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elfsThe afternoon session sits us all down with the big guy: Doc L, the doctor treating Miss T. He introduces himself as a Doctor of Osteopathic Medicine and Surgery (D.O.), with a 41-year practice. He talks to us of diatheramy and sclerotherapy, and I have to confess that I'm feeling bamboozled. I'm trying hard, and so far succeeding, in not looking this stuff up, in not "forming my own opinions" about the procedures he's describing, but instead taking what's said in the courtroom at face value. I know in this era that there's a gigaton of data about this kind of thing. I could ask Orac: he's a font of data about woo. Is sclerotherapy woo-ey? I have this fretful feeling that it is. That there's no real scientific evidence to back it up. I don't know, and it infuriates my network-born instincts that I'm not allowed to know.
Doc L talks about how his practice is "everything from dandruff to fallen arches." Cute. Sounds practiced. Uses the word "allopathic." Well, score one for him. "A Doctor of Osteopathic Medicine and Surgery is a full doctor. We are not limited. Not like them." We'll learn who Doc L believes is "them" shortly.
Landry goes on for some time, making the case with Doc L that Miss T was benefiting from his therapy. A line of questioning straight out of one of those textbooks. My discomfort is that there's no corroboration. No physical therapy was ordered, no neurology studies, nothing. It's all about the ligaments, which he asserts can only be healed primarily by an irritation technique: he introduces a foreign substance ("sterilized dextrose" or "cod liver oil"-- the last makes the woo-meter tick hard!) and that causes the ligament to grow defensive tissue to protect it against the substance. He makes the comment that skin grafts and bone grafts work the same way-- an assertion I would contest. Introducing growing tissue and spanning the gap sufficient to encourage growth is different from irritating the tissue to encourage defensive growth. Doc L says he looked at the head CT scans, skeletal X-rays, and abdominal ultrasound, but asserts (and I underlined "asserts") that none of them can tell you about ligament failure. (He later admits, under cross-examination, that he never actually saw the films, only the radiologist's reports.) The only way to do tissue density of ligaments is to assess the turgor with a needle; no visualization technique will give you an insight into the status of strained ligaments.
This therapy is his life's mission: it worked for his father, and his mother, and he went into osteopathic medicine to bring this technique to the world. The woo meter goes up another tick.
But he does say that he didn't start this procedure until two years after the accident. Instead, he concentrated on the traditional sports medicine treatments: pain relievers, muscle relaxants, ice, massage to break up swelling and move blood in and out of the injured portion, physical therapy of the injured parts to restore range of motion. He testifies that Miss T is "hypermoble," meaning she has more elastin than collagen in her ligaments, and so has less protection against this kind of soft-tissue damage.
He makes an interesting case against the current three-point seat belt, recommending a four-point instead, although he admits he doesn't have one. We get a show-and-tell, with a full-sized plastic model of the spine ("Gave 'em a bit of a start at the security checkpoint" -- really? Like they don't have personal injury cases come through here constantly?) as Doc L points to where the ligaments are, what the injections are like, and so forth. As he twists and bends the model spine, several members of the jury tense visibly.
I wrote in my notes, "Are there any EBM [evidence-based medicine - Elf] studies that back it up? Double blind, placebo, that sort of thing?" A few lines later I write, "Koenig delivers!" Because he does. His first line of attack upon standing up is a 2007 meta-study concluding that all the studies to date have shown no conclusive evidence that the procedure works at all. The doctor says he's not surprised: it depends upon the skill of the practitioner, and the substance used. My problem with his response is that the same is true of surgery, but if this procedure is fifty years old good grief you would think the docs would have figured out what works and what doesn't? Woo meter plus one. He goes on to diss the "other" members of his profession: chiropractors on the one hand-- "We have significant disagreement about what really goes wrong with the spine"-- and orthopedic specialists on the other-- "They're surgeons. That's what they do. Surgeons love to do surgery. ... I am not a fan of surgery, nor would I recommend it. In this case, I mean." Woo meter climbs once more.
Koenig then goes on to attack a different aspect of practice: the doctor's use of his own hand as an instrument of diagnosis, specifically his use of turgor. I find this a weak line of attack: the hand is a perfectly valid tool, and an experienced hand with a needle is probably better than a machine for determining the turgor of at least some conditions.
Koenig's last line of attack is to the documentation, specifically that his own objective assessments of Miss T's conditions do not match her subjective assessments. Doc L isn't surprised: he might see full range of motion but she might continue to report pain. And indeed, her reports do show "full range of motion" and "within normal limits."
Landry gets back and talks about the procedure. It's painful. No patient would go through it unless they absolutely have to. I write in my note, "What an evolutionary mess we are." A minute later Doc L mirrors my sentiment theologically: "I don't know why our Creator would create us so messed up. To make such marvels as our body, and then not give this one important part of us the ability to heal." His final point is that all of his treatments have been necessary and reasonable for the injuries she has sustained as a result of the auto accident.
