Case: Osteopathic Structural Exam on an ICU patient

I wanted to share a brief, informal case from my current internal medicine rotation:

My patient was a 61-year-old Hispanic female who I met in the ICU for a workup of CHF vs. COPD exacerbation.  She had a past medical history of hypertension, gastroesophageal reflux disease, hyperlipidemia, and gout.  My team got the page that her sugars were soaring in the 500’s.  We hooked her up to a rhythm monitor, ordered a chest x-ray, and turned on the pulse oximetry. The resident and I put her on Lantus, an insulin sliding scale, Lasix, Protonix, and an albuterol nebulizer.  

On exam, the patient was seated in a chair, rebreather mask strapped to her face, and the “usual crowd” at the bedside.  She had shortness of breath with exertion, and she complained of a vague epigastric pain.  My team was ready to move on, but something didn’t add up.  I looked at her back, and before I even untied the top of her gown, it looked like T3-T5 were jumping out on the left.  She had fine, purple, almost telangiectasic streaks extending from these segments down towards the angle of her left scapula.  On the other side, ribs 6-10 were inhaled, and the ipsilateral diaphragm was in a relentless spasm.  I suggested ordering cardiac enzymes and running a 12-lead EKG.

Her CK-MB came back as 80 (normal is less than 6).  Troponin-I was 8.1 ng/ml (normal is less than 0.4 ng/ml), and her total CK was over 1000.  The EKG showed S-T elevation in leads V4-V6 and inverted T waves.  I called my resident with the results, and there was silence on the end of the line.  We immediately paged the cardiologist and started her on Plavix and Heparin.  

I had diagnosed a MI in this woman, which would have been completely missed if not for my osteopathic structural exam.  Our early, suppportive intervention may have helped save much of this patient's heart, if not her life.

The instructors in medical school had told us to "keep an eye out" for this sort of thing, but it was pretty mind-blowing to experience it firsthand.  

Osteopathic Fun!

A response to Kelly's post is on the way, but in the mean time, I wanted to share some cool news from the "DOings" section of the latest The DO magazine. (p. 18, Vol 49, Num 4, April 2008)

1) The May issue (#842) of Batman Detective Comics mentions "osteopathy." Early in the issue, a villain named Gotham Jack notes that he has back pain from a "slipped disc." Toward the end of the story, when he is about to fight Batman, he says, "You'll be glad to know I've had some osteopathy since we met last time. My back's feeling a ton better...which means I'm so much more supple!"

2) An associated professor [and all-around AWESOME guy who I had the privilege of meeting at Convo last year] at the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg, Zachary Comeaux, DO, has written a historical romance novel based on the life of A.T. Still. Titled Fire on the Prairie: The Life and Times of Andrew Taylor Still, Founder of Osteopathic Medicine. The book was published in November 2007 by BookLocker.com, a print-on-demand publishing firm.

I'm off to San Diego for the weekend to hang out with a good friend (and new AZCOM admit!), but I'll post the rest ASAP.

[for more on light sabers, see OMM videos on youtube]

osteopathic instincts

ok, i finally signed up for the blog. sorry it takes me so long to do this stuff... as i alluded to before, i'm kind of in an "i don't wanna" phase when it comes to school. and as a result, my "jaded osteopath" meter is running a bit high these days. i guess i'm just low on energy in this arena. i do believe this is something that ebbs and flows for us over the course of our careers... at least, from what i've seen with the practitioners i know. i'm only now starting to get my act together researching residencies...

interestingly, my enthusiasm to treat patients with my hands never seems to wane. it continues to feel completely natural, applicable, and surprisingly easy to fit into a time-restricted environment. i think that as we develop our manipulative skills over time, the patient assessment process becomes very intuitive. there's no need to do a 'standing flexion test' when you can just look at a patient and tell which SI joint is misbehaving. why take the time to motion test individual vertebrae when you can lay a hand on the patient's back, feel the momentum of the entire spine and the (mal)position of several key ribs and determine that the crucial restrictions are actually coming from their shoulder?

i'm actually pretty mystified as to how this transformation occurred... perhaps you all can comment based on your personal experiences. i worry at times that i am becoming less "scientific" about my approach to patients, but medicine seems to be every bit as much 'art' as it is 'science' in my (limited) experience. i enjoy the opportunity to work as an artist, bearing in mind of course that my work must complement or at least not fly in the face of modern medical science.

