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Post by blinda on Jan 29, 2009 17:02:21 GMT
Hi All, I was called out to see a private pt yesterday (for a "blister on his big toe" see it on the image?) by the care home he was temporarily staying in following a short stay in hospital for a chest infection. Type 2 poorly controlled diabetes. Peripheral neuropathy up to both kness. PAD, previous hallux amputation on contra foot following Charcot neuroarthropathy. I requested immediate referral to specialist diabetic team for xray to see extent of infection, as i could probe to bone, and subsequent AB cover. Guess what? GP called me an "inexperienced recent graduate" and refused to admit . Took matters into my own hands; documented everything, inc telephone conversation with GP and took him to A & E. Would you have done the same? This scenario has happened to me before, does anyone else experience similar? (Consent was given to photo and use image for educational purposes, etc.)
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Post by Admin on Jan 29, 2009 17:25:04 GMT
Good for you! When I last worked in Primary Care I referred a pt (who clearly had circ problems - I suspected a blockage) to his GP with a request for urgent referral to Vascular Specialist. GP did nothing, pt lost his leg. I always regret I didn't staple myself to the referral letter....
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podmum
Full Member
"There is no dark side of the moon"
Posts: 169
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Post by podmum on Jan 29, 2009 18:13:27 GMT
Bel Good call! Can't believe this still happens with all the publicity re diabetes Wendy
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Post by ianl on Jan 29, 2009 19:27:32 GMT
Absolutely the right thing Bel. Even with your value of pt care it is all about covering your back because the GP would certainly drop you in it. It is the GP who now has to justify himself. Ian
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Post by twirly on Jan 29, 2009 20:09:35 GMT
Hi Bel, I requested immediate referral to specialist diabetic team for xray to see extent of infection, as i could probe to bone, and subsequent AB cover. Guess what? GP called me an "inexperienced recent graduate" and refused to admit I wonder at what point would this GP consider a qualified clinicians skill to be adequate? Possibly never Bel as this attitude appears to be ingrained in some. You followed all appropriate protocols as far as I can see. Your contacting the Pts. GP was exactly the appropriate course of action. Such a shame really that the Dr. appeared to have his head in proctology mode at the time! Your action may well save this patients leg/life. Why some GPs continue to disregard such professional advice & interaction is beyond me! I believed there was something in the Hippocratic oath dictating: 'Do no harm.' Unfortunately sometimes doing nothing is the most harmful action/ inaction of all. Mand'
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Post by dtt on Jan 29, 2009 20:39:19 GMT
Hi Bel Firstly WELL DONE in your diagnosis AND in educating an incompetent GP You make no mention of referring direct to a diabetic specialist pod in your local hospital ?/ Cast your mind back and you will remember I has a similar patient with a similar reaction from the GP who I sent in a taxi to the diabetic podiatrist with a phone call to say he was on his way !! Might I respectfully suggest you take your whole post to www.footindiabetes.com ( John McCalls site )where many of the "Diabetic policy makers post" and get a reaction from them. They agreed with me about a direct line for clinical emergencies in diabetic patients and were asking for this to be made available to all pods throughout the country. Perhaps your post would be a timely remeinder "It Aint working in your area" ?? Cheers D
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Post by blinda on Jan 29, 2009 22:47:03 GMT
yup, she certainly will. Occasionally, not very often mind, women also make monumental mistakes That`s cos there is no diabetic specialist pod here. There is, however, a first-rate, hospital based, specialist diabetic team (which includes an excellent pod) which, as a private practitioner, I am not meant to directly refer to. Policy states I must refer via the pts GP who, in the main, are ignorant of our scope of practice. The direct line for clinical emergencies that you speak of, Del, is not only a great idea, but an essential one if we are to utilise the monitoring and diagnostic skills that us private practitioners posses. We should be in a position to pass on the relevant findings directly to the appropriate professional and reduce the preventable amputations that we see on a daily basis, such as in Davidh`s example. Anywayup, thanks for the vote of confidence guys, sometimes you just have to ruffle a few feathers to be heard, eh? Cheers, Bel
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Post by dtt on Jan 30, 2009 8:41:44 GMT
Hi Bel Neither were we in this area ,thats why after meeting "the wall" from the GP ( who had been treating my pt for over a week as a non urgent condition) in desperation I rang the diabetic podiatrist who was curt and not very helpful to start with but when I told her he was already in transit she was annoyed but I think realised the seriousness of the situation. When the pt arrived he was admitted and..... now comes back to me for regular tx minus the toe. You may find that your "high risk" DM.s carry an emergency phone # see if you can get it and use it after all who is gonna complain if you get another one like that Cheers D
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Post by billliggins on Jan 30, 2009 15:07:12 GMT
Well done Bel
That looks to me like a case for amputation; (hopefully I'm wrong). Please let us know the outcome.
