Subject: Practice Notes - August
Date: Mon, 1 Sep 1997 09:39:47 -0400 (EDT)
From: Gaknutson@aol.com
To: chiro-list@silcom.com
    
   This electronic diary contains reflections from my practice.  I have a 
need to write, and thought others, particularly students, might find such 
stories interesting. 
-------------------------

   Janice dropped by today.  No matter how many times I look at her hands, I
wince.  The fingers are twisted like sapling trees in a harsh wind, her 
wrists grossly bent, locked in lateral flexion.  
   Rheumatoid.  At 46.
   Unlike people I have known, and patients I've had, who look upon the 
slightest discomfort as the golden opportunity to social security 
disability, Janice continues to work.  A grocery checker who often uses
those twisted limbs to pick up and pack gallon cartons of milk.
   And some people with "fibromyalgia" and "chronic fatigue" gulp down 
Prozac, lie in bed and whine, all-the-while collecting the government check.
   Attitude?  Upbringing?  Who knows.  
   I know whom I'd rather have as a patient.
   To help her get a little better leverage for packing groceries, I had the
idea of getting her a swivel stool.  That way she can turn from the register
and get square with the packing job at hand.  This has saved her from pulling
her thoracics, for which she is grateful.  
   I'm grateful for people like her.

   My first look at Jeff did not give me a good impression.  He had a bug-
eyed, wild look to him.  Then again, I was not surprised.  His grandmother 
was bringing the twelve year old in for chronic neck and back pain.  Turns 
out he has been diagnosed as having Tourette's syndrome and ADHD.  He was a  
walking drugstore.
   I thought schools taught kids to just say no.
   Jeff needed work, badly.  His mother was caught up in an HMO, so, given 
poor Jeff's condition, I relented to filling out the damnable referral 
authorization forms.  His grandmother smiled and said that regardless of what
the gatekeeper doctor decided, she'd be paying me.  Her other daughter had
been in to me for treatment of a long standing condition and responded quite
well.  Hell, we fixed her.
   I asked the all-powerful gatekeeper wizard of the HMO for six visits to
see what I could do for Jeff.  Truthfully, I expected none.  I got a letter
back OK'ing me, or to pay Jeff's mother, for one, that's right, one, visit.
   I wrote the MD back, expressing my amazement at what he thought could be 
accomplished in one visit.  I vowed to refer any patients I had that needed 
medical treatment to him.  If, in his estimation, one visit is all that is
necessary for a chronic condition, he was the man my patients needed to see.
   I got the six (whole) visits.
   As expected, adjustment fixed Jeff's chronic neck and back trouble.  On a
follow-up visit some weeks later, his grandmother also said he hadn't had a
Tourette's episode since seeing me as a new patient.  She and Jeff's mother
had talked the physician into taking Jeff off the Tourette's drugs.  When I
had last seen Jeff, he had been drug free for two weeks and had thinned
considerably, facial roundness and weight gain being side effect of the
medication.
   Poor kid still needs a man in his life and other than a bit of playful
wrestling in the office, I can't give him that.  You can help people, but you
can't fix their lives.

   I got a letter in the mail from the Dumba** Insurance company.  The 
letter said that payment had been delayed because they had sent the check 
to my old address, and I would not get payment until I sent them a change 
of address.
   Hello?
   In the first place, I had sent them change of address when I moved over 
two and a half years ago.  I sent them a change of address the first time 
they tried to send a check to the old address.  Some time later, I faxed 
them a signed change of address on my stationary when they failed to pay 
and said they needed a change of address.
   This letter was the last straw.  I called them up.
   "We need a change of address", the pleasant woman without a clue purred 
over the phone.
   "I've done that four times," I answered
   "Oh, you couldn't have, or we _would_ have it," she emphasized.
   I remained quiet for a second, letting the tension build.
   "Ah... let's see; you don't have my new address to send me the check,
but you do have my new address to send me a letter telling me that you 
don't have my new address."
   Silence.  "We'll get back to you."
   I'll hold my breath.

