How can something be tender but not hurt????

[Reality Check 2]

I am having one of those weeks.

 

I palpate the shoulder girdle and ask if it hurts. Yes, I am palpating the rotary cup ;)

 

"No, but it is tender......" 

 

Deep heaving sigh - what does this mean???????

 

I try to clarify - does it feel like a bruise? Is it sharp? Does it hurt to movement?

 

I have also spent the week discussing that a fracture is a break is a fracture is a break - there is no difference. One dad insisted his daughter's arm is broken but not fractured. Heaven help me - my head is going to explode.

 

Add in the immediate assumption that congestion equals infection and implies antibiotics and I have about hit my limit.

 

I am still not clear on how ribs come out either, if mine came out - could I throw it for the dog to fetch? 'cuz I am just not sure otherwise where it goes or how it gets there..... ie. the chiropractor debate.

 

Just venting - I know we all have those little peeves that make patient care challenging sometimes.

 

This is my week of challenge.

[PA-S Zoidberg]

First I shall state my qualifications! 

 

Prior to my PA-S path I worked for 5 years as an exercise therapist and have 2 years experience scribing in the ER and now with a manipulative DO.

 

When clients present to me with discomfort during movement I am very clear in getting them to differentiate between pain and discomfort. This can mean the difference between risky and restorative movement. Ribs do in fact "go out" and can be readily palpated during an osteopathic physical exam. Pain tends to refer from the anterior chest wall straight through to the associated thoracic vertebrae like a spear is being thrust through the chest (you can imagine that you would want to R/O MI, PE etc... in an acute setting). Manipulation for a rib (provided it is not 1st rib) is relatively easy and gentle with immediate relief. The patient does not in fact know that you did not receive chiropractic training. Keep in mind that if they say the rib is out maybe a referral to a chiro/PT/DO is a good idea. 

 

To your example about the father and the daughter. Remember that you are treating the parent as much as the patient and have to set aside ego to communicate with both. We may use simplistic language with a pediatric patient but also may have to use it for the parent haha. One of my first EMS experiences was treating a re-fractured proximal radius in a pediatric patient after a mountain bike crash. Dad obstinately refused to let me splint it ostensibly because that means it is a fracture (even after I explained that it was simply for comfort until he could go to an ED and not in fact a diagnostic test). 

 

A deep "blue breath" in followed by a "red breath" out can help quite a bit in these situations. Also realize that it is your responsibility to modify your communication style to match your patient's not the other way around. 

 

Just my thoughts. Hang in there!

[Reality Check 2]

Thanks for the response. 

 

I do not believe in chiropractics but train and work with DOs. Chiropractics is voo-doo in my opinion.

NOT TRYING TO PICK A FIGHT. MY OPINION OF LONG STANDING AND BAD EXPERIENCES.

I do NOT believe ribs go out. 

 

My vent was more rhetorical than anything else.

Personal perceptions of some patients are so incredibly nebulous during exams that they don't help us at all.

Some days are unbelievably frustrating when folks think this is a 30 minute TV show where everything is solved by the end of the show.

 

I AM very in touch with talking to patients. My vent was exhaustion with folks not getting stuff and poor descriptive abilities.

 

Not about my blue and red breaths. About 25 yrs of experience with some increasing frustration of late......

 

thanks for the response, though

[PA-S Zoidberg]

Patients are notoriously bad historians hahaha. That's why they pay you the big bucks (tongue in cheek). I hope you have a good decompression plan in place, I assume with 25 year old experience you do at this point. 

 

Now keep in mind that though you do not believe that ribs go out, the patient does, and a good DO can usually resolve that pain. 

[CAAdmission]

Ribs do in fact "go out" and can be readily palpated during an osteopathic physical exam.

 

 

Oy....

 

[winterallsummer]

Actual ER conversation.

 

Me: I'm so sorry to tell you but your child's ankle in fact is fractured

parent: oh I see. But is it broken?

[Reality Check 2]

Shall I add in Dr. Oz?…...

 

I am headed for a hot bath and sleep.

More hope for tomorrow.

[PA-S Zoidberg]

Oy....

 

 

Comparative question. If a PT adjusts a rib is that also voodoo? Most manipulative professions share similar to nearly indistinguishable exams with huge crossover in techniques. Granted I may just be feeding trolls here. Ref pages 6-7. It seems like chiro/osteo=voodoo, PT/massage therapist=legit many mindsets. 

