Referrals Are A Pain In The Foot...
ORTHO: “Has he been seen by a Tissue Viability Nurse?”
“No. We figured since this is likely osteomyelitis, he should be referred to Ortho directly.”
“Well we need them to see it first and then refer to us.”
“Okay.”
TVN: “It’s probably osteomyelitis. Please order an MRI to confirm and then refer back to Ortho.”
ORTHO: “Oh, you didn’t mention he has diabetes. Are his BMs stable?”
“They were fluctuating between 17 and 32 when he was first admitted, but he was reviewed by the Diabetic Specialty Nurse and they’re now under control.”
“Okay that’s good. But since it’s related to his diabetes, he’s not suitable for Orthopaedics anymore. You need to refer him to the Surgical Reg.”
SURGERY: “Sorry I only take referrals for general surgery. You need to refer him specifically to the Vascular surgeons.”
VASCULAR: “Have you sent a written referral?”
“Well I tried but they said I needed to call you first to let you know we need to refer somebody to you or else you won’t know to check the referrals box.”
“Okay, do the referral and we’ll come and see him.”
“Thank you so much.”
WARD CLERK: “Oh good you’re back from lunch. I have a message for you. The Vascular Registrar called about your patient- he won’t see him until you get the MRI and confirm that it’s osteomyelitis.”
“……….”
RADIOLOGY: “Hi would it be possible to get this MRI Foot done some time today to confirm or rule out osteomyelitis?”
“Has he been seen by Orthopaedics or the Vascular team to confirm that it’s likely osteomyelitis?”
“Ortho says it’s not their problem since it’s related to his diabetes and Vascular won’t do anything until we get the MRI.”
“Is he unwell?”
“Well… we’ve had to do an MCA and DoLS on him because he’s delirious from the sepsis which we suspect is from osteomyelitis due to his diabetic foot ulcer.”
“Okay. We’ll try and get it done today.”
MRI FOOT WAS NOT DONE UNTIL TWO DAYS LATER WHEN PATIENT WAS NO LONGER DELIRIOUS AS PATIENT REPEATEDLY REFUSED TO BE TAKEN DOWNSTAIRS FOR MRI SCAN.
ENDO: “He has an infected diabetic foot ulcer. The MRI showed it wasn’t osteomyelitis but we still think the infection might have caused his sepsis. We’ve investigated other possible causes and haven’t found any. He is no longer septic and has full capacity again.”
“Are his respiratory symptoms under control?”
“He never had any.”
“So what’s he doing on the Respiratory ward?”
“I don’t know. I think maybe he coughed once in A&E. Would you be able to come and review his foot and suggest further management?”
“Has he been seen by the Diabetic Specialty Nurse?”
“Yes.”
“Tissue Viability Nurse?”
“Yes.”
“Has he been seen by Orthopaedics or Vascular?”
“No they both said he’s not suitable for them.”
“Okay. Well since he’s better and his BMs are under control, we don’t really need to see him anymore. Just refer him to the Diabetic Foot team and they’ll discuss him at the MDT.”
Am now the Orthopod on the other side of that initial conversation lol. And if a Resp F1 called me now, the conversation would go pretty much exactly the same 😂😭
The policy in hospitals I’ve worked in is that Osteomyelitis goes to the medics for abx- usually they’ll get IVs in hospital so you can check they’re responding/ are no longer septic, then carry on for however long it takes until you can sort out a PICC line and send them home for ongoing IV abx in the community till they’ve had 6 weeks, then 4-6 weeks further of PO.
Surgeons only get involved if something needs debriding or draining. If the foot is attached to a diabetic, Vascular. If not, Ortho.
I’ve been told by quite a few Medics over the years that since Surgeons are doctors too, we should be able to manage medical problems in our patients. Fair. But the other side of that is that if they only have medical problems, why are they under Surgery in the first place? The most common argument I hear back as an Orthopod is with regards to conservatively managed fractures which need physio and pain control so often end up under Medics.
Well if the management of the pain isn’t surgical fixation, then they need medicine? Surgeons are going to give them Paracetamol, Morphine, Codeine, Gabapentin, Diazepam and Diclofenac. No laxative or PPI.
I promise you Betty with her L4 fragility fracture and no peripheral neurological symptoms is going to do better and get home much faster under Medics.
It seemed really unfair to me as a Medical F1 that surgery wouldn’t take seemingly “obvious” surgical problems, but now I realise every surgical bed that is taken by a patient who just needs medical management is a patient waiting longer at home or in hospital for actual surgery.
I cannot tell you the number of times I have had patients cry to me about how much pain they are in when I’ve had to call and cancel them the night before their scheduled surgery because I’ve been told there are no beds to bring them into, we already have 5 DTAs in ED and that patient is at home “stable”. Or because we have too many major traumas or NoFs, the Trauma List is full… so the trimalleolar ankle fracture is going to have to roll for the 6th day in a row… can I go tell her she can eat?
