As I was thinking about what to post this Monday after the long holiday weekend in the US that’s just passed, it occurred to me that there was a rather disturbing story from the week before last that is both relevant to this blog and of interest. I’m referring to the tragic case of John Lawlor.
I’ve discussed the complications of neck manipulation by chiropractors before. For example, there was the tragic case of Katie May, a young model who died after chiropractic neck manipulation. It turns out that there are other ways to die from a chiropractic neck manipulation. Witness the case of the unfortunate aforementioned man named John Lawlor. First reported over a month ago, the story is that John Lawlor died following a chiropractic adjustment:
A chiropractor has been arrested on suspicion of manslaughter after a retired bank manager died following treatment for backache.
John Lawler, 80, was undergoing routine treatment at a private clinic when he lost consciousness and appeared to have become paralysed from the shoulders down.
He was taken straight to hospital but died the next day as a result of a ‘traumatic spinal cord injury.’
His wife of 55 years, Joan Lawler, 81, was in the chiropractor’s clinic with her husband and witnessed the incident.
Police are investigating to establish whether or not criminal negligence was a factor in his death.
Dr Arleen Scholten, 40, the chiropractor who treated Mr Lawler, was arrested by police on suspicion of manslaughter and released pending further inquiries.
The reaction of the authorities regulating chiropractic in the UK was—shall we say?—less than heartening:
The investigating committee of the General Chiropractic Council met on September 28 to decide whether or not to issue an interim suspension order against Dr Scholten. It decided to allow her to continue to practise.
Speaking from her home in Tollerton, near York, Dr Scholten said yesterday: ‘I’ve been told not to comment at this time.’
Because of course a council of chiropractors won’t act, and of course Scholten is a true believer:
Writing about her life and personal philosophy on her company website, she comments: ‘Chiropractic is a lifestyle for our family. This includes good nutrition, regular exercise, plenty of time outdoors, little screen time and regular chiropractic care.
‘Yes, all five of us are adjusted regularly. Our children were all adjusted the day they were born, two were homebirths and I continue to check their spines regularly. There is a saying in chiropractic, ‘If the twig is bent so grows the tree’.
I will forever be dedicated to sharing the health benefits of chiropractic. I am passionate about the science of human wellness and feel morally obligated to educate my patients on ways to increase health and well-being through eating, thinking and moving, in ways congruent with our bodies.’
So she’s been adjusting the spines of her children since the day they were born? That’s some serious dedication to her quackery.
A vertebral fracture, followed by gross mismanagement
Two weeks ago, the results of the coroner’s inquest into the death of Mr. Lawlor were revealed. Specifically, Mr. Lawlor suffered a broken neck:
A MAN suffered a broken neck while being treated by a York chiropractor for an aching leg, an inquest heard today.
John Lawler’s widow Joan told how her husband was on a treatment table at Chiropractic 1st in The Mount in August 2017 when things started to go wrong.
She said he started shouting at chiropractor Dr Arleen Scholten: “You are hurting me. You are hurting me.” Then he began moaning and then said: “I can’t feel my arms.”
Mrs Lawler said Dr Scholten tried to turn him over and then manoeuvred him into a chair next to the treatment table but he had become unresponsive.
What happened next is that Ms. Scholten called an ambulance. She wondered if he had had a stroke, which tells me that she at least recognized the possibility of vertebral artery injury from neck manipulation. She dismissed the possibility because “his features were symmetrical.” She also noted that his lips were blue, but that he was breathing. It would be obvious to any physician that he was not getting enough oxygen.
After the ambulance arrived, the paramedics gave Mr. Lawlor oxygen, treated him, and rushed him to York Hospital, after which he was later transferred to Leeds General Infirmary. There, he underwent an MRI, and his wife was told that the results indicated that he had suffered a broken neck. The doctors also told her that he was now a paraplegic and required a 14 hour operation to stabilize the spine. However, he “just faded away” and died the next day.
There are a number of issues regarding this case. The first, of course, is a question that immediately came to mind: Why on earth would a chiropractor choose manipulation of the cervical spine to treat an “aching leg”? Another question that immediately comes to mind is: Why would a chiropractor treat an 80-year-old man with cervical spine manipulation? Edzard Ernst, who has commented several times on this case, provided a likely answer:
One might be surprised to hear that the chiropractor manipulated the neck of a patient who consulted her not because of neck pain but because of a condition seemingly unrelated to the neck. This is an issue that comes up regularly and which is therefore important; some people might be aware that it is dangerous to see a chiropractor when suffering from neck pain because he/she is bound to manipulate the neck. By contrast, most people would probably think it is ok to consult a chiropractor when suffering from lower back pain, because manipulations in that region is far less risky. The truth, however, is that chiropractors have been taught that the spine is one organ and one entity. Thus they tend to check for subluxations (or whatever name they give to the non-existing condition they all aim to treat) in every region of the spine. If they find one in the neck – and they usually do – they would ‘adjust’ it, meaning they would apply one or more high-velocity, low-amplitude thrusts and manipulate the neck. This could well be, I think, how the chiropractor in the case that is before the court at present came to manipulate the neck of her patient. And this might be how poor Mr Lawler lost his life.
