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This is how it should be
100% agree
This is how it should be
For patients I self clear, I send EKGs to the local imaging center. They subsequently contract a cardiologist to read it.My ASC requires anyone over 50 to get EKG done which means I have to send them to PCP for full medical clearance. It’s dumb.
Do you ever run into anesthesia that for whatever reason doesnt want to do MAC for diabetic cases? In residency tons of MAC. Where I am now its like pulling teeth to get a MAC even with discussion with anesthesia that there is no need for a popliteal block or deep anesthesia due to neuropathy. Its like they skipped the diabetic foot/neuropathy chapter in medical school. (generalizing - not all).
My ASC requires anyone over 50 to get EKG done which means I have to send them to PCP for full medical clearance. It’s dumb.
Doing a chronic Achilles repair (2 hours prone) on a 47 BMI. No meds, A1c is 5.3. One of those healthy morbidly obese people. Yeah I am having someone else see her before surgery. 1 facility all CRNA said no, facility with anesthesiology say yes can do her.I’m rural. Our staff is entirely CRNA. They function independently. They are salaried. They do MAC + local or MAC + regional on elective osseous cases in sensate patients if I book it that way. Really no questions asked. Occasionally they will convert or decide on general (LMA) even though I say I can get away with MAC, and that’s for airway reasons rather than them not believing I can adequately anesthetize the foot. I have never had anesthesia try to over-anesthetize a neuropathic patient. That doesn’t make any sense (other than the occasional obese/apneic patient where they’ve done general with an LMA). But even in those cases I will typically suggest just a little versed and let the patient chat it up with them on the other end of the bed. They are good in terms of erring on the side of lighter anesthesia as opposed to paralyzing and intubating these people.
You have a good gig but between clipboard nurses and anesthesia and no vacation because you’re responsible for every inpatient at all times, you work with *****s. No offense to said *****s or you.
You can’t just order an EKG?
We (podiatrists) don’t do any “high risk” or really even “intermediate risk” surgeries from a cardiac standpoint. I’ve heard of facilities requiring EKG on low risk patients without cardiac symptoms at a certain age (generally the cutoff is 50 or 60). Other than cardiac patients or patients with any recent cardiac symptoms, I get EKGs on diabetic patients, patients with renal disease, significant PAD or history of Stroke/TIA basically regardless of age. They usually happen to be older than 50 any ways. For low risk patients undergoing low risk surgery, I get an EKG if they are over the age of 60 and haven’t had one in a year (they usually haven’t unless they’ve had a recent surgery) mostly to make anesthesia happy. There are plenty of risk stratification flow charts that would suggest an EKG in a 61 year old with no known medical conditions undergoing low risk foot surgery (basically any foot surgery) does not need a pre-op EKG. But enough anesthesia departments make public recommendations regarding pre-op EKG on people over a certain age that I do it.
I think a lot of it is anesthesia can increase billing for deeper level anesthesia. Obviously thats wrong but clearly whats happeneing. Why would they demand a popliteal block when there is a large gaping wound on the plantar foot and no pain? There are a couple in my area that refuse to proceed with case without pop block. (and so im told popliteal blocks dont really pay very much).I’m rural. Our staff is entirely CRNA. They function independently. They are salaried. They do MAC + local or MAC + regional on elective osseous cases in sensate patients if I book it that way. Really no questions asked. Occasionally they will convert or decide on general (LMA) even though I say I can get away with MAC, and that’s for airway reasons rather than them not believing I can adequately anesthetize the foot. I have never had anesthesia try to over-anesthetize a neuropathic patient. That doesn’t make any sense (other than the occasional obese/apneic patient where they’ve done general with an LMA). But even in those cases I will typically suggest just a little versed and let the patient chat it up with them on the other end of the bed. They are good in terms of erring on the side of lighter anesthesia as opposed to paralyzing and intubating these people.
You have a good gig but between clipboard nurses and anesthesia and no vacation because you’re responsible for every inpatient at all times, you work with *****s. No offense to said *****s or you.
You can’t just order an EKG?
We (podiatrists) don’t do any “high risk” or really even “intermediate risk” surgeries from a cardiac standpoint. I’ve heard of facilities requiring EKG on low risk patients without cardiac symptoms at a certain age (generally the cutoff is 50 or 60). Other than cardiac patients or patients with any recent cardiac symptoms, I get EKGs on diabetic patients, patients with renal disease, significant PAD or history of Stroke/TIA basically regardless of age. They usually happen to be older than 50 any ways. For low risk patients undergoing low risk surgery, I get an EKG if they are over the age of 60 and haven’t had one in a year (they usually haven’t unless they’ve had a recent surgery) mostly to make anesthesia happy. There are plenty of risk stratification flow charts that would suggest an EKG in a 61 year old with no known medical conditions undergoing low risk foot surgery (basically any foot surgery) does not need a pre-op EKG. But enough anesthesia departments make public recommendations regarding pre-op EKG on people over a certain age that I do it.
