Back x-rays in the ER

[f_w]

The big debate around here with c-spine is "to CT or not to CT". We have a dedicated 64-slice scanner so the reformats are quick, and likely more accurate than plain film. But the cost is greater.

And the radiation exposure to thyroid and lense is about 12 times that one of a 5 view plainfilm c-spine series.
If someone deserves the CT, that is a non-issue. If imaging of the c-spine is done for pure CYA reasons, it is a point to consider.

So, right now we mainly struggle with "well, I'm going to scan the head, do I extend down or get plain film..." I, usually, in the adult patient will scan the c-spine if I am scanning anything else or if habitus +/- c-spine precautions might preclude a good film. The only exception is the elderly where I scan first because DJD makes the plain films almost unreadable (in terms of defining chronic versus acute).

If you bashed your head badly enough to deserve a head-CT, you might as well get the (almost) definitive study for the c-spine at the same time at little time-penalty (if you have mental status changes or other signs of head trauma warranting a head CT, I rather have you out of my department after a 30 sec CT scan rather than the 10-15 min it will take to get the plain-films in addition to the head-CT). I am trying to impinge onto my ED docs that anyone over 40 who goes in the scanner with a collar on should get the CT rather than the plain films. If it is a young kid who flipped his 4-wheeler, you can usually get good enough plainfilms that we don't have to incur that kind of a 'radiation penalty', but in anyone older I don't see the point.

Coming back to the question of the OP why people are able to leave the ER with back pain without having x-rays: Because once in a while there will be an ER doc on service who actually practices evidence based medicine. Outside of acute trauma, particularly L-spine films have a very low diagnostic yield when it comes to guiding therapy.

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Members don't see this ad.

 

[jesse14]

Nope, just hate quacks... not ODD. Especially ones whose whole career is based on sounding like they know something when, in fact, they are clueless.

- H

Would you be referring to the entire chiropractic profession with this statement?

As i achknowledge that i know next to nothing about the topic of this thread, i still have however a question. If i DC suspects something isn't right with a pt for whatever reason and he/she sends the pt for x-rays at the hospital (not the ER) does the DC get a call saying what the dx was on that pt? Or, is that pt now the soul responsibility of the MD and the DC is now left out of the loop regarding their pt's care?

Thanks

 

[f_w]

If i DC suspects something isn't right with a pt for whatever reason and he/she sends the pt for x-rays at the hospital (not the ER) does the DC get a call saying what the dx was on that pt? Or, is that pt now the soul responsibility of the MD and the DC is now left out of the loop regarding their pt's care?

If the DC sends the patient to the hospital or any other imaging facility with a requisition for x-rays, only the x-rays will be taken and a report goes back to the DC (if there is a 'major unexpected finding that warrants timely treatment', he will get a phonecall with the result, if there are just routine findings it will take a day or so to get the paper report). What he does with the result is his hown professional responsibility.

If the DC sends the patient for example to an orthopedic surgeon with a referral for evaluation and treatment. The MD, if he chooses to accept referrals from DCs, will assume responsibility for the further care of this patient as far as it pertains to the problem he was sent for.

If the DC sends the patient to the ER for x-rays, he just shows a high disregard for his patients finances.

 

[wayttk]

If the DC sends the patient for example to an orthopedic surgeon with a referral for evaluation and treatment. The MD, if he chooses to accept referrals from DCs, will assume responsibility for the further care of this patient as far as it pertains to the problem he was sent for.

When I make a direct medical referral(usually to a neurologist), I send or fax a brief patient introduction--What they presented for, what the findings were, what the treatment has been, what the progress has been, and the reason for the referral. Even if the patient is transferred to the neuro's care, they always send a report of their findings, and recommendations.

I have never encountered MDs or PAs with the attitude and animosity expressed here. It is extremely rare outside this board. It has been my experience that hospitals have been extremely cooperative. And no patient(with a properly executed "Release of Records") has been charged to receive such. Additionally, ER MDs or PAs are not in charge of records release-----The records dept. is.

And I'm not even a Palmer grad!!

 

[FoughtFyr]

If the DC sends the patient to the hospital or any other imaging facility with a requisition for x-rays, only the x-rays will be taken and a report goes back to the DC (if there is a 'major unexpected finding that warrants timely treatment', he will get a phonecall with the result, if there are just routine findings it will take a day or so to get the paper report). What he does with the result is his hown professional responsibility.

If the DC sends the patient for example to an orthopedic surgeon with a referral for evaluation and treatment. The MD, if he chooses to accept referrals from DCs, will assume responsibility for the further care of this patient as far as it pertains to the problem he was sent for.

If the DC sends the patient to the ER for x-rays, he just shows a high disregard for his patients finances.

See, here is where I disagree with you. If the patient is sent to the ED, they clearly fall under EMTALA. They will be examined by an MD/DO and they may or may not get the films requested. The ED is not an a la carte service for outside medical providers, yet alone alternative medicine providers.

I'm not so certain that you are right on the legalities of a chiropractor's patient presenting to a hospital based radiology department for an x-ray. EMTALA would clearly apply there as well. It might be done some places, but that doesn't mean that a suit couldn't be filed and won.

As for freestanding clinics, I've asked three friends who are radiologists. One said "I don't know, that is why I practice in an academic center, but it would seem to be a liability to me". Another felt it was "no problem, just as long as you document that you told the DC what you found." That radiologist couldn't believe, however, that any DC would ever attempt to treat any condition besides LBP. The last said that he "would only read films for a DC (he) 'knew and trusted'" because he felt there would be a liability to a radiologist if the DC mishandled the case or refused / failed to refer the patient to a medical provider.

So, the sense that I got was that the freestanding clinics (and any radiologist for that matter) does have a liability if the DC fails to get medical follow-up for a patient where serious pathology is found, but that many radiologists trust the chiropractors they read for to "do the right thing". The liability is also present if they read for an MD/DO, but the difference is that both the radiologist and the referring MD/DO are held to the same standard of care, which levels the playing field. Chiropractors are not held to that standard, as many state boards would hold that chiropractors can treat conditions that most MD/DOs would place FAR beyond their scope (e.g., ADHD, asthma, CHF, etc.).

- H

 

[FoughtFyr]

I have never encountered MDs or PAs with the attitude and animosity expressed here. It is extremely rare outside this board.

That's "odd", I've yet to meet an MD/DO that thought well of DCs or chiropractic in general. I would say supporters are "extremely rare". That said, the ones who do work with chiropractors (i.e., the ones with whom you interact regularly) probably are supportive of you. The rest, well, lets just say that the relative anonymity of an internet forum allows for more true feelings to be displayed as opposed to the professional niceties or polite discourse mandated in face-to-face interaction.

It has been my experience that hospitals have been extremely cooperative. And no patient(with a properly executed "Release of Records") has been charged to receive such. Additionally, ER MDs or PAs are not in charge of records release-----The records dept. is.

Absolutely! Hospitals will be very cooperative. HIPAA requires it. The patient has the right to records release and copies of everything, including x-rays. If your local facility doesn't charge for that, consider yourself lucky. Many do, and in this era of cost cutting, I would expect that number to grow. BTW - I am not insinuating that only chiropractic patients are charged. I've actually seen patients charged for the records and x-rays sent during emergency transfers by helicopter.

And ED MDs or PAs are not in charge of anything, except ED patients. If you (or anyone else) sends their patients to the ED to get something tested, or get records, we do take charge. It's that simple.

