Do emergency physicians (EPs) perform callous debridement of the foot in the emergency department (ED) or is it typically done by podiatry?

Callous Debridement in the Emergency Department: Role of Emergency Physicians vs. Podiatrists

Callous debridement of the foot is primarily performed by podiatrists rather than emergency physicians in most healthcare settings, as podiatrists have specialized training in this procedure and it is generally not considered an emergency intervention.

Role Distribution in Foot Callous Management

Emergency Physician Role

• Emergency physicians typically focus on acute, emergent conditions requiring immediate intervention
• In the ED setting, emergency physicians may perform:
  • Urgent surgical debridement for gas-forming infections, abscesses, or necrotizing fasciitis 1
  • Debridement of infected diabetic foot wounds when immediate intervention is needed 1
  • Basic wound care and preparation for referral to specialists

Podiatrist Role

• Podiatrists are the primary providers for callous debridement due to their specialized training 1, 2
• Podiatry is considered an essential component of multidisciplinary care for foot conditions 1
• Podiatrists regularly perform manual debridement or paring of hyperkeratosis (callous) using specialized techniques 1
• They possess the specific scalpel skills needed for safe, local sharp wound debridement 2

Debridement Techniques and Considerations

Types of Debridement

• Sharp debridement (with scalpel, scissors, or tissue nippers) is generally preferred for callouses 1
• Other methods include:
  • Mechanical debridement
  • Autolytic debridement (hydrogels)
  • Biological debridement (maggot therapy)
  • Enzymatic debridement

Evidence for Debridement Effectiveness

• Sharp debridement is strongly recommended for removing slough, necrotic tissue, and surrounding callus of diabetic foot ulcers 1
• Hydrogel-based autolytic debridement may have beneficial effects compared to saline-moistened gauze, though evidence quality is low 1
• Regular debridement of calluses has been shown to reduce peak plantar pressures, which is important for ulcer prevention 2

Clinical Workflow Considerations

When Emergency Debridement Is Warranted

• Urgent surgical debridement in the ED is indicated for:
  • Gas-forming infections
  • Abscesses
  • Necrotizing fasciitis 1
  • Severely infected diabetic foot wounds requiring immediate intervention 1

Anesthesia for Foot Procedures

• For plantar foot wounds requiring debridement:
  • Lidocaine with epinephrine can be safely used despite traditional prohibitions 3
  • For neuropathic ulcers, debridement can often be performed without any local anesthetic 3
  • Buffering the anesthetic with sodium bicarbonate can decrease pain during infiltration 3

Practice Patterns and Regional Differences

• Most clinicians (84% of podiatrists in one survey) perform callous debridement at every visit 4
• Regional differences exist:
  • Regional/remote podiatrists provide debridement less frequently than metropolitan colleagues 4
  • Debridement frequency is determined by clinical wound indications and staffing resources 4

Common Pitfalls and Considerations

• Overdebridement by inexperienced practitioners can make underlying skin susceptible to increased blistering and tenderness 1
• After debridement, emollients and non-adherent dressings should be used to protect the debrided skin 1
• Dressings should be selected primarily based on exudate control, comfort, and cost 1
• Removal of pressure from a foot wound (off-loading) is crucial to the healing process 1

In conclusion, while emergency physicians may perform urgent debridement for severe infections or complications, routine callous debridement is primarily within the scope of podiatric practice due to their specialized training and expertise in foot care.