Bingo. Always follow the money.I think a lot of it is anesthesia can increase billing for deeper level anesthesia. Obviously thats wrong but clearly whats happeneing. Why would they demand a popliteal block when there is a large gaping wound on the plantar foot and no pain? There are a couple in my area that refuse to proceed with case without pop block. (and so im told popliteal blocks dont really pay very much).
About EKGs as you said above its more for anesthesia comfort. If you show up and they demand a preop EKG and gotta wait for cards to read it it just slows the day down. I get a lot of EKGs to keep things moving.
If that happened to a DPM they would probably just tank the whole profession!makes national news, and you're done if that happens to you.
In residency, almost every surgical patient we had needed clearance by admitting doc (internal med lol) and if they had any cardiac issues at all, would also request cardiac clearance. I think moving forward, I will keep that olive branch open so they can send me more total nail replacement patientsIf that happened to a DPM they would probably just tank the whole profession!
I think a lot of it is anesthesia can increase billing for deeper level anesthesia. Obviously thats wrong but clearly whats happeneing.
I would agree with you and Feli. That was my first thought. It’s also why I mentioned our CRNAs are salaried. They get paid regardless of level of anesthesia…
Follow the money. Almost always.
SDN censored the word m o r o n s above. Seriously?
we should all post on Truth Social insteadThey are woke
Too busy with jams and jellies and EpiFix and stringing the patient along for as long as possible. It’s tragic and sad when a surgical option can save a limb much quicker.Love this thread, agree that a lot of foot ulcers need a surgical solution. Since the pandemic a lot of systematic reviews came out to support floating osteotomies and flexor tenotomies, I’m surprised that a lot of podiatrists still don’t think about these surgical options for diabetic problems
Can you point us in the direction of those?Love this thread, agree that a lot of foot ulcers need a surgical solution. Since the pandemic a lot of systematic reviews came out to support floating osteotomies and flexor tenotomies, I’m surprised that a lot of podiatrists still don’t think about these surgical options for diabetic problems
Can you point us in the direction of those?
Do you put the insoles in his shoes or in his underpants?...and cure his ED.
And if all else fails….a HyProCure should do the trick.
And if all else fails….a HyProCure should do the trick.
Please please pleaseSpeaking of fraud…
Please tell us how many times you catch podiatrists billing ORIF of STJ dislocation when all they do is implant an arthroereisis?
ALL the time. And some actually bill it as a subtalar arthrodesis.Speaking of fraud…
Please tell us how many times you catch podiatrists billing ORIF of STJ dislocation when all they do is implant an arthroereisis?
ALL the time. And some actually bill it as a subtalar arthrodesis.
But when those cases hit my desk I just smile knowing they aren’t getting away with it THIS time AND I’m getting paid to make sure these thieves don’t get the fraud approved.
Dear god what kind of facebook cancer group is this. How are these people allowed to practice medicine and operate on people?! Our profession is insane!View attachment 356870
For your amusement.
S2117View attachment 356870
For your amusement.
This is promising, but we are basically just viewing them as akin to doing met head resections from biomech result, right? I don't see how they won't have all of the same issues (transfer lesions, drifting crazy toe, eventual TMA even with best custom insoles afterwards). There is no reason to call 1.5yr avg f/u on diabetics "long term" when those DFU amputee pts will have quarterly - or more freq - pod exams lifelong.Metatarsal Osteotomies for Treating Neuropathic Diabetic Foot Ulcers: A Meta-analysis - PubMed
Diabetic foot ulcers (DFUs) are usually treated with conservative management based on debridement, topical agents, and nonsurgical off-loading; however, the recurrence rate following such standard care is reported to be high. In the case of recalcitrant or recurrent ulcers, a surgical...pubmed.ncbi.nlm.nih.gov
This is the most relevant one. Honestly just lookup all articles by that author since 2019, it’s all super relevant to this thread
I don't see how they won't have all of the same issues (transfer lesions, drifting crazy toe, eventual TMA even with best custom insoles afterwards).
Beyond belief. How did you know that was the word I used? Did you read it prior to them censoring the word?SDN censored the word m o r o n s above. Seriously?
