Indigenous and Intercultural Health/Case Studies/Podiatry

Draft Podiatry Case Studies

Contributed by Lesley Newcombe, a podiatrist working with indigenous populations at Boab Health Services around Broome, Western Australia. She was formerly Head of the Podiatry Department at La Trobe University.

'''SCENARIO 1. Between podiatrist and indigenous male patient'''

BACKGROUND:

Aboriginal male, 67 years old

Complex medical Hx inc diabetes, renal disease, cardiovascular disease, on a variety of medications including oral hypoglycaemics and insulin.

In Nov 2012, developed blood filled blister to lateral aspect of right heel on border of weight bearing area. He is uncertain of how this developed. Blister de-roofed and blood removed and area dressed. Wound has had periods of infection requiring antibiotics, and is currently healing but very slowly. Recent HbA1c in Jan 2013 was 14.7% which is well above the recommended level (> 8.0%  > 64 mmol/mol    Poor glycaemic control).

At the last clinic visit, he stated that now is a culturally important time and he is regarded as an important elder in the community, and now he has to go ‘out bush’ with the boys of the community to practice ‘law’. He is informed that this may have a detrimental effect on his ulcer if it is not taken care of and cleaned and dressed daily. Also, because of the location of the ulcer, it is likely to be subjected to pressure when he sits on the floor, crossed legged, which he will be doing for long periods. He assures the clinic staff that he will look after his foot, but that he does not know when he will be back, as ‘men’s business’ can take an indeterminate amount of time.

INTERDISCIPLINARY COLLABORATION IN THIS CASE:
 * Nursing clinic staff                -  Provide overall care, daily dressings, preparation of medication etc
 * Visiting GP                              -  Overseeing care, referring to other disciplines, ordering tests etc
 * Visiting podiatrist                  -  Monthly visit to community, general foot care, advice on wound care and dressings,
 * Visiting diabetes educator   -  Education regarding diabetes and trying to get blood glucose levels under control
 * Visiting dietician                    -  Ensuring access to nutritious food via HACC meals, adding supplements to improve wound healing ability

ISSUES TO CONSIDER: of the team etc.
 * 1) How to ensure adequate wound healing in adverse environment.
 * 2) Being respectful of this man’s status in the community and his need to leave the community to engage in men’s business.
 * 3) How to put aside your own opinion on what should happen, i.e. daily visits to the community clinic, appropriate cleaning, monitoring and dressing of the wound, close monitoring of his blood glucose levels by other members

OUTCOME:

Discussion took place with the client in respectful and supportive manner to ensure that he understood the possible consequences of not looking after his foot. Plans were made to ensure that sufficient dressings were supplied, and that he knew how to clean and dress the wound. Discussion also took place around his understanding of what to look for in the wound to indicate that it had become infected. Staff also ensured that he had a method of storing his insulin in a cool environment.

SOCIAL DETERMINANTS HIGHLIGHED IN THIS SCENARIO:
 * Access to appropriate clinical services
 * Health literacy
 * Hygiene

'''SCENARIO 2. Between podiatrist and indigenous female patient'''

BACKGROUND:

Aboriginal female, 64 years old

Medical Hx inc diabetes type II, osteoathritis, hypertension, obesity (wt 94.2 kg), fracture to left tibial plateau

This lady lives approximately 32kms from the nearest remote clinic, and has often not had transport to attend her scheduled appointments etc. She lives on a remote block with her husband who is also suffering with diabetes and arthritis. She sustained a bad fracture to her left tibial plateau, with an open wound on the dorsum of her ankle.

Whilst the bone fracture healed, the wound on the ankle persisted for a long time and had periods of infection requiring anti-biotics. When relating her story from that time, she explains that she became frustrated with western medicine, and it didn’t seem to be helping, so she stopped using the dressings, and started to use bush medicine. She describes going into the bush to collect bark from a certain tree, then soaking the bark to extract its properties and bathing the wound with this solution on a daily basis. She says “it became much better and healed up with blackfella medicine”. Now this lady often prefers to use bush medicine rather than western medicine for many ailments and infections.

INTERDISCIPLINARY COLLABORATION IN THIS CASE:
 * Nursing clinic staff                -  Provide overall care, dressings when the clients could attend the clinic, preparation of medication etc
 * Visiting GP                              -  Overseeing care, referring to other disciplines, ordering tests etc
 * Visiting podiatrist                  -  Monthly visit to her block, general foot care, advice on wound care and dressings, provision of shoes
 * Visiting diabetes educator   -  Education regarding diabetes and trying to get blood glucose levels under control
 * Visiting dietician                    -  Education regarding healthy foot choices etc and support for weight loss
 * Visiting Physiotherapist       -   Rehabilitation exercises following fracture

ISSUES TO CONSIDER:
 * 1) How to ensure adequate wound healing in an adverse environment.
 * 2) Being respectful of this lady’s choice to use bush medicine.
 * 3) Remaining objective, open minded and non judgemental toward her choice, and to remain supportive and in the background so to speak to offer advice or intervention if asked for.

OUTCOME:

Support was provided in the form of regular (two monthly) visits to the block to provide general foot care, and to ensure that she understood how to monitor for infection or serious changes in the wound environment. All service providers in her care are aware that she is unable to travel to the clinic, so arrangements have to be made to go to her home.

SOCIAL DETERMINANTS HIGHLIGHED IN THIS SCENARIO:
 * Access to appropriate clinical services
 * Health literacy
 * Hygiene

Reference Footcare in the dust…providing podiatry across the Kimberley

J Foot Ankle Res. 2011; 4(Suppl 1): P14. Published online 2011 May 20. doi: 10.1186/1757-1146-4-S1-P14 PMCID: PMC3102988