 

http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/12-13/May/The%20Thoracic%20Spine%20and%20Rib%20Cage-PT%20Patient%20Management%20Utilizing%20Current%20Evidence.pdf

[EMEDPA]

If you think of rib ends as joints it makes more sense. I have seen DOs examine a pt , apply a bit of pressure in the right place, and the pain goes from 8/10 to zero in 2 seconds many times. There is cartilage at both ends of ribs, no reason to believe there isn't a bit of wiggle room there, just like with an ankle or elbow. now adjusting cranial sutures as some claim to do....I'm not sure about that....

[Reality Check 2]

My intention of this post was not to argue about ribs or chiropractors. 

Not in the mood for a philosophical debate.

My history is really strong in ortho and DOs.

 

Yes, cartilage and soft tissue is mobile.

Yes, ribs hurt and spines hurt.

Muscle energy rocks as does strain/counterstrain.

Whatever cold laser or the little red clicker light is - voo-doo.

I LOVE OMT but do not care for chiro at all.

 

I am just not into the voo-doo of chiropractic adjustments 3 times a week for life.

 

Ok, I'm done. Have to go see patients.

 

Everyone have a good day!!

[PA-S Zoidberg]

Have a good day Reality Check! 

I agree about "chiropractic health". It would be contributory to point out a schism between "Mixers" (more like PT) and "Traditionalist" (more like naturopath) Chiropractic care. Mixers in my experience use a variety of techniques and are circumspect about treating non MS diagnoses with manipulation while Traditionalists are more dogmatic and full on voodoo. That said OMT was originally quite a bit like Traditional chiropractic and has evolved to meet the times and an empirical model. I am also skeptical of cranial, but have seen it work first hand for vertigo/headache. Whether the CS rhythm is to blame or it's more a "relaxation response/treatment effect" is beyond me. 

[CAAdmission]

Comparative question. If a PT adjusts a rib is that also voodoo? Most manipulative professions share similar to nearly indistinguishable exams with huge crossover in techniques. Granted I may just be feeding trolls here. Ref pages 6-7. It seems like chiro/osteo=voodoo, PT/massage therapist=legit many mindsets. 

 

http://www.udel.edu/PT/PT%20Clinical%20Services/journalclub/caserounds/12-13/May/The%20Thoracic%20Spine%20and%20Rib%20Cage-PT%20Patient%20Management%20Utilizing%20Current%20Evidence.pdf

 

 I guess my main concern is with clinicians who insist they can palpate a sub-1mm "subluxation" through an inch of tissue (when it is not even radiographically apparent). This is generally the realm of the chiropractic "physician."

 

I am also left wondering: if osteopathic manipulations are so great, why does it seem that so few DOs actually do them? Do PA programs affiliated with DO schools actually teach any OMT? I would be interested to know the percentage of DOs that incorporate any meaningful OMT in their practice.

[Reality Check 2]

DOs can't learn OMT if they do an allopathic residency and many get left behind in that aspect.

If the DO really wants OMT - they get a DO based med school residency.

PAs can't do OMT.

I have seen the same with DOs in my area - only a few do OMT.

It is generally less violent and high velocity than chiro and more based on human anatomy.

I can't read chiro notes and don't understand their lingo or basis - had the unfortunate experience of working around a bunch of chiros who adjust your neck to help your ear and claimed to fix supracondylar elbow fractures with adjustments. Pure Voo-Doo all the way around.

 

I like DOs and I like DO OMT. It is a dying art.

[PA-S Zoidberg]

DO's learn OMT as part of their med school training. They do not in fact need a neuromuscular medicine (generally most of the OMT guys) residency to do OMT. A PA can in fact bill for OMT provided they are collaborating with a DO that does OMT. 

 

Reality Check, you are describing an encounter with trad Chiro's. Many of them still out there and they favor quackery such as homeopathy and muscle energy (diff than actual ME for pure musculoskeletal complaints) diagnosis for allergies/intolerances. 

 

CJ Admission. You are assuming that all palpable findings are sub 1mm. In fact most OMT exams are done comparing movement between 2 points. It is quite easy to tell when one side moves and another doesn't. I find that many DO's that do OMT believe that OMT is a dying art form because many DO student do not value OMT and instead are attracted by the non-traditional nature of DO school. OMT also doesn't compensate well until you master the idiosyncrasies of billing for OMT. Assuming that OMT is not valuable because few DO student continue practicing it is akin to complaining that Rheumatology is not valuable because so few IM residents select a fellowship. It is a very specific skill set that not every DO student decides is applicable to their journey. That said, there are many DO physicians who miss their OMT who will welcome a PA who is willing to treat patients with OMT to bolster their practice...

