Academy of Chiropractic Personal Injury & Primary Spine Care Program

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From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: many of these issues are small, yet each issue is just that… an issue. If you take care of the small issues, then the larger issues often take care of themselves and you can focus on the larger issues… a larger, more profitable practice and more family time.

“Head Trauma Protocol & Death”

EVERYONE MUST take the Stroke Course
 
 
“Do you know what it is called when you say…I should have lerned that… DEATH”
Mark Studin 2018



When reading the following article by Michael Barone in CT., the only issue is that you NEED a good MRI over a CT and a good neuroradiologist. A CT misses much too much!!!

 
Uncle Bob’s Legacy

My wife and I just spent the weekend on Cape Cod. It was far from the fun getaway that most people would associate with the place, because we were there to say goodbye to her Uncle Bob, who was to be removed from the ventilator on Wednesday. I am updating my office procedures because of what happened to him.

Bob was a lively 72-year-old. Friend to all who knew him, and the life of the many parties he attended. Not what you would call a health nut, he drank socially and smoked about a half pack of cigarettes a day, even a few years after getting 3 cardiac stents. Before you think to yourself “Aha!” and moving on to a new article, let me tell you why we should not have seen him in that hospital bed with tubes and wires going in and out of him. At least not at this age.

Because of the stents, Bob took Plavix to prevent blood clots. When he fell in his kitchen on New Year’s Day and hit his head he didn’t think anything of it, other than how clumsy he was. He hadn’t lost consciousness, cut himself, or gotten dizzy, which is regrettable because if he had, he might still be here with us. The small broken vessel near his skull didn’t seal itself off, due to the anticoagulant, and he continued to bleed along the parietal bone and build intracranial pressure, like a balloon next to his brain. He went to bed and awoke with a headache. The next day, he refused his wife’s urging to see his doctor, and instead took more than the recommended dosage of ibuprofen throughout the day, sure that the headache would subside. Then, when he awoke the next morning and couldn’t move his legs, his wife called the ambulance He was in the CT machine 45 minutes later and the radiologist measured a 3-centimeter midline shift of his brain to the right. When the surgeon did an emergency craniotomy 15 minutes later, 350 milliliters of blood were removed. Even by that time the increased intracranial pressure had reduced the blood supply to Bob’s brain, causing hypoxic damage, and began to push his brainstem and medulla through his foramen magnum, making it difficult to breathe on his own. Thus, the life support.

So how does this affect me and my practice? Aside from the personal loss, I realized how I could possibly prevent this from happening to my patients. Many of the patients we see are suffering from traumatic injuries, usually from auto accidents or falls, and could be at increased risk of head injury.

I have identified 3 risk factors to give extra attention:
  1. The patient’s age- As we age, there is an increased tendency for the dura layer of the meninges to become directly adhered to the inside of the skull, rather than being attacked by dentate ligaments. This gives increased opportunities for the small blood vessels to be torn during even a minor head trauma.
  2. The patient’s history- Regarding medications, we are often fixated mainly on the pain medications the patient has been taking, and it is also common that the patient can’t remember all the medications they take. Even if we specifically ask if they take blood thinners, many patients do not know what each medication does, and the prevalence of generics may further cause confusion[1]. Does the patient have a history of stents, heart valve surgery, hip or knee replacement, pulmonary embolism, or DVT? If they take aspirin, how much and how often. There may be a tendency to think of these medications as “peripheral” to the patient’s injuries, but in the case of a head injury, they may be contributory to the condition. If there is a question, call their doctor(s) or pharmacy to inquire about their medications, as asking the patient to bring in their medications may take too much time to be useful.
  1. History of the trauma- Did the patient hit their head? Sometime an accident can happen so fast they don’t remember. In rear end collisions the patient often perceives they were thrown forward without realizing they hit the headrest and their head was propelled forward. Note if there is bruising, soreness, or abrasion on the face or scalp. If there is a positive plantar (Babinski) reflex, image them immediately. Be a bit more careful about the pupillary reflexes, and if there are abnormalities, before assuming that it is just a mild TBI, consider a CT, especially if the above risk factors come into play.
If there are risk factors along with head trauma, the patient’s condition deserves deeper scrutiny. CT studies are quick, relatively cheap, can generally be done on short notice, and show blood very well. 

Become aware of the nearby CT facilities and / or hospital emergency departments with CT and compile a list of their telephone numbers. If the patient is on Medicare, sending them to the emergency department of the local hospital, and calling the hospital to inform them of your concerns in case the patient is unable to articulate the issue, is a quick way to get the study and have their insurance cover the procedure without their PCP’s referral. Worsening headaches are certainly a valid reason for ordering a CT. So are slurred speech, confusion, dizziness, weakness, numbness, lethargy or excessive drowsiness, change in behavior, visual problems, nausea and vomiting, or seizures.

The procedures I’ve talked about are not too time consuming, as we do most of them already during our examinations. What I’m advocating is just a change of focus and awareness. 

In my office, that will be Uncle Bob’s legacy.

Michael Barone, Jr., DC, DIBE


Respectfully,



Mark Studin DC, FASBE(C), DAAPM, DAAMLP

Adjunct Associate Professor of Chiropractic, University of Bridgeport, College of Chiropractic
Adjunct Post Graduate Faculty, Cleveland University-Kansas City, College of Chiropractic
Adjunct Professor, Division of Clinical Sciences, Texas Chiropractic College
Educational Presenter, Accreditation Council for Continuing Medical Education Joint Partnership with the State University of New York at Buffalo, School of Medicine and Biomedical Sciences

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