The jury gets to ask its questions. Someone asks the obvious: even with the sclerotherapy can Miss T expect to see restoration to full health? Doc L answers no, of course not. But she will see significant improvement and that's what's important. He wants to try and restore her limbs to their pre-injury state, he says. He says he has no reason to believe that Miss T is a "malingerer" or is "being untruthful" about her subjective state.
After that, we're all free to go on our own recognizance.
I'm reminded of a quote I read once:
Doc L talks about how his practice is "everything from dandruff to fallen arches." Cute. Sounds practiced. Uses the word "allopathic." Well, score one for him. "A Doctor of Osteopathic Medicine and Surgery is a full doctor. We are not limited. Not like them." We'll learn who Doc L believes is "them" shortly.
Landry goes on for some time, making the case with Doc L that Miss T was benefiting from his therapy. A line of questioning straight out of one of those textbooks. My discomfort is that there's no corroboration. No physical therapy was ordered, no neurology studies, nothing. It's all about the ligaments, which he asserts can only be healed primarily by an irritation technique: he introduces a foreign substance ("sterilized dextrose" or "cod liver oil"-- the last makes the woo-meter tick hard!) and that causes the ligament to grow defensive tissue to protect it against the substance. He makes the comment that skin grafts and bone grafts work the same way-- an assertion I would contest. Introducing growing tissue and spanning the gap sufficient to encourage growth is different from irritating the tissue to encourage defensive growth. Doc L says he looked at the head CT scans, skeletal X-rays, and abdominal ultrasound, but asserts (and I underlined "asserts") that none of them can tell you about ligament failure. (He later admits, under cross-examination, that he never actually saw the films, only the radiologist's reports.) The only way to do tissue density of ligaments is to assess the turgor with a needle; no visualization technique will give you an insight into the status of strained ligaments.
This therapy is his life's mission: it worked for his father, and his mother, and he went into osteopathic medicine to bring this technique to the world. The woo meter goes up another tick.
But he does say that he didn't start this procedure until two years after the accident. Instead, he concentrated on the traditional sports medicine treatments: pain relievers, muscle relaxants, ice, massage to break up swelling and move blood in and out of the injured portion, physical therapy of the injured parts to restore range of motion. He testifies that Miss T is "hypermoble," meaning she has more elastin than collagen in her ligaments, and so has less protection against this kind of soft-tissue damage.
He makes an interesting case against the current three-point seat belt, recommending a four-point instead, although he admits he doesn't have one. We get a show-and-tell, with a full-sized plastic model of the spine ("Gave 'em a bit of a start at the security checkpoint" -- really? Like they don't have personal injury cases come through here constantly?) as Doc L points to where the ligaments are, what the injections are like, and so forth. As he twists and bends the model spine, several members of the jury tense visibly.
I wrote in my notes, "Are there any EBM [evidence-based medicine - Elf] studies that back it up? Double blind, placebo, that sort of thing?" A few lines later I write, "Koenig delivers!" Because he does. His first line of attack upon standing up is a 2007 meta-study concluding that all the studies to date have shown no conclusive evidence that the procedure works at all. The doctor says he's not surprised: it depends upon the skill of the practitioner, and the substance used. My problem with his response is that the same is true of surgery, but if this procedure is fifty years old good grief you would think the docs would have figured out what works and what doesn't? Woo meter plus one. He goes on to diss the "other" members of his profession: chiropractors on the one hand-- "We have significant disagreement about what really goes wrong with the spine"-- and orthopedic specialists on the other-- "They're surgeons. That's what they do. Surgeons love to do surgery. ... I am not a fan of surgery, nor would I recommend it. In this case, I mean." Woo meter climbs once more.
Koenig then goes on to attack a different aspect of practice: the doctor's use of his own hand as an instrument of diagnosis, specifically his use of turgor. I find this a weak line of attack: the hand is a perfectly valid tool, and an experienced hand with a needle is probably better than a machine for determining the turgor of at least some conditions.
Koenig's last line of attack is to the documentation, specifically that his own objective assessments of Miss T's conditions do not match her subjective assessments. Doc L isn't surprised: he might see full range of motion but she might continue to report pain. And indeed, her reports do show "full range of motion" and "within normal limits."
Landry gets back and talks about the procedure. It's painful. No patient would go through it unless they absolutely have to. I write in my note, "What an evolutionary mess we are." A minute later Doc L mirrors my sentiment theologically: "I don't know why our Creator would create us so messed up. To make such marvels as our body, and then not give this one important part of us the ability to heal." His final point is that all of his treatments have been necessary and reasonable for the injuries she has sustained as a result of the auto accident.