All the best
Bill
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Post by blinda on Jan 30, 2009 15:58:05 GMT
Whoops, wrong thread I got that Friday feeling....... Have a great weekend Bel
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Post by Martin Harvey on Jan 30, 2009 20:12:02 GMT
Hm! that sounds familiar, thats what Bill said when I showed him the corn on my little toe. ::)These Pod Surgeons ;D
But seriously Bel, great call and a gutsy course of action. Well done!
Cheers,
Martin
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Post by johnmccall on Jan 31, 2009 23:59:18 GMT
Hi Blinda,
You did exactly what I would have done given the situation.
I get well p'd off hearing about 'policy' which is often a barrier only in the heads of folks whose egos are bigger than their capacity for common sense. Sounds like you were asking for exactly what the patient needs.
In the words of Douglas Bader (ex war hero and amputee)"rules are for the obedience of fools and the guidance of wise men". This time you were the wise one. I'm sure your patient appreciates your prompt and entirely appropriate action. I tell anyone who thinks that policy is getting in the way that I don't know anyone worth their salt who would not see a patient urgently, provide a decent referral letter/phone call / or email contains everything needed to spark off urgent action. You have all the info in your posting that would make it very hard for most specialist pods or vascular surgeon or diabetologist to ignore.
If you were inexperienced (doesn't look that way to me) then all the more reason to seek another opinion anyway.
I wonder what the GP would have done if it was his foot?
What about your local diabetes specialist podiatrist -do you have any rapport with them?
Cheers John
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Post by robertisaacs on Feb 1, 2009 13:27:09 GMT
Nice catch! Mind you getting them in is only half the fight. I recently admitted an elderly t2 dm with similar toes, planter ipj ulcers to bone and cellutitis galloping up the legs. Got a call from the daughter 2 weeks later. Apparently the ward had not been dressing them because "the patient takes the dressings off". Poor woman (slightly doodleally) had been walking the ward barefoot leaving splats of blood and pus on the floor. Nice work from the acute team. This, of course is maidstone hospital (can you C the DIFFerence.) Oh it makes you to dispair... Robert
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Post by blinda on Feb 1, 2009 19:37:31 GMT
Exactly. Really strengthens yer faith in the system, eh? But just how involved do we become in care after referral? I`ve been there before, 4 years ago, (when i was a `qualified` chiropodist, but a mere `podiatry student`- according to the GP) where I referred a pt with acute Charcot Neuroarthropathy, via the reluctant GP to the diabetic team. I suggested infusion of Pamidronate in conjunction with offloading apparatus in the referral letter, only to hear from a family member, a week later, that he underwent below knee amputation as he was sent home after the x-ray and confirmed diagnosis of acute Charcot that day WITHOUT an offloading device, and booked apointments for Pamidronate infusions in 4 days time. He developed septicemia and had an MI……
Five weeks later, I received a letter from the pts insurance company demanding an explanation of why there was a delay from MY diagnosis of Charcot to him receiving APPROPRIATE treatment!!! Fortunately, I had documented everything, so was exhonorated.
Yup, despair is one word for it.
Doodleally Bel
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Post by johnmccall on Feb 4, 2009 23:40:55 GMT
Hi Bel
Basically you can't unless you have access to the full patient medical record plus microbiology, blood tests, X/ray or MRI reports etc because without them you don't have the full picture on which to base clinical decisions. If you've done the referral and got the patient access to care then (frustrating as it may be to you) it's out of your hands whether or not you think the treatment is correct or given quickly enough.
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