Osteopaths in the ED

[Nater44]

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How can you apply the principles of osteopathic medicine in the ED? I really like the philosophy behind osteopathic medicine. It feels comfortable to me and the idea of treating the whole patient is appealing. But in the ED how much of that philosophy can you apply? I want to go DO over MD and feel fairly confident I could gain admissions to either school, but don't see the true benefits (other than the philosophy taught in med school) of one degree over the other in the emergency department.

This is going to sound stupid, but I watched an episode of the TLC trauma/life show and the coolest ED doc I've seen is a DO in Vegas. The guy was amazing with patients and treated every patient (gangbanger or old lady passing out at a slot machine) the same.

Any thoughts on the subject without getting into the stale DO vs MD thing.

 

[bmickelsen]

Natr44
I am a second year medical student at an osteopathic school, I give you that so you can know how much worth you personally want to put on my opinion.
There are so many opportunities to apply osteopathy in ER, however as a physician you will need to be willing to put in a little extra time to do it. How many people present to the ER w/ sprained ankels, sore knees, low back pain, headaches, shoulder pain, breathing problems, etc. Osteopathic medicine allows a physician to help these patients in ways that an allopathic physician can't even begin to think of. Depending on what ER you are in, there maay be limited time to do some of these things, but I really feel that if you want to help these people you will be able to find the time under most conditions.

 

[Sessamoid]

I don't know how others do it, but we have several DOs in our private group. None of them do manipulation as part of their ED treatment regularly, or at all that I know of. Several I'm sure don't do any manipulation at all. The others I suspect don't do any since it's never been brought up, and we're a friendly-enough group (tripled covered during busy hous) that it would have been brought up in normal discussion if it ever happened.

I'm not sure why they don't do manipulation, but I suspect it's because of the time factor. We're busy and we get paid depending on how many patients we see and how well we can bill them. At least one of them I know of doesn't believe it has any place in the ER (for what reason I didn't ask). They are practically allopathic physicians with different initials behind their names.

 

[DrQuinn]

As a DO in an MD EM program... I perhaps have a good perspective on it... but let's give you a little bakcground on me first (besides the fact that its 220 AM and I should be reading Tintinalli's... but I am only up because I am on call tomorrow night so I will sleep during the day)...

I did well in DO school and learned all the OMT modalities just like everyone else... and know how to do them pretty well (except I have not done cervical manipulation since second year, that is one modality I will just not use).

Being in my third month of internship, I have a few hundred patients under my belt that I have directly been involved in the evaluation and disposition (albeit under an attending...). None of them in my opinion have required OMT.

Even in cases of "low back pain," the ED just doesn't tend to present itself as a place for OMT. IMHO, that is best left to the FP's at their office hours. Although I haven't done a search, I am not sure where OMT fits into my treatment algorithm as an Emergency Medicine Physician. If (God forbid) something were to go awry during a manipulation, I would be burnt even MORE than an FP would...

That beign said, I think the osteopathic education does give me some *slight* advantages than my MD counterparts. I am a little more keen on the somatic/visceral interplay... and have seen some Chapman reflexes help in the diagnosis (granted, I was just bored and thought to check them... but the clinical picture was extremely obvious anywyas).

You know what, I just read your original post... you were asking more about the philosophy...

I think you have to remember what the philosophy of Emergency Medicine is.

A) To not miss any life-threatening disease states
B) To disposition the patient to the appropriate level of care
C) To find out why the hell someone's vagina stinks at 3 AM

The DO philosophy doesn't quite meld well with Emergency Medicine, as your time with the patient is extremely limited and more chief-complaint oriented.

Hope this helps.
Q, DO

 

[Sessamoid]

Originally posted by Nater44

This is going to sound stupid, but I watched an episode of the TLC trauma/life show and the coolest ED doc I've seen is a DO in Vegas. The guy was amazing with patients and treated every patient (gangbanger or old lady passing out at a slot machine) the same.

The guy may be the second coming himself, but personally I always take that show with a grain of salt. Sure it's a real er and real patients, but people never act the same in front of a camera rolling all the time as they would in real life. In RL he probably rags on the stupid drunks as much as the rest of us.

I had a friend who was featured on that show once too. Afterwards, I was like "Dude you were so full of crap!" The guy he was on the show was this super-upright Dudley-Do-Right. In real life, the guy has the same frustrations and gets pissed at the same things most of us do.

 

[DrQuinn]

Originally posted by Sessamoid
The guy may be the second coming himself, but personally I always take that show with a grain of salt. Sure it's a real er and real patients, but people never act the same in front of a camera rolling all the time as they would in real life. In RL he probably rags on the stupid drunks as much as the rest of us.

I had a friend who was featured on that show once too. Afterwards, I was like "Dude you were so full of crap!" The guy he was on the show was this super-upright Dudley-Do-Right. In real life, the guy has the same frustrations and gets pissed at the same things most of us do.