Of course, the reason I also ask why a chiropractor manipulated an old man’s neck is because it’s quite possible that Mr. Lawlor had significant osteoporosis, which is common in the elderly. In that case, as Ernst further explains, it could be argued that manipulation of the neck with normal force could have resulted in the fracture that paralyzed and ultimately killed Mr. Lawlor and that Ms. Scholten wasn’t to blame. On the other hand, it could just as well be argued that she was obligated to check Mr. Lawlor for evidence of osteoporosis or other conditions (such as atherosclerosis if the vertebral arteries) that would put him at a higher risk for complications from cervical manipulation. Indeed, he makes a very persuasive argument that Scholten likely didn’t provide true informed consent by cautioning him about the risk of stroke or neck fracture due to high intensity manipulation. As he put it, “In my view, any clinician applying a potentially harmful therapy has the obligation to make sure there are no contra-indications to it. If that all is so, the chiropractor might have been both negligent and reckless”.
Ernst published a statement from the Lawlor family that was quite telling:
There were several events that went very wrong with John’s chiropractic treatment, before, during, and after the actual manipulation that broke his neck.
Firstly, John thought he was being treated by a medically qualified doctor, when he was not. Furthermore, he had not given informed consent to this treatment.
The chiropractor diagnosed so-called ‘vertebral subluxation complex’ which she aimed to treat by manipulating his neck. We heard this week from medical experts that John had ossified ligaments in his spine, where previously flexible ligaments had turned to bone and become rigid. This condition is not uncommon, and is present in about 10% of those over 50. It would have showed on an X-ray or other imaging technique. The chiropractor did not ask for any images before commencing treatment and was seemingly unaware of the risks of doing a manual manipulation on an elderly patient.
It has become clear that the chiropractor did the manipulation incorrectly, and broke these rigid ligaments during a so-called ‘drop table’ manipulation, causing discs in the cervical spine to rupture and the spinal cord to become crushed. Although these manipulations are done frequently by chiropractors, we have heard that the force applied to his neck by the chiropractor would have had to have been “significant”.
Immediately John reported loss of sensation and paralysis in his arms. At this stage the only safe and appropriate response was to leave him on the treatment bed and await the arrival of the paramedics, and provide an accurate history to the ambulance controller and paramedics. The chiropractor, in fact, manhandled John from the treatment bed into a chair; then tipped his head backwards and gave “mouth to mouth” breaths. She provided an inaccurate and misleading history to the paramedic and ambulance controller, causing the paramedic to treat the incident as “medical” not “traumatic” and to transport John downstairs to the ambulance without stabilising his neck. If the paramedics had been given the full and accurate story, they would have stabilised his neck in situ and transported him on a scoop stretcher – and he would have subsequently survived.
In general, it’s arguable to me whether Mr. Lawlor would have survived if this had been done. What is not arguable, however, is that the mismanagement of the aftermath of his spine fracture by Ms. Scholten greatly reduced his chances of survival or of recovering neurologic function with proper treatment, and that immobilizing his cervical spine would have maximized his chances of survival and recovery of at least some function. Also disturbing is how Mr. Lawlor had thought that he was being treated by a medically qualified doctor. I’m not sure if this meant that he thought Ms. Scholten was a medical doctor or that he considered chiropractors to be “medically qualified doctors”. This confusion, however, is a not uncommon consequence of how chirpractors like to call themselves “doctors” or even “chiropractic physicians” as part of their self-image and marketing.
Ernst also published the findings of the coroner’s inquest:
- Mr Lawler died because of a tear and dislocation of the C4/C5 intervertebral disc caused by considerable external force.
- The pathologist’s report also shows that the deceased’s ligaments holding the vertebrae of the upper spine in place were ossified.
- This is a common abnormality in elderly patients and limits the range of movement of the neck.
- There was no adequately informed consent by Mr Lawler.
- Mr Lawler seemed to have been under the impression that the chiropractor, who used the ‘Dr’ title, was a medical doctor.
- There is no reason to assume that the treatment of Mr Lawler’s neck would be effective for his pain located in his leg.
- The chiropractor used an ‘activator’ which applies only little and well-controlled force. However, she also employed a ‘drop table’ which applies a larger and not well-controlled force.
Chiropractic “drop tables”: Therapeutic tables or dangerous devices?
Oddly enough, I wasn’t familiar with chiropractic drop table techniques. So I did what I always do when I come across a technique with which I’m not familiar; I did a bit of searching on Google. It didn’t take me long to find a number of videos to help educate me, and some of them are scary.
This first video, for example, doesn’t show cervical manipulation itself, just the table, but the chiropractor states that the table is used for patients who have mobility issues and are hard to move. It also augments the force of the chiropractic manipulation:
Here’s one in which the chiropractors are explaining how the cervical drop table works:
And here’s a video by the company that makes a chiropractic drop table showing how the table works and touting its features:
As you can see from this video, there’s an actual pneumatic mechanism that augments the force of the adjustments:
And this one, too, with the cervical drop demonstration starting at around the 3:30, 4:45, and 10:50 marks:
Next up is a scary one:
And:
And:
I could go on, but you get the idea.
