The Voice of Podiatrists

Serving Over 12,000 Podiatrists Daily

July 16, 2010 #3,911 Publisher-Barry Block, DPM, JD

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MA Podiatrist Helps to Develop New NPWT Guidelines

In September 2009, an international panel of wound care experts from multiple disciplines convened to develop a guidelines document to provide healthcare professionals with an understanding of where NPWT fits into treatment paradigms for acute and chronic complex wounds, including surgical/traumatic wounds, pressure ulcers, and diabetic foot and leg ulcers.

Dr. Vicki Driver

"In today's healthcare environment, there are numerous factors influencing decisions on protocols of care," states Vickie R. Driver, MS, DPM, FACFAS, Associate Professor of Surgery, Director of Clinical Research, Endovascular, Vascular and Foot Care Specialists, Boston University, Boston Medical Center, Boston, MA, who was a member of the panel that developed the guidelines. "Healthcare providers must ensure that their assessments, treatment pathways and product selections are both clinically and economically sound. This guidance document will be a valuable resource for helping clinicians consider where NPWT and other treatment modalities such as moist wound healing dressings appropriately fit within a comprehensive plan of care for a number of complex acute and chronic wounds."

Source: Red Orbit [7/14/10]

Jensen Named New Dean at Barry

Barry University Provost, Dr. Linda Peterson, recently announced the new dean for the School of Podiatric Medicine and Physician Assistant program, Dr. Jeffrey Jensen. Jensen joins Barry from private practice in Denver, Colorado, where he has been the owner and clinical director of the Diabetic Foot and Wound Center since 1994.

Dr. Jeffrey Jensen

Dr. Jensen earned his DPM from the California College of Podiatric Medicine and accomplished his surgical residency training at Kern Hospital in Warren, Michigan. For the last 10 years, Dr. Jensen has served as Externship and Research Director at North Colorado Podiatric Surgical Residency. He has also been an Assistant Professor at the University of Colorado, Health Science Center since 1995.

WA Podiatrist Has Mixed Feelings About Barefoot Running

Strange and anachronistic as it sounds, barefoot running has become a hot topic. There's a bestselling book that explores the premise, and athletic companies are getting in on the act with "minimalist" shoes that are the next best thing to bare.

Dr. Larry Maurer

But Larry Maurer, a Kirkland, WA podiatrist and running specialist who has done research for Brooks, has mixed feelings about barefooting. "If you can run without shoes, I think you should," he said. "I just don't think there are very many people who are in that category."

Source: Maureen O'Hagan, McClatchy-Tribune Information Services [7/12/10]

FL Podiatrist Returns From Relief Effort in Haiti

On a recent warm summer evening, Jim Pruchniewski found himself on a rooftop in rural Haiti counting the shooting stars and listening to the drums emanate from the rural countryside below. "You just don't get that at your typical Holiday Inn," joked Pruchniewski, a podiatrist at the North Lakeland Foot Clinic.

Dr. Jim Pruchniewski

As a parishioner, Pruchniewski joined 15 others for the Corpus Christi Catholic Church's first medical mission trip to its parish twin, St. Michael Archangel, in Dilaire, Haiti, June 2 through 11.

Source: Jamie Pilarczyk, News & Tribune [7/14/10]

Meaningful-Use Regulations Released

The CMS and HHS' Office of the National Coordinator for Health Information Technology issued their much-anticipated final meaningful-use information technology regulations that hospitals and physicians must follow to tap into some $27.3 billion in financial incentives authorized by the stimulus act.

The rule gives providers something to cheer. The CMS backed away from a controversial all-or-nothing rule requiring physicians to meet a list of 25 criteria, and hospitals to meet a list of 23 criteria to be eligible to receive a subsidy for electronic health-records systems. Instead, hospitals must meet 19 criteria and physicians 20 under a formula that includes 15 mandatory quality measures for doctors and 14 for hospitals with a choice of five others from a 10-item “menu.”