[CAAdmission]

Assuming that OMT is not valuable because few DO student continue practicing it is akin to complaining that Rheumatology is not valuable because so few IM residents select a fellowship.

 

I am not sure that is an apples to apples comparison. OMT is supposed to be the entire philosophical underpinning of osteopathy. A better analogy might be someone who claims to be a Christian but does not believe that Jesus existed.

 

I am clearly a curmudgeon, but I am educable. I do not know enough about OMT to criticize it well. I am forced to wonder why something that subluxes a millimeter just doesn't re-sublux ten seconds after you "fix" it. (It is not like popping a shoulder back in, right?) I know the chiros use this as an excuse to have people come back to their office all the time.

[Evolute]

I am having one of those weeks.

 

I palpate the shoulder girdle and ask if it hurts. Yes, I am palpating the rotary cup ;)

 

"No, but it is tender......" 

 

Deep heaving sigh - what does this mean???????

 

I try to clarify - does it feel like a bruise? Is it sharp? Does it hurt to movement?

 

I have also spent the week discussing that a fracture is a break is a fracture is a break - there is no difference. One dad insisted his daughter's arm is broken but not fractured. Heaven help me - my head is going to explode.

 

Add in the immediate assumption that congestion equals infection and implies antibiotics and I have about hit my limit.

 

I am still not clear on how ribs come out either, if mine came out - could I throw it for the dog to fetch? 'cuz I am just not sure otherwise where it goes or how it gets there..... ie. the chiropractor debate.

 

Just venting - I know we all have those little peeves that make patient care challenging sometimes.

 

This is my week of challenge.

Reality, I feel your pain.

 

Few days ago I dx a 3 yo with influenza (in the ED). Symptoms started the morning before. Mother states; me and my husband have had "the same symptoms for the last week" and is wondering why the pt is getting tamiflu and they are not. I spend an exhausting amount of time explaining why.... The next day (i'm still on) the mother.... and her husband..... and the mothers sister..... with the sisters 2 kids (who are asymptomatic) all present to the ED because they are "worried we might have it".

 

that my friends is a great use of resources.    

[CAAdmission]

Reality, I feel your pain.

 

Few days ago I dx a 3 yo with influenza (in the ED). Symptoms started the morning before. Mother states; me and my husband have had "the same symptoms for the last week" and is wondering why the pt is getting tamiflu and they are not. I spend an exhausting amount of time explaining why.... The next day (i'm still on) the mother.... and her husband..... and the mothers sister..... with the sisters 2 kids (who are asymptomatic) all present to the ED because they are "worried we might have it".

 

that my friends is a great use of resources.    

 

Rectal temp time!

[Reality Check 2]

My brain pulled out Monty Python -- not completely dead yet, but not at all well....

 

Don't know why. Just that kind of day.

[Evolute]

Rectal temp time!

Man I wish I would have thought of that.... I will next time.

 

My brain pulled out Monty Python -- not completely dead yet, but not at all well....

 

Don't know why. Just that kind of day.

I hear ya, Initially I thought, merely a flesh wound...then, the next morning I thought... run away, run away!  

Man , you cant make this sh!t up.

[UpRegulated]

Few days ago I dx a 3 yo with influenza (in the ED). Symptoms started the morning before. Mother states; me and my husband have had "the same symptoms for the last week" and is wondering why the pt is getting tamiflu and they are not. I spend an exhausting amount of time explaining why.... The next day (i'm still on) the mother.... and her husband..... and the mothers sister..... with the sisters 2 kids (who are asymptomatic) all present to the ED because they are "worried we might have it".

 

Easy fix.  My plans wastes resources of the patient, not the health care system.

 

Recommended Patient Plan:

 

(1) Tamiflu for all!  That's at least $100 per person, hopefully probably out of pocket. They've earned it!

(2) Prophylactic OMT. Never heard of that?  Me either.  BUT... All that coughing could easily "pop a rib out of joint."  That's a slam dunk STAT referral to a chiropractor.  That's out of pocket too, but again, they've earned it.

(3) Essential oils.  Eat them, lather them on your skin, bathe in them, snort them, and burn them so you can inhale the smoke. And they are on sale at GNC right now!  What?!?!

(4) Watch 5 hours of of uninterrupted Dr. Oz.

 

I can guarantee this works 100% of the time for both spontaneously resolving self-limited illness, as well as non-existent illnesses with equal efficacy.

[UpRegulated]

Comparative question. If a PT adjusts a rib is that also voodoo? 