- H

 

[FoughtFyr]

And I'm not even a Palmer grad!!

Nope, but as a chiropractor you practice a system fully created by Palmer, "the fountainhead of all chiropractic knowledge"

{genuflecting sarcastically}

Hey, wayttk, since BackTalk won't answer my question, will you? Are there any patients in your practice that you treat with spinal adjustments for any condition?

- H

 

[f_w]

I'm not so certain that you are right on the legalities of a chiropractor's patient presenting to a hospital based radiology department for an x-ray. EMTALA would clearly apply there as well. It might be done some places, but that doesn't mean that a suit couldn't be filed and won.

Huh ?

EMTALA applies to patients presenting to the hospital requesting treatment. Yes, there have been some expansions to the statute and some case law expanding its scope, but it still only applies to patients requesting treatment, not to anyone walking through the door.

---------
42 USC 1395dd
(a) Medical screening requirement
In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1) of this section) exists.
(b) Necessary stabilizing treatment for emergency medical conditions and labor
(1) In general
If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—
(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or
(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.

-----

 

[wayttk]

Nope, but as a chiropractor you practice a system fully created by Palmer, "the fountainhead of all chiropractic knowledge"

{genuflecting sarcastically}

Hey, wayttk, since BackTalk won't answer my question, will you? Are there any patients in your practice that you treat with spinal adjustments for any condition?

- H

I don't practice chiropractic as "fully created by Palmer", anymore than a DO practices osteopathy as "fully created" by A. Still.

I doubt that Backtalk "WON'T" answer your question............try asking a comprehensible question.

My best answer:
*"Are there any patients in your practice"- yes

*"that you treat with spinal adjustments"- (adjustment/manipulation) many, but not all---- depends on the presenting problem, condition, findings and a myriad of other considerations. And those that do recieve adjustments/manipulations, never do in isolation. It is always combined with other therapeutic measures. And just to be absolutely clear----not all "adjustments"/manipulations are HVLA.

*"for any condition?"- Try re-writing this to make sense. It is unswerable in it's present form.

 

[deleted6669]

"*"for any condition?"- Try re-writing this to make sense. It is unswerable in it's present form."

ok...do you treat anything other than musculoskeletal pain disorders?
if so how do you treat these pts?
how are these treatments different than what an md/do would do?
how are these treatments different than what a naturopath would do?

 

[FoughtFyr]

I don't practice chiropractic as "fully created by Palmer", anymore than a DO practices osteopathy as "fully created" by A. Still.

Horse pucky. Palmer created it in it's entirety. Still created a system to be employed prior to drugs or surgery, but held those as "last resorts".

I doubt that Backtalk "WON'T" answer your question............try asking a comprehensible question.

O.k., the quick version is "do you use spinal adjustments in your practice?". I wasn't trying to trick you, I'm not suggesting you use it for everything, or for every patient, or for every condition. But there are times you do use it, correct?

- H

 

[Squad51]

Huh ?

EMTALA applies to patients presenting to the hospital requesting treatment. Yes, there have been some expansions to the statute and some case law expanding its scope, but it still only applies to patients requesting treatment, not to anyone walking through the door.

---------
42 USC 1395dd
(a) Medical screening requirement
In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1) of this section) exists.
(b) Necessary stabilizing treatment for emergency medical conditions and labor
(1) In general
If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—
(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or
(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section.

-----

From: http://www.emtala.com/faq.htm which is a well accepted training source on EMTALA...

"At locations on the hospital campus and within the 250-yard sphere (see paragraph 2 above and the special note) but not at a Dedicated Emergency Department, the obligation under EMTALA arises only if (1) a request for emergency services is made, or if (2) a reasonably prudent layperson would conclude, based on the person's appearance or behavior, that he is in need of emergency treatment. This will include new conditions which arise for visitors or employees.

Once the patient is admitted and stabilized, the EMTALA obligations end, under the 2003 regulations. A new emergency medical condition which arises thereafter does not invoke EMTALA. 42 CFR 489.24(d)(2)"​

Case law has expanded the definition to anyone walking through the door where "a reasonably prudent layperson would conclude, based on the person's appearance or behavior, that he is in need of emergency treatment". So, a patient who is limping, c/o pain, or otherwise appears ill falls under EMTALA. FF is right.

 

[FoughtFyr]

From: http://www.emtala.com/faq.htm which is a well accepted training source on EMTALA...

"At locations on the hospital campus and within the 250-yard sphere (see paragraph 2 above and the special note) but not at a Dedicated Emergency Department, the obligation under EMTALA arises only if (1) a request for emergency services is made, or if (2) a reasonably prudent layperson would conclude, based on the person's appearance or behavior, that he is in need of emergency treatment. This will include new conditions which arise for visitors or employees.

Once the patient is admitted and stabilized, the EMTALA obligations end, under the 2003 regulations. A new emergency medical condition which arises thereafter does not invoke EMTALA. 42 CFR 489.24(d)(2)"​

Case law has expanded the definition to anyone walking through the door where "a reasonably prudent layperson would conclude, based on the person's appearance or behavior, that he is in need of emergency treatment". So, a patient who is limping, c/o pain, or otherwise appears ill falls under EMTALA. FF is right.

Umm, what he said...

But I would add, look at the law as you provided...
"(1) In general
If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—
(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or
(B) for transfer of the individual to another medical facility in accordance with subsection (c) of this section."

If any individual comes to a hospital AND the hospital determines that the individual has an emergency medical condition, let's say, a back fracture discovered by x-ray...?

- H

 

[f_w]

The presence of an 'emergency medical condition' creates an EMTALA obligation, not the presentation of a patient to my department. E.g. a stable spine fx in a patient who presents with adequate therapy from the outside and doesn't request treatment doesn't incur an EMTALA obligation (If the patient is still present, I will give the PCP a call as to what he wants to do, but there is no obligation to pull $500 out of the patients wallet and hours out of their life for an unwarranted ER visit).

Anyone who is symptomatic for anything and asks for treatment will either have to go through the ED or I have to admit them to outpatient short-stay myself.

 

[FoughtFyr]

The presence of an 'emergency medical condition' creates an EMTALA obligation, not the presentation of a patient to my department. E.g. a stable spine fx in a patient who presents with adequate therapy from the outside and doesn't request treatment doesn't incur an EMTALA obligation (If the patient is still present, I will give the PCP a call as to what he wants to do, but there is no obligation to pull $500 out of the patients wallet and hours out of their life for an unwarranted ER visit).

Anyone who is symptomatic for anything and asks for treatment will either have to go through the ED or I have to admit them to outpatient short-stay myself.

Right, but what about the patient, undergoing assessment by some outside provider (let's leave chiropractic aside for a minute) who appears to be in significant pain / distress, and does not yet carry a stable diagnosis?

-H

 

[f_w]

Well, that person would have an 'emergency medical condition' in the eyes of EMTALA and any hospital with an ED that accepts medicare assignments would be obliged to act on it.

 

[FoughtFyr]

Well, that person would have an 'emergency medical condition' in the eyes of EMTALA and any hospital with an ED that accepts medicare assignments would be obliged to act on it.

So where is the line, what about "some pain / distress" but not "significant" pain or distress? Where does the prudent layperson standard lay? With 12 people not smart enough to get out of jury duty.

Now take the case of a patient with significant pathology on x-ray, that is not "visible" outside. Say a patient with a chronic subdural picked up on CT. Does that person meet EMTALA if they are still in your department? If so, what is your liability once they've left?

