Doctor vs. Doctor: Internist Sues Podiatrist Over Leg Amputation

6 thoughts on “Doctor vs. Doctor: Internist Sues Podiatrist Over Leg Amputation”

1. Dr. Adajar, internist is most likely incorrect in his assessment that Dr. Baloga was negligent. Dr Adajar most likely has renal transplant 2ndary to advanced diabetic renal disease. Multiple debridements for diabetic foot ulcers are very common. Total contact casting for plantar diabetic ulcers is standard of care. Dr . Baloga did not give Dr adajar his diabetes, his renal disease, his transplant, his immunosuppression, or his post debridement sepsis. He was the surgeon helping the internist with his problem foot, and saved his life. Dr Adajar is the internist who should have been more vigilant of his overall & multiple comorbidities. They together Are the team, and Dr Adajar didn’t do his part. I am a Hospital t based wound care plastic surgeon. Well familiar with this “ nature of disease” etiology. Perhaps HBOT should have been utilized. I am interested in working as a consultant with Dr Segal & Medical Justice.

2. Agreed. Diabetic foot care requires frequent debridement to prevent gangrene. The podiatrist did the best he could to cure the infection, but the internist’s severe immunosuppression was no match for Clostridium. 2 cents

3. i’m not a podiatrist, i am a general and plastic surgeon and diabetic disease involving the vessels of the lower limb plus neuropathy plus immunosuppression are a recipe for disaster. Dr. Adajar is probably wrong and trying to blame another doctor rather than the deadly disease afflicting him. Aggressive debridement is the standard of care here. Now if you tell us that the podiatrist closed the wound in the presence of active infection, he might have a case but most of the errors i have seen involving cases like this are from under-deriding rather than over.

4. More likely than not, the defendant is not liable for reasons stated above. The plaintiff’s amputation was probably a matter of time.

   Some observations:
   1) wound debridements are typically performed weekly, and the defendant only performed 10 debridements over the course of 6 months

   2) patients with CKD typically have comorbid peripheral arterial disease and no mention is made about attempts at vascular intervention. Usually it’s more of a diffuse calcinosis than focal obstruction in the setting of CKD but it merits inquiry.

   3) total contact casts are considered the gold standard in offloading, why wait 6 months before trying this modality?

5. What about the experimental use of dermoscopy in wound care? What about the experimental use of targeted antibiotic powder therapy after a bone or soft tissue culture and histopathological diagnosis? What about the experimental use of gentian violet solution?
   What about shoe excavations to offload the foot so that one can examine the foot much more frequently? What about experimental posterior tibial nerve blocks? What about a vascular consultation with an endovascular specialist? Any comments regarding the website below and regarding http://journalofdermoscopy.com and the use of dermoscopy regarding podiatric wound care?

6. The internist is the patient. Though he has an MD it is NOT his job to diagnose and treat himself. When one is “in trouble” they can’t be expected to be objective, especially on oneself. A non-involved internist should have been consulted to follow and advise on the co-morbidities.

   More information is needed on the vascular status, the Hgb1Ac, white count with diff, etc. to know if debridement and casting would be optimal without other interventions/referrals. Did the pod even take the patients temperature. I feel all diabetics with ulcerations should have that done at each visit.

   Mere mechanical debridement without concomitantly being cognizant of what’s going on “inside” is not quality complete care, in my opinion. While this may be usual and customary, mechanical care, I’d like to see the pods notes on him following leukocytosis, shifts to the left, bands, sed rate, as well glucose, C&S’s, gram stains etc.. While an independent internist would (should) be monitoring this it does not preclude the podiatrist from taking these factors into consideration. Again, not seeing his notes or whether he ordered or asked for lab results, there’s insufficient information on his care to indict his treatment. I’m just saying it’s not enough, in my opinion, to say, “that’s not up to me”, it’s the other guys job. When there’s overlap I feel both have a responsibility. The ‘ol intersection of the Venn diagram.

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