Treatment On the Envelope

by Jarrod Shapiro, DPM
PRESENT Resident Editor
Botsford General Hospital
Farmington Hills, MI

The other day in clinic we were seeing an unfortunate diabetic, chronic renal failure patient with a Charcot-induced plantar foot ulceration and a history of non-bypassable peripheral arterial disease. We’ve attempted just about every possible conservative care method including EVERY method of offweighting you can think of as well as almost every wound care regimen in the book. We were seeing this patient with one of my more adventurous attendings, discussing the options, as surgery was out of the question, when the idea of maggot therapy came across the table. We thought, “Why not? We’ve tried everything short of prayer sessions.”

Now, personally, I have a bit of trouble stomaching the image of little maggots crawling around a wound, happily gobbling up bits of necrotic tissue. But with no other options available, attempting this modality is in the patient’s best interest. This brings up the question, where do new and “untried” approaches fit into residency training—treatment on the envelope?

In my opinion residency training is the absolute most appropriate place for “unproven” treatments. I’m not only talking about wound care, of course; this includes both conservative and surgical treatments. In residency, we all learn the standard surgical management for the standard pathologies we see – arthroplasties for flexible hammertoes, for example – but I think we should also learn as many alternative methods as possible (always based on sound research and critical thinking). This requires pushing the envelope a bit.

In the same vein, we should try as many new products as possible, as long as they make sense. Instead of the same old end-to-end or peg-in-hole digital fusion push your more experimental attendings to use the Weil-CarverTM hammertoe implant (Arthrotek) or the StayFuseTM implant (Pioneer), for example. Consider some of the newer medications for painful diabetic peripheral neuropathy such as Lyrica (Pfizer). How about the STS Casting sock for orthotics and AFOs? Try it if you haven’t. Push the envelope.

In the allopathic community, residency programs often have nationally known physicians as staff, pushing the envelope. Patients with advanced disease with few options left are referred to these academic centers, often with excellent results. Is this not a picture of many of our attendings? I’m sure many, if not most of us have at least one attending, known to push the envelope, where patients who’ve been unsuccessfully treated by other docs are sent. Incidentally, these attendings seem to be the most open to discussion and suggestions – my favorite type. These are the attendings you want to try new ideas with.

When you attend a conference do you want to hear the same old bunion or heel pain lecture? No. You’re looking for the new ideas, the novel treatments. When you learn something new do you bring it back to your program and teach others? Do you use what you’ve learned? If you’re not, then why go to the conference? Apply what you learn. Continue to push the envelope. It’s the only way to advance ourselves and our profession. Write in and let the residency community know your thoughts. Push our envelope a bit.

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http://www.podiatricresidency.com/residencyrap/

Talk to me,

Jarrod Shapiro, DPM
PRESENT Resident Editor
jarrod@podiatry.com