STICK TO YOUR GUNS

by Jay Lieberman, DPM
PRESENT Editor

Having graduated from one of the seven fine Colleges of Podiatry, you are probably better equipped than you may believe, to handle foot and ankle pathology in a hospital setting.   The trick is to believe in what you have been taught.  Primary care physicians tend to diagnose all problems in the 1st MPJ as gout.   Anterior metatarsal pain is always a Morton's Neuroma.  Arch pain is, without fail, a heel spur.  Anything else is usually "a little arthritis".

Questioning an established diagnosis is a bit of tricky business when you are a lowly resident.   Here is an example of a situation that I have encountered numerous times.  Cases like these would spell disaster for patients if it were not for the special set of skills and knowledge that we as podiatrists can call upon and  bring to their care .   Quite often, I am consulted for evaluation of "diabetic with cellulitis and possible osteomyelitis".  These patients may have been admitted two to three times previously for the same diagnosis and may already be receiving a regimen of antibiotics.   A normal WBC and absence of erythema would ordinarily, put into question, this diagnosis.  A pervasive fear of inadequately treating a diabetic with a hot, swollen foot leads many uninitiated physicians to admit and treat as cellulitis/osteomyelitis despite these questions.   Of course, MRI/Ceretec Bone Scans, or "the Gold Standard", bone biopsy can help to make the distinction between osteomyelitis and acute Charcot changes.  

Great care must be exercised when suggesting an alternative diagnosis to an attending or PCP.   The first rule of thumb is to agree that this is a difficult case.  Next ask if the physician would consider alternative testing.  Finally, ask if the physician believes the alternative diagnosis is in the differential.  Ideally, this gentle nudge jogs the doctors memory resulting in the pursuit of an alternative course.   If the gentle approach doesn't have the desired effect, you may need to take a more assertive approach.  Remember, your first responsibility is to the well being of the patient.  Don't allow yourself to be intimidated.  Don't allow yourself to be convinced that you are wrong.   Believe in yourself and don't compromise your ethics.  Stick to your guns.

Another situation in which the unique "podiatry skill set" that we learn in residency served me well, occurred shortly after I completed my training.   I had purchased a small practice in South Florida.  Naturally, I wanted to make the best impression I possibly could on my patients.  It was my hope that every patient would have a positive experience under my care.   The first Austin I ever did in private practice was performed at a renowned medical institution with very few podiatrists on staff.   I believe that I may have been one of the first podiatrists to ever perform a metatarsal osteotomy at the facility.   I entered the OR and began my case only to find that the oscillating saw felt like a Campbell's soup can in my hand.  The reusable blades were well past their prime.  I succeeded in performing the osteotomy, however, the heat generated by the dull saw blade was significant despite the cooling saline irrigation.  Initially, the patient's post op course was normal.  Two weeks post operatively, I noticed some osteopenia in the capital fragment.  I wanted to attribute this finding to disuse atrophy, but subsequent x rays demonstrated virtual "washing out" of the capital fragment.  I suspected thermal necrosis and recommended a non weight bearing status.  Shortly thereafter, my patient ended up in the office of an orthopedist who felt that the patient had acute osteomyelitis and recommended a ray resection.  To confirm his diagnosis, he sent the patient for a second opinion with a prominent infectious disease specialist who concurred.  

No drainage, no erythema, no leukocytosis.  Just a bit of osteopenia and these well established practitioners were prepared to recommend amputation.

A Nightmare for a young doctor. 

I stuck to my guns and performed a bone biopsy with deep cultures.  All the results were negative for osteomyelitis.  Within weeks the capital fragment reossified.  The osteotomy healed uneventfully, the joint space was well preserved and the patient went on to an excellent result.     STICK TO YOUR GUNS.