   It was 48 this morning, in mid August no less.  A blessing of cool
Canadian high pressure air.  I blocked the door open at work, trying to get
that wonderful air into my sealed box of a modern office.  
   Central air and heat are great, but how about windows that actually
opened?  
   Walking outside I took a deep breath, letting the fresh air detoxify me
down to my toenails.  
   I didn't have a busy schedule today, it is August.  I've been on vacation
almost three weeks in the last eight, during which time I don't schedule new
patients (makes follow-up too hard).  Patients are also on vacation.  The
office rhythm just gets out of sync.  
   It is always slow this time of year; and not just for me.  The local 
work-like-hell-and-advertise DC's are doing just that.  The newspaper is 
filled with their smiling faces.  Of course, all the MD's not connected to 
the local pick-a-winner HMO are advertising also.  Healers advertising is, 
to me, unseemly.  It's as if we want to make well people feel sick, although
I realize that's not the intent.
   On impulse, I grab my desk chair and move it out the front door onto the
south facing, but shaded concrete slab in front of the office.  I grab my 
newspaper, sit down and lean back, each breath filling my lungs with that 
marvelously fresh air.  I laughed at myself.  Here I sit looking like Floyd
the barber in Mayberry.  
   That was a simpler time, less hectic.  Even if you were the town doctor, 
or chiropractor, you could sit outside and enjoy a fine day.  People looked 
up to you as a doctor, a professional, but you were also just one of the
local folks.  Times have changed.  Now it is expected that a doctor acts a
certain way, drives a certain car, lives in a certain neighborhood, ad
nauseum.  What's nice about being a chiro is I don't have to wear the white
jacket with the stethoscope around my neck; always looking and acting
serious.
   So I sat outside in my reclining desk chair, comforted by the fact that my
patients are used to my idiosyncrasies.
   One of my patient's, a transplanted Californian, called this San Diego 
weather.  If so, it is no wonder why so many people flocked to California.
   As I got busier that day, I left the chair out front.  It was used by many
people, mostly older folks who probably recalled those slower days.  And
children, who didn't know life was supposed to be serious.
   It isn't.

   Susan came in this week.  I had not seen her for almost a year.  Susan is
a professional singer - opera.  In the year of her absence from the office,
she had rubbed elbows with Placido Domingo and that round mound of operatic
sound himself, Luciano Pavarotti.  Susan is... good, very good, at what she
does.  A rising star.  
   Susan came to me some years ago after an auto accident.  Nasty whiplash on
a rain soaked San Francisco highway.  After the accident, she found her
voice, and by extension, her life, did not have the power that it should
have.  Susan's mentor/instructor teaches here at Indiana University, and
somehow Susan was sent to me.  She needed care.  Subluxation had caused
altered dynamics of the cervical spine and the anterior cervical muscles were
working to straighten the neck and keep the head vertical.  Those same
muscles are also accessory muscles of respiration.
   When you sing for a living, these muscles are put to use lifting the rib
cage, expanding the respiratory volume.  Now, they were not.  Or at least 
that's my story.
   After the second visit, she came into the office all smiles.
   "I can sing again," she announced, then proceeded to show me. 
   The sonic blast of her voice was unlike anything I had heard come from a
human being.  The resonance, the vibrato and the sheer power.  It was so
loud, so unexpected, that my jaw dropped open like a cartoon character.  I
felt like walking around her, looking for a microphone and amplifier.  I
understood why people paid money to hear her sing.  It was, unforgettable.
   I've been her chiropractor ever since.
   Susan comes from Alabama, but you'd never know it to hear her speak.  I 
teased her about it once, and she lapsed into lilting southern drawl to prove
she was the genuine article.  Of course, she has to speak fluent Italian,
French and German to sing; O mio babbino caro would not sound right with an
Alabaman drawl.  Susan comes in when she is in town to get checked or worked
on.  She needed it this visit.  We fixed her up and sent her traveling for
another six months.  A modern wandering minstrel.  
   Susan is going to make her solo debut at the Metropolitan Opera, New York,
this fall or early next year she said.  She's thrilled, and I for her.  She
is the most famous person I know.  Also, one of the nicest.

   For better or worse, this is practice.  Or anyway, my practice.  Have a 
good month, and take care of those patients, and of yourself.