Cervical spine manipulation and serious complications: How common?
How common are injuries like this? Like the estimates for strokes as a complication of chiropractic neck manipulation, estimates vary. A recent review of the practice from the Manitoba Health Professionals Advisory Council identified a total of 159 references: 86 case reports/case series, 37 reviews of the literature, 9 randomized controlled trials, 6 surveys/qualitative studies, 5 case-control studies, 2 retrospective studies, 2 prospective studies and 12 others. The review noted that serious adverse events are rare, but that minor adverse events are common. Minor adverse events range from transient neurological symptoms, headache, increased neck pain or stiffness, fatigue, dizziness or imbalance, extremity weakness, tinnitus, depression, anxiety, nausea and vomiting, blurred vision, and confusion. (Personally, I would consider depression, anxiety, and confusion not to be “minor” adverse events.) Serious adverse events include the aforementioned vertebral artery dissection and stroke complicating manipulation, as well as transient ischemic events (the so-called “mini-stroke” in which the neurologic symptoms are transient), nerve or spinal cord damage, disc injury and/or herniation, fracture or subluxation of vertebrae, and musculoskeletal injuries.
But how common are these serious adverse events? The incidence rates for all serious adverse events following cervical spine manipulation are reported to range from one in 10,000 to one in several million cervical spine manipulations (CSMs) although the literature does appear to agree that that serious adverse events are likely underreported. According to the executive summary, the “best available estimate of incidence of vertebral artery dissection of occlusion attributable to CSM is approximately 1.3 cases for every 100,000 persons <45 years of age receiving CSM within 1 week of manipulative therapy,” and the current “best incidence estimate for vertebral dissection-caused stroke associated with CSM is 0.97 residents per 100,000.” The report also looked at risk factors for serious adverse events, concluding that a number of factors can place patients at a higher risk for these serious complications, including “vertebral artery abnormalities or insufficiency, atherosclerotic or other vascular disease, hypertension, connective tissue disorders, receiving multiple manipulations in the last 4 weeks, receiving a first CSM treatment, visiting a primary care physician, and younger age.” The report also noted that “patients who have experienced prior cervical trauma or neck pain may be at particularly higher risk of experiencing an adverse cerebrovascular event after CSM.”
The conclusion:
The current debate around CSM is notably polarized. Many authors stated that the risk of CSM does not outweigh the benefit, while others maintained that CSM is safe—especially in comparison to conventional treatments—and effective for treating certain conditions, particularly neck pain and headache. Because the current state of the literature may not yet be robust enough to inform definitive prohibitory or permissive policies around the application of CSM, an interim approach that balances both perspectives may involve the implementation of a harm-reduction strategy to mitigate potential harms of CSM until the evidence is more concrete. As noted by authors in the literature, approaches might include ensuring manual therapists are providing informed consent before treatment; that patients are provided with resources to aid in early recognition of a serious adverse event; and that regulatory bodies ensure the establishment of consistent definitions of adverse events for effective reporting and surveillance, institute rigorous protocol for identifying high-risk patients, and create detailed guidelines for appropriate application and contraindications of CSM. Most authors indicated that manipulation of the upper cervical spine should be reserved for carefully selected musculoskeletal conditions and that CSM should not be utilized in circumstances where there has not yet been sufficient evidence to establish benefit.
Personally, I’m of the opinion that high-velocity, low-amplitude cervical spine manipulation like that performed by chiropractors should never be done because there is no robust evidence that it is effective for anything and, in the absence of efficacy, even the very small risk of very serious adverse events ranging from artery dissection to stroke to vertebral fracture (all of which can lead to major disability and even death), is unacceptable. A second part of the report that is spot on is that, if CSM isn’t going to be banned outright, harm mitigation should involve rigorous protocols and genuine informed consent. There’s where the General Chiropractic Council in the UK should come in.
The General Chiropractic Council: Putting the fox in charge of guarding the henhouse
Here’s where the story stands right now. Ms. Scholten is still practicing, as I learned in a story about the case published last Friday. Before I get into that part, I can’t help but note a new revelation in this story, namely that Mr. Lawlor’s GP had recommended a course of physiotherapy, not chiropractic. However, there were waiting lists for both NHS and private physiotherapists; so Mr. Lawlor made an appointment to see Ms. Scholten.
Also:
I don’t think Mum actually knew there was a difference between a physio and a chiropractor,’ says their youngest daughter Clare, 49, an executive in a London publishing house. ‘I wouldn’t have been that aware of the differences either. I was only vaguely aware that Dad was going for a spot of physio.’
Joan certainly assumed that ‘Dr Scholten’ was a medical doctor. ‘You do, don’t you? Particularly that generation,’ says David, 55, the couple’s eldest child who works in finance.