- H

 

[f_w]

So where is the line, what about "some pain / distress" but not "significant" pain or distress? Where does the prudent layperson standard lay? With 12 people not smart enough to get out of jury duty.

I practice a very conservative style of medicine, still, if I made each and every medical decision dependent on how it could potentially twisted against me in a court, I would be a very bad physician.

If you read the case law on EMTALA, you realize that while there is allways a theoretical way how it can be twisted against you, for the most part the people who got bitten where asking for it (like those *****s that let a kid die in their ER driveway because they wanted to play semantics on the 'presented to the emergency department' issue, or the OB who refused to go into the room of a uninsured patient who was in labor and signed transfer orders to the county hospital 100+ miles away...)

Now take the case of a patient with significant pathology on x-ray, that is not "visible" outside. Say a patient with a chronic subdural picked up on CT.

A chronic subdural is there for a couple of weeks and doesn't represent an emergency.

Does that person meet EMTALA if they are still in your department?

No.

If so, what is your liability once they've left?

That I notify the ordering provider of the 'significant unexpected finding' and document this notification properly.

(this week I had two patients sent in by their internists for 'headache' and 'altered mental status'. Both had big masses and signs of herniation, both went from the CT scanner, to the ER, to the county airport.... Emergency condition-->EMTALA-->treatment)

 

[FoughtFyr]

I practice a very conservative style of medicine, still, if I made each and every medical decision dependent on how it could potentially twisted against me in a court, I would be a very bad physician.

To be sure. And I fully agree. The question is if you "notify the ordering provider of the 'significant unexpected finding' and document this notification properly" but that provider does not have the scope of practice (legally, not medically - remember that all MD/DO physicians have a license to practice medicine and surgery) to care for that disorder, are you "on the hook" to provide for that adequate follow up? I would argue yes, maybe not as common practice but as a "ivory tower" argument of policy.

- H

 

[f_w]

but that provider does not have the scope of practice

I hate to say it but: That's not my problem.

At times I have wondered about the legalities of accepting referrals from chiros or other laypeople when it comes to medicine. In the past, I have refused to perform exams 'ordered' by a defense attorney for a death-row inmate (the expert witness requesting the study to be performed didn't have an active license. they had to hire another expert to sign the requisition).

 

[FoughtFyr]

I hate to say it but: That's not my problem.

At times I have wondered about the legalities of accepting referrals from chiros or other laypeople when it comes to medicine. In the past, I have refused to perform exams 'ordered' by a defense attorney for a death-row inmate (the expert witness requesting the study to be performed didn't have an active license. they had to hire another expert to sign the requisition).

But if the radiologist just performs and reads the study without responsibility for the patient, then they are reduced to mere technicians. Now I don't believe that in the slightest. Radiologists are physicians, as such they bear the rights and responsibilities of the profession.

- H

 

[f_w]

Aha, and the pathologist has an obligation to ensure that every patient whose specimen he signs off on gets proper cancer treatment ?

But if the radiologist just performs and reads the study without responsibility for the patient, then they are reduced to mere technicians.

I am a consultant for my clinical colleagues when it comes to imaging. I bear responsibility for 'supervision and interpretation' of the studies done in my department. The responsibility for therapy decisions and follow-up lies with the ordering provider. Radiology and pathology are different from the other medical specialties in that regard. Call me a technician, I am doing just fine on my technicians salary.

This is different for my 'own' patients, the patients sent for interventional procedures. I see them in the clinic, consent them, do the procedure and follow up with them.

 

[FoughtFyr]

Aha, and the pathologist has an obligation to ensure that every patient whose specimen he signs off on gets proper cancer treatment ?

I would argue not because pathologists are not "beating the bushes" to obtain samples from providers not otherwise qualified to provide treatment.

I am a consultant for my clinical colleagues when it comes to imaging. I bear responsibility for 'supervision and interpretation' of the studies done in my department. The responsibility for therapy decisions and follow-up lies with the ordering provider. Radiology and pathology are different from the other medical specialties in that regard. Call me a technician, I am doing just fine on my technicians salary.

Look, I am a HUGE fan of Radiology. I've been offered by two programs to switch into their residencies with some advanced standing (but the idea of taking the physics board with less time than some of my cohorts scares me!). I don't view you as technicians but as consultants and I enjoy a close working relationship with our ED radiology folks. I frequently visit the cave and base many of my clinical therapies on their recommendations. I just don't see how, ethically or legally, a radiologist can turn a patient back to a chiropractor (or other alternative provider) with a new diagnosis of {insert significant pathology here}. As a physician that makes no sense to me. As an emergency physician who has seen the after effects of chiropractors trying to treat advanced diseases on their own, that scares me...

- H

 

[FoughtFyr]

Would you be referring to the entire chiropractic profession with this statement?

Yep!

As i achknowledge that i know next to nothing about the topic of this thread, i still have however a question. If i DC suspects something isn't right with a pt for whatever reason and he/she sends the pt for x-rays at the hospital (not the ER) does the DC get a call saying what the dx was on that pt? Or, is that pt now the soul responsibility of the MD and the DC is now left out of the loop regarding their pt's care?

IMNSHO, the DC should be left out of the loop. In theory there may be some legal arguments to support that view, but in real world practice they are not unless the pathology is so dire (e.g., unstable cervical spine fracture) as to require immediate intervention to save life or limb. Even then a courtesy call would likely be placed, but the DC would not be consulted on treatment. Does that sum this discussion up accurately f_w?

BTW - I am still looking for a chiropractor to answer the simple question - do you ever use spinal adjustments in your practice?

- H

 

[wayttk]

>>>"BTW - I am still looking for a chiropractor to answer the simple question - do you ever use spinal adjustments in your practice?"<<<


BTW- a DC answered your "simple question"(see below). Apparently(?) you missed it.............................

*"that you treat with spinal adjustments"- (adjustment/manipulation) many, but not all---- depends on the presenting problem, condition, findings and a myriad of other considerations. And those that do recieve adjustments/manipulations, never do in isolation. It is always combined with other therapeutic measures. And just to be absolutely clear----not all "adjustments"/manipulations are HVLA.

 

[jesse14]

Yep!



IMNSHO, the DC should be left out of the loop. In theory there may be some legal arguments to support that view, but in real world practice they are not unless the pathology is so dire (e.g., unstable cervical spine fracture) as to require immediate intervention to save life or limb. Even then a courtesy call would likely be placed, but the DC would not be consulted on treatment. Does that sum this discussion up accurately f_w?

BTW - I am still looking for a chiropractor to answer the simple question - do you ever use spinal adjustments in your practice?

- H

I must admit, i'm kind of shocked at your responce. I know this is regressing to prior discussions we've had but i really don't care. As badly educated as you feel chiro's are, they're simply not as dence as you would have others believe. YES I KNOW some of the tactics DC's use is incomprehensable and just plain wrong but ca'mon man. Are telling me that in 4 years of post undergrad education DCs are still considered lay people? I'm i to believe in all the the dx classes DC's have(http://cmcc.ca/undergrad/Dept_Prof_Ed/Clinical_Diagnosis.htm) , they still can't be thought of as any better educated than a Massage Therapsit? I know you didn't say that, but it's just the vibe i get from you. I'm aware of the classic argument " just b/c a class is called xxxxxx doesn't mean they learn close to what an MD does". If that's the case, what are they doing for 4 years? This is not to say that DC education is comparable to MD education but i strongly feel you are not giving DC's the respect they deserve. FF, you're much better at debating than me and that's apparent, so i really can't explain myself anymore. It's just that that after something like 4200 class hours, 4 years of education, final exams, board exams (steps 1 through 4) and a hell of a lot of work put in that DC's are still looked upon as nothing better that pt's in terms of their knowledge base. Tell me this though. Why is it that the Minister of Training, Colleges and Universities of Ontario feels that the CMCC program is on par with that of MD's DDS's and OD's? The Minister did grant the cmcc degree granting privleges -http://cmcc.ca/undergrad/undergrad_studies_doctor.htm .This tells me that they feel the program gives DC's the ability to be proficent health care providers (to the extent to which their scope entails).