Gary Knutson DC
		****************************

Subject: Practice Diary - September
Date: Mon, 29 Sep 1997 23:14:41 -0400 (EDT)
From: Gaknutson@aol.com
To: chiro-list@silcom.com

   This electronic diary contains reflections from my practice.  I have a 
need to write, and thought others, particularly students, might find such 
a practice diary interesting.  
-------------

   Some older patients of mine drive me crazy.  They sit around the office 
and compare ailments like Hooper, Quint and the Chief Brody drinking rum and
compared scars in the memorable scene from Jaws.  I wonder what is the
psychology behind the need to be or have been the "sickest".  Does the 
winner have a gravestone that announces, "See!  I _was_ sicker than you!"?
   We all have a need to be good, perhaps the best, at something; at least 
in our own little pond.  But to choose illness as something to be the best
at!?  To focus on illness cannot be good for you.
   Then again, maybe I'm wrong.  It isn't the illness; it is the surviving of
the illness, the conquering of the illness.  Perhaps that is what is worth 
comparing yourself to others about.  It is about your personal ability to 
suffer hardship and survive.  Yeah, that sounds right.
   So I'm thinking these thoughts and Allen comes in.  Allen is a big, tall
strapping fix-everything mechanic.  Yet, he has this unnerving habit of 
wanting or needing to exaggerate his symptoms.  Almost like, because of his
physical stature, I will not believe him when he says he hurts.
   This could also be his reaction to having been told many times by the
medical system that there was no cause for his pain, that nothing was 
_really_  wrong with him, even to the point of suggesting psychological 
consultation.  I can't imagine telling _that_ to Allen; a man who could 
crush you by twitching his little finger.  Whatever Doctor told him that was
brave or arrogant; either way, misguided.  
   Perhaps as Allen was sucked further and further into the medical whirlpool
with treatment after treatment being ineffectual, he began to amplify his 
symptoms in the hopes they would take him seriously and finally get the 
diagnosis and treatment correct.  Of course, they saw this amplification and
because of his behaviour, labeled his whole problem as psychological.  He 
would not be my first patient who's been told that they are, essentially, 
crazy.
   Allen had back, neck and shoulder pain, with his trap so tight it pulled 
his shoulder up significantly towards his ear.  I see this a lot, and call 
these cases trap spasms.  Like many cases labeled "hopeless" or 
"psychological" by the medics, we were able to fix him up.  But now, when he
jams himself out of line, he insists on coming to the office with his shoulder
raised to the height of his ear.  But this in only for show.  If I engage 
him in conversation, or he sits and waits, the shoulder drops lower and 
lower until it is at a normal height.  As soon as he becomes aware of this 
- zip - back up the shoulder goes.
   In the end, and for whatever reason he does this, it seems harmless to 
me.  It is just another one of those things you learn about people, and how 
differently they react.  How many people do you suppose amplify symptoms in 
order that attention be paid?  And attention must be paid.
   The psychology of practice.

   For some reason, I am being challenged with unusual cases lately.  It's 
not that I don't like the unusual, on the contrary, they tend to break up 
the everyday low back, neck and headache cases.  The problem is I feel 
uncomfortable taking money for providing services in an attempt to provide
relief for a condition that I basically have no clue about.
   Of course I realize that does not stop the medical machine from taking 
money x 100 to find and do nothing.  But like my ma-ma always said, two 
wrongs do not make a right.
   A seventy year old man is sent to me by his wife.  He has a diagnosis of
idiopathic peripheral polyneuropathy, with which he is duly impressed.  I 
point out that this diagnosis is merely describes his condition, prefaced 
with "we don't know why".  He nods his head in assention; he has known as 
much.  Melvin is not a smoker and does not have diabetes, so the _cause_ of
the peripheral polyneuropathy is unknown.
   Eight years ago his right leg began to feel cold.  Miscellaneous medical 
tests found nothing.  Gradually he developed foot drop in the right leg.  A 
brace was put on the right leg and under the right foot to keep Melvin from 
tripping over the dropped foot when he walked.  The "unnerving" problem 
spread into the left leg, again beginning with coldness, then what seems 
to be loss of muscle control.  There are no other symptoms.  The only history
was disc surgery, shaved a bit off, some twenty years ago.
   I feel like Keanu Reeves at the hands of the mad bomber (Dennis Hopper), 
in the movie, Speed; "Whaddya do now, hot shot?"
   Has the Medical Diagnostic machine been exhausted - yes.
   Evidence of subluxation - yes.  
   Could you imagine a scenerio in which subluxation could cause this 
symptomatic complex - yes.
   I explained to the patient that I was not sure at all whether what I do 
could help him, but that it _might_.
   We decided to go ahead and roll the dice.  Sometimes _might_ is all the 
chance you get.  It sure beats watching yourself slowly get worse with the 
possibility of a wheelchair in your future.