‘You see certificates on the wall and you think, “These are people who know what they are doing.” You put yourself into their hands.’
In addition:
‘For one, she used a stick, an “activator”, which is a small hand-held device that delivers a force to the spine. We heard the sound it would make during the inquest. It was like a thud. There was a sense that a lot of it was for show.’
Yet it was the table-drop treatment which did the damage. This wasn’t the first time John had had it. At an appointment the previous day (he’d had five sessions, although only three were ‘hands on’) Mrs Scholten had carried out this procedure, too. David adds: ‘Dad was shocked by that. Mum was shocked by it. They didn’t like it at all but they went off after with no ill effect, so Dad assumed it must be doing some good.’
Now here’s where the issue with regulation comes in and it’s a key reason why I so strongly oppose the licensure of quack professions:
They [Mr. Lawlor’s family] had hoped that the coroner would record a verdict of unlawful killing. Coroner Jonathan Heath instead recorded a narrative conclusion that Mr Lawler suffered spinal injuries while undergoing chiropractor adjustment and died from respiratory depression.
However, he did say he would ask the chiropractic regulatory authorities to consider first aid training for chiropractors. He is also calling on the General Chiropractic Council (GCC) to bring in pre-treatment imaging, such as X-rays or scans, to protect the vulnerable.
‘We’ve since discovered that some chiropractors won’t treat patients of Dad’s age, or certainly not without doing scans first. He had a history of degenerative disease, too. He’d had some rods inserted in his lower back in 2009. He should not have been treated, quite simply.’
According to the story, the General Chiropractic Council is still reviewing the case. Ms. Scholten was indeed arrested and barred from practicing, but with the coroner’s final ruling, there are no longer any charges against Ms. Scholten, and she can continue to practice. Suspiciously, contrary to the usual practice of the GCC, it is conducting its hearings in private and wouldn’t allow Mr. Lawlor’s son David to attend, leading him to say:
Suspension hearings are normally open to the public but, on the day, they said I couldn’t be there. I find that unacceptable. This is a different world. It seems to be a little self-regulatory chiropractic bubble, where chiropractors regulate chiropractors.
That is, of course, exactly the problem with giving legal status to pseudoscience and quackery. The laws establishing licensure of chiropractors, acupuncturists, naturopaths, and the like inevitably also create boards to regulate and discipline these quacks, and who’s on the board? Members of the same quack profession. That leads to the boards that regulate these quack professions to turn into exactly that, little quack bubbles that regulate quacks. Thus far, the GCC has done next to nothing, and it wouldn’t surprise me if Ms. Scholten’s actions of having undergone a first aid course and altering her website to make it clear that she is not a medical doctor will satisfy the Council.
Patients like John Lawlor are just collateral damage to the licensure of quackery.
39 replies on “The tragic case of John Lawlor and death by chiropractic neck manipulation”
You can understand why they may have thought visiting a Chiropractor was an acceptable alternative treatment to physiotherapy, from the NHS website (https://www.nhs.uk/live-well/healthy-body/ways-to-manage-chronic-pain/) :
“Physical therapy is usually delivered by a physiotherapist, chiropractor or osteopath, or in some cases, an occupational therapist.”
“Your GP may be able to refer you for physical therapy on the NHS, although physical therapy is only available privately in some areas.”
Although the entry on chiro saying that it usually isn’t covered by the NHS should raise question marks.
I know UK-ian nurses and doctors who don’t really understand what chiro is, let alone whoever wrote that thing on the NHS website.
Yours,
A disgruntled retired UK-ian nurse and child of 2 physiotherapists
Chiropractic is based on a “theory” of subluxations. No scientific basis has ever been established. However, probably placebo effect; but also some technics no different from physiotherapy, some people feel better after treatment by a chiropractor. I wouldn’t use one and would advice anyone not to. However, that one person died after being treated by a chiropractor is not a science-based medicine piece of evidence. It is an anecdote. I can promise you that somewhere, at some time, someone has died or been seriously hurt by a license physiotherapist. We have doctors, not just a few, who have killed and injured patients in surgery because they were incompetent. We don’t then attack surgeons in general.
So, I agree that chiropractic is not a scientific-based approach and, as such, should be condemned; but don’t like using one case. At least do some research and find a case series.
Joel, Orac’s article mentions multiple cases and literature reviews just on the subject of arterial dissection following chiropractic neck manipulation, and he has covered this subject before on RI (check out the Katie May case).
It is tragic when an evidence-based treatment results in severe injury or death. It’s beyond tragic when an inappropriate, non-evidence based therapy (i.e. forceful neck manipulation for leg pain) results in death.
It’s completely unacceptable, and standards need to be created and enforced to ensure that such events, however rare, do not happen.
You are right. Early morning, insomniac. However, a friend of mine did his doctoral dissertation comparing chiropractic and physiotherapy for lower back pain. He found, in most cases, that simple rest, ibuprofen or the like and moist heat did as well. No real difference between chiropractic and physiotherapy. Of course, even if not medical accepted there still needs to be some standards that forbid certain clearly harmful procedures.