Those are just my thoughts

 

[f_w]

I just don't see how, ethically or legally, a radiologist can turn a patient back to a chiropractor (or other alternative provider) with a new diagnosis of {insert significant pathology here}. As a physician that makes no sense to me. As an emergency physician who has seen the after effects of chiropractors trying to treat advanced diseases on their own, that scares me...

The legislature of our great state has decided to allow them to practice whatever it is they do, the legislature has also decided to give them the priviledge of using 'death rays' to support whatever it is they do. The federal appeals courts have decided that I can't use my market position in our town to lock them out of getting studies done. So, I provide whatever they order and give them the same type of report I would give to a MD,DO or NP (luckily, the guys around here are quite smart and have well established referral patterns to the respective medical specialists, it is really not something that keeps me up at night).

 

[BackTalk]

BT - a question - is there any condition or any patient you treat with spinal adjustments in your practice?

- H

I've been busy and also have been out of town. Not sure what you are looking for here. First, I didn't answer this question because it made no sense.

Hey, wayttk, since BackTalk won't answer my question, will you? Are there any patients in your practice that you treat with spinal adjustments for any condition?

- H

Yes and no. There are patients I treat with chiropractic/spinal adjustments but not for any condition.

 

[wayttk]

>>>since BackTalk won't answer my question, ....<<<<

Pretty funny!!!!........"Backtalk WON'T answer......."

I guess Fought can now read minds/ESP too!!!

 

[CFS]

This discussion has apparently evolved into one that interests me - the relationship between radiologists and chiropractors. Probably out of all MD/DC relationships, this has proven to be the strongest alliance (probably not the right word but I can't think of a better one right now, maybe "cooperative" or "friendly"). I beleive radiologists were the first specialty to drop barriers to chiropractor and their patients.

They provide us with expert consultation on the case, a sense of comfort that there is no occult pathology hiding on that film and the DC provides direction on pain management/rehabilitation, maybe who next to consult if they are unresponsive, an area that the radiologist would have little to no impetus for offering professional input.

Simply put, pharmaceutical pain managment for NMS conditions is a crapshoot at best, something the public has realized but I don't think research has caught up to what the public intuitively knows.

But by the same token, when I send a patient to the radiology center, it does have to be remembered, they are consulting a physician and his "extenders" (the rad. tech). It's not like they are going to LabCorps and getting some blood drawn and analyzed by a machine, a mistaken assumption on the part of patients sometimes.

I think it's good to have attitudes and prejudices exposed here and talked about.

I have always been suspicious that because I am a chiropractor, that my referrals to radiologists and MD's are not taken as seriously (now confirmed). As a consequence of that, I have to be extra diligent in doing an overread of films. Sometimes I think radiologists just scan the film, "Ah, it's a chiropractor patient" and put "Normal spine with minimal degenerative changes."

Subsequently, I have caught pathology and brought it to the attention of MD radiologists because of this lazzieze-faire attitude.

Moral of the story: Watch your backs, DC's. Although it's probably them who'll be responsible, it could theorectically hurt you if you don't exercise due diligence.

The same attitude was reflected (I believe, who knows the psychology) of when I referred a cauda equina syndrome case to our local ER, where the patient received a rectal exam (good boy, they were at least thinking CES) and promptly sent home without an orthopedic referral/consult, just an instruction of "Go get an MRI." I found him an orthopedist after much wrangling, who remarked after doing emergency decompressive surgery, "You were the only one who understood the gravity of the situation." I don't think he was being overly flattering, just stated it matter of factly.

I share these stories to hope to change your thinking a bit. If you don't want to put us in the "physician category", that's fine. I really don't care. I hardly introduce myself as doctor and it seems you are more hung up about it than me. I have to tell the medical staff in my building to stop calling me doctor.

But at least place us in with PA's and NP's and at least take our referrals with some sincerity.

Maybe even say to yourself, "Hmmm. . .there might be something there."

As Jesse14 noted, at least some of my education was worthwhile and who knows, maybe I even know a thing or two that you don't after 9 years in practice.

 

[f_w]

I have always been suspicious that because I am a chiropractor, that my referrals to radiologists and MD's are not taken as seriously (now confirmed). As a consequence of that, I have to be extra diligent in doing an overread of films. Sometimes I think radiologists just scan the film, "Ah, it's a chiropractor patient" and put "Normal spine with minimal degenerative changes."

Have I said anything here to confirm your suspicion ?

I will take your referrals, no questions asked. I will look at them with the same diligence as I will look at a study sent by a family practice doc who doesn't have any particular expertise in imaging.

I just refuse to take any particular responsibility regarding clinical follow-up based on the fact that you are a chiropractor and not a physician. You have the priviledge of being allowed to order x-rays, I have to assume that you are able to handle the responsibilities that come with the findings.

 

[CFS]

F-W,

No, I re-read the post(s) and I can't point to anything you said specifically.

And you shouldn't have to and don't have to take any responsibility for follow-up. That's my job.

I beleive in the philosophy of "spread the liability around" anyway. If a signficant finding is on the MRI or x-ray, generally, I send the patient for a second opinion. I want them to have a medical opinion as well as mine.

Again, I beleive our two specialities generally get along well and don't mean to ruffle any feathers.

Something somebody said (can't remember now) that made me think of the mantra, "Watch your back" and do overreads.

I don't think it's a complex of some sort. I don't think MD's take our referrals with the same seriousness as they do other specialities. I am not convinced the family doctor reads my reports. I am not convinced specialists read my brief letter of introductions.

I would love to get a copy of a DEXA scan once in awhile from an OB/GYN or family doc. Gee, that info would be nice for a chiropractor.

Which is weird - I don't care if I got a letter of introduction from a massage therapist scratched out in crayon. I would read it to be informed on pt. history. What's often embarrassing for the specialties (orthopedists in particular) is that the pt. knows I sent a summary letter and they come into the exam room and ask, "So what's the problem?"

My patient asks, "Well, didn't you read Dr. S's letter?".

Because of this, I am certain my communication back is NOT what it should be. I just assume the both of us plurally want to leave the other to be to "do our thing."

It's too bad for the patient.

Maybe some interdisiplinary conferences where we open up some dialogues and start breeding more trust is in order. As far as yanking the patient out of my care for whatever reason, obviously for life-threatening conditions, this is not even an issue. That was part of the point of my thread. When they go to your radiology center, they are already seeing a physician.

You have got to be a doctor and do what you feel is necessary. I take nothing personal about that.

If you find lytic mets and want to call the patient and tell them about interventional radiology or this oncologist or that oncologists, I really don't care. Although it's probably better I break the bad news. . .

As far as I am concerned, for all intents and purposes, their chiropractic care has concluded with discovery of serious pathology, esp. if it relates to the symptoms they are having.

