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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 studies.
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 elderly.
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 considerations.
Allen Jacobs, DPM, St. Louis, MO
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