When it comes to the field of podiatric medicine and surgery, it is vital to emphasize and defend the unique nature of the profession as a specialty in and of itself, and how that specialty training encompasses all facets of general medicine. Podiatry consults can manifest in a multitude of manners. Its constant growth and appreciation among other medical specialties within the hospital setting, in particular, is reassuring of job security for our profession and has the potential to be extremely rewarding (both financially and personally). These consults encompass aspects of the various subspecialties within the realm of pertinent foot and ankle pathology. Having a grasp on what to expect in each subset, however—whether in observing a new patient in the clinic, approaching a patient during an externship or in your own practice—can make all the difference with regards to effective and efficient patient care… not to mention earning some points with your attending physician.
This subspecialty is all about knowing your materials. Mepilex is a fan-favorite adhesive of surgeons for covering incisions after closure. Xeroform or Adaptic also may be used if you prefer non-adhesives. If a patient exhibits too much drainage, we expect to provide some type of drying dressing or agent, or a device like a WoundVAC in extreme cases or in the OR. If the patient has dry, necrotic, or fibrotic tissue around an open wound, we expect to debride the area and/or stimulate bleeding to ensure healthy granulation of the underlying wound bed. Got one with a level of depth that’s concerning? Collagen Medifil particles can fill the defect. Infected hardware? Remove and add an antibiotic spacer mixed in with bone cement. These are all just a few of the seemingly endless amount of dressings at your disposal. Constant monitoring and diligence of wound care patients may test your own patience, so the satisfaction of seeing improvement in these patients cannot be overstated.
There are 3 key things to note about trauma. First is classifications, second is classifications, and third—you guessed it, CLASSIFICATIONS.
There are 3 key things to note about trauma. First is classifications, second is classifications, and third—you guessed it, CLASSIFICATIONS. It is absolutely crucial to know these ‘cold’ since the best ones typically provide evidence-based prognoses and more importantly, treatment plans based on the severity of the injury. In several instances (ex: Lauge-Hansen classification of Ankle Fractures), they can provide the mechanism of injury via characteristic radiographic findings. This assists the clinician in obtaining an H&P if unable to obtain from the ER physician, or if the patient is a poor historian. Additionally, in cases involving motor vehicle accidents, acts of violence, burns, etc., polytrauma occurs, so you must prepare to work as a team with plastics and orthopedics.
As a former middle and high school basketball coach and current lover of all things sports-related, there is one thing I personally wish was conveyed to me when I chose podiatric medicine—sports medicine is NOT simply working with athletes on your favorite team! Instead, you will observe and treat athletes at all levels of performance and conditioning, as this facet of the profession incorporates essentially every component of orthopedic and soft tissue foot & ankle treatment. This encompasses everything from basic ankle sprains and plantar fasciitis to high-impact injuries and awkward falls from height, amongst other things, making available a vast array of treatment modalities. Whether that patient has a construction job and plays for an adult rec league, or suits up for the 2018 Super Bowl Champion Philadelphia Eagles (shameless shout-out), you begin to develop an appreciation and focus for the urgency of these patients needing to recover and return to their activities. Physical therapy and rehabilitation modalities will become second nature if they weren’t already in your professional toolbox as well when dealing with patients with injuries related to sports medicine.
In my opinion, our academic dean and one of the many surgical and clinical professors at TUSPM, said it best with respect to why he loves treating pediatric patients: “They heal quickly, they don’t want time off, they don’t want pain meds, and all they want to do is get back to playing.” Pediatric patient management and care rely heavily on the process of “simplifying down” your explanations and assessment and plan, and as a result, tests your own education level in the process by providing explanations to both the parent and the child. Having said that, knowing how to approach the parents and legal guardians of this age group can make or break the compliance and eventual success of your plan, whether conservative or surgical.
This crosses over and goes hand-in-hand with all of the above, especially in the absence of trauma or when there is an unknown or inexplicable source of ailment. Not only that, but certain features can even clue the clinician to other systemic issues that may or may not be receiving additional care from primary physicians or specialists. For example, nail pathology like clubbing has shown associations with pulmonary disease, while others like Terry’s nails have shown links to abnormalities in liver function. Pyoderma gangrenosum in wound care patients need to also be checked for IBD or Crohn’s disease, while splinter hemorrhages and dark longitudinal streaks in nails can manifest as signs of subacute bacterial endocarditis and melanoma, respectively. Acral lentiginous melanoma is the most common skin cancer associated with African-American populations and thus, anything suspicious in this population should be monitored. Recognizing these instances and the likelihood of prospective comorbidities can garner both respect and referrals within your region of practice.
A general rule regarding supplies and tools
Regardless of the rotation or immediate task at hand, there are some things one should ALWAYS be prepared with:
- Bandage scissors
- Stethoscope/Blood pressure cuff
- Pen light
- Reflex hammer—many available nowadays come with other compartments to evaluate light touch and sharp discrimination, in addition to reflexes, thereby allowing for a quick but comprehensive lower extremity neurological exam on its own.
By Joshua Elkadios
Temple University School of Podiatric Medicine
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