Exposure to Nail Dust – An Occupational Hazard?

By Dr. Helen Rees, B. Sc.. (Hons)

The use of nail drills by Podiatrists/Chiropodists to improve patient toe nail conditions and therefore their ‘quality of life’ is a plauditory aim but what effect is it having on our health?

Exposure to nail dust and the inhalation risk was first described in the early 70′s  as an “Occupational Hazard”. Using a drill to reduce onychauxis nails generates finely divided nail particles. This airborne material could consist of keratin, fungal elements (eg Trichophyton rubrum) , bacteria, moulds and other microbial debris.

As far back as 1975, two female UK Podiatrists were diagnosed with allergy hypersensitivity to nail dust. Research by Millar (2000) suggested that, within podiatry, there was four times the UK prevalence of asthma, giving cause for concern. Breathing in respiratory sensitizers at work can cause occupational asthma. In the same study, podiatrists frequently reported problems with rhinitis and conjunctivitis, suggesting occupational health risks. As recently as February 2014 a study by Tinley et al showed podiatrists had an increased prevalence of nose microbes, most commonly Aspergilus, compared to a control group.

Obviously, exposure to nail dust and the associated risk will vary in offices due to the polices and practices in place, type of drill/burr, personal protection used and extraction/ventilation systems. However, with many more podiatrists complaining of or presenting with symptoms should we still be using drills?

Should we be developing our skills to move away from nail drills? What should we be teaching the next generation? If we know the risk to our health should we be changing our practices and policies?

Medical Marvel in Saskatchewan

By Dr. Axel Rohrmann

Every so often we’ll meet a patient whose story will take our breath away.  This patient was just such a patient and his story is nothing short of a miracle.

It was a cold winter’s day when he was huddled around a fire to keep warm while fighting the elements and threats of being a “homeless or street person”.medicalmarvel1

He couldn’t tell what exactly happened but recalls falling into the fire that was supposed to keep him warm. The nylon jacket he was wearing instantly melted to his skin. Fortunately a witness pulled him from the flames and smothered him in snow. He was rushed to the La Ronge hospital and then airlifted to Saskatoon where he was induced into a coma. During the weeks and months that followed he underwent numerous plastic and orthopedic surgeries. He had lost  all his fingers on his right hand and three from his left hand ( The thumb, third and 5th finger couldn’t be saved).

We all know the importance of a thumb so what the surgeons did is amputate the left hallux and transplant it to his left hand.medicalmarvel2

The transplant was a huge success and the thumb is functional, vascularised and sensate. It has enabled him to care for himself without the use of a prosthetic on the left hand. He has been newly diagnosed with  Type 2 diabetes and was seeing me for his baseline neurovascular assessment.  I will be seeing him in 6 months for a follow up and would relay any questions you may have. Wishing you all an inspired 2014.

 

Working in Canada

Written by Stuart Berry, BSc (Hons), Podiatry

They say moving house is one of the most stressful things that you can do in your life, therefore for those of you that are moving province or territory, or indeed moving country, I thought it would be helpful to ease the burden by giving you a page of resources which will help with your transition to your new home and new place of work by helping you get work-ready.

One of the things which will differ between continents, countries or event regions within countries is the regulatory frameworks which govern our practice – so do your research now is my tip.

Cultural, geographical, historical and demographic differences are some of the reasons regulatory frameworks may sometimes differ.  Within Canada it is worth remembering that podiatric medicine is therefore regulated at a provincial level and those working in one region will need to register with the appropriate regulator when working in another region.

It is of no surprise we see the differences in regulators reflected across the globe also reflected somewhat across Canada – for example the regulators of podiatry in Alberta and podiatry in British Columbia vary from the regulators of la podiatrie au Québec.   Similarly the other Canadian provinces or Territories will be different.

Each U.S state will also have a different regulatory framework and for those looking to work in a different continent, such as the Europe or Australasia again, there will be different regulators for either the country or region depending on the model of regulation.

TOP TIPS:

It is important to prepare ahead of time.  Like a good scout “be prepared”.  Know who regulates you in your new destination and how to access the relevant information you require.

Check that that you meet, or know how to meet, the requirements the new regulator will place upon you since all regulators are different.

Do as much as you can before your move.  Ensure you have registered with your regulator and are ready to practice as soon as you arrive, since going through the regulatory process can take weeks or months and you want to ensure you are work-ready.

Look out for words like ‘council’ or ‘college’: these are often words that indicate a regulator.

For those within Canada or moving to Canada to work within podiatric medicine, here are some useful resources to help with your research and relocation:

For information on credentials for foreign trained individuals.

Information on Alberta podiatry licencing.

Information British Columbia podiatry licencing

Information Manitoba podiatry registration

Information Nunavut podiatry licencing

Information Ontario podiatry or chiropody registration

Information Prince Edward Island podiatry licencing

Information Quebec podiatry licencing

Information Saskatchewan podiatry licencing

For Podiatry associations in the maritime provinces check out New Brunswick, Nova Scotia, PEI,

Overseas:

Finally, if you are looking at Australia or the United Kingdom, check out these regulators.

Like a good holiday, they say half the fun is in the planning, so with that in mind have fun doing all your research!

Well, I think that sums up my whistle stop tour of first step research for before you relocate, I hope it helps.

To debride or not to debride? That is the question

“To debride or not to debride? That is the question”.

By Dr. Helen Rees, B. Sc (Hons)

A critical question in the treatment of chronic wounds, diabetic foot ulcers, venous ulcers and pressure ulcers, is whether and how frequently debridement is needed.

