A Gem of an ER Patient

Every once in a while, an ER patient makes chiropractic look like the best procedure a hospital could ever offer. I recently had the good fortune of treating just such a "gem." In fact, to protect her identity, I will call her Gem for the purpose of this account.

I was in my car looking for a parking spot near my office when the ER clerk called my cell phone. She transferred the call to the ER physician, who explained I would be seeing a patient with a one-month history of neck pain. I never parked, but rather headed directly for the hospital, arriving just 10 minutes later.

On the way to the hospital, I contemplated what I should expect upon my arrival to the ER. The ER physician was new to our hospital. It usually takes a short time for the new ER physicians to become acquainted with chiropractic services and to better understand what types of problems are most likely to respond to chiropractic care. When one of the regular ER physicians told me a patient had pain for one month, I took it as code for, "You are about to see a whining cry-baby who we want you to take off our hands because we don't have time to listen to them complain!"

Upon entering the ER, a nurse advised me my patient was waiting. The nurse rolled her eyes and said impatiently, "Her name is Gem and she's had neck pain for about a month." I felt certain I was there to help relieve the ER staff with this patient, so the staff could devote their time and energy to more worthwhile patients.

Upon entering the examination room, I saw Gem. She appeared to be suffering significant pain. Her head was turned and tilted to the right. Her eyes were red and tears were streaming down her face. I quickly checked the chart and asked the patient to tell me her name. The nurse had failed to warn me I was about to be confronted by such a tearful and scared young woman. Her condition looked too acute for her to be a patient with one month of neck pain. She appeared to be afraid to move for fear of aggravating her pain. Her tears turned out to be due to a combination of severe pain and frustration that there would be no help for her suffering. Her story turned out to be much different from the one I had imagined on my quick drive to the hospital. After consulting the ER physician's notes, I asked Gem to repeat the history of her pain.

Gem reported that one month earlier, she awoke with severe neck pain and was unable to turn her head. Since she lived reasonably close to "Super Hospital," the regional university medical center (designated state trauma center), she decided to go there for treatment. After all, Super Hospital is the biggest and the best medicine has to offer. At Super Hospital, she was evaluated, radiographed and medicated with narcotics and muscle relaxants, followed by discharge with additional prescriptions in hand.

Gem's pain was tolerable with increased mobility until the next morning, when the medication wore off and the pain returned with equal intensity. She filled her prescriptions and achieved additional relief by continuing the analgesic medication. Eventually, the medication wore off again and the pain and immobility returned. She took more medication to mask the pain a little longer. Trusting the treatment deemed appropriate by Super Hospital, she faithfully kept up the regimen for about two weeks after her initial visit to the hospital. Unfortunately, the pain and immobility continued to return as the medication wore off. Gem began to worry that the medication was masking symptoms or a more serious disorder.

Gem returned to Super Hospital, remembering the instructions to return if her pain did not improve. Unfortunately, the treatment she had already received was the only emergency treatment available. Once again Gem was examined, radiographed, and prescribed narcotics and muscle relaxants. With her fears temporarily relieved, she returned home to continue the same regimen, but with one difference - Gem now feared her prescription would run out before her condition resolved. She decided to reserve the analgesics for when her pain was the most severe.

Almost a month later (a few days before coming to the hospital I work at), Gem had to bring one of her children to the pediatrician. As Gem sat in the examination room with her son, the pediatrician inquired about her immobile neck. Gem explained the sad, twisted tale of her persistent pain and frustration. Coincidentally, the pediatrician held staff privileges at "Small Hospital." Small Hospital is not a major medical center, level-one trauma center or university teaching hospital. However, Small Hospital has something Super Hospital does not - a chiropractic department. The pediatrician advised Gem that she would have been better off if she had gone to Small Hospital, where she would have had the opportunity to have a chiropractic consultation.

Unfortunately, Gem again suffered a severe episode of pain and immobility. It was now one month after her initial onset of pain. She did not trust returning to Super Hospital. She felt her condition had never really been treated, only camouflaged. She followed the pediatrician's advice and went to Small Hospital. Gem explained the whole history to the ER physician, including the pediatrician's advice to go to the hospital because there was a chiropractor on staff. It was my good fortune to be on call that day so I could take credit for what any one of our chiropractors would have easily handled.

After completing the history and performing a complete examination of her neck, I formulated a working diagnosis: acute exacerbation of chronic cervical radiculitis with concomitant torticollis and attendant vertebral subluxation complex. This is a common diagnosis treated by the chiropractors in our emergency department. While treatment varies according to the needs of the individual patient, it generally consists of electrical muscle stimulation, peripheral neurofacilitation techniques and spinal adjustments.

Following treatment, Gem demonstrated full cervical range of motion and verbalized a significant decrease in pain. She was discharged from the ER without any medication or even a prescription for medication. Most importantly, she exited the ER with a smile replacing her tears - just after stopping at the nurse's station to demonstrate her full and nearly pain-free cervical range of motion.

After Gem left and I completed my consultation report, I had the opportunity to discuss Gem's case with the nurse who initially believed Gem to be chronic and an inappropriate patient for the ER. While many patients such as Gem can be successfully treated in the private office setting, her severe pain and immobility were reasonable indicators that she could have been suffering from a catastrophic condition. The patient could not have been reasonably expected to diagnose herself before choosing which facility should be responsible for her care. With two past treatments in a major medical center without relief, Gem believed (reasonably so) that her condition must be both severe and difficult and beyond the capabilities of a private office.

The ER physician, knowing the patient's history, felt uncomfortable either discharging her in severe pain or covering her problem with additional analgesic medication while knowing the pain was likely to return soon after discharge. The ER physician's clinical judgment was to take advantage of the chiropractic service and attack the problem immediately. The ER physician also knew that if the chiropractor could not provide reasonable relief, it would be indicative of the need to search for an unlikely occult cause of her symptoms.

In spite of her significant improvement from the ER chiropractic treatment, Gem chose to follow up in my office the next morning after awakening with moderate pain. She returned one additional time to my office with subsequent discharge from care.

ER physicians routinely use analgesic medication to mask neck and back pain. Unfortunately, the patient often returns as the medication wears off. Taking advantage of the on-call chiropractor provides the ER physician with additional alternatives to resolve the patient's complaint at the time of the encounter. There is increased patient satisfaction and the patient is then directed to the most appropriate follow-up care.