Good point. T:LITER has come to Tampa General twice (the first season of the show and then again a year or so ago)... four of my attendings were on that show... the last episode I saw (I had it on TiVO but erased it dangit) had one of our more... er, eccentric attendings, and the show really focused on it (i.e. his shoe collection, etc), but in real life, that's how he is. I don't think they changed much in front of the camera (I'll let y'all know when I do more ED months)...

However, the Surgery Resident that they showed was a bit... er, pompous. I do not believe he is still at TGH, but I couldn't stand to watch the guy. His patient rapport was horrible (used medical terminology to an immigrant and his wife) and it just got worse from there...

But then again, he's a Surgery Resident, not a DO EM Intern extraordinaire (who approaches everything holistically and blah blah) like myself. 🙂

Q, DO

 

[Nater44]

Originally posted by Sessamoid
The guy may be the second coming himself, but personally I always take that show with a grain of salt. Sure it's a real er and real patients, but people never act the same in front of a camera rolling all the time as they would in real life. In RL he probably rags on the stupid drunks as much as the rest of us.

The guy was named doctor of the year in Nevada or some such thing. But he couldn't save Tupac so he can't be all that great.

Seems to me that if I become an osteopath I'll be able to practice EM without a hitch and can chose what I decide to implement from my osteopathic training.

This weekend this guy came into the ED with a greater trochanter fracture. He climbed a 15 foot ladder and decided to smoke a joint at the top. Must have wanted to decent view while high. This poor bastard sat in the ED for 18 hours.. (was still there when I left) because he didn't have insurance and no ortho would see him in the middle of the night. Even county USC rejected the guy. What do you do with someone like him?

 

[Sessamoid]

Originally posted by Nater44

This weekend this guy came into the ED with a greater trochanter fracture. He climbed a 15 foot ladder and decided to smoke a joint at the top. Must have wanted to decent view while high. This poor bastard sat in the ED for 18 hours.. (was still there when I left) because he didn't have insurance and no ortho would see him in the middle of the night. Even county USC rejected the guy. What do you do with someone like him?

CMS relaxed the EMTALA obligations a little for surgeons, but that's more than pushing it a little. From what I hear, LA county hospitals are starting to refuse these patients since several of them nearly closed (including UCLA Harbor which houses one of the most prestigious EM residencies in the country) due to lack of funding.

 

[daveswaf]

DO's in the ER...

A lot of the shadowing I've done is in a smallish hospital ER that is staffed by about half DO's and half MD's. Once I was following an MD and he was seeing a 5 y.o. boy with nursemaids elbow. The MD was unable to reduce the dislocation (somewhat to my surprise, because he is a med/peds dude) and instead of causing the kid undue discomfort, he went and grabbed the other physcian working that night because he was a DO. He told the parents something like "This is Dr. so and so, he is a DO and has much more experience dealing with this sort of procedure." The DO literally fixed this kid up in 5 seconds. It was pretty cool.

 

[Nater44]

Originally posted by daveswaf
DO's in the ER...

A lot of the shadowing I've done is in a smallish hospital ER that is staffed by about half DO's and half MD's. Once I was following an MD and he was seeing a 5 y.o. boy with nursemaids elbow. The MD was unable to reduce the dislocation (somewhat to my surprise, because he is a med/peds dude) and instead of causing the kid undue discomfort, he went and grabbed the other physcian working that night because he was a DO. He told the parents something like "This is Dr. so and so, he is a DO and has much more experience dealing with this sort of procedure." The DO literally fixed this kid up in 5 seconds. It was pretty cool.

That's a great story Dave. It's encouraging to learn that the little extra taught in DO school might be helpful. Taking nothing away from MD schools of course. The ED I work in has an MD I think can bring Jimmy Hoffa back from the dead given half a chance. The guy is amazing.

Thanks again Dave.

 

[Sessamoid]

Originally posted by daveswaf

A lot of the shadowing I've done is in a smallish hospital ER that is staffed by about half DO's and half MD's. Once I was following an MD and he was seeing a 5 y.o. boy with nursemaids elbow. The MD was unable to reduce the dislocation (somewhat to my surprise, because he is a med/peds dude) and instead of causing the kid undue discomfort, he went and grabbed the other physcian working that night because he was a DO. He told the parents something like "This is Dr. so and so, he is a DO and has much more experience dealing with this sort of procedure." The DO literally fixed this kid up in 5 seconds. It was pretty cool.

I'd be beyond embarrassed if I couldn't get a simple nursemaid's elbow reduced. Perhaps this just highlights that one ought to be EM-trained if one is to be working in an ED. Med/Peds get little to no trauma training, including reduction of fractures and dislocations. So what does this guy do if he doesn't have another doc in the ED who can reduce these things? Does he call a pediatric orthopedist to come in and reduce a nursemaid's elbow? If I were that orthopod, I'd be pretty upset.

 

[Captain Solo]

Ah!!!!!!!!!!!!! chalking the cue stick works everytime!

 

[bmickelsen]

There is a wonderful article in this months issue of JAOA about treating acute sprained ankles in the ED. It was a small study, but it was found that OMT was a definite help in treating these people.