 

Yes.

[Febrifuge]

Painful = discomfort at rest or with normal daily activities

 

Tender = discomfort with palpation or passive manipulation

 

I know I'm a few days late to the thread, and RC2 was just venting, but I want to caution everybody, especially the newer/ younger/ less-experienced types, against this bad habit we sometimes have (and I include myself in this too) of rolling our eyes at patients, in their fumbling, awkward attempts to explain their symptoms.

 

Yeah yeah, it's a bonding experience for us. It helps us blow off steam. It helps us cope with the larger, more general sense of madness that permeates our whole healthcare system. But it gets in the way of getting good histories, and providing good care. There's a difference between being objective and being jaded. If we can't make sense of the history, we need to recognize it as OUR problem, not the patient's, and we need to take responsibility for overcoming it.

 

We're only human, so it's going to happen, and some patients are just jaw-droppingly, stupefyingly obtuse in how they describe stuff. We all have done the thing where they describe a tender spot (say, left trapezius/ superior shoulder) and we palpate nearby structures looking to zero in on the problem, and instead of just saying "yes" or "no" to tenderness anteriorly or posteriorly, they keep saying "yeah but it hurts up here." We've all heard bizarre descriptions that don't correspond to any structural or functional unit of anything.

 

All I'm saying is, it's all part of getting a history, and that's part of our job. Tell them "yep, I understand, and now I want to make sure that these specific spots don't hurt when I mash on them with my fingers." Say "it can be hard to put into words the way stuff feels, so would you say this feels like a pinching pain or an aching pain, or is it something else?" Say "when you say it's tender but not painful, how do you mean?" Don't shy away from saying "I don't think I understand." It doesn't make you look dumb, it makes you look like someone who is trying to get it right.

 

Many many times, I've seen someone in urgent care who has bounced around the daytime clinics for a couple of weeks, with nobody ever figuring out the deal. And often, it's because the patient's complaint makes no sense. But 99% of the time, just by slowing down and clarifying -- and reminding myself that the patient has never been exposed to good information on the subject, and they've certainly never been educated in the difference between visceral and somatic pain -- I can avoid falling into the trap of expecting them to think about or describe things a certain way. I can ask very basic, clarifying questions, acknowledge what they're feeling without buying in to their theory about why, and uncover some actual problem.

 

And when that happens, I can't help but notice all the other schmucks who, based on the clinic notes, just had no idea and figured they would throw some Flexeril or PT at the patient and get them out of the office. And I'm sorry, but that's crappy care.

 

...And, that's MY rant of the day. Thank you. The soapbox is free now.

[PA-S Zoidberg]

Yes.

 

Refer back to my link...

 

You are willfully denying best practices and empirically supported treatment. 

[CAAdmission]

Refer back to my link...

 

You are willfully denying best practices and empirically supported treatment. 

 

Exactly what happens to a rib that it needs to be adjusted? I have seen a clavicle dislocated form the sternum but not many ribs out of whack.

[PA-S Zoidberg]

Exactly what happens to a rib that it needs to be adjusted? I have seen a clavicle dislocated form the sternum but not many ribs out of whack.

 

Good question CJ and possibly why there is so much misconception about rib adjustment. It is not in fact the rib that is out of place but more the associated thoracic level that is restricted in a plane of motion. The patient feels the acute pain of the rib dysfunction though generally OMT will address the spine. If you have a restricted thoracic level the corresponding rib does not move with the upper and lower level and can compress intercostal soft tissues or press into the scapula with shoulder movement. Those who have had their lower backs "lock up" without associated disc pathology in many cases suffer from a similar restriction in the lumbar vertebrae. 

 

DO's use the ART exam finding to define a rib dysfunction. Asymmetry is determined by palpation with movement (forward flexion with fingers on transverse processes, rotation, inhalation with hands on corresponding CVA angles etc...), Restriction is determined by functional movement tests (i.e. 30 degrees cervical rotation to the left, 90 to the right), and Tenderness refers to the presence of discomfort or pain. 

 

PA ortho manipulation, OMT, and to a degree chiropractics, can all address thoracic level dysfunction with HVLA (rack and crack), ME (isometric contraction on behalf of the patient), and MFR (massage, rolfing style techniques). The goal of all techniques is to restore proper movement to the rib and the associated thoracic vertebrae. 

 

Knowledge of these techniques may make the difference between discharging somebody on pain meds with no relief in symptoms after ruling out PE, MI, pleuritis, etc.. and discharging somebody with true relief. I am happy to have some OMT in my toolbox.