Just a little anecdote from my past. In my early teens I began having horrible headaches. Always the same, one side, right nostril would clog, severe pain behind right eye. Lasted usually 1 1/2 to 2 hours and could experience two, rarely three, in a day. After 7 – 10 days ended. Several episodes per year. My family physician sent me to an Ear, Nose, and Throat Specialist who said I had a deviated septum which he could operate on. I don’t really know why to this day; but I hesitated, just didn’t make sense since my breathing was fine in both nostrils. Several years later went to another ENT. First, he wanted to do an X-ray; but I pointed out I had already been X-rayed. Finally, he relented. His suggestion was to insert in each sinus a time-releasing cortisone derivative. Again, can’t say why I hesitated; but did. Several years later when I was living and studying in Sweden, while home for a visit, another round of headache, went to a third Board Certified ENT. Again, refused X-ray. Note that each of the three owned their own X-ray machines. His treatment suggestion was to cauterize with an electrical needle my sinuses, that is, to cause scar tissue. Since I was covered by Swedish health, I said I would get it done in Sweden. He simply stated his negative opinion of Swedish socialist medicine. Went I got back to Sweden, made an appointment with an ENT. Related history, starting with early teens. He did a very thorough physical exam, asked questions about diet, etc. I asked why he didn’t want an X-ray. He said that if nothing was found on the first X-ray and same problem, would only expose me to more radiation, not add anything. Finally, he suggested I consult with a neurologist. Well, I just happened to be friends with a neurologist. She was an American who did her doctorate in neuropsychology at University of Uppsala. Then went to Med School, which in Sweden is 5 1/2 years. Then did a 20 month internship, 6 months internal med, 6 months surgery, then electives, e.g., pediatrics, infectious disease. Then 5 year training in neurology. Years later she became Associate Professor of Neurology at UCLA med school. In other words, she was well-trained. In any case, I phoned her and she invited me to dinner and said I should arrive half hour early so she could examine me. After examination she said I was suffering from Cluster Migraine (also called Horton’s Syndrome). She suggested, just to be sure, that next time I had one I use an ergotamine tartrate suppository which causes vasoconstriction. But shouldn’t continue with because can cause rebound effects. In the meantime, I went to the medical library, found the then up-to-date book on Headaches and looked up both sinus headache, cluster migraine, and a few others. Sinus headache symptoms not even close to what I had been experiencing; but cluster migraine made me wonder if I had an identical twin somewhere who they based the chapter on. So, three Board Certified American doctors, an X-ray that showed NOTHING, no symptoms of sinus problems and yet they wanted to carry out treatments that would probably have caused me long term problems.
And when I returned to the States, I was prescribed meds that had never been evaluated for cluster migraine; but for classic migraine. For classic migraine, despite a number of side-effects they did show clear benefit/cost; but they took 1 1/2 to 2 hours to work. With classic migraines that last a long time, great; but for me, would have made little to no difference; but side-effects greater than benefit, so, again, I declined. Finally, a few years ago found a treatment that actually works, at least for me, and 2/3 of those who try it. Oxygen. Had oxygen delivered to my home. Set it up. Then 2 am woke with severe cluster headache. Put oxygen mask on, started egg timer, set to 15 minutes, and within less than 10 minutes basically gone. However, never trust one or two, since other factors; but over next eight days, had two clusters per day and in every case over in less than 10 minutes. Miracle. Of course, I was lucky was at home. But could have arranged portable oxygen to carry with me. One of the few good things about cluster migraines, also called suicide headaches, is that for some reason as one ages many have fewer and fewer. For me, from two to three rounds per year to now one round every three to four years. I have standing order from neurologist that if one breaks out oxygen delivered either same afternoon or next morning.
The point is that I went to three Board Certified Specialist and, despite no symptoms of sinus headache, they would have performed interventions that would have caused me potentially life-time problems. And added to cumulative radiation by performing X-rays because they owned the equipment. In addition, I later found NO scientific evidence for any of their interventions. So, while I have had many good experiences with licensed physicians, nurse practitioners, physicians assistants, and physiotherapists, no guarantee.
As for chiropractors, despite what some do, talking to some who belong to my gym, and to friends who have used them, and my long-time friend who did a doctorate in physiotherapy in Sweden, many basically do the same as physiotherapists. Again, I would NEVER go to one and would try to discourage others; but, if they avoid the neck manipulations and do basically gentle physiotherapy type treatments, probably a combination of placebo effect and some physiotherapy. Given this, would be best if one just went to a physiotherapist.
So, you are right that Orac did mention far more than one case, again, insomnia, should have read more carefully; but, as my cluster headache experience shows, even with Board Certified specialist, best to get more than one opinion, even several.
I still don’t know why I questioned at such an early age; but since then have taken three graduate courses in Philosophy of Science (basically how we draw causal conclusions), an undergraduate course in logic which included both a classical logic text and a book on logical fallacies, e.g., post hoc ergo prompter hoc. And continue to read articles on related subjects. Which is why I also love scientific methodology and probability theory.
