Sometimes you need to help the blind pig.

Sometimes you need to help the blind pig.


When people are at the end of their life they like to pass on their life lessons. One thing I have never had a patient say is “Doc, I sure wish I had spent more time at work.”

I try and keep that in mind, but then there are those work commitments that are hard to avoid. I need to have a talk with Drs. Gorski and Novella. No one should have write a blog entry any week their team is in the play-offs. The Blazers were not meant to win more than 25 games, much less be the 5th seed in the West with a chance to make the conference finals. I know. Trailblazers fans are not always grounded in reality. But we are up on the Clippers 3–2 and heading home to close out the series tonight. For the record I wrote the preceding sentence during the game 5 tip-off. I really should not have to do any work this week. Basketball is simply more important.

Take this case report. Anywhere else.

Case reports are a tradition in medicine. Usually they are unique or unusual cases, diseases you are likely to see but once in a career, if that. There are all sorts of medical curiosities that need to be reported. I have a blog over at Medscape devoted to Infectious Disease case reports.

Some case reports, however, inspire eye rolls and sniggers. Why are these even reported?

Take “Cellulitis of the Knee in a 16-Month-Old Boy: A Case Report.”

Somehow it is worth killing a tree to discuss a child with cellulitis, a common a disease, in a chiropractic journal.

A diagnosis of cellulitis was rendered based on the presentation of the rapidly spreading erythema and radiographically confirmed findings.

Sorry. Anyone who knows anything about cellulitis would not get an x-ray to confirm a diagnosis of cellulitis. I’ll take water is wet, fire is hot for 500 Alex:

This case demonstrated that for this young patient with cellulitis of the knee, timely recognition and referral, together with patient or parent education and immediate treatment, were essential to a successful outcome.

Really. My god. Who would have thought of using proper medical care for the treatment of an acute infection? For chiropractic, the most mundane of medical cases is considered worthy of publication. It shows that chiropractors either have zero experience of cellulitis or no publishing standards, not that the two are mutually exclusive.

You learn early in medicine that patients never read the textbook. Actual disease presentation is often very different from the typical case you learn about in lectures and books.

Angina, for example, is classically heavy, substernal chest pain radiating to the neck and down the left arm brought on by exertion. Angina, by the way, means neck pain in Latin. I once had a patient who had exertional left wrist pain as the only manifestation of angina, quite the language/anatomy disconnect. Everyone knows the presentation of angina, and of all diseases, is as often atypical as typical. It is part of what makes medicine difficult.

Except for “Presentation of Coronary Artery Disease in a Chiropractic Clinic: A Report of 2 Cases” by Captain Obvious.

Patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.

It does make one worry how many coronary artery patients have been missed if chiropractors need to be reminded of information learned in the 4th year of medical school.

Unfortunately chiropractors are 4 years of medical school and residency short of medical training, which is why they need to be reminded to consider imaging for patients with unexplained focal neurologic symptoms.

Examination showed slow gait with a lack of arm swing, bilateral hip flexors and knee extensors were all graded as 4/5 on muscle testing, and cranial nerve examination was unremarkable with the exception of 2 beats of nystagmus on left lateral eye movement. Because of these findings and a family history of multiple sclerosis, the patient was referred for a brain magnetic resonance imaging scan… Imaging showed a craniocervical junction mass centered at the floor of the fourth ventricle with obstruction of foramina and marked impingement on the medulla.

It is the purpose of medical case reports to make other clinicians aware of unusual manifestations of diseases. Or in the case of these reports, remind the oblivious chiropractor of the medically obvious.

Or the patient who has a “”crunch-like” sound” and sudden onset of 7/10 neck pain. Crunching sounds from bone should make one cautious. That would be an impressive presentation of a subluxation. Let’s try:

Axial compression of 2–3 lbs of pressure did not contribute to or alleviate his symptoms. Cervical traction was painful.

Mucking about on a crunchy neck with no diagnosis. Gives me the willies. Nothing bad happened to the patient, which is lucky since the patient had a burst fracture of C4 from myeloma without the typical findings. They conclude:

This case should serve as a reminder that in some circumstances, orthopaedic tests may be of limited clinical value. Practitioners need to be diligent in their clinical assessment of patients to be aware of subtle signs of disease processes.

Which is difficult when you have no real training in medicine.

Or:

A tall thin 25-year-old male anxiously presented to a chiropractic clinic with six days of sudden unexplained left thorax pain. His breathing was laboured and his dry cough aggravating.

Is it worth presenting a classic case of spontaneous pneumothorax for chiropractors? I suppose they are so short for real medical knowledge anything would help.

And now the kickers

One case report was published only because it supports the contention that chiropractors do not cause stroke, but they can recognize it. As providers who allege they are expert in the nervous system, one would think they would recognize a stroke in progress. I guess not, since it was worth publishing “Vertebral artery dissection in evolution found during chiropractic examination.”

Or be wary of metastatic breast cancer.

The aim of this case is to heighten awareness of the presentation of metastasis to the brain and the spine in a chiropractic patient.

What an insight. Cancer metastasis can show up late? Who knew? I mean besides everyone with an MD/DO/NP/RN but not DC after their name.

Not all case reports are diagnostic triumphs worthy of a medical student on their first clinical rotation. One chiropractor sat on a case of acute appendicitis for two weeks, the patient “was treated with soft tissue therapy (?)” and eventually diagnosed with:

phlegmonous appendicitis. After a failed trial of conservative care (antibiotics and fluids), he required an emergency hemicolonectomy due to the massive inflammation that encased and adhered the ruptured appendix and ileum, to the abdominal wall.

Diagnosing an acute appendix can be difficult for trained physicians, much less chiropractors with no experience because:

physical tests taught in the chiropractic curriculum may be antiquated. As such, it is pertinent that chiropractors co-manage patients who present with complaints that may be visceral in origin.

Co-manage? Why on earth would you need a chiropractor for an abdominal complaint of any origin? Chiropractors would add nothing. The correct phrase should be “it is pertinent that chiropractors have no business managing patients who present with complaints that may be visceral in origin.”

These reports never seem to mention specifically whether spinal manipulation was done. It makes me wonder if manipulation was not done or not reported due to embarrassment.

These are all be interesting cases. If you were teaching 4th year medical students with zero clinical experience.

But these cases are directed towards practicing chiropractors to make them aware of diseases that are bread and butter for real medicine. The editors of the journals felt that such papers would be of value to their readers. Maybe they should start with I Am Joe’s Body for supplemental information. It would be age appropriate for those that found these case reports valuable.

And remember, chiropractors are agitating to be primary care providers.

Conclusion: Maybe an extra weekend course will be enough?

These case reports confirm chiropractor’s understanding of basic medicine is every bit as lacking as you would expect from their education and training, just what you want in a PCP. At least in Oregon.

Over the years I have had casual conversations with chiropractors as patients or at social events, situations where I try to be less snarky. It is not uncommon for them to mention the one medical case they diagnosed, demonstrating their medical competence. Color me unimpressed.

Even a blind chiropractor gets a diagnosis once in a while.

By the way. I had a patient years ago who was literally a blind chiropractor. He assured me he could still read the spine x-rays, that he could sense the energy signature of the subluxation. True story. And one of the few times in my life I was speechless.
 
 

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.