Spasmodic torticollis

It was 2:30 a.m. and I had already been asleep for three hours when my beeper went off. It was the Emergency Room at Meadowlands Hospital Medical Center in Secaucus, New Jersey. I returned the call to find that a three-year-old girl had developed sudden neck pain while playing. The parents went into a panic at the sight of their daughter tightly clutching her head and screaming in agony. Unsure what was wrong, the parents proceeded immediately to the ER.

As the on-call doctor of chiropractic for the hospital's Emergency Department, I was at the ER within the required 30 minutes. The emergency physician had ruled out underlying pathology and fractures through physical and radiological examination and had fabricated a small, soft, cervical collar out of a strap from a shoulder sling. A cervical collar and Motrin, however, were not nearly enough to relieve the severe muscle spasm in the child's neck, or to remove her parents' concern and skepticism over the prescribed treatment. Narcotic analgesia might lessen the symptoms, but it would also produce an obviously drugged child -and possibly further frighten her parents. The emergency physician said she was looking to me, as the on-call DC, to reduce pain, increase mobility, avoid narcotic analgesia, and increase patient (and parent) satisfaction.

Upon entering the patients room, I saw a terrified child and two worried parents-all three had tears in their eyes. The child sat in the middle of the ER stretcher, while the parents were huddled in a corner, seemingly afraid that if they got too close, it would cause the little girl to scream again. I took a few minutes to speak with the parents in a reassuring and gentle tone. As the tension in the room subsided, I touched the child's shoulder while still speaking to her parents. I needed the child to trust my touch. Even though it was past 3:00 a.m., just "getting down to business" as a doctor of chiropractic did not seem to be the best approach. The child protested somewhat as I removed the cervical collar, but I convinced her that I needed to take it off in order to help her. Examination revealed antalgia, muscle spasm, muscle tenderness, and severe vertebral joint fixation. She was suffering from acute spasmodic torticollis.

Treatment consisted of a muscle contraction/stretching technique, followed by cervical adjustments. Each part of the treatment was performed slowly with a complete explanation given to both parent and child. Subsequently, the three year old was able to touch her chin to both shoulders and chest. She was able to look up at the ceiling. The same little girl who clutched a cervical collar like a trusted teddy bear and refused to have it removed now refused to have it placed back on her neck. The ER physician discharged the family with instructions to give Motrin as needed, and to follow up with the doctor of chiropractic as instructed.

Pain relief is perhaps the No. 1 reason that patients go to a hospital's Emergency Department. Despite the statistics that confirm this fact, most ERs do not have pain specialists on call such as doctors of chiropractic, physiatrists, anesthesiologists, acupuncturists, psychologists, etc. Emergency physicians have to rely heavily on chemical means of treating pain, which provide only limited and temporary relief. Often, as in the example of the three year old with torticollis, NSAID medication is unlikely to be enough, yet narcotic medication is too extreme and carries unwanted side effects. Patient satisfaction is often based on the degree of pain relief, yet many conditions -especially those related to musculoskeletal pain -are rarely alleviated in the Emergency Department. By offering non-pharmacologic remedies for pain, such as chiropractic care, an Emergency Department is able to expand its scope of care and pain relief.

This particular program, "Emergency Chiropractic Care," was piloted in November 2000 at Meadowlands Hospital Medical Center in Secaucus. Gina Puglisi, MD, director of the Emergency Department, was familiar with chiropractic care, having been a chiropractic patient herself. Challenged to provide greater pain relief in the Emergency Department setting,

Dr. Puglisi looked to the hospital's chiropractic department. Doctors of chiropractic had been placed on the on-call schedule in the same manner as all other on-call specialists. They are required to be available by beeper 24 hours per day, seven days per week, and must respond within 30 minutes. Patients are seen by the emergency physician first. Fractures, neurological deficits, and other pathology need to be ruled out before a patient is referred to a DC. The determinant for this type of call is musculoskeletal pain involving the back and neck. The pain may have originated with improper lifting, a motor vehicle accident, a slip-andfall injury, or spasmodic torticollis. Treatment modalities include manipulation, soft-tissue techniques, hot/cold therapy, ultrasound, and electrical muscle stimulation. In each case, the patient is asked to complete a confidential patient satisfaction survey after treatment. The results have been very complimentary of the Emergency Chiropractic Care program.

At the Meadowlands Hospital Medical Center, ER physicians, nursing staff, and medical staff have the opportunity to observe and appreciate the results of chiropractic. For their part, the doctors of chiropractic have gained a better understanding of medical conditions, procedures, and practices.

In its second year, the Emergency Chiropractic Care program's list of DCs on call has expanded. The word is getting out that the Meadowlands Hospital Emergency Department is serious about treating pain.

To learn more about how to obtain hospital privileges, order the ACA's new Doctors of Chiropractic: Part of the Hospital System booklet. Call 800/368-3083.

Please contact Dr. Cerf at ced@aoLcom with questions about this article.

Copyright American Chiropractic Association Jun 2002
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