K. Jeffrey Miller, DC, MBA
When I entered the outpatient clinic in chiropractic college, my initial patient population consisted primarily of patients with chronic problems. They were all in pain, but none was incapacitated by the pain. This was consistent for the first few months. Then one day, a patient showed up who was in terrible shape. Her name was Naomi and she had injured her back while working in her yard. She was antalgic, barely able to walk and in tears.
This definitely wasn't what I was used to. She was so upset and in such pain, it unnerved me. Once I had her in the exam room, I went looking for help. Fortunately, my unit director was nearby and available to assist me. I felt assured by his presence and everything turned out well.
Since that time, I have treated thousands of patients in Naomi's condition. But even with experience, these situations can still be unnerving. That's why it is a good idea to have a plan in place for when patients with debilitating pain enter the office. Here is the plan I developed years ago and still follow.
Step #1: Avoid Panicking
This is necessary for both doctor and staff. Everyone must remain calm to comfort and sooth the patient. Obvious panic by the doctor and/or staff will undermine the patient's confidence in your abilities. Being calm also helps soothe anyone who is accompanying the patient.
Step #2: Determine the Patient's Most Comfortable Position
I usually say something like this to the patient: "I have to ask you a few questions and examine you. Would you be more comfortable sitting, standing or lying down?"
Step #3: Determine If the Patient Is in the Right Facility
If the patient has experienced severe trauma, has significant neurological signs and symptoms, is losing consciousness or has other substantial findings, he/she may be better off in an emergency room. If the emergency room is the more appropriate facility, call an ambulance. Do not allow the patient to rely on him/herself or an accompanying party for transportation.
Step #4: Discuss What You Will Be Doing, Including Pain Reproduction
Let the patient know that in order to formulate a diagnosis you will have to reproduce his/her pain. Reassure him/her that while this may be a little unpleasant, it won't create additional injury or harm.
It is also a good idea to assure the patient that you will explain the history and examination process as it proceeds, and that there will not be any sudden movements without warning.
Step #5: Determine How Detailed Your History and Examination Will Be
In some cases, based on the presentation of the patient, the content and order of your typical history and examination may need to be altered. For example, you may want to X-ray the patient before the physical examination.
Step #6: Consider the Diagnosis and Coding Requirements
Examination content must be sufficient enough to develop a working diagnosis and meet coding requirements. It must be stressed here that the content sufficient enough for diagnosis and the content sufficient enough for coding are not always the same.
Clinical needs of patients are fluid and evolve. Coding requirements are rigid and seldom change. You must be familiar with the Current Procedural Terminology evaluation and management codes to determine if you are meeting standards for care and coding.
Step #7: Discuss Your Plan of Care
Once diagnosis is complete, and if the emergency room is not necessary, a plan of care must be developed and reported to the patient. It will need to be decided if chiropractic care alone is appropriate, if concurrent care utilizing providers in other fields of health care will be necessary or if frank referral to another field must occur.
If you will be treating the patient, you will also have to select the most appropriate forms of care to utilize for office and home care.
Discussing the plan of care with the patient in these situations can be tricky. The patient is distracted and will sometimes agree with anything in order to get some relief. Make sure your description is slow and thorough. When possible, the discussion should occur in the presence of anyone accompanying the patient who will be able to reinforce the patient's understanding and follow-through.
Step #8: Send the Patient Home With Written Instructions
The instructions should cover the plan of care and include information regarding what to do and not to do at home. Written instructions are also important to reinforce the patient's understanding and follow-through.
Step #9: Timely Follow-Up
It is an extremely professional and caring act for a doctor to call a patient the evening of his/her initial visit. This gives you an additional opportunity to comfort the patient and reiterate your home-care instructions.
While things went well with Naomi back then, I am sure both of us would have been more comfortable if I had been this organized. Make sure you're organized as well to help ensure these delicate clinical encounters go smoothly.
