My Scope of Practice: Keeping Their Feet on the Ground

   Vickie R. Driver, DPM, MS has a thing for feet… especially feet at risk. As Medical Director of Madigan Army Medical Center’s (MAMC) multidisciplinary Foot at Risk/Limb Salvage Clinic, Tacoma, Wash., Dr. Driver oversees foot-at-risk admissions, performs foot surgeries, and treats complicated patients with at-risk feet and limbs, including active duty patients and civilians. She also conducts research, teaches, precepts nursing students from the University of Washington, coordinates fellowships, and hosts “train the trainer” conferences — all in an effort to prevent the effects of diabetes from robbing patients of full use of their feet.

   Dr. Driver believes limb salvage is a specialty in itself. Her interest in limb preservation began during her primary care rotation at MAMC in 1996, where the Chief of Surgery, Dr. Charles Anderson, founder of the Foot-at-Risk service, was seeing five to seven patients a week when this complex clinic first opened. Dr. Driver expressed an interest in doing her surgical residency at the clinic, and as a senior resident, she was given responsibility for overseeing the clinic. Eventually, she was hired as clinic director. “I have a background in business,” she says. “I knew about productivity, systems, and people, so running the clinic came naturally to me. Diabetes is one of the leading causes of disability and death and without treatment capabilities, we cannot provide ultimate care. And as a child diabetic, I was very much aware of the potential for foot problems.” Dr. Andersen has been Dr. Driver’s mentor since she began her residency and subsequently became director of the Limb Salvage Clinic. His knowledge, skill, and commitment to diabetic limb preservation were contagious — the clinic now sees up to 100 patients per week.

   The Madigan Foot at Risk Clinic is the only clinic of its kind in a Department of Defense (DOD) facility that studies treatment of diabetes-related limb loss where limbs are at high risk for amputation. It is part of a medical center that boasts an annual patient population of more than 350,000 in a six-state region — one of the busiest in the Pacific Northwest. The four buildings at Fort Lewis (of which MAMC is a part) boast 360 doctors, 627 nurses, 166 residents, 50 interns, and 19 fellows. Outpatients number 821,00 per year. “We see 219 emergencies per day in the ER,” Dr. Driver says, “and fill 3,700 prescriptions every day.” In 1999, MAMC was only the second military hospital to achieve a perfect score of 100 from the Joint Commission.

   “Patients come to me through consults, other clinics at MAMC, and all four branches of the military, including families and retirees,” Dr. Driver explains. “Initially patients are evaluated by Mary Anne Landowski, MSN, RN, CWOCN, a wound care nurse specialist who screens them for vascular and neurological impairment as well as other high-risk components. After screening and education, patients are stratified according to risk (low, moderate, and high) and those at high risk are directed to the foot clinic, where we provide medical and surgical treatment that may involve aggressive infection management and debridement.” In addition to her clinic duties, Dr. Driver is on-call to provide emergency surgery to patients who come into the ER at MAMC and may require a limb preservation procedure or partial amputation.

   Several times a year, Dr. Driver hosts a 2-day, multidisciplinary conference to “train the trainer.” Doctors and nurses who want to begin or improve their clinics come from the DOD, the Veterans Administration medical system, and the Indian Health Care System from as far away as Puerto Rico to share their successes and failures at this limb salvage forum. Plus, clinicians learn advanced limb-salvage techniques to teach to their own staff. Dr. Driver says, “We have vascular, orthopedic, and podiatric surgeons, wound care clinicians, primary care clinicians, internal medicine clinicians, physical therapists, and prosthetic clinicians attend — people responsible for treating complex, high-risk patients who have been treated everywhere else and who now are seeking their help. We can offer advanced care modalities. Plus, our multidisciplinary approach to practice and education attracts a great deal of research. I recently helped create a Diabetic Research Fellowship position to aid with these important projects. Because we avail ourselves to and provide so much education in this area, it is common for several research projects to be conducted simultaneously. We are fortunate to have three surgical residents, a fellow, a wound care nurse specialist, research coordinators, a department nurse, and a sergeant who helps make this all happen.”

   Although this patient population is challenging — especially in terms of providing the necessary education so that the patient “gets” the message — Dr. Driver says the best part of her job is the people she treats. She also takes pride in the fact that the clinic functions as a team with support from the administration of various departments. “No one person makes this work,” she says. Continuity of care is stressed through standardization of protocol across facilities with convenient ways to access patient information, which includes photographs. The focus is primarily on the patient, with an added emphasis on self-care.

   Dr. Driver’s training sessions encourage care providers to discard the old model of patient care (where the provider sees the patient after the illness occurs) and recognize the importance of proactively testing patients for diabetes-related conditions, while encouraging patients to take an active role in managing their healthcare. Patients are urged to conduct daily visual foot examinations to check for cuts, bruises, or redness. This is especially important because people with diabetes often have no feeling in their lower extremities and even the most insignificant-appearing skin disturbance can be trouble if not promptly treated. Plus, treatment of infection is often frustrated by antibiotic-resistant strains of bacteria. “We must educate clinicians to educate their patients,” Dr. Driver says.

   The biggest barrier to providing optimal care is being able to handle the patient load. “We conducted a screening study regarding diabetic foot education,” says Dr. Driver. “It affirmed that MAMC provides good education at all clinics. The more aware patients are about what can happen to their feet, the better the system works.” Dr. Driver wants to help other government agencies (eg, Indian Health Care, DOD, VA, and HMOs) develop these clinics. She also is working on research on how to prevent long-term disabilities, as well as developing limb preservation societies. “I want to spread the gospel,” she says.

   “Brig. Gen. Michael A. Dunn, Western Region Medical Commander and MAMC commander, TRICARE NW Lead Agent, has strong interest and commitment in developing this Limb Preservation Center,” Dr. Driver adds. [Ed. note: TRICARE is the DOD’s managed health care program.] “We see ourselves as a center of excellence, and our goal is to become a model for preservation of limbs for multiple types of high-risk patients.”

   Dr. Driver advises clinicians thinking about developing wound clinics to keep patients as the focus of concern, to develop continuity of care, to be vigilant about high-risk patients, and to educate patients about foot care and their need to seek prompt treatment if they suspect a problem. “Our goal is to decrease amputations,” says Dr. Driver. “Before, we had an orthopedic surgeon who was referred to as the ‘stump doc’. Now, there’s no more ‘stump doc’ in our scope of practice.” 

   My Scope of Practice is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.