Sometimes we need a reminder as to just how good we really are. Today was one of those days for me.

I had two situations this morning before 9:00 AM that tested my own personal faith. In one situation, I succeeded in remaining true to myself, while in the other my doubts got the best of me. In tribute to my wife’s love of mystery television shows (which I have grown to dislike) I am titling each situation as a mystery case.

The Case of the Declining Kidneys

I was about to do an elective surgery this morning. The patient was diabetic, and her pre-op labs showed a few irregularities. Before I began the surgery, I ordered new labs to see if there had been any changes. The main issues were that the patient was mildly hyperkalemic with an elevated creatinine. The lab results were borderline, and I had previously received full clearance from the patient’s primary care doctor and cardiologist. However, when I saw the patients’ repeat labs this morning, it turned out that her kidney function declined slightly while she was dehydrated due to her NPO status. Because of this, I canceled her surgery.

Knowing all the details, and considering I had received clearance from two other doctors, one could argue that I should have proceeded with the surgery. However, looking at the patient as a whole, considering the elective nature of the surgery, and standing my ground in the face of other physicians, I feel I did the best thing for the patient. Would the patient have been okay despite these borderline labs? Possibly. However, how could I live with myself if the patient had complications that I could have avoided?

In this case, I was responsible and confident in making my own decision for my patient’s health. In the next situation, I should have been more confident in my knowledge as a lower extremity specialist.

The Case of the Smelly Wound

After canceling my “case of the declining kidneys”, I had a little extra time on my hands, so I was getting some work done in my office when I received a call about another patient on whom, five days ago, I had done an operative debridement for a diabetic ulcer. Despite the fact that I give my patients my cell phone number to call in case of emergencies, I received a call from a very nice doctor in an emergency department (ED). I was surprised to hear the patient had come to the ED due to pain. The ED doctor thought the patient had a Pseudomonas infection due to the particular odor. Likely, this was a colonization, as Pseudomonas is a rare infecting organism in the foot. Despite this, the doctor gave the patient IV aztreonam, and we decided to send the patient home on oral antibiotics. The patient was already scheduled to see me the next day.

Here’s the part where I should have remained more confident. The ED doctor and I had a short discussion about the appropriate antimicrobial with which to discharge the patient. When I recommended levofloxacin, the doctor disagreed with me saying this medication does not cover Pseudomonas. As I’m sure many of you already know levofloxacin does, in fact, cover Pseudomonas.

Just so we stay somewhat academic here, let me ask the following question: Is there medical evidence to prove levofloxcin is an effective antimicrobial for Pseudomonas infections?

As it turns out, there is. Bonfiglio in 2001 published a study comparing in vitro activity of levofloxacin to multiple antimicrobials for the treatment of Pseudomonas aeruginosa obtained from hospitalized patients. He compared it with ofloxacin, ciprofloxacin, piperacillin, amikacin, ceftazidime and imipenem. Using minimum inhibitory concentrations (MIC), he found levofloxacin to have equivalent activity to ciprofloxacin and slightly less activity compared with imipenem and piperacillin. Levofloxacin was stated to have, “excellent bactericidal activity” and was “a good option for the treatment of infections sustained by Pseudomonas aeruginosa.”¹

Take that sucka!!!

Despite my apparent superior knowledge to the ED physician, I bowed to his judgment, and we agreed on ciprofloxacin (to be totally honest this patient probably could have been discharged on topical antimicrobials, but I had just applied an engineered tissue, and I didn’t want the patient messing with the dressing). I should have remained confident in my own knowledge. Just because I am a podiatrist does not mean that my skills or knowledge are less than any other physicians’. In fact, podiatrists are the experts in the foot and ankle and even more so for patients with diabetes. Who knows more about the diabetic foot than podiatrists?

I don’t particularly love advertising my shortfalls, but if this helps some of you remember to stay confident in your skills as podiatrists, then it’s worth every minute of my embarrassment. You know more than other medical providers about your chosen specialty. Stay strong and confident in yourself, and you’ll be the best advocate for your patients.

*Approved for 16 CME/CECH Credit Hours

PODIATRISTS: This activity has been planned and implemented in accordance with the standards and requirements for approval of providers of continuing education in podiatric medicine through a joint provider agreement between the New York College of Podiatric Medicine and PRESENT e-Learning Systems.

The New York College of Podiatric Medicine (NYCPM) is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine. The NYCPM has approved this activity for a maximum of 16 continuing education contact hours.

PHYSICIANS: Professional Education Services Group (PESG) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Professional Education Services Group (PESG) designates this live educational activity for AMA PRA Category 1 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. A maximum of 16 AMA PRA Category 1 Credits^TM will be awarded.

NURSES: Professional Education Services Group (PESG) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. PESG is awarding a maximum of 16 contact hours for this activity.