Academy of Chiropractic’s Doctors PI Program
From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
“Trauma Consultation Intake”
Creating a diagnosis, prognosis and treatment plan for the trauma patient is this different from managing the non-trauma or chronic patient. What differentiates a trauma trained doctor is often not the treatment and focuses more on the diagnosis and prognosis of their injuries. In a chiropractic and or rehabilitation scenario once the diagnosis and prognosis is determined the treatment is often the same modalities as the chronic patient. However, the application of that treatment as a rule is quite different. Herein lies the reason why traumatically injured patients should seek the care of the trauma trained specialist... YOU
Many decades ago I trained under a neurosurgeon who made a very bold statement and has been my guiding “set of rules” ever since. He stated that “almost every diagnosis was created during the history taking process.” In my training we went through a set of exercises, of which I was given a set of clinical constructs and in each scenario I had to formulate the diagnosis. After I concluded what I felt was an appropriate diagnosis I was then given the examination results followed by imaging and/or electrodiagnostic results. It almost every scenario my diagnoses were accurate. The question I had was “why then do we need all the testing?” The answer quite obviously was to verify the initial clinical impression with demonstrative evidence concurrently ruling out underlying pathology.
Through the years following that set of rules, I have uncovered numerous malignant tumors, infections, congenital deformities and a host of other comorbidities that necessitated either concurrent care with medical specialists or triage to a different healthcare provider. This type of triage is quite different from my formative years when I was just a chiropractor.
When I was just a chiropractor I would do a cursory examination focusing solely on the chief complaint, performing a cursory examination, x-rays only for subluxation listings and then adjusting my patient with the “belief” that they will get well. In my circle of colleagues anything more than that would give you the label of “Medi-Practor” and subjected you from being ostracized from our circle. Through my evolution as a healthcare provider I realized that I was not just a chiropractor, I was a Dr. of chiropractic in those two words “Dr.” and “chiropractor” are inclusive and in the absence of both you become a public health risk and contribute to the erosion of the reputation of our profession.
On my journey to becoming a better doctor, I realized I did not have to give up being a good chiropractor. A concept too many fail to realize that you are not compromising at any level, you are simply getting better at what you do while concurrently removing any doubts or uncertainties about what is wrong with your patient. The simple fact allows you to be a much better chiropractor or any clinician and can afford you to be more aggressive in care with a certainty that you will not create additional problems or hurt the patient more in your blind attempt to help them. In healthcare your intentions do not matter, only the outcome does.
When doing your initial intake of an injured patient you must remember the “gating mechanism of pain.”
Ronald MelzackandPatrick Wallintroduced their "gate control" theory of pain in the 1965Sciencearticle "Pain Mechanisms: A New Theory"The authors proposed that both thin (pain) and large diameter (touch, pressure, vibration) nerve fibers carry information from the site of injury to two destinations in thedorsal hornof the spinal cord: transmission cells that carry the pain signal up to the brain, and inhibitory interneurons that impede transmission cell activity. Activity in both thin and large diameter fibersexcites transmission cells. Thin fiber activityimpedes the inhibitory cells (tending to allow the transmission cell to fire) and large diameter fiber activityexcites the inhibitory cells (tending to inhibit transmission cell activity). So, the more large fiber (touch, pressure, vibration) activity relative to thin fiber activity at the inhibitory cell, the less pain is felt. The authors had drawn aneural "circuit diagram"to explain why we rub a smack.They pictured not only a signal traveling from the site of injury to the inhibitory and transmission cells and up the spinal cord to the brain, but also a signal traveling from the site of injury directly up the cord to the brain (bypassing the inhibitory and transmission cells) where, depending on the state of the brain, it may trigger a signal back down the spinal cord to modulate inhibitory cell activity (and so pain intensity). The theory offered a physiological explanation for the previously observed effect of psychology on pain perception.
Based upon the gating mechanism, which has personally proven valid over the last 35 years, you must consider not just the primary (chief) or secondary complaints of the patient, you must delve into all regions of the body to ascertain if there are bodily injuries anyplace else. This consultation is based on a conversation I had with a doctor I spoke to yesterday who quite some time after an accident had to causally relate a shoulder complaint when the patient initially only complained of a cervical and trapezius problem in the initial examination and subsequent re-evaluations. The doctor stated that he never asked about the shoulder because the patient didn’t complain of shoulder pain. The patient asserted that the shoulder had been hurting more and more to the point where the pain in the shoulder was now debilitating.
This falls perfectly in line with the gating mechanism, as the cervical pain abated the secondary issues (neurologically) starting to surface neurologically (pain). What my experience has dictated is that initially you are able to focus patients on both primary and secondary issues regardless of the gating mechanism.
As an example, when a patient would complain of cervical pain I would completely go through a cervical protocol of questions and then I would go into the extremities. I would ask the patient “do you have any pain, discomfort, numbness burning or tingling in your shoulder either at rest or when you move?” I will go through the same process for the elbow, wrists and hands and the lower extremities accordingly and ensure the patient would focus on the body part I was questioning. More times than not, there would be positive responses top that level of inquiry. If the patient changed the subject and said "doctor, I am more concerned about my neck then my elbow because it hurts more" my response would typically be "I already have that understood, now it is time for me to learn about all the other less pressing issues, but it gives me a complete picture and in turn will also put me in a position to help your neck better." That always gave the patient confidence I was being thorough and had their best interest moving forward.
In trauma related patients more times than not, you will learn that the patient has additional complaints and each positive complaint must be evaluated, causally related when applicable and then treated. Although this is huge for the lawyers and the Colossus algorithms, I really don’t care because my job is to create an accurate diagnosis, prognosis and treatment plan. This goes well beyond listening to the simply the chief complaint as most medical specialists do and therefore makes you a very valuable asset in the entire process.
Those days are OVER… and my patients and I are happierJJJJ