Podiatrist Diabetic Foot Escalation: Kolb

Concrete experience

A man in his sixties with type 2 diabetes and peripheral neuropathy attended my community clinic for a routine review of a forefoot ulcer that had been stable and slowly improving over six weeks. On examination the picture had changed: the ulcer was deeper with undermining edges, there was new malodour and surrounding erythema, and he mentioned feeling feverish overnight - though he considered the foot 'about the same', having no pain to warn him. I probed the ulcer, suspected deep infection with possible bone involvement, and decided this needed same-day assessment by the multidisciplinary foot team. Getting that assessment took most of my afternoon: the MDT referral inbox had a 48-hour turnaround, the hot clinic line went twice to voicemail, and I eventually reached the diabetes specialist podiatrist directly through a colleague's mobile number. The patient was seen that evening, admitted for intravenous antibiotics, and imaging confirmed osteomyelitis. He kept his foot.

Reflective observation

Two things stand out. First, the clinical recognition was the easy part - the pattern change was textbook, and my training carried me. What nearly failed was everything after recognition: the urgency lived in my assessment but not in any pathway I could reliably reach, and same-day escalation ultimately depended on a personal phone number, which is to say on luck. A podiatrist newer to the area, without that informal network, makes the same correct assessment and the patient waits two days. Second, the patient's own report - 'about the same' - was actively misleading, not through stoicism but because neuropathy had removed the signal he would normally rely on. I had always known this intellectually; watching it nearly delay an osteomyelitis diagnosis made it concrete.

Abstract conceptualisation

The general lesson is that in high-risk foot care, escalation is a system property, not a clinical skill - a correct assessment only protects the patient if the pathway can move at the speed of the pathology, and pathways default to the speed of their paperwork. Informal networks patch this gap but silently, so the system never learns it is broken. The secondary principle: in neuropathic patients, the interval history must be rebuilt from objective markers rather than symptom report, because the usual patient-as-early-warning-system assumption is structurally void.

Active experimentation

I wrote up the escalation delay - not the clinical case - as a formal incident-adjacent learning report and took it to our service lead, which has triggered a review of the urgent referral route; the interim fix is a monitored urgent phone line with a named daily contact, now on a laminated card in every community clinic room. In my own practice, I have started photographing high-risk ulcers at every visit with a measurement scale so that deterioration is demonstrable rather than arguable at referral, and I have added a standing question about systemic symptoms to every diabetic foot review, weighted more heavily than foot symptoms. Six weeks on, I used the new urgent line for another patient; assessment happened within four hours.