You have seen many patients who complain about neck pain following a car accident, and usually treat them for whiplash. While they may be suffering from whiplash, patients could also be dealing with symptoms other than neck pain.
The effective chiropractor will observe these rules in a potential whiplash case: Listen and record each and every symptom; examine every symptom to see if there is any objective test that would either confirm or deny that the symptom is real; write down a diagnosis for each symptom confirmed by examination; formulate a treatment plan for each diagnosis; and educate, encourage and comfort the patient.
The first rule is to thoroughly consult with your patient. As a lawyer, I review doctor records every day, and most of them reveal that the doctor failed to thoroughly consult with the patient or simply did not record what the patient said. I suggest using a comprehensive Symptoms questionnaire that includes not only musculoskeletal injuries, but brain concussion symptoms as well. Generally, the patient will only fill out 30 to 40 percent of what is really wrong with them. Accordingly, the doctor must consult carefully with the patient using the Symptoms form as a guideline. I find that when I explain or define the words on the paper that were not checked, the patient often says, "Oh, yes, I have that." They just didn't understand the word.
The second rule is to examine every symptom. Once you know all your patient's symptoms, you are responsible for examining all of them. If the patient states they have sleep disturbances, anxiety while driving and difficulty concentrating, you must evaluate, test and treat these symptoms (or refer the patient to someone who will). Ignoring all the non-chiropractic symptoms is malpractice. Statistics from more than 400 chiropractors that have attended my seminars and learned how to diagnose concussions indicate that between 35 and 55 percent of the patients that walk in with a whiplash also have concussions. There are questionnaires and tests for concussion that are easy to administer, and the doctor can appropriately bill for performing these consultations and examinations, resulting in giving the patient better care. If you have never diagnosed a concussion in your entire career, you have probably missed a lot of concussions.
Another major injury that many doctors miss is torn neck ligaments. The diagnosis code 728.4 is used when the flexion and/or extension x-rays reveal stair-stepping of George's line. This is very common in whiplash patients and many doctors incorrectly call it a sprain/strain. Patients with this injury have sclerogenic referred pain into their occiput, neck, shoulders or upper back, depending on the level of the ligament tear. Since you are irritating the already torn ligaments, vigorous neck adjustments make these patients more sore. Proper examination of this injury with a full Davis series is crucial to an accurate diagnosis and prognosis.
The third rule is to diagnose accurately. If a doctor fails to even ask the patient about all the symptoms and then neglects to properly examine each and every symptom, how can he be expected to make the appropriate diagnoses? There are many diagnosis codes, and various attorneys over the years may have told you to use this one and stop using another one. I advise you to simply be a good doctor. You are not the advocate for the patient. Leave that to the attorney. Your job is to describe each and every diagnosis for your patient. There are separate codes for neck spasms (728.85), neck pain (723.1), neck muscle pain (729.1), cervical strain/sprain (847.0), neck subluxation (839.00 for one, 839.08 for multiple), and loss of lordosis (737.29). Does any one or two of these describe the typical whiplash patient? Of course not; most of them have all five. In addition, when there is hand numbness, there are separate codes for cervical nerve injury (953.0), cervical sensation disturbance (782.0), and cervical disc herniation with neuritis (722.0). Can only one of these describe the patient's true clinical picture to a non-doctor such as a claim adjuster or lawyer? No. The "how to diagnose" lesson here is to be thorough, accurate and honest. Use each and every appropriate diagnosis so that the lay person reading your records knows exactly what is wrong with your patient.
The fourth rule is to treat all injuries or refer out those you do not treat. It is dereliction of duty for a chiropractor to consult, examine and even diagnose correctly, but then just start adjusting the spine while ignoring all the other injuries. If you do not treat TMJ, refer the patient out to someone who will. If you do not know how to treat brain concussions, diagnose it and refer out to a neurosurgeon or neuropsychologist. You should not be the only doctor treating your patient when they have injuries that you simply do not treat.
Finally, the fifth rule is to educate, encourage and comfort the patient. Chiropractors traditionally excel at this and display wonderful bedside manners. However, if you missed the brain concussion, there is no way you can comfort the patient or teach them what to expect. I have told hundreds of patients (and now law clients) to go home and tell their families "why they have been acting so weird since the accident." The patient knows they are highly irritable, forgetful and not thinking clearly, but they try to hide it from their family and boss. Nobody wants other people to know how truly messed up they feel. They withdraw socially, lose libido with their spouse, yell at their children, and sometimes end up getting fired at work after a few months because they could not hide their concussion symptoms as well as they thought they were. They silently hope that the symptoms will just go away before they have to tell anybody.
Whenever I advise a patient to tell their family, they always come back and say, "I told my family that I have a concussion and they were so relieved and supportive. They thought I was crazy for the past few months." Part of your job as the doctor is to educate, encourage and comfort the patient. You can only do that if you know all your patient's injuries. Educating your patients is beneficial not only for helping them, but for expanding your practice.
Dr. Steven Eggleston, a 1987 graduate of Los Angeles College of Chiropractic, practiced chiropractic for 20 years before becoming a lawyer. He now practices law in Newport Beach, Calif., and is the author of the newly released book Whiplash & Motor Vehicle Collisions.