Well, this was a long-winded trip down memory lane. Time to go to Costco. Monday mornings when they open least crowded.
And, in the future I’ll try to wait until caffeine does its job and read more carefully.
My experience with cluster headache is just one of several I have experienced or family or friends. And the literature is rife with therapies with little to no scientific validity and/or incompetent licensed physicians. So, CAM, no; but some practitioners of CAM, if they don’t make outlandish claims, just advise reasonable diets, etc. I wouldn’t go to, wouldn’t recommend, would prefer they didn’t exist; but we can’t outlaw faith healing???
If you had gone to a primary care physician instead of ENT specialists, you may have been referred to a neurologist much sooner. You go to an ENT, they’re going to look for problems in the area of their specialty. Perhaps they shouldn’t assume that other potential causes of the problem had been investigated, but that’s why you shouldn’t always self refer to a specialist even if you can. The value of a good primary care doctor is vastly underappreciated.
Just curious if anyone ever worked you up for OSA?
I went to cluster headaches right away, based on the description of your symptoms. PF made a great point’ a family care provider would have probably sent you to neurology not ENT.
There’s an old saying: when all you have is a hammer, everything looks like a nail. ENTs think, well, ENT. Primary care providers start with the easiest most common explanation and then narrow it down to the less likely based on symptoms, exam, and diagnostics.
Although it has been a long time since my last first aid classes, so I am nowhere near current, I would think that blue lips would prompt thinking “not getting enough oxygen” from anyone with a modicum of medical education. Is chiropractic training so far gone that they get none in conventional first aid and that their system is the treatment for every literally every condition or problem?
C’mon now, there’s a ton of Science proving that chiropractic adjustments are just the ticket for breathing difficulties.
http://chiropractordenvercolorado.com/what-can-chiropractic-treat/respiratory-function/
“8) Case #2 Adjustive treatment for chronic respiratory ailment in a five year old. Case reports in chiropractic pediatrics. Esch, S. ACA J of Chiropractic December 1988.
This is the story of a 5 ½ year old girl with a four-year history of what the parents called “bronchial congestion.” She had pneumonia “several times a year” since she was 18 months old. In addition to he attacks of “bronchitis” she suffered from congestion and was wheezy after running and upon waking up in the morning. The father and mother both reported having allergies. Chiropractic Examination reveal subluxations at C-2, T-4 and L-5. At the second adjustment two days after the first the mother reported the child was not coughing as much and by the third visit a week later the mother reporting the child was breathing normally. Twelve adjustments were given over three months and the chief complaint did not recur. A follow-up call four years later revealed no recurrence.”
One presumes that a good neck cracking took care of that C-2 subluxation.
Logical Fallacy: Post Hoc Ergo Prompter Hoc (after something so because of it). Parents “bronchial congestion” too vague. Pneumonia? Was she hospitalized? Or is everything just the parents take. I can think of a number of things that could explain the outcome, not any the “adjustments.”
One case report is an anecdote, nothing more, nothing less
The child probably had asthma (frequent chest infections, congestion, wheezing, family history of allergies). The symptoms commonly improve or even disappear spontaneously as the child gets older. This case report is not impressive.
I’m, by no means, an expert on chiropractic; but my friend who did his doctorate in Sweden in physiotherapy is. It is wrong to assume all chiropractic education is the same. In fact, those I’ve talked with don’t even discuss “subluxations” and have had good courses in anatomy and physiology. As I wrote, some simply carry out physiotherapy, calling it chiropractic. And, though I’ve taken advanced first aid several times, long before I knew that blue meant emergency. My main problems with chiropractic is not that some basically carry out physiotherapy; but there is NO rigorous scientific requirements compared to physiotherapists.
When I was in Sweden, dentists could NOT give general anesthesia without first going a quite rigorous course and following an anesthesiologists during surgeries and supervised practice. In U.S. at the time, a dentist was NOT required to have any training or education in anesthesia; but many used it. In any case, I always opted for a local for root canals and one tooth extraction. And even today, requirements for various professions differ somewhat from state to state.
I’ve never even taken a first aid class, but I know that if my kid’s lips turn blue, he’s not getting enough oxygen. One of mine was kinda choking once and when the usual slap on the back didn’t help, I called 911. They started asking a zillion questions and I saw his lips turning blue in front of me. I dropped the phone, grabbed him, turned him upside down (he was about six), sort of bounced him up and down and a piece of some food (can’t remember what) came out. Now, I’m terribly worried you are all going to tell me I could have killed him or that as a mother, I should have had a first aid course, –and I know it’s an anecdote– but it remains one of our favorite family stories. I’ve never really trusted 911 since then, however; they were utterly useless.
The last couple of times I’ve done first aid training part of it has been “what 911 will ask you and what to tell them”, because they need a bunch of specific information, but in the heat of the moment it can seem pretty irrelevant.
