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07/09/2019    Allen Jacobs, DPM

Failure to Diagnose PAD

Increasingly, I have observed that plaintiff
attorneys specializing in litigation involving
care of the elderly are looking at podiatry care.
One major area is the failure to diagnose and
treat or refer for treatment geriatric patients
with PAD.

The argument being advanced is as follows; the
patient is qualified for care by a podiatrist by
virtue of class findings consistent with PAD.
Therefore, why was the patient not referred for
vascular studies or to vascular surgery or
interventional cardiology? Given advanced age,
and the common presence in elderly patients of
comorbidities with which PAD is associated, a
potentially compelling argument is that such
patients should have been referred for PAD
assessment. I would ask those involved in such
care to consider appropriate strategies for the
care of such patients.

Similarly, I have witnessed an uptick in vascular
complications resulting in ischemia, infection,
and amputation following non-emergent surgery in
elderly patients. Please either document well the
pre-operative vascular status of such patients,
look carefully at their medical history and
comorbid conditions, and refer when appropriate
for pre-surgical objective, quantitative vascular

Finally, I believe that we need a podiatric
equivalent of the Braden scale for prediction of
foot ulceration in the elderly patient. Such a
scale, once validated, would be useful in
identifying high risk patients and initiating
preventive strategies in an effort to reduce
ulceration, infection, and amputation in the

The great academic, clinician, and educator,
Arthur Helfand DPM, alerted us years ago of the
coming wave of diabetes and elderly that we would
be charged to evaluate and treat. He was dead-on.
That time is now and will continue into the
future. Podiatry has established its potential
role in the care of patients with diabetes. We
must go the same for the larger at risk geriatric
population. From skin disorders to fracture
management, from from nail care to TAR, care of
the geriatric patient often requires special

Allen Jacobs, DPM, St. Louis, MO

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