Debridement is defined by Hinchcliffe et al (2008) as the removal of slough, surface debris and infected matter from the wound bed in an attempt to leave clean, viable tissue. Methods of debridement include sharp, mechanical, chemical, maggot therapy, surgical, autolysis and ultrasonic.

As skilled practitioners Podiatrists/ Chiropodists are ideally placed to undertake sharp debridement, a fundamental technique in daily clinical work, as long as it is remembered not to go beyond clinical scope of practice. It is essential to undertake a thorough vascular and neurological assessment prior to picking up a scalpel and be aware of the debridement risks if ischemia, poor venous return or poor tissue viability is recorded.

Debridement promotes healing by converting a chronic nonhealing wound environment into the ideal wound bed preparation, promoting wound healing. In addition to altering the environment of the chronic wound, debridement is a technique aimed at removing non-viable and necrotic tissue, thought to be detrimental to healing (Lebrum et al 2010 and Gordon et al 2012).

Debridement is achieved by removing wound edge tissue, such as hyperkeratotic epidermis (callus) and necrotic dermal tissue, foreign debris, and bacterial elements known to have an inhibitory effect on wound healing (Edmonds and Foster, 2006). Research by JAMA dermatology proved that patients with chronic wounds coming in every week for debridement were associated with faster wound healing.

The Royal College of General Practitioners’ Guidelines (RCGP, 2000) recommends debridement as a treatment of diabetic foot ulcers alongside local wound management and appropriate dressings.  Debridement is also recommended by the SIGN guidelines (1997), in conjunction with antibiotic therapy for infection and offloading modalities.

While the rationale for debridement seems logical, the evidence to support its use in enhancing healing is scarce. One of the most fundamental practices, debridement, has never been studied closely in randomized clinical trials.

So, as a Chiropodist/ Podiatrist, should we bring our patients in for wound/ ulcer debridement?  If so how often should we be debriding?

Let’s discuss this topic further, please add your comments:

Podiatry and the wound care patient.

Written by Dr. Axel Rohrmann

We all start out with visions of where we see ourselves within the profession, and as time passes our patient’s make changes to our vision that often come quite unexpectedly. I’ve just said good bye and have a wonderful Christmas with your family, to a patient who had been seen in the clinic for wound care once every 2-3 weeks over the past 3.5 months. Though there may be nothing unusual about the good bye gesture, what is unusual is  the fact that Christmas is still 9 weeks away. During the time that I had started treating this particular patient he had become a grandfather, completed some renovations in the home, and set a date for his retirement. Also while I was treating this patient new developments in the wound dressing industry presented themselves and we had the opportunity to trial a new dressing. As good fortune would have it, the dressing was a new antimicrobial dressing and although another silver dressing, the delivery system of silver was more efficient and effective than dressings of a similar nature. Wound care for this patient was multifaceted to accommodate his activities of daily living and footwear. He required offloading, arrangements for community dressing changes and regular debridements. Initial ulcer presentation was a sloughy and necrotic plantar proximal first lesion measuring 2.5 cm x 1.8 cm and Grade 2 on the University of Texas wound classification. Today was the first follow up after wound closure and scar tissue appeared to have good tensile strength.

Wound care is a changing and fascinating industry so long as the products are being understood and used appropriately during the appropriate stage of wound healing or wound state. The other challenging and exciting element of wound care if that every case is unique. Wounds may present in a similar fashion and have the same treatment outcome or goal of wound closure, but they reside on very different people. Different people have different environments, requirements and activities of daily living, nutritional status, transportation, socioeconomic means, understanding and self motivation. It is up to you, the clinician to understand not only the wound, but the person.

I absolutely love what I do, I’m blessed to be considered a wound healer and though I only treat the hole in the lower extremity it’s the whole patient that makes the process rewarding. We need to remember the moments that make our profession the special profession it is. We’re privileged to be able to provide the services we do and I look forward to many more years and helping many more patients.

Case Review – Toe Walking

By Dr. Axel Rohrmann

A healthy  9 year old girl was referred to me for “walking on the top of her feet”. Interesting as this sounds, I thought there had to be an error.

The patient, parents and a sibling sister were met at the reception and shown to my clinic room. Observation of gait showed that all gait determinants were within normal limits. During introductions and history it was revealed that the 11 year old sister also used to walk on the “top of her feet” until around age 6 when she spontaneously stopped. Assessing the feet it could be seen that there are mild skin changes on the dorsum of the inter-phalangeal joints and the metatarsal-phalangial joints. Read more »

Vandenbos Nail Procedure for Ingrown Toenails

By Dr. Axel Rohrmann

I received a call from a patient who inquired if I do a nail procedure called the Vandenbos nail procedure for ingrown toenails. I advised that there are many different ways to perform partial or total nail avulsions and that It would be best to see the site in question before deciding on the appropriate procedure. Read more »

Reflections of the past 30 years and excitement for the future

Let me introduce myself.  I am a chiropodist/ podiatrist who has been happily practicing for 27 years in southern Ontario.  Why I am happy?   I love my profession.  I am not sure how many people can say that today, but I am one of those lucky people.  Every day, I help people and make them feel better as they walk out my office in less pain.  Over the years, I have been honoured to treated 4 generations of several families.  Hopefully, I will get to treat 5 generations.  I have heard about births, anniversaries, weddings, retirements, graduations, the trials and tribulations of daily living and unfortunately deaths. The deaths of your patients are difficult since you have developed a relationship over years and sometimes decades.   Read more »

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