Applying new diagnostic tools and exams for chiropractic patients
A WELL-CHECK OR WELLNESS CHECK, a physical exam for evaluation of overall health, puts an overall focus on preventative care in order to maintain good health or to review or evaluate a previously identified health concern.
Depending on age and other factors, millions of patients are advised to obtain a physical exam each year. According to some sources, 92% of Americans believe it’s important to obtain a yearly exam. However, the problem is that only 62% get one. DCs have an important role to play, if only they would embrace it.
The leading causes of poor health
The National Institutes of Health has stated that valvular heart disease (VHD) is a leading cause of cardiovascular morbidity and mortality worldwide, and negative outcomes from VHD are expected to increase in the future. Millions of Americans have VHD, and millions of Americans have it and don’t know it. Hence, detection, especially early, is key. Because VHD is structural, VHD can be identified by an evaluation of heart sounds and murmurs.
Up until recently, ECG machines have been large, bulky and expensive, but ECG devices are becoming more portable and affordable. The new stethoscopes combine the benefits of a digital stethoscope and an ECG machine. They allow a clinician to listen to their patient’s heart and lungs and immediately obtain the heart’s electrical signals.
One leading platform delivers earlier detection and better outcomes to detect heart murmurs and lung diseases thru a combination of AI-powered detection and analysis; it uses a Bluetooth stethoscope with live streaming and compares what it hears to a vast library of recorded heart sounds used to detect and identify heart conditions in just three minutes. The stethoscope combines amplification and noise cancellation to obtain more accurate readings, allowing providers to detect heart disease in the background that might otherwise be missed.
For doctors of chiropractic, the platform clarifies and increases provider confidence in performing physical exams for patients who, through occupation or generally observed risk factors, have been identified as being at higher risk for heart disease. Every DC has patients who exhibit increased risk factors such as obesity, poor physical conditioning, advancing age or a family history of CVD. Those in certain occupations are known to have an increased risk of cardiovascular disease, such as drivers of commercial vehicles. Driving a commercial truck, and other safety-sensitive jobs, involve not only the patient, but public safety. Avoiding a heart event in a driver may save the lives of others who are in their path.
For chiropractic patient visits related to neurological and musculoskeletal conditions, performing the “vitals,” combined with a quick, simple cardiovascular evaluation, is not only potentially lifesaving, but well-accepted and appreciated by patients.
I saw it in my own practice, and you will as well. DCs who use these new exam devices and systems have the added benefit of building increased patient trust in identifying not only immediate musculoskeletal concerns, but previously undetected life-threatening conditions. You can provide peace of mind for your patients who wonder if they have an underlying heart condition, and it is nearly guaranteed that you will save lives.
As a source of support for certified medical examiners in the national registry performing medical exams for commercial drivers, we are always searching for ways to improve driver medical exams. I would also add to this group of examiners those who have obtained certifications as internists, sports physicians and occupational health specialists, as well as DCs who perform local school sports/athlete physical examinations, and any DC who treats chiropractic patients who work in safety-sensitive positions.
These DCs are treating or examining patients who either have an increased risk of developing heart conditions, are susceptible to sudden death while participating in a sporting event, or represent a significant risk to themselves, coworkers and the public. DCs in these groups should consider if their patient has identifiable risk factors and/or is routinely being checked by their treating physician. This might prompt the performance of vitals, including a cardiac evaluation to determine if an undetected medical condition is present.
Telehealth, DCs and certified exams
Unfortunately, telehealth for chiropractic physicians has been hampered in its development due to significant differences in treatment provided, the patient’s treatment interest and the patient’s perception of the role of DCs in health care.
If the reason for the patient’s visit is limited to an adjustment for their musculoskeletal condition, telehealth does not seem to have carved out a path to making itself helpful, feasible or economical. However, doctors of chiropractic have significantly enlarged the services they provide through postgraduate training, certification and diplomate programs.
The largest postgraduate certification program is the National Registry of Certified Medical Examiners. These 4,000+ chiropractic CMEs perform comprehensive physical exam and health history review for the more than 5 million drivers of commercial vehicles. Because of the medical examinations they provide, the expected role of chiropractic physicians is expanding to meet the skill and training requirements we all met to be doctors of chiropractic.
As a practicing DC, I used computer-aided heart auscultation on every commercial driver. As I share the heart findings with them and select others, I see and hear for myself the surprise and gratitude from those “patients” who have never been evaluated for a heart condition past auscultation.
There was one instance when the computer-aided heart auscultation program I was using determined that the driver needed to be referred to a cardiologist; I would not certify the driver until he went to a cardiologist. About six weeks went by and the driver returned to thank me. He had undergone immediate heart surgery and was told that when he went in that he had only two weeks to live. Now for the sad part of the story. Before I started using computer-aided heart auscultation, I had a driver I examined who died from a heart attack while driving his truck just two weeks after my exam. His wife questioned how that could happen after just having a medical exam. I did not find any indication he was even at risk of having a heart attack. I heard nothing out of order during auscultation. I had been confident in my auscultation skills.
It didn’t help to know that 50% of those with heart disease suffer sudden death as their first heart symptom. It wasn’t much later that I started using some new technology, a computer-aided auscultation program, and the more I used it, the more of a believer I became.
Other vital tools
DCs performing physical exams should also consider using other diagnostic tools. The nine essential tools all clinicians should have are a stethoscope, pulse oximeter, thermometer, reflex hammer, blood pressure cuff, penlight, ophthalmoscope and otoscope.
Vital information can be obtained using a pulse oximeter/plethysmography that illustrates the appearance of an arterial pressure waveform, premature ventricular contractions and a waveform that matches the heart rate and regularity. Pulse oximetry measures the oxygen level of the blood; those who have less than 92% oxygen saturation may have an undetected lung or heart condition. This equipment is inexpensive, readily available on the internet and is a “should have” screening tool.
Doctors of chiropractic have a significant role to play in the evaluation and treatment of musculoskeletal conditions — and if we will embrace it, the role of performing routine physical exams not only on those who are at risk, but all of those we encounter.
MICHAEL MEGEHEE, DC, was appointed by the Federal Motor Carrier Safety Administration in 2005 as a subject matter expert for the National Registry Survey Working Integrated Product Team and the National Registry Education Team that developed the core curriculum for certified medical examiner training. He is a nationally published author and radio show guest and has traveled the U.S. training physicians regarding the DOT physical exam. He was the first doctor of chiropractic to be designated as a Walmart distribution center medical examiner. He founded the TeamCME® National Network of DOT Examiners in 2010. As past president of the nation’s largest provider network of national registry certified medical examiners, he is the medical examiner expert resource to 800 TeamCME member clinics. TeamCME is an Accredited National Registry Training Organization. Learn more at TeamCME.com.