The Voice of Podiatrists

September 28, 2006 #2,700 Editor-Barry Block, DPM, JD

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Blister Popping a Fine Art: PA Podiatrist

Everyone gets them -- those painful blisters on toes and feet. Blister-causing culprits range from sandals to sneakers, but it’s not that hard to nip that rubbing pain in the bud, according to Rothman Institute’s Dr. Nicholas Taweel. They are caused by the combination of pressure, friction and sweat, but if one is unlucky enough to come down with a blister, many doctors believe doing nothing is often the best prescription.

Dr. Nicholas Taweel

“The body will eventually absorb the fluid,” Taweel said. “But if it becomes tense and becomes very painful, then you can puncture the side of the blister to drain it.” But don’t just grab any old needle. Blister-popping is a fine art, and it must be done with care.

First, the doctor said sufferers should wash the blister area with soap. Next, apply antiseptic. Then the fun part; grab a sterilized needle and puncture the side of the blister, allowing it to drain. Finally, apply clean gauze or medical tape, but don’t use a Bandaid.

Source: Cherie Bank, NBC TV [9/26/06]

CPMA Names Mazza Podiatric Physician of the Year

The California Podiatric Medical Association has named David S. Mazza, DPM of Chula Vista, CA as its 2006 Podiatric Physician of the Year. Mazza is Past President of the San Diego County Podiatric Medical Society, and a representative to Medicare’s Carrier Advisory Committee.

Dr. David S. Mazza

Mazza serves on the medical staffs of Scripps Memorial Hospital of Chula Vista and Sharp Chula Vista Medical Center, and holds a position on the clinical teaching faculty of the University of California (UCSD) Medicam Center and has served as director of podiatric services at the UCSD Diabetes Center since its inception in 1985.

New ACFAS Diabetes Guidelines Target Foot Complications, Amputations

New guidelines for healthcare professionals could lead to significantly fewer foot complications and amputations by changing the way doctors treat the feet of diabetes patients. The new guidelines from the American College of Foot and Ankle Surgeons (ACFAS) introduce two substantial changes since their last publication in 2000: a focus on prevention, and the use of multidisciplinary teams of specialists.

The changes reflect medical evidence from around the world that a multidisciplinary team approach achieves dramatic reductions in complications and amputations in diabetic feet. They also mirror an increasing emphasis on management of chronic diseases like diabetes. You will begin to see more podiatrists getting more involved with the care of their patients with diabetes.

The ACFAS published the guidelines as a supplement to the current issue of the Journal of Foot & Ankle Surgery. “These state-of-the-art guidelines give foot and ankle surgeons and other medical professionals a powerful new tool to help improve and maintain the quality of life for millions of people with diabetes,” says James L. Thomas, DPM, FACFAS, a Birmingham, AL foot and ankle surgeon and president of the ACFAS. “But they don’t erase patients’ responsibility to manage their disease, inspect their feet daily, and get regular check-ups.”

Query: Duty to Disclose Malpractice Termination

I had my malpractice coverage terminated three years ago. I have used alternative coverage ever since and am now looking for coverage with a lower premium, knowing I have to pay tail coverage for the past 3 years. Is there a way to reapply with more common podiatric carriers and not have to indicate I was denied coverage on future credentialing forms?

Name Withheld

Editor’s comment: PM News does not provide legal advice. In general, there is a duty to truthfully disclose any information requested on a malpractice application or any other credentialing form. To do otherwise constitutes fraud and can result in having professional misconduct charges brought against you.

If the question phrased is “Have you ever had your malpractice insurance terminated?”, the answer must clearly be “yes.” If, however, the question is not asked, you are not obliged to volunteer this information. In cases where a question is ambiguous, you should seek the opinion of a healthcare attorney as how to best respond to that question.

Query: Obesity and the ADA

Any suggestions on how to discharge an obese fat patient? I have a patient in my practice who is close to 500 pounds with severe Charcot feet B/L. He travels with a motorized chair and always wants to sit in my "podiatry chairs." He has broken two chairs, costing me close to $ 500 to repair. Are the obese a protective class under American Disability Act (ADA)? If so, how do I discharge him as I do not have the infrastructure to "support" the care he needs?

Bret M. Ribotsky, DPM, Boca Raton, FL, Ribotsky@doctorbret.com

Editor’s comment: PM News does not provide legal advice. The ADA defines "disability" as "a physical or mental impairment that substantially limits one or more of the major life activities of [an] individual." Disability also includes a record of having such an impairment or being regarded as having such an impairment. The statute, then, by its terms neither expressly includes nor excludes obesity. The implementing regulations, promulgated by the Department of Labor, suggest that obesity is not supposed to be considered a disabling impairment, except in rare circumstances.

Courts, however, have increasingly decided that “obesity” is not the same as “morbid obesity,” which does qualify as a disability. Your first step is to check with a FL healthcare attorney for applicable state statutes. Your best grounds for discharge will likely be based on either patient non-compliance or your inability to make “reasonable” accommodations for his disability.