Beyond belief. How did you know that was the word I used? Did you read it prior to them censoring the word?
This is promising, but we are basically just viewing them as akin to doing met head resections from biomech result, right? I don't see how they won't have all of the same issues (transfer lesions, drifting crazy toe, eventual TMA even with best custom insoles afterwards). There is no reason to call 1.5yr avg f/u on diabetics "long term" when those DFU amputee pts will have quarterly - or more freq - pod exams lifelong.
A lot of things just get rinsed and repeated in podiatry...
The "let the met head find its own level" float central met osteotomy was popular awhile ago, before DPMs realized it crashed and burned... and Weil became standard.
The rope-a-dope for HAV got reinvented as tightrope for HAV and failed even faster that time.
MPJ 1 implants from silicone to hemi to totals are on their ump-teenth generation... still suck and no real benefit (except that cpt pays better than fusion).
Scarf and other midshaft stuff gets played around with , but they're fairly disastrous in practice and with long term re-op and recur f/u.
MIS had its brief heyday and now has its rebirth moment in the sun right now.
A lot of things didn't work then and are unlikely to now (small exception to Lapidus with tight flannel bandage vs Lapidus with internal fixation).
I would hope so too, but here is no appreciable long term f/u...Floating met heads are completely different than resecting met heads, you leave the DTML and that helps stabilize it. Much less incidence of transfer lesions than resections.
I would hope so too, but here is no appreciable long term f/u...
The MIS float osteotomies for elective that were all the rage, taught in schools, promoted at CME, etc in 1980s and 90s (either pin them with driving back hammertoe k-wire for a month until removed... or just float the met cuts from the getgo) had very bad results with f/u. Weil obviously became the norm. Everything looks great for short and maybe medium term f/u... look at implants, base wedge, etc. The float met cuts fell out of favor quick back then 20-30+ years ago... doubt they are even given lip service in McGlamry or major texts anymore. 'Follow-up is the enemy of good surgery.'
Granted, the DM ulcer ppl might not be as active, but most are bigger folk. We shall see. I hope it ends better.
...I just saw a new pt lady in 40s today who had that done (unfixated distal met osteotomies bilateral... along with 1st met/MPJ under-correction) by "the best foot surgeon in Chile" just a year ago, now with dorsal dislocated central MPJs and recurring hammertoes less than 2yr post... not pretty. Her calluses are sub 4th MPJ and 2nd and 3rd dorsal PIPJs, medial 1st met head. It will be a pretty complicated save - and less than 2yrs after the "correction"... MPJ1 desis with Weils to try to correct parabola etc that the met osteotomies messed up? Not fun.
View attachment 356984
All those headless screws must have cost a fortune
I like Dr. Chiu’s work and his dedication to student/resident education.
Great article/technique here. Worth a read. I've done it a couple times in the office already with fantastic results (for h. limitus, NOT rigidus).
Great article/technique here. Worth a read. I've done it a couple times in the office already with fantastic results (for h. limitus, NOT rigidus).
I do p. fasciotomy.What CPT code do I bill for this crap?
Concur. ^In the author’s experience, it was difficult to feel the subtle increase in hallux dorsiflexion, so confirmation of the release was done by remov-
ing the needle and palpating for the defect. Another confirmation wasd one by re-inserting the needle and gently swiping the needle again in
the coronal plane to feel for any snags of residual fibers
Is this just a fancy way of just jamming it in there and hacking away?
Yes, that's the whole reason for this "innovation."I [bill] p. fasciotomy.
Yeah, that and the fact that maybe 3% of such patients have a fully reducible deformity with minimal/no rigidus componentI have a ton of these wounds in the wound center right now. Same spot/location. They can be difficult to heal.
I know of others doing this same procedure and stating good results.
Ive yet to try but I am intrigued as I find them difficult to heal.
6 patients is not enough to make me dive in tho
18ga vs plantar fascia = elephant hunting with a BB gun. It's a good way to break a needle off inside the foot or certainly to fail to accomplish what you set for.
again, 18ga unreliable at best
Yeah, that and the fact that maybe 3% of such patients have a fully reducible deformity with minimal/no rigidus component
We are probably talking different things...I’ve done maybe a dozen of these and far more flexor tenotomies with 18ga needles. The statements above are rather ignorant. You actually believe you are going to break an 18ga needle in the foot while swiping across the plantar fascia?
Thinking that a prefab is healing these people in my clinic (procedure is only done when they have already failed custom accommodative inserts and or daily felt offloading) is also pretty ignorant.
Feli is slowly morphing into bitter old TFP man around here 🙄