Heck, the best thing I’ve learned in all my first aid/CPR classes is: in an emergency, point at a bystander and tell them, specifically, to call 911. “You! Call 911!” It’s amazing how often people don’t do that, or think someone else has done it. (Also, if you’re in an office building, have someone go tell security so they can let the EMTs in.)
We were told to point to a single person, not only to ensure someone does call 911, but to point to a specific person so not everyone calls 911.
My work offered a refresher, and one thing they have said is since we have an internal phone system, do not call 911 from a desk phone. Call the security desk to have them call 911. (I was told the same thing at college). The issue is that 911 will see your switchboard information, not your actual location, and people rarely have accurate address information for locations within a college campus or office building complex. Many security teams also have training to help guide you through the emergency, as well as work with 911 for what they need.
@JustaTech and Terri
That’s good to know, but I was standing in my kitchen clearly stating that my six year old son was choking and turning blue, and I had already given my address and name. No other adults were at home. I think I should have been handed over to someone of at least EMT level medical knowledge.
@ PF
You wrote: “If you had gone to a primary care physician instead of ENT specialists, you may have been referred to a neurologist much sooner.”
I guess I’m not the only one who doesn’t sometimes read carefully as I wrote: “My family physician sent me to an Ear, Nose, and Throat Specialist.”
By the way, my family physician, which is what primary physicians were called then, was a great guy. He took care of my entire family, parents and grandparents, for many years and one weekend a month he went to Mexico to work at a free clinic for the poor. I even went to school with his daughter. Having been involved in medical research for a greater part of my life, even the best of doctors get it wrong. Though I didn’t research it, I would bet that cluster migraines were not as well known back in early 1960s as they are today.
And despite what people in U.S. think of “socialized” medicine, doctors don’t make more by doing more and, yet, on all health care outcome variables Sweden ranks quite high. When I lived in Sweden, on a per capita basis, they had more published articles in peer-reviewed journals than U.S. and this was long before the predatory for-profit journals.
And I do endorse having a good primary care physician. In Canada, approximately half of ALL physicians are primary care, in U.S., unfortunately, only around 20%. Canadians see PCP more times per year than Americans and average visit longer as well.
Many years ago, Robert Brooks of Rand Corporation, did an evaluation of coronary bypass surgeries. Result was only 10% clearly called for and 30% uncalled for by any criteria. Several years later, Arizona ended its “certificate of need” program which required hospitals to show a need in order to open certain specialty units. Within a year more bypasses were being carried out with much higher mortality and morbidity. And then a major scandal where Redding Medical Center in Northern California was found to have performed over 1,000 bypasses unnecessarily, one on a young kid with gastroesophogeal reflux disease. Several died and several developed long term disabilities. It was only found out when one patient who was told he needed a bypass was due in Las Vegas, if I remember correctly to attend a wedding, and saw a doctor there who found NOTHING wrong with his heart. The cardiologist at Redding wasn’t even board certified; but it was a for-profit hospital. Doctors didn’t go to jail, just lost their licenses, and corporation was fined. I can give many such stories, including that morbidity and mortality stats are higher for for-profit hospitals than non-profits year after year.
The U.S. healthcare system is the most expensive in the world and ranks poorly on almost all outcome measures. See my article: The Case for a Non-Profit Single Payer Health Care System at:
http://pnhp.org/news/the-case-for-a-non-profit-single-payer-healthcare-system/
Thank you! That is a very good thing to be reminded of–as I have probably forgotten that. Booster shots are always welcome for the aging brain. 🙂
Ugh. I made the same mistake PF did, then fell asleep on the couch before scrolling down to read this. My apologies. I should have known better than to comment when I was half asleep.
I guess we are both guilty of sometimes being half asleep when reading something. Oh well. Only human???
Most of the time, I am likely to be over-caffeinated because of tea: the (so-called) ‘drink of intellectuals’ according to de Quincey who certainly knew a bit about drugs.
I keep waiting for my radiation accident to turn me into a superhero. I’d love to have the ability to not need sleep.
Taking this sad event as an opportunity to remind everyone: if you have any reason to suspect that someone has a spinal injury Do Not Move Them!
If you must move them, use a backboard and a c-collar. But really, just don’t move them and don’t let them move themselves.
I know. I was face palming as I read Orac’s post on this. However, if they insist on moving themselves don’t force them to stay where they are. You could cause worse damage forcibly holding someone in place.
And if you come across a motorcycle accident, don’t take off their helmet…
Talk to them soothingly until the EMTs get there. Tell them the chicks will dig the compound fracture scars.
I think showing them the one on my arse might get me arrested before the attraction cuts in.
That philosophy only works if the rider is (1)male and (2)heterosexual .
If I’d had a major accident on my motor bike I wouldn’t have cared what the “chicks” thought
The current guidance is that if the casualty is conscious (and presumably not paralysed) to let them move themselves because they will “protect” their injury.
I am a motorsport marshal with a rescue licence so I receive regular training in casualty handling
“Drop table” sounds so much better than “gallows”.