but i'm always afraid that patients will leave after a treatment and not improve... i rarely have those doubts when recommending to them more 'traditional' standardized courses of treatment... antibiotics, steroids, and the like. perhaps it is because of the research issue that martha raised. i think it is also in part because of the 'art'. i haven't yet learned to trust my muse in the same way that i trust what i read in my textbooks. this is sad to me, but perhaps understandable, given that i've been in academia for the majority of my life and i've only been involved in osteopathy for 3 years. the more i trust my instincts, the more they grow and the less often i struggle in my approach to patients... with both OMT and 'conventional' methods.

it is still very prominent in my consciousness, however, that i must ask permission to shift into 'osteopathic gear' from my preceptors and lay hands on my patient to heal... not just to palpate the precordial impulse or percuss the liver. i look forward to a time in my career where all my activities as a physician can blend together in a more organic fashion. as i look at residencies, this is something i am trying to keep in mind... it would be nice to find a program that allows me the support and freedom to practice medicine the way i want.

Evidence-Based Manual Medicine

After Martha's post, I drove out to our Mesa campus and checked out the "EBM and Manual Medicine book" -- it is AWESOME. It effectively combines anatomy, pathophys, research, controversy, and technique in one manual. As a first edition, it has some flaws, but I think it does what the FOM was meant to do, in a much more user-friendly arrangement. It's perfect for teaching -- or anything that requires presenting manual medicine in a credible, communicable way. Also, It comes with a DVD that outlines many of the techniques described in the book. I'm purchasing a personal copy ASAP.



The book is Evidence-Based Manual Medicine by Michael Seffinger, DO and Raymond Hruby, DO, illustrated by Dr. Kuchera.
Publisher Link
Amazon.com Link

I'll also be adding this to the Recommended Reading page on the site with the next update.

Conundrum of Osteopathic Medical Education

Hey Erik,
Nice to "meet" you and welcome on board!!

I can answer your question about why we aren't taught OMT treatments for every disease yet there seems to be a pharm treatment (albeit, even the pharm treatments are sometimes ridiculous by just throwing steroids at someone, etc). Research.

What I'm about to say is my pure conjecture, which should not hold any weight. Actually, I need to read more about the history of medicine/physiology/pathology.

It is my belief the original research deducing basic physiology was elegant yet simple, reproducible and irrefutable. Drugs may have been used to help prove a hypothesis, but they weren't used in excess. Concurrently, drugs were being used clinically without a clear rationale. For both of these reasons further research revolved more and more around drugs: how they changed the biochemical make-up of a disease model, their clinical effect, etc. Drugs are handy because you can do a well-controlled study where you have 2 parallel systems, the only difference being the addition of a drug. A researcher's dream. Not to mention the investment of pharm agencies in the funding of said research.

So, our instinct agrees with Dr. Still's idea that the body contains all the ingredients to heal itself, however, our ethical/societal obligation is to "buy" into the pharmacological approach to treatment of disease because that is how society says we should operate. If we don't follow standard recommendations, we could lose our licenses. Another influence in our education are the scientific sticklers (PhD professors) who blindly believe in the scientific method and EBM, shunning most OMT (especially cranial) for conditions other than pain syndromes because they lack clinical experience to valid the non-scientific ways of healing. Thus, these PhD folks want us to maintain our scientific credibility, which I can respect, however they limit us by not seeing what's possible. That leaves us with the clinicians to teach about the possibilities of OMT in the setting of disease, but how many of them are trained appropriately?

It really is a conundrum, which is why I am so thankful to people like Jonathan and Kelly and yourself who are as passionate about the topic as I am. The Osteopathic Integration website is a great start to give students that speck of hope regarding what MIGHT be possibility with OMT for treatment of disease. There are some excellent texts that SHOULD be cited in our course work, but those god damned PhD people believe that if students are interested, they would fine the resources theirselves. I about went through the roof when one professor told me that. Luckily, a DO stepped in and said she thought my request was reasonable.

On the topic of resources, have any of you heard that Ray Hruby and Mickey Seffenger recently wrote a book on EBM OMM?

Martha

Welcome

Welcome to the official blog for osteopathicintegration.org ! While we're frequently updating the site, we realized that there was no good way to point out the new content we receive. From now on, all site news, updates, and announcements will be posted here. For easy updates, subscribe to our RSS feed.

Kelly, Martha, and I would also like to welcome our newest team member -- Erik Gulbrandsen, OMS III. Erik is finishing up his third year at KCOM and currently rotating in Carbondale, Illinois. Erik brings many talents to the team; he's an accomplished, self-trained web developer, is drawn to service, and hopes to create a model for continuity clinics in osteopathic med school curricula. We also have Erik to thank for the creation of this blog. Welcome, Erik!

- Jonathan