Common Emergency Department Presentations OMT Application

00:01 So get to specific conditions you're going to see in the emergency room.

00:05 There are a few classic studies that have been very effective at demonstrating the efficacy of osteopathic manipulative medicine in the emergency room.

00:15 The two biggies are pneumonia and ankle sprain.

00:19 When you talk about the pulmonary system, pneumonia is one of the top reasons for admission to the hospital, particularly through an emergency room, and it occurs in most age groups.

00:31 Other respiratory conditions, like acute bronchitis, are also common in the emergency room in the younger age group, and COPD tends to make patients chronic needers of the services provided in the emergency department.

00:47 So you are going to see these people in the emergency department.

00:50 The MOPSE study, put together by Kennedy Hensel and others in the DO Research Network, have shown that there is a beneficial effect of OMT in patients with pneumonia, that by treating thorax lumbar soft tissue, by doing rib raising and expanding the intra thoracic negative pressure, and enhancing breathing by doming of the diaphragm and releasing of myofascial in this area, you will help with the breathing techniques and with the breathing of the person. Suboccipital decompression is another treatment you can do that's traction at the base of the skull, which is a secondary finding from pulmonary conditions that can improve nerve function and breathing.

01:33 Thoracic lymphatic pump is a common treatment for issues related to breathing that is very helpful, and pedal lymphatic pump is another way to enhance lymphatic return and help people feel better.

01:47 There are some positive effects of osteopathic manipulative medicine that we strive to get in our patients.

01:53 Number one is you can increase the vital capacity of the lungs.

01:57 You will also increase rib cage mobility by manipulating a person. You can improve the peak expiratory flow rates.

02:04 You can improve diaphragmatic functioning, which also will enhance breathing.

02:09 And you'll enhance the clearing of airway secretions.

02:12 You can enhance autoimmune functioning through O&M and decrease the workload of breathing, all of which will increase patient well-being.

02:22 So just some pointers for treatment in the ER.

02:25 Always obtain consent and explain what you're doing when you intend to treat a patient and why you're doing this.

02:31 What are the intended possible outcomes, and what's the benefit you expect to get? Adapt your treatment to the hospital situation and the seriousness and the illness of the patient.

02:42 I tend not to lie a patient with breathing problems prone.

02:46 Work with the patient.

02:48 If there is pain in one area, you don't want to exacerbate the pain to do manipulation. And when you're treating around nebulizers, IVs and other things.

02:57 Be respectful.

02:58 Understand that there are going to be limitations due to other treatments, and the issue that would cause the most damage the soonest is the one that gets addressed the first. Musculoskeletal conditions are a common reason for presentation to the ER. We do know that sprains and strains are common in young patients between one and 17 years of age.

03:20 It's also seen, at age groups between 18 and 64 years of age. You will also see non-specific chest pain, which is the top ranked reason for E.R.

03:32 visits in patients 45 years of age and older.

03:35 It's also a very hard condition to diagnose comfortably.

03:39 Oftentimes, even when patients don't have two out of the five Framingham five risk factors, we often feel uncomfortable sending them home.

03:47 And we need to look and prove to ourselves that it's not cardiac because even though non-specific chest pain may only turn out to be cardiac in 5% of patients, you don't want to miss that 5%.

03:59 So looking at the musculoskeletal findings, to confirm or deny what's going on can be very helpful.

04:07 The other conditions include abdominal pain and back pain problems.

04:11 These are some of the most frequent reasons for ED visits and are sometimes difficult to discharge as the discomfort remains.

04:21 Treating abdominal pain or the secondary symptoms of abdominal pain, particularly the hypotonia of the muscles in the thorax, can be very helpful.

04:29 Treating back pain and getting the patients somewhat better so that they leave the ER feeling better than when they came is often very helpful.

04:38 With chest pain.

04:40 1 to 3 of office visits to a primary care provider involves chest pain.

04:44 And the most common cause is musculoskeletal.

04:48 Teaching the patient to deal with it themselves through deep breathing, turning, positioning or arm movements that can help or hurt the pain is often very helpful.

04:58 It's often instructive to the patient to know if they know what causes the pain.

05:03 They'll feel more comfortable living with the pain, with osteopathic diagnosis. Using the musculoskeletal system to elicit other, other pains and other problems is often helpful, particularly in knowing if the pain is due to secondary causes and whether it's viscerosomatic in nature. If you can distinguish between acute and chronic problems, it'll give you a sense of how long it's going on and how seriously to take the patient.

