Prior to getting familiar with the case I am about to describe, I highly recommend to read this article.
I called this article “Critical vs. Clinical Thinking.” I hope we all agree that critical thinking is involved in most situations of our life, including and not limited to intellectual dynamics of clinical thinking. But if critical thinking will compel you to a search for scientific data, it will lead you astray from the specific clinical picture thus becoming useless and having nothing to do with clinical thinking process and the outcome of it.
Last Monday, September 7th, 2015, a 47-year-old lady, a nurse practitioner came to me, complaining about an intensive lower back pain; more toward the left side. According to her report, the last three days it was getting worse. Painkillers and anti-inflammatory drugs did not really help.
Palpation is the part of a massage therapy examination procedures where we try to discover trigger points, tension within the fascia, muscles, etc. I didn't discover many trigger points that would support skeleton-muscular disorder in the lower back. The description of symptoms she offered, and what I have felt with my fingers didn't match. However, when I examined abdominal, even a light touch produced an unusually sharp pain, and mostly on the left site. I told her that this was not the case for a massage therapist, and highly recommended her to go to an emergency room. She asked me to explain her my suspicions.
As usual in such cases, my responses that I am not a medical doctor and cannot diagnose, but from my experiences it didn’t look good. I also explained to her that if the trip to an emergency room would not entail any real concerns it also would also not pose any threat – better be safe than sorry. However, if this is a life-threatening condition, not going to ER, at the very least, is irresponsible.
She told me that she was a nurse practitioner and she could diagnose and that she wanted to hear my opinion. I said that her condition looks like diverticulitis, and, possibly, her condition was progressing. I felt with my hands an unusual stuff. Luckily I examined her at a hospital research laboratory, a few yards from ER where I volunteered to walk to.
Three days later, when I was back in the laboratory, I asked about her and the guys who knew the story praised me, claiming that my actions saved her life. I answered what saved her life was simply my refusal to treat at that moment.
What it turned out to be was a difficult case of peritonitis, including infected pouch ruptures, spilling intestinal contents into the abdominal cavity. The client’s condition required emergency surgery, IV and significant amount of Antibiotics. She was in a life-threatening condition. The confusing part of the diagnostic process was the fact that she didn't experience abdominal pain, but the pain in the lower back.
There are cases when people complain about pain in certain body parts, which isn’t an indication of orthopedic disorders. We, as massage therapists, should be careful prior to starting a treatment if we cannot palpate obvious trigger points that can explain the symptoms. I advise forming questions in a specific manner. They should clarify if a client feels pain in places where trigger points, related to the described symptoms, usually reside. Unless this is done, it is easy to misinterpret the complaint and come to the wrong conclusion. It could be a coincidence. A person can develop trigger points, but similar to what happened in this case, it wouldn't be related to diverticulitis.
In the aforementioned case, I asked the questions in the manner I recommend. The client’s recognized the presence of trigger points, but they were not related to her lower back pain. She just described what she felt, and this helped me to make the right decision, after careful investigation of abdominals. Three days later, I went to visit her at the hospital. She presented me to nurses and doctors as a hero. I responded that all my heroism was in the fact that I decided not to provide a treatment.
Sometimes even doctors can make mistakes and refer us patients with a similar clinical picture. In the above case, it was very easy to miss diverticulitis without complaints on the abdominal pain, high fever, and much nausea. Just a light touch was enough to determine that this is not the case for a massage therapist, and to come to a conclusion that this was diverticulitis. We are not only the first door-keepers but sometimes, also frontiers in recommending the urgent medical attention.
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