Academy of Chiropractic
Quickie Consult 1243
Clinical Information 279 CI
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006
"Triaging Potential Post-Trauma Vascular Issues"
Dr Studin: So you had a patient come in yesterday. Could you please explain what happened with your patient?
Guest Dr: A patient is referred from an attorney; he was at a stoplight. He rear ended by a work thing, when we're doing the exam, he is 29 year old male. He couldn't stand, eventually got to be uncomfortable. So as we're going through the exam, I did the student Perkins protocol for stroke. We did a couple of VVAI maneuvers and he failed them.
Dr Studin: Give the name of the test.
Guest Dr: We did decline and the mains test. So he failed both of those. And that really irritated his symptoms. So even though he's 29, he was diabetic, which is another count against him as far as should we refer or not refer for additional testing.
Dr Studin: It was another risk factor in his history.
Guest Dr: we decided we need to shift them.
Dr Studin: what are the clinical evaluation really sets you off?
Guest Dr: when we performed the maneuvers, he had some of the stagnates and he got dizzy and that was a symptom that you had after the accident. And he was really disturbed after the test, we had to keep them in a dark room, give him a water to really calm down. He wasn't driving, I wouldn't let him drive home.
Dr Studin: So the issue is in this particular case that we spoke about is he has no health insurance. Then he's got a lawyer and it's not a letter of protection. So the only money from this is going to be through the letter of protection with the lawyer. Now for what you explained to me earlier is that the challenges, he needs at least three MRIs made before. Cervical, lumbar, but definitely an MRI and an MRA and it’s expensive, so the clinical decision you made was?
Guest Dr: we're going to have to order it and they're just going to have to sort it out later.
Dr Studin: Because I guess the person's life obviously comes before.
Guest Dr: it comes first, we want to try to be judicious and not just order, the kid he lost his health insurance, he lost everything. You just in a bad situation. So of course that weighs in your mind, but you can't let that affect your clinical judgment.
Dr Studin: what you consider for what you explaining to me before is to do an mrangiogram? Which checks the integrity of the vertebral artery and the carotid artery of the neck and an MRI of the brain to check out the circle of Willis to see if there's any post traumatic vascular insufficiencies going to the brain which could possibly cause stroke. Because when you extended the heavy one to immediate my stag MIS, dizziness, sweating. I mean it's classic. Super positive. the cervical, he also had pain when you extended his neck. So you ordered an MRI of the cervical spine also to see what is going on there. And then the lumbar spine is going to wait.
Guest Dr: That's going to wait cause that's not as urgent.
Dr Studin: Now did you send them to the emergency room?
Guest Dr: yes.
Dr Studin: Did you call the emergency room to let them know?
Guest Dr: I just got in here today. I think Michelle sent our notes over for that, but I haven't followed up with her on them.
Dr Studin: You have to call the emergency room and speak to them and focus on the fact that you simply extended his head on a simple mainstay test and he had immediate my stag list and all these other things to focus them on what's needed or they're just going to do a cat scan of his brain and let him go. But you got to talk to the ER doc and you've got to call the lawyer to keep them in the loop and let them know, this is going to eat up a chunk of money, but his life comes before the case.
Guest Dr: I already did that part. I let it go with this paralegal.
Dr Studin: you've got to call the emergency room. I know you're busy right now, but you need, is he on his way to the ER now?
Guest Dr: Like I said, I just got in, he was on the end of the day patient yesterday.
Dr Studin: So you need to handle that sooner rather than later, okay.