05:30 Acute problems tend to get you much more concerned than a chronic problem, so having the ability to discriminate in the ER is very helpful.

05:39 You also want to screen for and document key somatic dysfunctions that can contribute to your patient's presentation.

05:46 Again, any time you can have a person leave feeling better and feeling healthier than when they came in, they'll feel that it was a successful ER visit, and you did what they, what you had been asked to do.

05:59 Musculoskeletal injuries that come to the ER can often be treated with osteopathic manipulative medicine.

06:05 You will find the region.

06:06 You find the restriction.

06:08 You show them biomechanical what they can't do and should be able to do.

06:12 Oftentimes, you may just be documenting age or deterioration of a patient's health, but that's still helpful and that they can see and assess for themselves where they have problems.

06:24 Giving them a biomechanical marker and a biomechanical understanding of a problem is often helpful. And then applying OMT as tolerated to a muscle spasm or a decreased range of motion can often be very helpful.

06:37 In the ER, we tend to use more indirect techniques as patients have a heightened sense of anxiety and direct techniques like velar may not be as well tolerated as they are in the outpatient setting.

06:49 We also want you to think anatomically and think logically OMM does give you some of the tools to be an active searcher for answers and to use the biomechanics of the body to look.

07:03 With Osteopathic Techniques.

07:04 We do use a lot of myofascial release soft tissue techniques that are helpful strain. Counter strain techniques for musculoskeletal conditions tend to be very well tolerated and easy to do, although 90 seconds seems to be more in the emergency room and take longer than it is in other places. Articulatory techniques, including HVLA, can help to mobilize and increase motion and can be helpful, particularly when you need to get some benefit or when the patient has had a history of manipulation and knows what they want done.

07:38 Muscle energy and facilitated positional relief can be helpful with improving the range of motion and decreasing muscle hypotonia and lymphatic techniques. A favorite of many of us DOs, to help return lift will help identify areas of the body where you may have uncompensated zinc patterns or pooling of lymphatics or congestion in the muscles gives you good information, and this allows you to treat the patient at the same time.

08:07 With abdominal pain, which is a common presentation to the ER.

08:11 It helps with assessment to look for viscerosomatic reflex.

08:15 You can treat localized sources of pain as well as referred pain, and an understanding of the reflexes can help guide your diagnosis and treatment.

08:27 While severe abdominal pain is not going to respond to OMT.

08:32 Again, using it for the diagnosis is helpful.

08:36 An awareness of visceral innovation and how the abdominal viscera and pelvic viscera are innervated can be helpful knowing where the innovation comes from, whether it's the greater splanchnic nerve, or the celiac ganglion, whether it's the lesser splanchnic nerve or the superior mesenteric ganglion or the least splanchnic nerve.

08:58 And the inferior mesenteric ganglion is a good way of thinking about where the innovation is and where are you going to see changes in tone.

09:06 With hyper sympathetic tone, you'll see impaired GI motility, you'll see a decrease in GI secretions, a hypoperfusion of abdominal contents, and decrease oxygen supply to the abdominal viscera, as well as leading to a prolonged healing time for these patients and decrease lymphatic drainage so that they're going to have pooling and congestion occur and make it harder for them to get better.

09:32 It's important to always educate your patient as to what you're doing, giving them an understanding of what their pathology is as well, as well as what the potential treatments can do and why you're thinking about the treatments you're thinking about doing. Explaining the tenets of treatment is also important. I don't usually go into the five models, but it does help me have a world view on what the patient is coming for and what they're looking for in an ER visit. And again, getting informed consent from the patient is also critical.

10:03 When I treat patients I'll use techniques that I know are comfortable.

10:07 They're not going to put the patient at risk or worsen the primary condition that brought them into the ER.

10:12 And I always point out the restrictions they have and what are the biomechanical findings we're seeing, so they understand what's going on and feel a part of their treatment. Follow-up care includes advising the patient that they may be sore and that they may have changes and discomfort in areas distal to where they initially had instructions for follow-up care should be provided and you should establish some form of continuing plan for the patient to make sure they know where to go and how to continue to receive care. So as an ER doc, there are definite places that osteopathic manipulative medicine has a place, has made a difference, and the data is out there to support it in a number of different areas.

10:57 I wish you the best.