Source: Andis Robeznieks, Modern Healthcare [7/13/10]

Take Your Time - Part 1

Feeling rushed can make you sound less confident. Use these tips to establish a comfortable pace for telephone conversations:

•  Pause before you reply. Preface every response with two or three seconds of silence. During that time, mentally confirm that you understand the question or comment. While the delay might seem awkward at first, you will become more comfortable with the technique as you practice it.
•  Seek clarification. A great way to slow down is to ask “Would you please repeat that?” or “I am a bit confused by your question.” Use the extra time to refine your response.
• Narrate your actions. Because callers cannot see you, they may wonder what is going on if they hear too much silence on your end. Reassure them by saying “I’m thinking” or “I am just jotting down a few notes.” Telling the caller what you are doing increases rapport and eliminates mystery.

Source: Communication Briefings

Query: Recurrent Nodular Tumors

I have a female patient who is moderately obese, 50 years of age, diabetic type I x 20 years and has SLE. I have removed several large (3-4cm) subcutaneous masses from her forefoot that have recurred on multiple occasions in different but adjacent locations. On each dissection the pathology report is the same. It reads as follows: "Fat necrosis with surrounding fibrosis, adjacent hemosiderin laden macrophages and vascular proliferation with congestion. No diagnostic features of malignancy.” The cystic-like nodules are semi-demarcated from surrounding tissue, but very adherent to deep fascial tissue, rubbery texture and whitish-grey in appearance. The patient and I are both frustrated with recurrences over the years. Any comments or suggestions?

Angelo J. Bigelli, DPM, North Providence, RI, toedocri@aol.com

Query: Office Ally

After reading about Office Ally on this site, I want to know if there are any cons to using their service. I would not be using Ally Office for my Medicare claims as we transmit them ourselves. I was told there is no charge for non-Medicare claims. What experiences have PM readers had with their service?

Barrett E Sachs, DPM, Plantation, FL

RE: Coumadin Patient and Phenol Alcohol Matrixectomy (Elliot Udell, DPM)
From: Multiple Respondents

We often do phenol procedures on patients on Coumadin without stopping it. We have never had a problem (knock on wood).  If a patient is uncomfortable about not stopping Coumadin, we contact the physician who is monitoring the Coumadin and get instructions on what the physician recommends. We are also lucky that one of our nurses has 10 years of cardiac and Coumadin experience. We never do a procedure, though, on a patient on Plavix until the patient is off it for 5-7 days. As a CV surgeon told me, "Coumadin doesn't scare me and I'll operate on them, but Plavix, it scares me." 

Neil A Burrell, DPM, Beaumont, TX, nburrell@gt.rr.com

I have not had the need to taken anyone off Coumadin for an elective matrixectomy.  I recommend using a digital tourniquet and taking special care not to tear or lacerate the nail bed when taking off the nail.  If it is a partial matrixectomy, I would not use a beaver blade as this would increase the likelihood of nail bed damage.  Also, phenol would help to cauterize any small bleeders. Following the procedure, use some Lumicaine on the areas not phenolized as this may also help to achieve hemostasis. Last, as always, explain to your patient about the increased chance for bleeding and post-op hematoma. Compression dressings would help for the first 24 to 48 hrs. So long as the procedure is done with minimal soft-tissue damage, there is no need to stop the Coumadin.

Todd Lamster, DPM, Phoenix, AZ, tlamster@gmail.com

I do not believe that stopping Coumadin is necessary for a nail matricectomy procedure. I have spoken with several hematologists as well as anti-coagulation clinics who manage these patients in regards to this specific question. They all have felt the minimal amount of trauma/blood loss with this minor procedure does not require stopping Coumadin, although you may wish to apply a temporary compression bandage and monitor patients an additional 5-10 minutes for any excess bleeding before they leave your office. I have performed these for years on Coumadin patients and have never had an issue with excessive bleeding. I do utilize sodium hydroxide rather than phenol for my procedures (for all patients, not just Coumadin patients). You may also wish to verify that their Coumadin level (INR) has been stable. If still concerned, contact the patient's physician who is managing the Coumadin, and ask about any concerns before performing the procedure.

Richard Frost, DPM, Spokane, WA, rfrost@rockwoodclinic.com

RE: Coumadin Patient and Phenol Alcohol Matrixectomy (Elliot Udell, DPM)
From: Multiple Respondents 

Is it worth the risk of taking the patient off the blood thinner for an elective procedure when his condition is well managed three times a year via more conservative therapy? Ask the PCP.  Has anyone done a matrixectomy on such a patient without taking him off the medication? Yes, and you just need to make sure you use a toe tourniquet, hold pressure longer (5 min. after taking the tourniquet off), use Coban, and tell him to expect more bleeding and to elevate like hell (no more than walking to the bathroom and kitchen the 1st 48h).  We do it on our diabetic inpatients all the time. Maybe try to be slightly more atraumatic in technique to minimize excessive bleeding. 

