Osteopathic Recognition Resource Library: ER

Case Study 1

53 yo F Pt presents in clinic with DIB for 5 months and chronic, focal chest pain, now 8/10.  Sent for PFTs, which were negative.  Seen in ED, had negative Chest XR and diagnosed with Tietze’s Disease (costochondritis).  Pt had anterior 4th Rib R and post 3rd Rib on L, with stacked T3 and T4 ERS-L, and incidental finding of superior subluxation of L Rib 1.  Tx with ME for lower ribs and BLT on upper rib.  Pain immediately decreased to 4-5/10, and pt reported taking first deep breath in months.  Asked to follow up in 1 week for subsequent SD. Total time of treatment was 5 minutes.

Case Study 2

A 24 yo M comes into the emergency department complaining of acute onset pain in the region of his tailbone after falling backwards onto cinderblocks while “horsing around” with his friends.  Radiological imaging indicates no acute findings or signs of fracture to pelvis, sacrum, lumbar, or coccyx.  Rectal examination corroborates findings of no apparent coccyx fracture.  Upon physical examination, the patient has negative standing and seated flexion tests, but his prone prop (“sphinx” test indicates a bilaterally counternutated sacrum, which is tender to palpation at the apex and along the breadth of the base, and there is an absence of spring bilaterally on the on the sacral base.  The patient is treated with myofascial (sacral rock) after gapping the SI joints, and pain is reduced from 9/10 to 2/10.  He is discharged home on ibuprofen and advised to ice and follow up with his PCP.  Total time of treatment was 10 minutes.

Readings

• Foundations Volume 2, Chapter 26 “Osteopathic Medicine in the Practice of Emergency Medicine”
• Foundations Volume 3, Chapter 66 "Acute Neck Pain"
• Foundations Volume 3, Chapter 69 "Acute Low Back Pain"
• Greenman Chapter 23
• Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003 Sep;103(9):417-21.
• McReynolds TM, Sheridan BJ. Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial. J Am Osteopath Assoc. 2005 Feb;105(2):57-68.
• Ray AM, Cohen JE, Buser BR. Osteopathic emergency physician training and use of osteopathic manipulative treatment. J Am Osteopath Assoc. 2004 Jan;104(1):15-21.

Soft Tissue to distal tibia and fibula, cuboid reduction, counterstrain to the lower leg, review lymphatic techniques (Thoracic pump), Ankle ME, Ottawa Rules, BLT ankle (Review Blood SD. Treatment of the sprained ankle. J Am Osteopath Assoc 1980;79:680-692. )

1. When Evaluating a patient in the ED, in which of the following patients is the would it be permissible (i/e/ not contraindicated) to treat:

1. A patient with ankle swelling, a negative three-view radiological studies, and mental status changes.
2. A patient who is under the age of 18 with no radiological findings of fracture.
3. A patient who has negative Ottawa rules, acute onset of injury, and no indications of a third-degree sprain.
4. A patient who has a positive ankle drawer test.
5. A patient with radiological findings of distal fibular fracture.

Rationale

2. Among the most common reasons ER doctors report not using OMT in the ED, which of the following lists shows their reported concerns (from highest number reporting to lowest number reporting):

1. Liability Concerns; Lack of formal Guidelines for use of OMT; Fellow Physicians/Administrators discouraged use of OMT; Insufficient time for OMT; Uncomfortable with own OMT skills
2. Insufficient time for OMT; Uncomfortable with own OMT skills; Lack of formal Guidelines for use of OMT; Liability concerns; Fellow Physicians/Administrators discouraged use of OMT
3. Fellow Physicians/Administrators discouraged use of OMT; Liability Concerns; Lack of formal Guidelines for use of OMT; Uncomfortable with own OMT skills; Insufficient time for OMT
4. Lack of formal Guidelines for use of OMT; Liability concerns; Fellow Physicians/Administrators discouraged use of OMT; Insufficient time for OMT; Uncomfortable with own OMT skills
5. Fellow Physicians/Administrators discouraged use of OMT; Uncomfortable with own OMT skills; Liability concerns; Lack of formal Guidelines for use of OMT; Insufficient time for OMT; 

Rationale