not be "cleared"? I havent. Because I/we pre-clear them before sending to PCP when I look at their chart. Smoker/elevated A1c/PAD/cardiac disease/27 allergies etc is a no go from the get go.

Still leaves the critically ill patient that needs surgery in less than a few days but doesnt need hospitalized. Theyre the tricky ones with risk stratification from a podiatrist H&P

 

[Retrograde_Nail]

@adamsmasher

Yes it doesn’t make sense but it’s happened. The patients I operate on sometimes I think don’t get good care until they actually need something done.

But it’s happened

 

[Adam Smasher]

Has anyone ever had a bunion patient not be "cleared"?

I once had a 16 y/o with a VERY benign congenital cardiac valvulopathy get cleared by his pediatric NP for bunion surgery under local anesthetic. I only read the "clear" part and the case got cancelled day of surgery because implicitly he was not cleared for MAC anesthesia.

He ended up getting cleared by his pediatric cardiologist in the big city--again, templated note. But this is an instance where I learned I need to do my own history taking and make my own cardiology referrals because PCPs are not invested in these clearance notes.

 

[air bud]

My issue is when I need to amp a toe in a week or less and a PCP appointment is 2-3+ weeks. I either have to clear them or admit them. Hospitalists dont want to admit a non septic toe amp. In that situation what do you/I do?

I clear them. MAC. EKG/BMP preop. MAC anesthesia has minimal risks. Never zero. But minimal.

A real doctor (anesthesia) will review it the morning of surgery anyway. Its bad to look at it that way. I get it. But admitting every toe amp because a PCP preop appointment is weeks out isnt logical.


Yeah thats why I did one of his local only. But piggybacking off Felis post about involving PCPs and not cutting them out of the process. It can piss them off. But this PCP pisses me off so I dont care. Dont send me patients for my expertise if you are going to micromanage what I do.

Dude is a crap PCP and hurts his patients with his ego.

Guy sucks.

Thanks again for listening.

I do a ton of stuff local only. Hell I will even do local and have anesthesia do a pop block if I have to. Neuropathy? Unless crazy it's local only. TMA, gastroc whatever. Lay there and take it. We will put on your favorite music

 

[air bud]

I once had a 16 y/o with a VERY benign congenital cardiac valvulopathy get cleared by his pediatric NP for bunion surgery under local anesthetic. I only read the "clear" part and the case got cancelled day of surgery because implicitly he was not cleared for MAC anesthesia.

He ended up getting cleared by his pediatric cardiologist in the big city--again, templated note. But this is an instance where I learned I need to do my own history taking and make my own cardiology referrals because PCPs are not invested in these clearance notes.

History taking? I am not sure what part of the surgery that is. We are surgeons bro. ACFAS and the schools told us so .

 

[DYK343]

I do a ton of stuff local only. Hell I will even do local and have anesthesia do a pop block if I have to. Neuropathy? Unless crazy it's local only. TMA, gastroc whatever. Lay there and take it. We will put on your favorite music

You do TMAs under local only?

I once had a patient jump off the table mid case during a local only Austin/Akin bunion right out of residency. She was scared to go under anesthesia so I agreed to do it local only. But mid case she had a panic attack and started jumping off the table contaminating everything. Ill never do it again (well thats a lie. As above I recently did a keller because PCP wouldnt sign off).

Maybe a toe amp because its fast/easy/if they jump off the table its probably salvageable given no exposed cancellous bone. But anything more invasive I usually want MAC.

 

[air bud]

You do TMAs under local only?

I once had a patient jump off the table mid case during a local only Austin/Akin bunion right out of residency. She was scared to go under anesthesia so I agreed to do it local only. But mid case she had a panic attack and started jumping off the table contaminating everything. Ill never do it again (well thats a lie. As above I recently did a keller because PCP wouldnt sign off).

Maybe a toe amp because its fast/easy/if they jump off the table its probably salvageable given no exposed cancellous bone. But anything more invasive I usually want MAC.

Yeah absolutely TMA local only. If a patient is pathetic enough to let their foot slowly rot off...then they can just sit there for 30 mins and sleep.

Also, I want to start doing more toe amps at bedside. Like in hospital.

 

[Hybrocure]

I do a ton of stuff local only. Hell I will even do local and have anesthesia do a pop block if I have to. Neuropathy? Unless crazy it's local only. TMA, gastroc whatever. Lay there and take it. We will put on your favorite music

My hospital won’t let me do surgery under local only. No anesthesiologist in the room.

This is assuming you’re talking about no sedation whatsoever. No Mac or general = no OR room

 

[DYK343]

My hospital won’t let me do surgery under local only. No anesthesiologist in the room.

This is assuming you’re talking about no sedation whatsoever. No Mac or general = no OR room

Where I practiced before I had pushback with this. Told me to go to surgery center.
Where I am now so far no push back for local only but I dont do a ton.

 

[air bud]

My hospital won’t let me do surgery under local only. No anesthesiologist in the room.

This is assuming you’re talking about no sedation whatsoever. No Mac or general = no OR room

nurses bro. one nurse in the anesthesia chair, one doing normal stuff. never been anyplace where its an issue

 

[Feli]

I'm with DYK... sed/gen for anything osseous or using power instruments. It's crazy not to... too many pitfalls. Pts logically tend to freak out with power instruments going ton the other side of drape.

Point of note: at the vast majority of facilities, local procedure in the OR does not mean you don't need H&P (for safety, if the pt had rxn, needed to convert to real anesth, needed to admit, etc). Many an associate podiatrist new out of residency have embarrassed themselves this way: showed up with a heifer to do a toe amp or ganglion or hammertoe or something... not knowing anything about the PMH or meds. Not a good look.

...personally, I will do office local anesth for perc lesser digit tendonotomies, skin lesions, lesser toe amps (DIPJ disarticulation or most commonly PIPJ disarticulation or occasionally mid-prox phalanx) in office. I use "bone forceps" (big nail nipper) for cutting the prox phalanx for some toe amps. I don't do plantar fasciotomies or plantar wart sharp excisions in office (very hard/painful to get the block... infinitely better with sed).

 

[heybrother]

I don't get PCP clearances unless the patient tells me the PCP is actively treating them for a problem.

Cardiology if there's any question on cardiovascular health.

Anesthesia "clears" podiatry patients everywhere I go. I don't need a note for an NP on a 16 year old bunion.

One of my hospitals has an excellent anesthesia service that will call the week before on sick patients to make sure the case is a success. They'll examine ahead of time.

My surgery center puts everyone to sleep. They'll put a 85 year old to sleep for a 2nd toe amp. My hospital wants everyone awake.

 

[Feli]

...

Anesthesia "clears" podiatry patients everywhere I go...

It was that way many place when I was a resident and a bit afteward. It's regional.

This is no longer the norm most places - particularly hospitals, though (liability, avoid same-day cancels, pt safety, etc).