Formulating The Optimal Limb Preservation Team

Q:What health and wellness professionals make up your preferred limb preservation team?

A:

Kazu Suzuki, DPM, CWS references the original “toe and flow” paper by Rogers and team in his response.¹

“Podiatry (toe) and a vascular specialist (flow) are the two absolutely required roles for a proper limb preservation program,” he says. “One can then branch out from the starting point by engaging endocrinology, infectious disease, orthopedic surgery, prosthetists and other specialties as supporting roles.”

He expands upon his answer by saying that his definition of “vascular specialists” encompasses vascular surgeons, interventional cardiologists and interventional radiologists with peripheral intervention expertise.

Haywan Chiu, DPM, FACFAS feels that a complete limb salvage team will include a group of like-minded podiatrists with different training and interests. For example, one or two DPMs will focus on more complex salvage such as flaps, frames, and Charcot cases, while others will do everything else, providing year-round call coverage for their area.

“Other members of the team would include vascular, a case manager or social worker, wound care nurses, therapists, diabetes educators, primary care physicians, endocrinologists, and probably more,” he adds.

Rebecca Moellmer, DPM, FACFAS, DABPM, FAAPSM agrees with the crucial nature of the podiatry-vascular relationship and adds that other wound care professionals, along with respiratory/hyperbaric oxygen therapy staff are valuable members of her wound care team. She clarifies that hyperbarics addresses small vessel disease while vascular tackles the larger vessels.

She adds that physical therapy is part of the wound care team already in her facility and that social work would add benefit for patients with complicated home lives. Home health staff are also important, she says, as many of these patients aren’t fully mobile or are supposed to limit weight bearing.

Q:What unique qualities do you feel these individuals bring to the overall limb preservation process?

A:

Dr. Chiu relates that limb salvage patients, in his experience, are among the sickest and exhibit the least adherence (both intentional and unintentional) to treatment plans.

“Some are even terminal, although it’s hard to identify when or admit that someone is ‘terminal with diabetes,’” he says. “So, the team will have to be flexible in meeting their patients’ needs.”

He goes on to say that some patients will want very detailed instructions, while others will pursue only minimal treatment of the acute condition with no intention for follow up or future self-care. Dr. Chiu adds that some patients are very ill, and nearing the end of life, but have family who wants to aggressively treat the wound.

“The limb salvage team members have to handle these different and difficult situations on a daily basis without letting it get to them or becoming too frustrated to the point of burnout,” he says.

Dr. Moellmer feels the team members each have a primary focus that, when working together in concert, can make the process more efficient and successful.

“Podiatry focuses on biomechanics, whether that be offloading or surgical reconstruction, vascular reperfuses, wound care cleans and offloads, and respiratory/HBO increases oxygenation for the small vessel component,” she says.

Dr. Suzuki looks at the team’s focused roles as a streamlined way to address logistics of a complicated care delivery process, especially for patients with advanced complications such as chronic or end-stage kidney disease.

“Although we would like to think we are super doctors who know everything, we are limited in our time and training to address every aspect of medicine that our challenging patients need,” he says.

Q:Do you feel there is one profession in particular that you feel is especially impactful that you have forged an important relationship with?

A:

Each of the panelists emphatically shared that their relationship with their vascular specialist is the most impactful in their practices. Dr. Suzuki cites help with lower extremity angiograms and intervention, screening and performing vein ablations and creating dialysis port access as key vascular contributions to the process.

“For the same token, they find us (DPMs) valuable as they may not have expertise or knowledge to deal with our most challenging diabetic foot problems,” he says.

Dr. Chiu adds that open communication is important with vascular in particular, as it allows each to learn the other’s thought processes, so it becomes easier to educate patients on what the team as a whole will do for them.

Q:What professionals do you feel could make an impact on such a team, but may not be employed in your area or in general?

A:

Dr. Moellmer shares that prosthetists are a great addition, but that in her county system, patients are contracted to specific facilities for this service. Dr. Suzuki agrees, however, about their value to such a team.

“If I were to pick, prosthetists (and eventually, physical therapists) should be a large part of a limb preservation team, as we want to get our patients mobilizing and ambulating as much as we can,” he explains. “It is my experience that our patients could deteriorate rapidly once they become wheelchair-bound and stop ambulating on their own.”

Adding that in her area, insurance issues can prohibit this pursuit, Dr. Moellmer goes on to say that she appreciates the assistance of interventional radiologists in cases where the vascular team has signed off.

“In my experience, interventional radiology performs pedal-plasty, whereas vascular may stop at improved flow above the ankle,” she says.

Dr. Chiu thinks a social worker or case manager with a special interest in diabetes, dedicated to outpatient management of these patients after discharge would be helpful to facilitate necessary follow-up.

“A lot of these patients will need repeat procedures, and managing all their meds and blood thinners in the perioperative period can be very difficult,” he shares.

Q:Any other thoughts you’d like to share?

A:

Dr. Chiu stresses that limb salvage in private practice is possible, and is an easy way to build one’s practice quickly. He feels this is true even if one is just starting in private practice, even without having to do much advertising.

“Just be available, treat your patients well, and be willing to put in the hours,” he advises.

Dr. Suzuki strongly reiterates that every podiatrist should have a trusted vascular specialist who can perform arterial and venous Doppler and angiograms on a short notice.

“If you don’t have one, make a connection as I did via vascular device (balloons and stents) companies,” he says. “They need your help and expertise as much as we need theirs.”

Dr. Moellmer reinforces that all of the pieces of the puzzle are vital in optimizing outcomes.

“The whole team is really important because merely being seen by one specialty can, unfortunately, lead the patient down a road more likely to end in a below-knee amputation,” she says. n

Dr. Chiu is a Diplomate of the American Board of Foot and Ankle Surgery and previously served as an Assistant Clinical Professor in the Department of Orthopaedics and Rehabilitation at the University of New Mexico. He currently practices in Albuquerque, N.M.

Dr. Moellmer is the Assistant Director of Pre- Clinical Curriculum and Faculty Affairs, and an Assistant Professor of Podiatric Medicine, Surgery and Biomechanics at Western University of Health Sciences College of Podiatric Medicine in Pomona, Calif.

Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles. He can be reached at Kazu.Suzuki@ cshs.org.

1. Rogers LC, Andros G, Caporusso J, Harkless LB, Mills Sr JL, Armstrong DG. Toe and flow: Essential components and structure of the amputation prevention team. J Vasc Surg. 2010;52(3 Suppl):23S-27S.