RE: EHL Tendon Rupture (Scott Hughes, DPM)
From: Multiple Respondents

Getting the tendon without opening it up completely may be challenging. You can try to find the proximal stump with a small incision at that level and find the distal stump with a small incision. Pass a hemostat subcutaneously from distal to proximal at the appropriate level and exit the tips of the hemostat at the incision site of the proximal stump. Either grasp the stump of the tendon or suture the proximal tendon with a locking Krachow-type suture and grasp the suture with the hemostat and pull the stump distally to meet the distal stump. If this does not get you to length, you will need to open up the incision larger.

Recently, I have been using a new product called Orthoadapt from Pegasus Biologics that is equine pericardium and extremely strong, yet very thin. It easily holds sutures and can augment your repair or even bridge the gap of the repair.

Be careful not to make the repair too tight and dorsi-flexed, as you might trade one problem for another. The Pegasus product might help prevent that.

Lowell Weil, Jr., DPM, MBA, Des Plaines, IL, WeilJr@aol.com

If the tendon is "balled up" as you say at the navicular, make an incision directly over this area. Make another incision at the 1st MPJ. Run a tendon passer from distal to proximal to exit out the proximal incision. Retrieve the tendon and pull it distally. You should have enough tendon length, but if not you can split the tendon and bring the split portion distal. A tendon graft could be used but probably won't be necessary. You lengthened the tendon during your initial surgery to weaken it, so if you have to split it for the repair it should be fine for your desired result. Hope this helps.

Thomas A. Graziano, DPM, Clifton, NJ, TGrazi6236@aol.com

An MRI should presumably help you find both ends. I have seen instumentation called "Tendon retrievers" though I have never used them. With regards to all possibilities of repair - I wrote an article in Journal of Foot and Ankle Surgery Titled "EHL Tendon Laceration: A case Report and Literature Review of EHL Tendon Injuries. ( Jan -Feb 1997) It covers just about all possible ways to repair as reported in the literature.

If you have to make a long incision to find the tendon - so be it. I believe it is more important to find it and repair it.

Jeffrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com

RE: Restylane for Prominent Metatarsal Heads (Dan Methuselah DPM)
From: Bret M. Ribotsky, DPM

I have spent the past year trying over 10 different products used in cosmetic dermatology, including Sculptra, Restylane, Radiesse, and others. The results have been scattered. Most of the companies who are in the cosmetic dermatology business state that research is needed. So far the dollars are way too great in the cosmetic market for them to think about weight-bearing research.

There are many questions that need to be answered in a scientific manner: How much material, how long to guard from weight-bearing, and many more. At this summer’s APMA meeting, I presented a few cases using ultrasound and x-rays to follow patients. I can tell you the "stuff moves" from where you place it. So far, patients are happy, but time will tell. I have spoken with over 20 DPM's who are working on this and all have opinions, but no facts. I am still awaiting responses from the companies to start the research (the protocol has been written).

Bret M. Ribotsky, DPM, Boca Raton, FL, Ribotsky@doctorbret.com

RE: Query: Digital Scanning For Orthotics (Bruce Williams, DPM)
From: Robert Scott Steinberg, DPM

The fact that Dr. Williams has to “program in" lateral forefoot wedges, reinforces my thinking that computer scans do not provide enough information. How does the scan detect forefoot varus or valgus? I have seen countless patients with foot-scanned generated devices. I feel the failure of these devices is because the scan is done weight-bearing, with incomplete control of STJ neutral, and that the scan cannot pick up forefoot varus or valgus when it compensates, as evidenced by the number of patients I have seen with scanned-foot impressions that did not pick up the forefoot varus or valgus component. Is this user error or a short coming of the system?. The computer scan companies claim that other methods of impression capture do no have reproducible results, I find just the opposite.

Robert Scott Steinberg, DPM, Schaumburg, IL, Doc@FootSportsDoc.com

RE: Off-Label Use of Drugs (Richard Gosnay, DPM)
From: Pat Caputo, DPM

Dr. Gosney has the off-label issue of drugs 100% correct. (If we are going to limit our use of drugs to the FDA-approved indications, we aren't going to have much to work with. We just need to be reasonable and document our prudent use of all of our therapies.) Common antibiotics, NSAIDS, Lamisil and even topicals, often do not have the FDA/PDR indication for the condition we are prescribing for. The point is we use FDA off-label drugs all the time and we don't even know it! The PDR and FDA are references, highly respected, that should be read and understood in detail to help guide us. They are not, however, the final word. I suggest we all take a refresher course in our prescribing habits, and use FDA off-label and on-label drugs in the way to best address the pathologies affecting our patients. In that way, we, as podiatrists, can maintain the vanguard in foot and ankle care, both medically and surgically.

Pat Caputo, DPM, Holmdel, NJ, pat_caputo@alumni.rutgers.edu

RE: Breast Cancer Research Walk Support Requested
From: Pamela S. Dolber, DPM

I will be participating in the 3-day breast cancer walk in Tampa, FL October 13-15th. I'm know that many people have been touched by this disease and I am enlisting the support of the podiatry profession in helping me reach my goal to raise as much money as possible in the fight against breast cancer.

