When Do You Refer A Patient For Vascular Intervention?

Desmond Bell, DPM, CWS

   Several years ago, during a trip to Detroit, I opened up the local phone book to see if any old classmates may be practicing in the area. While this exercise did not yield any information regarding old classmates, it did send a jolt through my system that I have not forgotten since that day.

   There in the yellow pages of the Detroit phone book was an attorney advertising that he specializes in cases surrounding lower extremity amputation.

   Consider an earlier Podiatry Today article from by Janov that highlighted the story in which a Michigan jury awarded $1.23 million for a podiatrist’s failure to refer a patient to a vascular surgeon in a timely manner.11 A patient initially saw the podiatrist for severe vascular insufficiency and ischemic foot ulceration. The patient received antibiotics and instructions to return in two weeks. Upon his return, the patient got a referral to a vascular specialist for consultation 17 days later and one month after the initial podiatric evaluation.

   The patient, however, went to a local emergency room with a necrotic foot before ever seeing the vascular specialist. He subsequently underwent a below-knee amputation a week after finally seeing the vascular surgeon while in the hospital.

   The patient filed a lawsuit against the podiatrist. Ultimately, the jury rejected the podiatrist’s defenses including the following alleged points:

• “The patient had chronic but stable symptoms.”
• “The patient did not need an urgent referral.”
• “Any delay was due to the vascular visits.”

   Was this case an isolated incident? Perhaps in the broadest sense but given the results of the Podiatry Today poll I alluded to at the beginning of this article, there must be a high suspicion that we often do not detect or screen aggressively for PAD and CLI.

   This statement refers to the fact that there are many who are not using what would be considered sophisticated methods in combination with their clinical observations when it comes to identifying patients who are at increased risk for PAD and CLI. In fact, relying solely on any screening method at the exclusion of clinical judgment is foolish to say the least.

   As this article goes to press, 293 people have replied to the poll question “Which non-invasive test do you rely on (in your office or hospital) for PAD diagnosis?” (see “What An Online Poll Revealed About Non-Invasive Tests And PAD” at left).

Where To Turn For Help To Find A Vascular Specialist

Since we are often the frontline providers when it comes to detecting PAD and CLI, the chances are that at some point, you will be the one holding the figurative “hot potato” and find yourself with a patient in need of a vascular specialist referral. Indeed, this will happen sooner than later if you haven’t already encountered these patients in your practice. Knowing the litigious nature of society today, protecting yourself is as important as serving the best interests of your patients. The key here is not to overlook or take the consequences of PAD lightly.

   Screening patients for PAD and CLI may also uncover those who could have possibly faced myocardial infarction or a cerebrovascular accident in addition to preventing a lower extremity amputation.

   Frustration can come from the helpless feeling of realizing a patient is in real need of a vascular specialist referral but not knowing where to turn. Hospital or community politics can sometimes play a role in getting a patient into the hands of the specialist who has the skill set and determination to not make amputation a first-line treatment.


Being in home health definitely puts us in the frontlines. Thank you for your article.

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