Roody Samimi, DPM, Sacramento, CA, roody.samimi@gmail.com

I would check with the primary physician regarding the discontinuance of his/her Coumadin and most recent blood labs. You usually require a 72 hour discontinuance of the Coumadin, assuming PT/PTT levels do not exceed 2x normal bleeding times. Usually, Coumadin is stopped for 48 hours prior to the phenol matrixectomy and for 24 hours post-operatively. In addition, I have found that the use of an alginate dressing post-operatively with a compressive dressing more than adequately addresses any "post-op bleeds" through the dressing which such a patient may find post-operatively.
 
Gino Scartozzi, DPM, New Hyde Park, NY, Gsdpm@aol.com

I’m not sure what a “high dose” of Coumadin is. For my patients maintained at a therapeutic INR of around 2, and knowing they are stabile and being monitored, I do the procedure. I do not take them off of the Coumadin. Other than some prolonged bleeding that has always stopped prior to their departure from the office, I have yet to encounter a problem. That does not mean it can’t happen, but at this point, I have done so many, I don’t hesitate.

Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

RE: Digital Scanners for Orthotics (Jeff Kass, DPM, Ken Meisler, DPM)
From: Dennis Shavelson, DPM, Ken Meisler, DPM

To Dr. Kass: It is my understanding that most of the shells of the high-tech, semi-rigid OTC orthotics being used in these studies come from a library of shells are file-driven from STJ neutral custom casts. They are then formatted according to size, and an algorithm is then produced that averages these casts on file for each size. The final product is a shell that conforms to size and “algorithmic” STJ neutral. These shells can then be posted or corrected by prescription as would be a custom shell. FootMaxx would be one example...

Editor's note: Extended-length letters by Drs. Shavelson and Meisler can be read here. This topic is now closed. 

RE: Patient Who Brings in Wild Child (Alan Berman, DPM)
From: Multiple Respondents

I keep a variety of books and toys (no markers or pens of any kind are given to any children), and frequently I talk to the children while the parent is in the treatment chair. Usually, when the patient/children arrive, I and/or my staff spend one or two minutes making the children comfortable. One of the toys I keep is a car track that cars go down, and most kids love it. After the kids are comfortable with the toys, I then address the parent/patient. 

On the occasion that the subject becomes very difficult to discuss, I bring in one of my medical assistants and have her distract the child for the detailed discussion. I end up getting pediatric referrals this way too. The main problem is that the children have nothing to distract them. A few simple toys can really do the trick. Another thing my staff does is tell the kids that they have stickers for them if they are good during the visit. It takes patience and some extra time, but usually is not too difficult. If the patient needs a matrixectomy or another type of procedure, then the patient is advised to bring another adult and keep the kids in the waiting room or at home.

Marjorie Miller-Khawam, DPM, Long Beach, CA, footssy@aol.com

  I have had this same situation on a number of occasions. I approach it just as I would with my own children. I address the issue on the first visit. At the next visit, I let the parent know it will not be tolerated again. If there is no one to watch the children in the waiting room while I treat the parent, the parent will not be seen - and I stick to it. When they are called back and want to proceed in with family in tow, they are asked to reschedule at a time when the other children can be watched or are not present. 

Often, these children are labeled as ADHD and are on medication, with parents who have no boundaries with their children or themselves. They apparently have never been taught what is and is not appropriate in a public setting. You would think anyone with half a brain as an adult, regardless of how they were raised, would get the point after so many times of being told by others that they are acting inappropriately. I think it’s the parent who needs the medication.

Jon Purdy, DPM, New Iberia, LA, podiatrist@mindspring.com

RE: Software Choices (Michael M. Rosenblatt, DPM)
From: Marc Garfield, DPM

Using a word processor for records is probably not a good idea, for at least two reasons: First, it is fairly ineffective as far as time consumption, leading to more need for staffing, and thereby costing more money. Secondly, I do not believe that the use of MS Word for patient chart keeping, is a sound plan to satisfy HIPAA requirements.  I believe HIPAA requires each physician to...