I was pleased to read Wikipedia’s ** article on Chiropractic which included SB definitions and references including Edzard Ernst, Simon Singh, Ted Kaptchuk and Steven Barrett. It went into detail about chiropractic’s philosophy, origins and limitations.
It’s obvious why woo-meisters are unhappy about articles about CAM.
** Notice to Orac and other sceptics:
For a year and a half, PRN has been cataloguing the sins of Wikipedia BUT they seem to have been disappeared- looking at PRN’s Articles / Wicked Wikipedia section where many were stored yields a You broke the internet! sign. Originally, there had been more than 50 but now only a few on the front page and some of those also gone missing!
I WONDER WHY?
@ PF and Panacea
As I wrote, it was my PCP (family doctor) who referred me to ENT. I just did a quick and dirty search for prevalence of cluster headache. It is considered quite rare, around 1 per 2,000. Far fewer than classic migraine. So, a family practitioner with a panel of, say, 2,000 patients, might NEVER find one patient with it. And back in late 1950s. early 1960s, just beginning to be researched.
As for a specialist will look for his specialty, try his best to make it fit, yep, which, despite my family physician, who was a great guy and doctor, getting it wrong, he actually diagnosed a rare condition in my dad and saved his life. It was the ENTs, who found nothing on the X-ray, found nothing when looking into my sinuses, who were at fault. Without anything at all, they were going to carry out unscientifically validated treatments. So, yep, on the whole, ones best bet is a primary care physician and, as I wrote above, the U.S. has far fewer percent of them than many other nations. And PCPs usually less expensive for same treatment given by specialist. Even if one needs a specialist, in most cases, it is best that they coordinate with ones PCP, as specialist focus on one things, whereas PCP knows you “completely.”
However, back in early 1950s, family physicians gave penicillin shots for everything, e.g., common colds. Currently, I have a great PCP, kept him for 20 years now. Years ago, he was doing a bit of research and I helped him with the stats, etc.
You’re spot on with the role of the primary care provider. That’s exactly why I want to go into primary care when I finish my FNP program. I want to build those relationships with patients, and know the whole picture and let the specialists deal with the complicated stuff.
@ Panacea
Once finished with your training, you might want to consider a stint with Medicin Sans Frontier. I know several who have done it. Or you might want to work in an inner city where good people are underserved. Just a thought.
As I mentioned earlier, some CAM practitioners, e.g., chiropractors, basically act as physiotherapists and as I discussed, licensed physicians do carry out unnecessary, even harmful, procedures, that are totally unjustified. In fact, Public Citizen, a consumer advocacy group, has done several reports on just how few doctors ever lose their licenses, despite incompetence, alcoholism, drug use, and doing unnecessary procedures.
However, the answer to problems with scientific medicine is NOT complementary and alternative medicines. In 1993 or 4 the Congress even passed a law basically banning FDA from even determining if CAM medicines were contaminated and/or had the ingredients and amounts on label. INSANE! ! !
What is needed is to use the latest science and oversight to improve the quality of medicine. For instance, a single-payer system with one database could allow teams of researchers to evaluate treatments, etc. And, we could create an FBI unit just to look at fraudulent billings and other problems. Research has shown that for every dollar spent 10 dollars is recovered. FDA should be fully funded, not receiving some of its funding from industry and post-marketing surveillance should be removed from FDA and placed with CDC.There is a somewhat conflict of interest when same group approves then has to find out if maybe they should not have. Also, the law requires drug companies to supply all data and all analyses. Most don’t and the fines are minimal. See, for instance, Ben Goldacre’s book, Bad Pharma. An incredible list of footnotes and references. He did his homework.
The law exempting CAM from FDA should be repealed. At minimum, they should be able to evaluate ingredients and visit production facilities. And, though we can’t ban, for instance, faith healing, the law should be quite clear and enforced regarding any claims made by alternative practitioners, e.g., anecdotes and testimonies shouldn’t be allowed. And the law should clearly ban any procedures, drugs, that are found to have serious adverse events. If people want to pay for homeopathic remedies, at least FDA should ensure not contaminated and NO claims as to efficacy can be made. At least they should have to state that there is NO credible scientific evidence that it works; but some people believe it does.
And the Department of Agriculture has a conflicted mission, to support American agriculture and to monitor and deal with problems in food supply, e.g., outbreaks of food poisoning. As with FDA, the monitoring of food safety should be removed from Dept of Agriculture and a new unit created at CDC.
And, currently, as far as I am aware, only vaccines can be halted if serious adverse events discovered. Other meds and foods begin with asking for a voluntary recall. Long delays before more action taken and more people hurt. Something antivaxxers don’t know or don’t want to, that vaccines can be stopped cold, immediately by law.
The cure for problems with any science is more and better science and separating regulatory agencies contradictory missions.
“Minor adverse events range from transient neurological symptoms, headache, increased neck pain or stiffness, fatigue, dizziness or imbalance, extremity weakness, tinnitus, depression, anxiety… blurred vision, and confusion.”
I have all of these without ever visiting a chiropractor. DIY has saved me a pile of money.
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