Mrs S is a female patient in her mid 40’s who had visited me for the first time a couple of years ago complaining of back and leg pain. She had a diagnosis of degenerative disk disease and spondylosis (arthritis) in her low back and was in significant pain. She was sometimes unable to work. She was considering surgery and was on a lot of medication.
After a few sessions, Mrs S was feeling remarkably improved. She no longer felt like she needed an operation and was virtually free of pain. Her doctor agreed that surgery as a last resort was no longer on the table. Over the course of the next year I’d see Mrs S occasionally if she had a flare up, but she was maintaining herself fairly well on her own using the tips and exercises I had given and reviewed with her at our sessions.
One Tuesday afternoon I got a voicemail from Mrs S saying that she had been out of town and put into the hospital for severe back pain over the weekend. She said that she had started to feel better, but today she was unable to get up off the sofa and was in terrible pain. She asked if I could come over. Mrs S lives just around the corner from me, quite literally a two minute walk.
I don’t usually do home visits. Very often if someone cannot get to me it means they are in too much pain to really examine properly and reliably diagnose the problem. Without a good diagnosis, I can’t know if it’s safe or appropriate to treat someone, and so home visits often end up being a frustrating experience for both myself and my patient. In this case, Mrs S was a longstanding patient, she had a consistent and known previous diagnosis but most critically there was just ‘something’ in her voice that compelled me to go around to see her even if I couldn’t treat her.
Mrs S’ friend had come over to take care of her dog and remained there until I arrived. Mrs S was on the sofa, and I sat on a chair next to her while she was trying to talk to me. She was yelping and crying out loudly in waves, sometimes without movement. She explained that she had some middle lower back pain on the right earlier, but now a few hours later the pain was in her lower right abdomen. She fidgeted to try to arrange herself in hopes that I could examine her – but given the level of pain and distress she was in I knew it would be impossible.
I sat next to Mrs S and put my hand on her wrist while I talked to her a bit. She felt clammy, and her pulse was rapid but this could have been the stress of the pain. I very gently questioned and observed her – she did not feel tenderness and her abdomen was not hard or distended. There was no reverberating pain or sensation of pulsing in her abdomen – which could have been a sign of a serious problem with the largest blood vessels that run deep through the body. She explained that she had felt unwell, not eaten for a day or so and had not used the loo. All of her symptoms and answers to my questions leaned clearly in one direction: osteopathy was not appropriate here.
I explained to her that in my judgement this pain was not being caused by her back and that I needed to call her an ambulance. I strongly suspected she was passing a kidney stone, or perhaps experiencing an intussusception (where the intestine ‘slides’ inside itself) or some other serious acute bowel problem — if it was the former she needed immediate medical attention to alleviate the pain and dissolve the stones, and if it was the latter, it was a medical emergency. Even if it was something else – it was not appropriate for me to treat and was clearly outside my remit as a clinician and she needed urgent care and she wasn’t going anywhere on her own.
I phoned the ambulance and waited for them to come. I packed Mrs S a little bag of things and saw her into the ambulance. On her request I locked up her house and placed her key in the lock box.
I waited to hear how she was. She rang the next day to say that they had admitted her and said she was passing kidney stones, and to thank me for looking after her. She rang my bell a month or so later, with a bottle of bubbly to say thank you again.
This is a perfect example of how back pain is not always back pain and how appropriate clinical thinking and questioning are so important in assessing if someone is safe to treat. Some therapists of various kinds are not trained to triage in this way, and are trained to ‘rub it better’. I am not against use of soft tissue therapists or massage therapists at all – I use those techniques, I use massage therapists myself and I refer people to these therapists as well. But it is hard to know if some therapists are trained well enough to do a comprehensive triage of a problem before treating someone’s pain. With an osteopath one knows that the standards for such training are high.
My duty to patients is multi fold:
-to ensure care is safe and appropriate and
-to ensure my care does not delay necessary or more appropriate medical care.
In this case it was not safe or appropriate to treat Mrs S for a number of reasons: 1) I couldn’t assess her (so I had no diagnosis) 2) treatment may have made her worse given I was not able to be certain it was a condition appropriate for treatment. And 3) treating her as a means to make her happy or reassure her would have delayed appropriate care. And 4) my triage questioning indicated that the problem she had was a) emergent and b) inappropriate for treatment anyway.
Osteopaths can do many things, but I couldn’t help her with my hands that day – the best thing I could do for her was assess her to get an impression of the problem, to get her rapid medical help, and to hold her hand.
— with permission from Mrs S