Editor's note: Dr. Garfield's extended-length letter can be read here.

PRACTICE & STATE LICENSED ASC FOR SALE (MARYLAND, DC SUBURB)

38 yr old general podiatry practice grossing over $550K. Fully equipped with digital x-ray, diagnostic ultrasound, 2 orthotic scanners, computer network and well-equipped surgical suite. Retiring owner will stay on as needed. Email - dpmpracticeforsale@yahoo.com

PODIATRY ON CALL - MIAMI-DADE & BROWARD COUNTIES, FLORIDA

Call us for vacations, "unexpected emergencies" and playing hooky. Part-time or Per Diem Basis! Extensive surgical and non-surgical training with Dr. Stanley R. Kalish in Atlanta, Georgia. On call everyday to meet your office needs! Contact: podiatryoncall@gmail.com or 305-342-9797.

ASSOCIATE POSITION - SOUTHEAST GEORGIA

Beautiful weather year round & near the Coast. Opportunity for Early Buy-in. Seeking associate or new residency graduate to join practice. Must be PSR-24/36 trained. Multiple locations. Full range of services with new facilities. E-mail cover letter & CV to melissafoot@pol.net

PART-TIME, LICENSED PODIATRIST - WEST BLOOMFIELD, MICHIGAN

Immediate opening for treating patients in a nursing facility setting.  If interested, please email drteetime@aol.com

PART-TIME ASSOCIATE - NY LOWER HUDSON VALLEY (PUTNAM COUNTY)

Wednesday's & Saturdays  compensation dependent on collections. Hospital privileges & wound care center available. Excellent relationship with local Drs. including orthopedists- References required. Great opportunity for recent resident to gather cases for ABPS. Reply to PodAssociate@aol.com

ASSOCIATE POSITION - FREDERICK, MARYLAND

Fredericks premier group practice is located only 45 minutes from both DC and Baltimore. Immediate opening for a minimum PSR 36 Podiatrist for full time position. We have it all: EMR, digital x-ray, ultrasound, ASC, etc. Excellent salary with bonus structure and benefits. Please email resume to docsbnb@aol.com

POSITION AVAILABLE - SOUTHERN CALIFORNIA

Very well established, multiple location group practice has immediate opening for associate doctor. Attractive compensation and benefit package offered. E-mail resume to mrsmcmackin@aol.com

PODIATRISTS NEEDED NATIONWIDE

Podiatry referral company has thousands of diabetic patients nationwide in need of immediate service. We are looking for podiatry practices interested in joining our network to receive referrals. Email coasttocoastpodiatry@yahoo.com

ASSOCIATE POSITION - VIRGINIA IS FOR LOVERS

TN PRACTICE FOR SALE (SOUTH OF NASHVILLE)

Active, established practice with new equipment (digital x-ray, ultrasound, computer network, etc.). Great referral network with an excellent scope of practice. Turn-key operation with seamless transition. Grossed over $350K last year. Call 931-446-5724 or e-mail mchad500@gmail.com

PRACTICE FOR SALE – MAINE

25 year full scope in medical building, podiatrist friendly hospitals, appreciative and cooperative patients, excellent expansion potential, physician referrals. Wonderful place to raise a family. Retiring seller will stay for transition. mainefootdoc@yahoo.com

MANHATTAN MEDICAL SPACE AVAILABLE

Multispecialty Medical Building with 24/7 doorman. Prime Luxury Building and Location, Gramercy, Stuyvesant, Peter Cooper Area. 305 Second Avenue (17th-18th). Prior tenants past 23 years; podiatrist, dentist (plumbing/electric intact), internist. Ideal for podiatry, co-share with dentist, MD, etc. (flexible lease terms). E-Mail; jbdrun@aol.com Phone; 480-951-2480.

PM News Classified Ads Reach over 12,000 DPM's and Students

Whether you have used equipment to sell or our offering an associate position, PM News classified ads are the fastest, most-effective way of reaching over 12,000 DPM's. Write to bblock@podiatrym.com or call (718) 897-9700 for details. THIS OFFER DOES NOT APPLY TO BUSINESSES PROVIDING PRODUCTS OR SERVICES. Note: For commercial or display ads contact David Kagan at (800) 284-5451

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