APMA News - March/April 2018 - APMA3

SUPPLEMENT TO APMA NEWS

YOUR APMA / PAGE 3

WHEN A PATIENT DEMANDS SURGERY
By Barbara Bellione, RN, CPHARM, ARM, director of Risk Management, PICA

Have you ever given in to a patient who insisted on immediate surgery
against your better judgment, then later regretted your decision?
Consider the following case:

he patient presented to the insured podiatrist requesting surgery for a recurrent
right bunion. Twenty years earlier, the
insured had performed bilateral bunionectomies on the patient. She was happy with
the results of those bunionectomies, so she
returned when the bunions recurred. She

had complaints of pain in her right first metatarsophalangeal joint (MPJ) when she wore
high heels for an extended period of time.
The podiatrist obtained a history, which
was unremarkable for any significant health
issues. Upon physical exam, the insured
noted bilateral hallux valgus deformities.

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X-rays were taken and showed prior surgical
changes and marked hallux valgus deformity,
bilaterally.
The podiatrist recommended conservative
treatment options such as inserts, injections,
NSAIDs, and shoe gear changes. However,
the patient was "very adamant" about having surgery on her right foot because of pain
when wearing her dress shoes. The insured
suggested she obtain a second opinion
regarding surgery and scheduled a follow-up
appointment.
When the patient returned two months
later, she had not obtained a second opinion
and was still insisting upon surgery for her
right bunion. She again refused conservative treatment. The insured acquiesced and
performed an Austin bunionectomy with
Kirschner wire fixation of the right foot.
The patient was extremely non-compliant
post-operatively. She failed to obtain
ordered X-rays in a timely manner, missed
several appointments, refused to perform
range-of-motion exercises, and did not wear
her post-op shoe as instructed. Fortunately,
she eventually healed well and stated she
was happy with the results.
Approximately one year later, the patient
saw another podiatrist with complaints
of excruciating throbbing pain, burning,
and numbness in her right foot, which she
reported had been present since her recent
bunionectomy. X-rays were taken, showing
subluxation at the first MPJ with the distal
first metatarsal subluxed laterally, as well as
degenerative changes at the joint. EMG and
NCS studies of the right leg were normal.
The subsequent treating podiatrist
diagnosed right foot dysesthesia, which
he suspected was caused by injury to the
cutaneous branch of the superficial peroneal
nerve. He referred the patient to a neurologist, who diagnosed her with neuropathy
and arthritis.
The patient sued the initial podiatrist who
performed the bunionectomy alleging inappropriate placement of the K-wire that was
placed to stabilize the osteotomy site which
prevented healing in a normal manner and
loss of mobility.
Upon review of the patient's medical
records by the defense experts, there was no
indication that the patient's current right foot
pain was related to the bunionectomy. Based
upon the initial podiatric surgeon's medical
records, the patient was not experiencing
Continued on Page 4

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Table of Contents for the Digital Edition of APMA News - March/April 2018