The Toe and Flow: Structure of an Effective Amputation Prevention Team

The core theme of our team at SALSA has been “team”. What my friend and co-director Joe Mills and I have found in participating in and developing amputation prevention initiatives in North America and around the world is that the “irreducible minimum” to this team involves a “toe team” (someone taking care of the foot medically and surgically) and a “flow team” (someone taking care of the flow into the foot medically and surgically). This is then enveloped by clinicians with varying types of skill sets (nursing, medicine, infectious diseases, physical medicine/rehabilitation, etc) that support the “Toe and Flow”. 

But who takes primacy and at what time? We can turn to the work that our International Working Group on the Diabetic Foot has done in this area to guide us. What we can posit is that healing and perfusion to the extremity are related– in a sigmoid-esque curve. 
If we then apply that curve to the team, we are able to define who manages the person at what time. If the acute problem at hand is more flow than toe, then the flow team takes primacy, pushing the patient up the healing curve. When that problem has been addressed, then the embedded toe team takes over to heal and prevent the problem. When perfusion is marginal, then simultaneous care can take place. 
Obviously, this is an idealized setting. Most clinicians and patients around the world don’t have the luxury or benefit of this type of near immediate access to their colleagues. We believe, however, that this can change for the better. 
  

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