08/08/2024    Martin M Pressman, DPM

Replace Your Neck Stethoscope with a Hand-Held Doppler to Save Limbs

Podiatry standard of care requires us all to
palpate pedal pulses. This standard alone is
simply not high enough to get the job of limb
preservation done. The following list contains
some hard won knowledge acquired over the last 47
years of practice. Hard won pearls given freely
with the hope that some of the 20,000 subscribers
might take notice. This note was motivated by a
leg -off case where the podiatrist found +2 pulses
and 9 days later the patient had an AK amputation
for thrombosis. The current standard of care is
pulse palpation. If a Doppler were used perhaps
this could have been avoided.

1. Your cardiologist does not palpate your heart;
she uses auscultation with a stethoscope to hear
cardiovascular flow abnormalities.
2. We need to up our game and use office Doppler
auscultation as a routine screening tool in high
risk patients(smokers, diabetics , CVD patients ,
ulcer patients with palpable pulses ,etc.)
3. Pulse palpability does not rule out stenotic
lesions above or below the point of palpation. A
pulse may be palpable at pathological low
pressures. Hearing a monophasic pulse yields much
more information than feeling a pulse. Two
monophasic pulses in the same limb requires
advanced imaging or referral….No different than
absent pulses.
4.If every podiatrist routinely used Doppler
auscultation on at risk patients and followed up
with arterial ultrasounds when indicated(absent or
monophasic sounds) ,we would serve those patients
at a higher standard of care and save more limbs.
5. I used a $120 hand=held 8mhz doppler for this
exam and like my cardiologist did not charge for
this 30 second physical exam technique. I listened
to the DP, PT and peroneal arteries and when
indicated the Popliteal artery. When your patient
loses a limb and your notes say “pulses intact” or
+1 pulses that does not have the same authority or
diagnostic sensitivity as “doppler examination
revealed biphasic sounds in the DP, PT and
peroneal arteries”.
6. Podiatrists with stethoscopes around their
necks are simply not as helpful as those with a
doppler in the pocket of their white coats.

Martin M Pressman, DPM, Milford, CT

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08/09/2024    Paul Kesselman, DPM

Replace Your Neck Stethoscope with a Hand-Held Doppler to Save Limbs (Martin M Pressman, DPM)

Kudos to Dr. Pressman for pointing something out
which I have been preaching for my over 40+ years
as a clinician. I first came aware of non-invasive
vascular technology back in the late 1970s and
early ‘80s during my undergraduate medical
education at rotations at various VA hospitals in
the Chicago area. In those days the machines were
big, bulky and took up an entire room. Their costs
and size relegated them mostly to large clinical or
research facilities.

With computer technology eventually the machinery
got more sophisticated and totally paper free and
can integrate directly into your computer and
eventually into your patient's EMR. Most cost 1/3
of what digital x-rays cost with many fitting into
your brief case. The current machinery can combine
pulse volume recording and photoplethysmography,
which are far more sophisticated than Doppler,
which can miss many small vessel diseases.

There are other technologies such as laser Doppler,
Sp02, Skin perfusion pressure and others which are
even far more sensitive to microvascular changes
than Doppler. Even arterial duplex testing while
having the capability of showing dynamic flow,
often will not be able to show microvascular
disease.

But Dr. Pressman is correct, in that podiatrists
should at least be familiar with doppler technology
at least as a "gatekeeper" to determine whether or
not a patient requires more sophisticated testing.
Whether you send those out or do those more
thorough testing yourself, is not his point nor
mine. These diseases must be caught early if we are
to avoid more complicated and expensive care.

Beware though that screening testing with extremity
vascular testing is not covered by Medicare and
most third-party payers. Those who are performing
these tests as a way of generating some additional
revenue beware.

Performing these tests takes both time and skill to
acquire. Done right they take some time and your
results will be held to the same standards
as any other professional (e.g., vascular surgeon,
vascular lab, radiologist) performing these
procedures. Performing these tests correctly will
however provide significant results which can often
save a limb and also guide you when to refer
patients for either further testing or vascular
surgery.

For more information on non-invasive vascular
testing, one should study the testing technology
available and review the anatomy in detail prior to
leaping into purchasing any units. There were some
very well written articles on this subject which
can be found by doing a "Google Search" and
researching some back issues starting in Podiatry
Management (Nov/Dec 2006).

Once one has mastered arterial testing, non-
invasive venous testing is also a skill one should
aspire to acquire. Especially in those states which
allow DPMs to treat many manifestations of lower
extremity venous disease, performing venous testing
is an essential test and just the beginning.

Paul Kesselman, DPM, Oceanside, NY