If it is an incidental finding. . .that's another story, I guess. That should be shot over to the family doctor to put into clinical perspective. As much as it is tempting and sometimes easy to fall into that rut, I am not their family doctor.

It's just that. . .and this may be hard for a lot of you to understand. . .because we see the pt. so much, they start asking general health questions - what can I do for my cholesterol besides Lipitor, I have HTN. . .I get frequent bladder infections. . .and so on.

Some DC's take on consulting with this sort of thing - I always do my best to punt it. It's easy to fall into the trap of starting to talk about health problems outside the domain of the spine and NMS problems.

 

[deleted6669]

"you find lytic mets and want to call the patient and tell them about interventional radiology or this oncologist or that oncologists, I really don't care. Although it's probably better I break the bad news. . .
As far as I am concerned, for all intents and purposes, their chiropractic care has concluded with discovery of serious pathology, esp. if it relates to the symptoms they are having.
If it is an incidental finding. . .that's another story, I guess. That should be shot over to the family doctor to put into clinical perspective. As much as it is tempting and sometimes easy to fall into that rut, I am not their family doctor.
it's just that. . .and this may be hard for a lot of you to understand. . .because we see the pt. so much, they start asking general health questions - what can I do for my cholesterol besides Lipitor, I have HTN. . .I get frequent bladder infections. . .and so on.
Some DC's take on consulting with this sort of thing - I always do my best to punt it. It's easy to fall into the trap of starting to talk about health problems outside the domain of the spine and NMS problems."


sounds like you practice chiropractic in a manner that most medical folks(myself included) would respect. as long as a chiro practices within the accepted scope of practice for the profession it is not a problem. what the medical community at large has a problem with are those chiros who advertise themselves as family practice pcp's and claim they can cure ANYTHING with chiropractic and nutritional supplements.

 

[CFS]

sounds like you practice chiropractic in a manner that most medical folks(myself included) would respect. as long as a chiro practices within the accepted scope of practice for the profession it is not a problem. what the medical community at large has a problem with are those chiros who advertise themselves as family practice pcp's and claim they can cure ANYTHING with chiropractic and nutritional supplements.

And truthfully, I am not sure how big or small those number of DC's are.

I am sitting here now going mentally through a list of providers in my area, other chiropractors that is, and I am hard-pressed to think of someone who fits that description. I can think of one, who recommended that a pt. drink 7 Cokes for a gallstone. An ex-pt. of hers also said she freaked him out by waving her hand over his heart and saying, "I detect heart problems."

Yeah, ol' Dr. P - A real wacko. She's been in and out of practice, moved a couple of times. Even the pt.s knew she was a wacko and would laugh about it.

But by the same token, I know her practice was small. How much damage she did (in PR terms and terms of pt. care), I don't know.

Other than that, I know a couple of overtreaters but they aren't like 3x/week for 18 months (I do know one in my town who recommends a weekly adjustment for "wellness" or to "feel good"; for chronic conditions this may not necessarily be a bad recommendation).

Again, this is out of maybe 60 or so DC's in my county, I am thinking of 3, maybe 4 who ride the ragged edge. Of course, it's not like I know all of them and keep tabs.

Truthfully, I know my colleagues wish we could have a little more internal quality control but aren't sure how to do that without being draconian (license disiplining).

One thing is for sure - if you want to be a weirdo practicioner, people will seek out the DC license/degree as a means to that end. It IS the easiest degree to gain admittance into and obtain and that in of itself is probably the biggest problem.

But who knows? Even 4.0 students go wacko. . .I can recall a person in our class, probably top 5 student, who was off the deep end but who aced all of the boards. She admittedly graduated well ahead of me and my 3.0 GPA.

There's an interesting psychosociology in my profession that goes way beyond the scope of this conversation.

Anyway, I'm sorry if I hijacked this thread. Carry on. I won't be participating much here so if you have any questions or comments geared towards me, speak now or forever yadda yadda.

 

[CFS]

Oh, one more thing - I know there's an ER physician here reading this or participating in this.

I have received two referrals from ER docs in my career. One was because I treated her mother and did a bang-up job. So she dutifully referred me a patient with a blown L4 reflex (2+ on the contralateral side), antalgic posture and unable to straighten up past flexion of 20 degrees. He could barely get on my table. I was very flattered she thought highly of me and my amazing healing and gifted hands but geez, this was a neurosurgical case if I ever saw one.

I told him, "Listen, I've been doing this awhile but you need surgery."

5 months later out of the blue he calls me up to see if Medicare paid me because I was the only doctor who knew what he was talking about in 5 months of hopping from neuro to pain management to surgeon and round again. He was finally scheduled for surgery.

The point of this isn't to brag or talk about the medical merry-go-round.

My point: geez, how about a little easier case? Some whiplash maybe? Some rib dysfunction?

Which brings me to my second case. Not specifically referred to me but a patient went to the ER with chest pain and pain on inspiration, had the entire work-up (EKG's, CK's, CKMB's, chest films, all those things you do that you do so well). After all the testing came up negative, the ER doc said, "Find yourself a good chiropractor tommorrow. I think you have a "rib out."

(his words, not mine, I know the subluxation concept is a hot potato)

Sharp ER doc. That's what it was. Improvement was had in 1 visit. Resolution in 3 visits.

So, how about a few more of those and less of the surgical low backs? I ain't Jesus you know.

You have got to have a few dozen negative MI cases per week, no?

Need a speaker on rib dysfunction?

I'll bring coffee, donuts and bagels.

I got PowerPoint.

I got some amazing zingers and witticisims.

 

[BackTalk]

Just an observation but +2 DTR is considered normal.

 

[FoughtFyr]

Yes and no. There are patients I treat with chiropractic/spinal adjustments but not for any condition.

BT- I guess I worded the question poorly. The point is that you do use Chiropractic SMT? The reason I ask is that I have recently come full circle in my views on SMT in general. I used to think it was more the downside / risks of chiropractors overstepping their bounds (I think wayttk summed it up when he said that he treats "any condition, inside or outside of (his) scope of practice") but now I have to ask what is it that SMT does? What I mean is that, regardless if you believe that an MD/DO giving a prescription or performing a procedure is the "right" thing to do, we know what it does to the molecular level. I can describe the pathways, interactions, etc. for all of the medicines I prescribe. At worse (the psychoactive drugs) we understand the molecular effects but do not always understand why they effect the body in the physiologic manner they do. But there seems to be no science behind SMT. I understand that you practice "distant" from subluxation theory, but then what does the spinal adjustment do?

Jesse, I do not doubt that chiropractors go to four years of school (in Canada). But do not confuse governmental accrediatation to issue degrees with the degrees being equivalent. They aren't. If they were everyone with any graduate degree in any field (be it engineering, philosophy, linguistics, etc) would have all of the rights and privledges of every other degree. For me asking a chiropractor about health is the equivalent of asking an priest (who holds a doctorate of divinity - from an accrediated school) about the history of the biblical era. They will get some of the big concepts right, but in the end, their faith (and not arceological {sp?} science) will guide the discussion. Like it or not, chiropractic was invented, part and parcel, by DD Palmer a little over 100 years ago. In order to find that it is valid, one must believe that Palmer (with no formal medical training - in sharp contrast to A.T. Still), not only found the key to all of health, but that when his son and his followers expelled DD that the additions they made to the art were also valid. Not only did these individuals create a new system of healthcare without regard for the centuries of healers who came before them, but the system they found defies any scientific testing. That is just too many consequences for me...

