OMM in the ER?

[Shodddy18]

So I'm a second year osteopathic med student and I'm thinking about emergency medicine. Obviously there are many cases where OMM “could potentially” be utilized in an emergency room, but am I being naïve in thinking that I will be able to use OMM in an ER? I mean with a bunch of patients stacking up will taking a few extra minutes to use OMM really be feasible? I think that I would rather do an AOA residency so I’m assuming OMM will be integrated into the curriculum, but what about after residency? What about DO’s in ACGME residencies? I’m sure it will depend on a lot of factors like how busy it is on a particular day or what the hospital is like, but does anyone have any experience with this. Do any of you DO’s have any anecdotes you want to share?

Thanks a bunch!

---

Members don't see this ad.

 

[FlemishGiant]

I've used OMM in the ER. It works REALLY well for todo cuerpo dolor (total body pain) x2 years, but worse in the last 3 weeks. I rack'em, crack'em and send them out w/ motrin w/ clinic f/u. Patients like it and seem happy about it. Would I consider fixing a T4 problem in someone w/ an acute MI... Emmm prob not, but OMM does have its place in the ER.
Good luck,
FG

 

[stoic]

one of the EM DO's I shadowed a bunch USED to do OMM in the ER... until people started showing up specifically for the OMM....

 

[corpsmanUP]

You bring up an excellent question. The truth is, if you ever use the excuse that "OMM will be integrated into an AOA residency", then you better just buy some winter clothes as well for your next trip to Cancun. What I mean is that don't believe the myth that AOA residencies embrace OMM in any way...not even in primary care. There is an FP residency here at my school that has to send its third year DO residents over to the student led OMM review workshop prior to boards. I swear to you when I tell you that last year I had a group of them that couldn't recall how to define "somatic dysfunction".

It even seems on occassion that DO's in AOA residencies try to distance themselves from OMM because its like some sort of joke to them. And the opposite trend is coming to fruition among some ACGME programs if you can believe it. I think it is because ACGME programs are just now getting their share of DO's who spark their interest in OMM.

Here are the ways I believe OMM can be useful in the EM.

1. Asthma, to relax the thoracic musculature acutely.
2. Severe headaches of the benign variety...venous sinus release and cervical/OA
3. Obviously any time you are doing a joint reduction you are using OMM
4. Obviously any time you are doing a joint aspiration, you are using anatomy gained from manip class

I think the thing I have gained most from becoming a DO is the precision with which my anatomical knowledge way exceeds most allopathic MS4's. When a preceptor hands me a syringe full of Kenalog and tells me to enter the glenohumeral joint anteriorly, I can visualize in my head that I need to be slightly lateral to the coracoid and aiming for a spot just below the posterior/inferior acromion. Manip is way more about anatomy than it is about viscerosomatic reflezes and such. DO's are anatomical experts by and large, and that makes a good EM physician as well as any physician. Truth be told, even if they never proove OMM works, the anatomy knowledge gained through practicing palpatory skills on each and every joint in the body cannot be overemphasized.

 

[governator]

never seen one done in my ER.

 

[tool]

never seen one done in my ER.

Neither have I...wouldn't recommend it either unless you want to be the laughing stock of the hospital. No place for OMM in the ED.....

 

[fuegorama]

Neither have I...wouldn't recommend it either unless you want to be the laughing stock of the hospital. No place for OMM in the ED.....

While this is a little harsh and inaccurate the limited use of OMT in the ED is more a function of loss to followup and potential liability than of disputed efficacy.

In a similar thread some time back, Quinn made a good point about the risk involved in using manipulation on a defined transient patient/doc relationship.

If the back pain patient described above were to experience ANY neurodeficit in the next several years you can bet that the "rack and crack" he received in the ED would be a potential focus for some professional advertising at the back of the phonebook.

So agressive manipulation may not play a role, but OM diagnostic skills can be invaluable. E.G. Chapman's points and viscerosomatic reflexes are not something that you would hang a surgical consult on, but they can be one more tool to firm up your hunch.

The last ED I worked in as a nurse had in-department PT coverage from noon to 8pm. These guys sat in the dept. and were consulted for basically every work/sports related injury that came through. I am now in the throes of a two week rehab elective and am just realizing how much so called OMM has been the purview of PT. Soft tissue dx. and tx, gait mechanics, extremity neuro exams are all part of the DO toolkit that can definitely benefit the ED physician.

 

[allendo]

While this is a little harsh and inaccurate the limited use of OMT in the ED is more a function of loss to followup and potential liability than of disputed efficacy.

In a similar thread some time back, Quinn made a good point about the risk involved in using manipulation on a defined transient patient/doc relationship.

If the back pain patient described above were to experience ANY neurodeficit in the next several years you can bet that the "rack and crack" he received in the ED would be a potential focus for some professional advertising at the back of the phonebook.

