Tips for Attorney Podiatric Case Review and Doctor Treatment

TASA ID: 1128

During my review of podiatric cases from 1993, I have come across items that I feel would be of interest to attorneys and doctors.  Each item below represents a discussion of a case that I have reviewed.  

• Do you have experience/training to perform this particular surgery?  How many times have you done it?  Have you taken courses to learn how to do this procedure?  How many times per year do you perform this procedure?  Have you done this procedure since residency?  

• DVT prophylaxis controversial. Protocols vary by weight of the patient, the procedure performed, was a cast applied?  

• Do Culture & Sensitivity with infections. Check results - document, check antibiotic prescription versus the culture results. 

• Document indications for surgical procedure. Indicate the Intermetatarsal angle, x-ray findings, exam findings, patient request; CT, MRI or bone scan results.  

• For lateral ankle stabilization procedures, document the stress x-ray findings, i.e., the increased lateral gutter, the talar tilt.  

• Document ulcer findings during your exam, i.e., signs of infection, appearance of the ulcer, size of the ulcer.  

• Document intraoperative findings, also breakage of hardware, instrumentation.  Document discussion with the patient. 

• Be aware of frequency of injections.  This concerns changes in the skin, fat, soft tissue, and tendon.  The records should note the amount of the material and the type of steroid used.  

• Many cases involve chronic pain, allegation of nerve damage. 

• Early recognition of Chronic Regional Pain Syndrome (CRPS) or the older term Reflex Sympathetic Dystrophy (RSD) and referral to neurology or psychiatry.  

• Document initial past medical history/review of systems, initial exam.  Document conservative treatment or that the patient refuses.  Document patient's desire for surgery.  Itemize the risks and state that the patient is aware of the risks.  

• Perform surgery well - in regard to type of fixation, osteotomy placement, placement of hardware. Fixation can vary from absorbable to metal. Should double headed screws be used for more compression?  

• Discuss sesamoid position on the postoperative x-ray after bunion surgery. If the sesamoids are not in adequate position, is this an indication of poor procedure? 

• Bunion recurrence is not below the standard of care.  

• Consent should be written, signed, witnessed, dated, and contain risks, diagnosis and procedure in layman’s terms.  

• There should be a statement in the chart or on the consent to allow any procedure to be performed so that a good result can be obtained.  Sometimes other procedures need to be performed that were not contemplated during the initial discussion.  

• Postoperative gangrene is possibly not preventable.  

• Mid foot fusions are hard to heal because there is an increased incidence of nonunion and chronic pain. (Warn the patient of this in the chart and on the consent.)  

• If you have used an implant during surgery, what has been your experience with this implant in the past?  Did you have training in its use?  How many times have you performed the procedure?  Do you have any conflicts of interest with the implant company?  

• Document patient cancellation of appointments and no shows. Document the patient's complaints in the record or lack of complaints.  

• Recognize postoperative infection early and treat early.  Avoid osteomyelitis - Diagnose osteomyelitis early, refer to infectious disease early, obtain necessary testing; MRI, bone scan or bone biopsy. 

• A number of cases involve diabetic wounds & peripheral vascular disease leading to complications, i.e., ulcer surgery and amputation.  

• Avoid wrong side surgery, even in foot cases.  An example is "heel" spur surgery - is it the posterior or plantar?  

• X-ray findings should agree with your diagnosis and treatment plan.  

• Cooperate with new treating physicians - send records and return phone calls promptly.  

• Document patient phone calls - to and from.  

• Avoid cast compression. Document the type of cast applied, anatomical location (i.e., does it press on the peroneal nerve at the fibular head) and technique (i.e., well padded).  Document that the patient has been given instructions.  

• A Podiatrist is an expert for x-ray review of the foot, not the radiologist.  

• Avoid excess bone removal from the digit during hammertoe repair.  

• Recommend continued persistent investigation for unexplained pain; ruling out occult fracture with MRI, CAT scan or bone scans.  

• Be aware of which certifying boards are affiliated with the American Podiatric Medical Association. A fellowship is not board certification. 

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

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