And before you scream about the LBP studies, stop. They are simply not valid. There is no endpoint. Let me give you a non-chiropractic example. If a 70 kg. male patient ingests ten augmentin tablets and is immediately given activated charcoal and doesn't develop a critical illness, you have not proven that activated charcoal prevents acute augmentin poisoning. Now if you repeat the experiement with 200 people, and none of them develops a critical illness, you still haven't proven activated charcoal works. Why? Because you haven't looked at 200 people who didn't recieve any treatment. Now, let's assume that you do look at those 200 (without any treatment) and none of them develops a critical illness. Now you have essentially proven that AC doesn't work. Even if some people liked the taste or were convinced that the AC worked, it didn't really do anything. And that is how the studies of chiropractic have gone. They look at LBP. And when you look at the natural course of idiopathic low back pain - it will go away on it's own. Sure, chiropractors will recieve high marks for sympathizing with their patients. And that perception will color some studies. But it doesn't mean anything. And that is the problem.

And CFS - I guarantee you, chiropractic referrals (despite the two examples you have had) are not the standard of care in EM. Until they are, keep your powerpoint, coffee and donuts. You'll need them for the free "screenings" you use to hawk your wares at the "health fairs".

- H

 

[f_w]

I beleive in the philosophy of "spread the liability around" anyway. If a signficant finding is on the MRI or x-ray, generally, I send the patient for a second opinion. I want them to have a medical opinion as well as mine.

I know that many generalist physicians practice the same concept. It is one of the reasons why the US burns 15+ % of its GNP on healthcare. I find the concept of 'what referral will benefit the welfare of my patient the most' a lot more appealing.

When they go to your radiology center, they are already seeing a physician.

No they don't ! They come to get an imaging study done. This study will be done in a state of the art manner and it will be interpreted by someone who does that for a living.
If you want a physician to see a patient, make a referral to the respective medical specialist and leave the decision on advanced imaging up to them.

If you find lytic mets and want to call the patient and tell them about interventional radiology or this oncologist or that oncologists, I really don't care. Although it's probably better I break the bad news.

I don't do that on PCP referrals, why should I do it for chiro referrals? Based on my background in oncology imaging and care, the PCPs at times ask me as to what the next step in a patients care should be, but outside of mammography I won't talk to a patient directly unless so requested by their treating physician.

Some DC's take on consulting with this sort of thing - I always do my best to punt it. It's easy to fall into the trap of starting to talk about health problems outside the domain of the spine and NMS problems.

Thank the more prominent protagonists of your profession who go on TV to perpetuate the myth that chiropractic offers comprehensive solutions for all ills that can befall the human body for that.

 

[611]

Sharp contrast to A.T. Still????????????http://www.atsu.edu/about/our_founder.htm

 

[FoughtFyr]

Sharp contrast to A.T. Still????????????http://www.atsu.edu/about/our_founder.htm

Yes, sharp contrast. Form the site you provided:

"Around 1853, he decided to become a physician. It was common practice in those days for a would-be doctor to train by studying medical books and working with a practicing physician – in this case, his father. He may have received additional, formal training at a school in Kansas City, but no records remain to establish where and when this training took place."​

A.T. Still served as a civil war doctor. He was a physician, trained to the standards of the day. While early osteopathy shunned drugs and surgery, they did allow these as last resorts. Still thought he found a new way within medicine as opposed to Palmer, never educated as a physician who threw out all of medicine. Then he himself was thrown out by his son who went on to refine his father's system. That system was, and remains, completely separate from medicine. While osteopathy has "returned" to medicine, chiropractic has moved further toward the edge.

- H

 

[611]

Further from the edge of Medicine. But that does not make one system correct and the other wrong. When you have more years as a practicing physician under your belt you will see plenty of the bizarre things physicians within your professional do. Medical practitioners are FAR from perfect. There are plenty of money grubbing physicians in the profession who stray from accepted practice and are only out for money or to get their patients in and out of their offices as quickly as possible. Don't get me wrong, I 100% believe in medicine but "let the buyer beware" does not only apply to Chiropractic.

 

[PublicHealth]

Or, is that pt now the soul responsibility of the MD and the DC is now left out of the loop regarding their pt's care?

Palmerian slip? (check spelling of soul)

 

[FoughtFyr]

Further from the edge of Medicine. But that does not make one system correct and the other wrong. When you have more years as a practicing physician under your belt you will see plenty of the bizarre things physicians within your professional do. Medical practitioners are FAR from perfect. There are plenty of money grubbing physicians in the profession who stray from accepted practice and are only out for money or to get their patients in and out of their offices as quickly as possible. Don't get me wrong, I 100% believe in medicine but "let the buyer beware" does not only apply to Chiropractic.

One system is correct and the other wrong. One system is the pseudo-scientific ramblings of an egomanicial freemason and the other is the collected wisdom of thousands of years of healers supported by the best science the human race is currently capable of using. The systems are right and wrong.

But I agree with you, people are not right and wrong by their professional affiliation alone. There are plenty of MD/DOs whose practices are unethical and stray far from the standard of care. My favorite example is Dr. Lorraine Day MD. This nut job believes she has cured cancer (as well as other diseases) through diet alone. The difference is that several medical organizations have essentially removed her right to continue to see patients medically. There is no support for her in the medical community and, while she retains a license, the local QI/QA mechanisms have effectively prevented her from using anything but her academic title to hawk her wares. This is the case with almost all MDs. Earlier in the thread someone equated DCs to MDs without hospital affiliation who solely held outpatient practices. Even that is not a fair comparison. To really equate the two, a DC is equal to an MD, who holds no hospital affiliation, employs no nurses, doesn't accept medicare / medicaid, and also owns and runs a full pharmacy out of their office, dispensing the prescriptions they write. Now, I would fully agree, if you come across such an MD do NOT employ their services. Something is very, very wrong. Likewise, realize that there exists no standard of care within chiropractic. Realize that if a chiropractor chooses to treat cancer, heart disease, or even spinal deformities with chiropractic methods, he or she is "safe" from professional rebuke (yes, many have been disciplined for doing so, but when you read the cases they are actually disciplined for using herbs, liquid diets, or other "unproven" remedies. Had they stuck with chiropractic adjustment alone, they would have been o.k.). Even the idiots still preaching against immunizations do so with impunity, and children die. So where is the upside? What is the benefit? Low back pain gets better with or without medical or chiropractic care - and nothing else chiropractic treats has even that logical falsehood supporting it.

Now I know that chiropractors go to school for a long time. That is a shame and they should all be compensated by the individuals running those schools who have profited from their students for so long. But a great example can be found in those studying medical illustration. When I was in medical student, the art students majoring in medical illustration were always in the anatomy lab. They not only drew the cadavers, but also our body positions as we dissected. They took histology and physiology with us and several of them were favored study partners. They were hard working and knew their stuff. In four years of undergrad they had spent more time in the anatomy lab than us, and had taken about half of the basic science courses we did. I know for a fact that many medical illustrators, over a career, develop quite a visual diagnostic acumen. I'm certain that their opinion is asked when a strange pathology is noted is the surgical suite. I have absolutely no doubt that their skills (after quite a few years in "practice") surpass those of interns or residents in certain arenas. But when my child is ill, I don't go to a medical illustrator, I take her to a pediatrician.

- H

 

[FoughtFyr]

And truthfully, I am not sure how big or small those number of DC's are.