Please support me in my walk for the cure. We will be walking 20 miles a day for three days. Donations may be sent to the following link: http://www.the 3day.org/Tampa Bay06/1bigdog Thank you.

Pamela S. Dolber, DPM, Lake Placid, FL, potsapan@aol.com

ASSOCIATE POSITION-INDEPENDENT CONTRACTOR – FLORIDA

High Income position for ethical hard working podiatrist, great for semi-retired or to supplement office practice, part time. Must have Florida license and active Medicare/Medicaid numbers. FAX CV or Resume to 727-785-4697

WELL ESTABLISHED PODIATRY PRACTICE IN MT. AIRY, NC

Dr. John H. Hodges had a well established podiatry practice in Mt. Airy, North Carolina that is either for sale or in need of an associate/partner to come on board to take over patient care. Dr. Hodges unexpectedly passed away in January 2006, leaving approximately 3,500 patients without a podiatrist to care for them. This is a unique opportunity to be able to begin work in an extremely busy podiatric practice. If interested, contact Carolyn McMackin at (336)577-2886 or cmcmackin@triad.rr.com

ASSOCIATE POSITION - NEW ENGLAND

Terrific Opportunity Now Available in growing New England practice. Well established and respected practice with new, large office space, latest technology, very helpful staff, loyal patients and solid referral base. Close proximity to hospitals with modern surgical suites. Opportunity for shared ownership. Prefer 24 month PSR with clinical practice experience or an experienced doctor looking to improve their situation. E-mail CV and particulars to NEAFC3@aol.com

PRACTICE FOR SALE/ASSOCIATE/PARTNERSHIP - WASHINGTON, DC

Established busy practice for sale in hospital's medical building. Fully equipped. All aspects of podiatric medicine/surgery. Large diabetic practice with wound care clinic. Large referral base. Hospital to be renovated and expanded. Charcot, forefoot, rearfoot, orthopedics. Residency required for privileges. Moving - will stay for transition. Associateship until purchase. Unbelievable potential to expand. Will finance sale with adequate down-payment. Serious inquires only. Contact scottr0666@yahoo.com

PRACTICE FOR SALE – FLORIDA

Miami-Dade and SW Ft. Lauderdale, well established surgical practice for sale. This one has everything. Surgery, Orthopedics, Pediatrics, Trauma, ER, General Podiatry. Participates in all local and national managed care plans. $850,000 but will discount depending on amount up front. Mature, serious inquires with business experience preferred. email response to podfootdocs@aol.com

IMMEDIATE ASSOCIATE NEEDED - PHILLY SUBURBS

High volume office-based practice suburban Philadelphia. Full-time office, near hospitals for surgery, consults, and in-house pt. care. Candidate must be hard-working dedicated to pt. care and well-trained. Needs to be personable. PSR12/24/36 Board Certified/Eligible required for a fast-paced, fun atmosphere to work. Email CV and contact info to: mrgpod@hotmail.com Or fax CV to 610-668-5175.

NURSING HOME ASSOCIATE NEEDED- PHILA AREA

Extremely high volume nursing home and home care practice. Well-established and respected Suburban Philadelphia practice seeking an associate who is hardworking. Full-time or part-time available. Very busy practice which can be worked every day and be very lucrative for a hard-working individual. No nursing home further than ½ hour away from office. Email CV and contact info to: mrgpod@hotmail.com or fax CV to 610-668-5175

PRACTICE FOR SALE – SOUTH FLORIDA

Miami-Dade and SW Ft. Lauderdale, well established surgical practice for sale. This one has everything. Surgery, Orthopedics, Pediatrics, Trauma, ER, General Podiatry. Participates in all local and national managed care plans. $850,000 but will discount depending on amount up front. Mature, serious inquires with business experience preferred. Email response to podfootdocs@aol.com

EQUIPMENT FOR SALE - Computed Radiography System

SCANX 12 digital imaging system is a computed radiography system (CR). Replacing film and plates can be reused thousands of times. Saves images to your computer. CPU and monitor included. Purchased 2004. Asking $15, 000. Call 970-232-1717 for additional information. Product information found at www.allproimaging.com

ASSOCIATE POSITION - ARIZONA

Excellent opportunity for an experienced DPM looking for a change or young podiatrist looking to jumpstart their practice. Practice is well- established over 25 years, successful and a large volume in the Phoenix metro area. Current AZ license preferred as position is available immediately. The right person will join as a salaried associate leading to partial ownership in the group practice. Email CV and inquiries to: scfcs@cox.net

ASSOCIATE POSITON - SOUTHEAST TENNESSEE/ NORTH GEORGIA

Immediate position available or will wait for the right individual. Unique practice opportunity in growing multi-physician/multi-office practice. Well established/cutting edge within the medical community. Close proximity to hospitals as well as opportunity to become involved with a free standing podiatric surgical center. Must be BQ/BC. Minimum PSR/24. Competitive salary, bonus structure and benefits. E-mail CV to afcjen@hotmail.com

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