So agressive manipulation may not play a role, but OM diagnostic skills can be invaluable. E.G. Chapman's points and viscerosomatic reflexes are not something that you would hang a surgical consult on, but they can be one more tool to firm up your hunch.

The last ED I worked in as a nurse had in-department PT coverage from noon to 8pm. These guys sat in the dept. and were consulted for basically every work/sports related injury that came through. I am now in the throes of a two week rehab elective and am just realizing how much so called OMM has been the purview of PT. Soft tissue dx. and tx, gait mechanics, extremity neuro exams are all part of the DO toolkit that can definitely benefit the ED physician.

Im a D.O. and will probably end up in the ER and I'm 99% sure I would not use OMM in that setting. Although, I can see how it is beneficial in the PM&R world.

 

[electra]

I have never used any HVLA in the ED, but I have certainly found soft tissue and indirect techniques useful on patients and staff alike. How many times does someone come into the ED for musculoskeletal pain? Put some heat on it, work it out with your hands, give a shot of Toradol if it's huge pain, and send the patient home with motrin 600. Works great.
And, being in MI and having to lift and move patients that weigh >300 lbs means the nurses and staff could use some OMM, too.

 

[pushinepi2]

...So agressive manipulation may not play a role, but OM diagnostic skills can be invaluable. E.G. Chapman's points and viscerosomatic reflexes are not something that you would hang a surgical consult on, but they can be one more tool to firm up your hunch. ...

Fueg makes some excellent points. Only one Chapman's point of contention, however. OMM is inexorably linked with dogma and simply dated tradition. The theory behind a "viscerosomatic reflex" is distinctly different from the so-called idea of Chapman's points. CPs are reducible to nothing more than one esteemed physician's opinon on 'tapioca-like' tissue consistencies that were thought to represent localized areas of, 'congestion.' Even die-hard OMM experts will tell you that there is no microbiologic / histologic / or physiologic evidence to support their existence. Nevertheless, osteopathic physicians insist on utilizing Chapman's points as a diagnostic aid. According to the "Foundations of Osteopathic Medicine" Textbook, these findings are supposed to "clue" the physician in on underlying dysfunction. References listed to substantiate CP's date all the way back to 1938 and demonstrate extremely poor inter-examiner reliability. It seems that the continued teaching of Chapman's points amounts to little more than an oral history lesson, passed down in a mythologic fashion from osteopathic generation to generation. Fortunately, osteopathic medicine has stepped up to the plate with regard to EBM and has offered newer generations of physicians some much needed validation. There's little question, for example, that muscle hyper-excitability results from localized injury. Furthermore, internal injuries may manifest themselves as localized tissue texture changes due to upregulation of neural pathways, release of inflammatory mediators, and so forth. Indeed, there is data to support the notion that changes in the musculoskeletal system can reflect underyling organ system dysfunction. Dr. Chapman may have been knocking on the door of neuromusculoskeletal discovery, but he was far from scientific credibility. For those (not me, admittedly) who are eager to advance osteopathic manipulative medicine as a viable complement to the current standard of care, it is of prime importance to distinguish the dogma from the science.

In case I haven't convinced any of the sceptics, here are some excerpts from Foundations in Osteopathic Medicine:
-"Ada Hinkley Chapman.. and W.F. Link, DO, collected [Chapman's] notes and published the ONLY reference text material on the subject" (506).
-The few histopathologic studies of biopsies of Chapman's reflexes have identified nothing" (940)
-"Chapman's reflex diagnosis is highly efficient in these days of expensive diagnostic, medical, and surgical care. Imagine how useful it is to have evidence that a patient's abdominal pain arises from the colon than from the ovary" (937).

I can see it now..
Attending: "Do you want to get that abdominal CT?"
Osteopathic Resident: "Nah, I'm pretty comfortable that her right sided abdominal pain is nothing more than a Chapman's reflex consistent with indigestion."
Attending: "Oh. Ok. Send her home."
Osteopathic Resident: "Okay, I will. Her Chapman's pregancy reflex is absent."

All in good stead,

Push

 

[fuegorama]

Osteopathic Resident: "Okay, I will. Her Chapman's pregancy reflex is absent."
Push

But if her 'pregnancy reflex' is positive, can the gifted osteopath reduce the lesion?

 

[pushinepi2]

But if her 'pregnancy reflex' is positive, can the gifted osteopath reduce the lesion?

Yes; the current osteopathic literature suggests that you squish and maneuver the pregnancy reflex, provided that is anteriorly located, in a clockwise fashion. Thusly and hithertofore, you shall release localized lymphangiectasia and provide negative feedback to the uterus via a viscero-somato-viserofeedback loop. It may induce fetal resorption.