In both Illinois and Nebraska (and many other states I'm sure) chiropractors have fought for the right to (and do) advertise as primary care physicians. In fact the aacp (American Academy of Chiropractic Physicians) is pushing "advanced practice" chiropractic. Yep, chiropractors who prescribe. Now that makes sense. Take what little, now debunked, basis there was for chiropractic and remove it. But hey, chiropractors are really smart people and it is just unfair that medical school is so hard to get into, so let's just let them prescribe, I mean we need more doctors right?

We have moved so far from the findings of the Flexner Report that we might as well go back to apprenticeships...

- H

 

[611]

I was really just talking about the many physicians who practice poor medicine not strange medicine.

 

[FoughtFyr]

I was really just talking about the many physicians who practice poor medicine not strange medicine.

Sure caveat emptor always applies. But even the "best" chiropractor is still limited to chiropractic...

- H

 

[611]

Definately, and that is the way it should be.

 

[CFS]

FoughtFyr,

You say it's outside the norm for an ER doc to refer to a DC. But in one part of New Jersey, there are chiropractors available in the ER. John Cerf, DC at chiroweb.com writes a regular column on this. Just hop on over and read the articles he wrote by doing a search. The experience seems to have been a positive one so far for all (health professionals and pt.s). Of course, we only hear his side of the story. I beleive the hospital is Meadowlands or something like that up in N. Jersey.

However, I see the profession more as an outpatient paradigm so I am not going to hold that up as a shining example of how chiropractic should be administered to the masses. I can't see this becoming widespread but at a community-based hospital, it probably has some utility.

As far as your insult towards doing screenings. . .I don't do them. However, ironically, my wife works in a marketing dept. for a hospital. One of their complaints they have had with marketing their Urgent Care Centers is the MD's (board certified ER MD's) sit on their fat asses, collect a paycheck and expect the hospital system to do all marketing. To suggest a Saturday Morning Sports Clinic or some other forum of public relations, well, crap, you may as well expected one of your pretty-boy sons to pick blueberries on the local blueberry farm for $3/bushel.

I don't deal well with the entitleistic mentality you exhibited.

So, get the silver spoon out of your mouth. Yes, DC's muttle their way through marketing; they aren't born with a silver spoon. Some of it is good; some of it downright stinks (screenings). It's hard for the newbie to know what particularly to do to build a practice tastefully.

Your comment on advanced practice chiropractic is a bit politically skewed. Some DC's are advocating limited prescriptive powers for pain and inflammation. Similiar to the dentist, the proposal is the prescription would last 10 days or less. DC's don't want to be medicating as a general rule or for it to be their primary intervention. I have not heard any push by any significant group to adopt broad-based prescriptive powers as did the DO's in the 50's. The American Academy of Family Chiro. Physicians I can't imagine has any large number to be considered representative.

Most DC's I know who want the prescriptive powers want about 10 or 20 drugs and for NMS complaints only.

However, being an East Coast DC, I do realize that midwest chiropractic can be practiced a little differently in that region and the thinking is a little different. So perhaps this is skew.

It's kind of like East Coast healthcare/medicine being superior to midwest healthcare.

It's all academic anyway. It ain't happening for internal political reasons anyway so you can go in today with one less thing to worry about.

As far as you analysis of research and chiropractic, stick to diabetic comas and MI's. . .I have frankly heard evidence-based chiropractors make better analyses of the literature and criticisms.

Chiropractic remains and will remain an effective form of pain and mobility management for chronic and permanent degenerative spinal conditions. That's why a DC served as past president of the American Academy of Pain Management (I think a MD is now president). Acute conditions? Whiplash, yes. LBP - probably better with some NSAID's for awhile and then come to me if it doesn't resolve.

But then again, I may be talking out my lower orafice here. Pain management is not something that you hospital practicioners take seriously, now, is it? You had to have your accrediting agencies actually post posters around the hospital that the "patient has a right to pain control." What seems intuitive to DC's and most of the public, you actually had to have mandated and be reminded.

Frankly, if you sit back and actually examine yourself, you'll discover the reason we exist isn't because we are so hot or because DD thought up subluxation; it's the fact you do such a crappy job sometimes.

BackTalk,

2+ on the contralateral side. 0 on the ipsilateral side.

F-W,

You seem reasonable. It would be a fair criticism that spreading the liability around is NOT good healthcare practice for $$$ to cents.

Frankly, I have been just referring back to the family MD or NP/PA and let them redirect the pt. as of lately. That's probably a waste too.

I'll admit my reasoning is more economic; they supply me with referrals and if they want a neurologist vs. a neurosurgeon or pain management vs. physiatrist, I let them decide. They are, after all, in charge and they were kind and generous in their referrals so. . .well, you know.

It keeps the peace.

 

[BackTalk]

There is a standard of care within chiropractic and that standard is enforced by the state chiropractic board or in other states the medical board. In Illinois, it is overseen by the Department of Professional Regulation. The board is comprised of mostly medical doctors; I believe a DO and one chiropractor. The scope of practice for chiropractic is loosely defined and falls under the medical practice act of 1987, which governs MD/DO and DC. The only difference between scope of practice is that chiropractors treat human ailments without the use of surgery or prescriptive drugs. The human ailments treated “as learned in Chiropractic College”. As far as I know, there is not one Chiropractic College I am aware of that involves courses for treating “cancer or heart disease” through chiropractic methods. So, if a chiropractor were using chiropractic methods to treat these diseases the board would reprimand him. I have suggested to patients with heart disease the importance of omega 3’s, the effects of homocysteine levels, triglycerides etc. That doesn’t mean I would ever persuade them to discontinue their medications or quit seeing their PCP. The PCP should be letting these patients know this as well. This is important information.

As far as “what does a chiropractic adjustment do” there is a lot of information out there that covers the subject from a neurological perspective involving mechanorecptors, nociceptors, muscle spindles, spinal reflexes etc. I could go on and on about the neurological mechanisms involved in a chiropractic adjustment. Too much information to post here and decipher. If any chiropractors out their care to go through the whole mechanism of the chiropractic adjustment feel free do so. I just don’t have the time.

 

[FoughtFyr]

Wow. Are you arrogant. O.k., since you've seen fit to enter into a discussion between folks who have routinely exchanged views on this forum and browbeat me for shortening my arguments for convenience's sake here you go. I highly doubt I'll keep my reply under 10,000 words, so this will likely be a "two-parter"

FoughtFyr,

That's "Dr. Foughtfyr" to you.

You say it's outside the norm for an ER doc to refer to a DC. But in one part of New Jersey, there are chiropractors available in the ER. John Cerf, DC at chiroweb.com writes a regular column on this. Just hop on over and read the articles he wrote by doing a search.

Actually, one of the first things you would have learned had you attended medical school is that the plural of anecdote is not fact. But perhaps since you have already "hopped on over here" you should do a search. This has already been discussed here ad nauseam

From: http://forums.studentdoctor.net/showpost.php?p=2120312&postcount=49

Interesting articles...

http://www.chiroweb.com/archives/20/21/04.html
http://www.chiroweb.com/archives/21/11/06.html

Very interesting. To quote "Patients who present to the ED with neck or back pain are screened by the attending ED physician, who is responsible for ruling out serious pathology, fracture, neurological deficit, and other findings that might contraindicate spinal manipulation. The ED physician may order x-rays, blood work or other diagnostic tests. When a severe condition presents, orthopedists, neurologists or neurosurgeons are enlisted to take over the case. Historically, all patients without serious pathology were given prescriptions and discharged from the hospital, with or without adequate relief. With our chiropractor-on-call program, the ED physician now has the option of calling for a chiropractic consultation, which gives the patient the opportunity to receive additional relief."