   Marjorie had been referred in by two good patients.  One whose husband 
was an OD, and ran the clinic at the college here.  But that didn't 
matter... Marjorie was quite nervous.  You'd think I had horns and a tail 
or something.
   Marjorie's problem was with her left hip and leg.  The leg begins to 
cramp after being in bed for a few hours.  She was up at three or four every
morning, walking around, trying to stretch out her leg.  Minimal exercise 
helped, heavier exercise just made the leg and hip cramp.  Hot baths made 
the leg better, but just temporarily.  
   Marjorie's was well plugged in to the medical world; her son is an 
anesthesiologist who specializes in giving nerve and joint blocks and 
epidurals for back pain.  She's been poked, prodded, shaked, baked, ray'd and
MRI'd.  Nothing.  Nada.  Zip.  Zilch.  So to make everybody happy, they 
gave her problem a name - sciatica - and prescribed pills which she does NOt
like taking.  
   So now, a year and one-half later, she's in the office of the devil 
himself... me; a simple country chiropractor.
   I've heard her symptom complex before, and to her amazement, begin to 
tell her other things she does that bothers or helps her leg.  Surprised at 
what seems to be my knowledge of her problem, she twists her mouth into a 
frown and says, "what are you doing to me now?"
   Because she wants details, I tell her she has an atlanto-occipital joint 
dysfunction causing a pathologic asymmetric tonic neck reflex and pelvic 
torsion which has resulted in a piriformis syndrome which tends to mimic 
sciatica and abnormal contraction of the soleus causing the calf pain. 
   That'll give her something to chew on.
   The next day, we review the findings.  Before we begin treatment, which 
will involve upper cervical work, she wants to know the risk of stroke and
spinal cord damage.  I explain that it is about 1 in a million, and with the
kind of linear, vectored work that I do, probably less.  In any case, much 
less than the risk of taking NSAIDS, which is what she is doing now.
   She is directed to the table, nervous, stiff and uncertain.
   "My son wants to do an epidural for this," she says.
   My patience is thinning.
   "He has a large practice giving injections to people with back pain."
   "Probably failed back surgery patients," I interject, getting irritated.
   "He drives a Mercedes convertible," she says, wincing before I even 
touch her.
   I adjust her, and roll her over.
   "Wiggle your toes," I say.
   She does.
   "See, you survived!"
   Five days pass, and Marjorie returns, doing much better.  Over the next 
three weeks this problem she's had for over a year, a problem that has 
stumped the best medics she could find (including her son) resolves 
completely.  If what I do depends on the placebo effect, one thing is for 
sure - she was not a willing or "believing" patient, yet, despite her fear 
and ignorance, she got better.
   She even thanked me for explaining things about how the body works to 
her.  It seems her son just doesn't have the time.
   Must be that personal magnetism chiropractors are renoun for.  HA!
Then she wondered out loud if her leg and hip pain could have just gone 
away in the three weeks we were working on her.
   Oye vay...

   Al came in today, I hadn't seen him for over four years.  Last time he 
was in with a nasty acute antalgic low back.  Erector muscles so tight you 
could bounce a quarter off them.  He had to roll off the table and get on 
all fours ont he floor so he could use his arms to push himself up.  
   I had seen things like this before, so his condition did not disturb me. 
What bothered me was Al was a transient patient from Florida.  His wife's
son, a patient, lived here, and they were just stopping by on their way to 
Indianapolis.  There, they were scheduled to be contestants in the couples
horseshoe pitching contest.
   The scene ran in my head, "Hi.  I'm Al.  I've had a bad back for months,
and it suddenly got so bad that I can hardly move and cannot get up without
help.  I've got a contest tomorrow for which we have spent months in training

Then we're headed back to Florida.  So fix me."
   Yeah, right.  No pressure here.
   I did my best with the time and rescources available.  
   I never saw them again - until today, over four years later.
   Turns out he made a miraculous recovery, and they had taken first in 
state for couples horseshoe pitching.  He's had no trouble in the years 
since then.
   Goes to show, lack of follow-up does not mean the patient didn't do 
well.  It could just be the opposite.  And, hey, transients need care too.

   For better or worse, this is practice.  Or anyway, my practice.  Have a 
good month, and take care of those patients, and of yourself.

Gary Knutson, DC