Sounds an awful lot like what I suggested. MDs referring to DCs after all serious pathology is ruled out! Now, if all patients of DCs were generated in this fashion - I might be a convert.

Now, if you really want to make things interesting, have that ED run an odd/even day RCT study were PTs are used (in the manner described in the article) on even days, and DCs on odd. Measure pain relief, patient satisfaction, etc. It may make a compelling case for this type of program. Again, protect the public from chiropractors who overestimate their diagnostic and/or therapuetic abilities (i.e., no direct access - physician referral mandatory), and I'm all for it! I even acknowledge chiropractic (in that setting) is likely as efficacious as PT. My objection is solely risk vs. benefit.

The experience seems to have been a positive one so far for all (health professionals and pt.s). Of course, we only hear his side of the story. I beleive the hospital is Meadowlands or something like that up in N. Jersey.

Now, as I've said, I don't mind the New Jersey experiment because it at least insures that all of the patients see an MD/DO first, removing a fair amount of the risk. If folks want to waste their money on quackopracty at that point so be it. However, ONE hospital, not even an academic center, hardly makes the case for a chiropractic referral being the standard of care in emergency medicine. You'd be hard pressed to find an expert witness for the defense if such a referral went badly.

However, I see the profession more as an outpatient paradigm so I am not going to hold that up as a shining example of how chiropractic should be administered to the masses. I can't see this becoming widespread but at a community-based hospital, it probably has some utility.

Ah, the hallmark of the chiropractor &#8211; "this probably works". Let's try studies shall we? As I have pointed out, the ED in question has the perfect set-up to put chiropractic head-to-head against traditional therapies. Wonder why the study hasn't been done? Oh yeah, it is far easier to market "probably".

As far as your insult towards doing screenings. . .I don't do them.

Wow, that was an insult? Are you saying that screenings are not employed by many chiropractors? Are you stating the "market building" strategy programs for chiropractors don't recommend them? So, how is it insulting that I suggest your resources might be better spent on that audience? Would you be insulted if I suggested that you employ spinal manipulation therapy? How about if I said you were a DC? Is that also insulting?

However, ironically, my wife works in a marketing dept. for a hospital. One of their complaints they have had with marketing their Urgent Care Centers is the MD's (board certified ER MD's) sit on their fat asses, collect a paycheck and expect the hospital system to do all marketing.

Well most "Board Certified Emergency Physicians" see urgent care as an anathema. It really exists to provide convenient primary care and take that load off overcrowded EDs. Few EPs want to do it, and most see it as "adding to the problem" of ED overcrowding (by equating EDs with UC centers when the latter are closed). Urgent Care Centers are "primary care medicine" and that is not something EPs are generally interested in. Case in point would be the lack of outcry from the Emergency Medicine Pprofessional organizations (AAEM and ACEP) to the AAFP (Family Medicine) beginning to offer "Urgent Care" fellowships. So it doesn't surprise me that an EP was/is relucatant or resistant to market them. And to be truthful, outside of plastic surgery (and don't get me started there), few MD/DOs are interested in, or good at, marketing. That's why hospitals employ folks like your wife...

To suggest a Saturday Morning Sports Clinic or some other forum of public relations, well, crap, you may as well expected one of your pretty-boy sons to pick blueberries on the local blueberry farm for $3/bushel.

WTF?!? Sorry I don't understand this reference&#8230;

I don't deal well with the entitleistic mentality you exhibited.

So, get the silver spoon out of your mouth.

Silver spoon, my left foot. I spent eight years in the fire / EMS service putting myself through undergrad, an MPH and medical school. I even rode an additional two years, part-time, during the first two years of medical school. Everything I have, everything I've achieved, has been through blood, sweat and tears. And I didn't take some "cop-out" three year pseudo medical program that anyone could get into. I worked until my medical school application was acceptable.

Yes, DC's muttle their way through marketing; they aren't born with a silver spoon. Some of it is good; some of it downright stinks (screenings). It's hard for the newbie to know what particularly to do to build a practice tastefully.

Try not building one at all. The practice is, at best, minimally supported by evidence for a very small number of patients, at worst, it is flat out snake oil sales.

Your comment on advanced practice chiropractic is a bit politically skewed. Some DC's are advocating limited prescriptive powers for pain and inflammation.

Gee, once again, "hop on over and do a search"

From: http://forums.studentdoctor.net/showpost.php?p=2554292&postcount=7

Healthcare is in an ever-changing state of flux, bro. PAs are prescribing and performing surgery, nurse practitioners are prescribing, psychologists are prescribing psychotropics (in some states), optometrists are performing eye surgery (in OK), podiatrists prescribe meds and perform surgery, etc. Who knows what will be going on 10 years from now.

That said, why do you think it's so ridiculous to believe that chiropractors may one day be able to prescribe a limited formulary of medications? Philosophy aside, healthcare practitioners have to keep up with the needs of their patients and should evolve professionally over time. Demonstration projects are paving the way for many fields.

Philosophy aside?!? You have to be kidding! Other than the "chiropractic philosophy" what do chiropractors offer? Less education, lower admission standards, less clinical training time, and no residencies, but now we are to make them prescription providers? That aside, here is the rub - they don't want them (prescription rights)! Don't take my word for it, here is an (albiet old) interview witht the presidents of each of the U.S. chiropractic colleges. None of them is for prescription rights for chiropractors.

See: http://www.worldchiropracticalliance.org/tcj/1994/mar/mar1994e.htm

Similiar to the dentist, the proposal is the prescription would last 10 days or less.

Dentists are medical doctors. They have the training and the right to prescribe meds and their prescription last as long as needed. And meds are part and parcel of their underlying philosophy &#8211; even more so now that microbial causes for dental caries have been identified.

DC's don't want to be medicating as a general rule or for it to be their primary intervention. I have not heard any push by any significant group to adopt broad-based prescriptive powers as did the DO's in the 50's. The American Academy of Family Chiro. Physicians I can't imagine has any large number to be considered representative.

Most DC's I know who want the prescriptive powers want about 10 or 20 drugs and for NMS complaints only.

Who cares. See the quotes above. You can't train under an alternative philosophy that clearly eschews drugs or surgery, then claim you want them to improve your market share. It simply doesn't work.

However, being an East Coast DC, I do realize that midwest chiropractic can be practiced a little differently in that region and the thinking is a little different. So perhaps this is skew.

Cool. Except that in medicine the standard of care is the standard of care. Region doesn't matter. Thanks for helping to make my case that chiropractic varies in practice pattern so wildly as to be unsafe.

It's kind of like East Coast healthcare/medicine being superior to midwest healthcare.

Umm, I'm a senior resident at a little place in the Midwest that most people (including the U.S. News and World Report) consider superior to everywhere else (for many specialties). Perhaps you've heard of it &#8211; The Mayo Clinic&#8230; But if it makes you feel better, I work for an East Coast based municipal consulting firm as well.

It's all academic anyway. It ain't happening for internal political reasons anyway so you can go in today with one less thing to worry about.

The only thing I "worry about" with regard to chiropractic is how many patients I will see today who have been injured by their chiropractor. The number is actually scary high.

{to be continued...}