The jury gets to ask its questions. Someone asks the obvious: even with the sclerotherapy can Miss T expect to see restoration to full health? Doc L answers no, of course not. But she will see significant improvement and that's what's important. He wants to try and restore her limbs to their pre-injury state, he says. He says he has no reason to believe that Miss T is a "malingerer" or is "being untruthful" about her subjective state.
After that, we're all free to go on our own recognizance.
I'm reminded of a quote I read once:
Cardiac physicians are fitness freaks. They exercise and eat right. They know the consequences of a heart attack. Oncologists, in contrast, are usually eat-drink-and-be merry types. They know the consequences of cancer. They'd rather have a heart attack.I don't know why my brain thinks that's relevant right now, but I wrote it down.
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no subject
Date: 2008-05-23 11:34 pm (UTC)no subject
Date: 2008-05-23 11:38 pm (UTC)OMG. One wonders, based on this report, if plaintiff is suing the correct individual. Or if her own insurance company is just incompetent, to not have had her get a 2nd opinion (assuming they managed her care and billed back to defendant, as would happen in California under no-fault provisions). One feels bad for her, regardless.
The therapy he's using must be something other than what you named, btw, as sclerotherapy is a laser technology for reducing varicose veins.
I love your quote at the end.
no subject
Date: 2008-05-24 12:54 am (UTC)What's your opinion of epidurals, induced labor, and episiotomies? I believe obstetricians have been doing them all for over 50 years, yet there are so few studies out there on their effectiveness.
no subject
Date: 2008-05-24 01:59 am (UTC)** this information is over a decade old. Perhaps they have climbed further out of obscurity and you're being funny and I missed it.
no subject
Date: 2008-05-24 03:20 am (UTC)Some other more recent studies:
http://www.northwestern.edu/univ-relations/media_relations/releases/2005/02/epidural.html
http://news-service.stanford.edu/news/2005/march16/med-cohen-031605.html
http://www.uic.edu/com/mcas/anesth_aug-2006_p394.pdf
http://www.yale.edu/opa/newsr/02-05-16-03.all.html
I was grateful to have the use of an epidural after 18 hours of labor when my labor stalled and I didn't know how much longer it would end up going on. Bad thing when increased pain can cause seizures.
no subject
Date: 2008-05-24 04:20 pm (UTC)no subject
Date: 2008-05-25 04:52 am (UTC)My midwife never induced me.
Did they tell you how much you were dilated during the 18 hrs?
My midwife kept me and my "team" (which was my husband and four other close friends) apprised of my situation, including dilation, throughout.
no subject
Date: 2008-05-24 04:34 pm (UTC)None of them compares outcomes with natural labour.
I'm a *big* believer in having technology available for cases where it is warranted. Your case is one such, where pain may trigger other concerns. My second labour was another -- after two days of full labour with broken water at home, I wasn't even close. Midwife called it, and another day at the Hospital on Pitocen with no other intervention (no pain killers, no permanent monitor) to interfere with labour still didn't get us there, and by then the baby was showing signs of distress. Three days without waters and in contractions; that didn't surprise me.
I would almost certainly have lost my second child, and possibly my life, were it not for the availability of surgery, and I'm grateful for the technology that makes that possible.
However, the routine use of a variety of interventions early in labour increase the complications and C-section rates in every study I've seen. Most of those have come from Scandinavia, and to a lesser extent throughout Europe. The U.S. is very resistant to serious evaluation of the issue (because it won't support the current standards?) and our litiginous society makes it dangerous for doctors to go against the stream. (And often impossible as Hospitals have policy to protect themselves as well.)
no subject
Date: 2008-05-25 05:00 am (UTC)Unfortunately, you didn't state that in your earlier comment...you stated that the studies uniformly did not support these medical practices as of about ten years ago.
Perhaps it's because I live in an area where using more natural processes is encouraged, but I had to give birth in a hospital (the possibility of complications should I go into a seizure during labor was too high to make a homebirth or birthing center practical), and the hospital had a midwife group.
This is an older teaching hospital, and so they hadn't yet finished their birthing rooms, and I was in a more standard hospital room (though still more comfortable than you might think). My midwife was excellent, and we worked with all kinds of natural methods, and explored all the options should one or the other thing occur to make sure my desires were followed as much as possible.
no subject
Date: 2008-05-24 04:21 pm (UTC)no subject
Date: 2008-05-24 02:44 am (UTC)Though I never did find out exactly what caused the problem, I did get it diagnosed. I had (and still have) a bulging disc in my lower back. I went to traditional sports therapists first. This caused me to stand up, for some definition thereof. I could walk a little faster, and I could sleep with a little less pain. Large amounts of Ibuprofen were still called for.
I went to a Chiropractor. Again, a saw an improvement, but not enough to justify the expense. I got better range of motion, was able to walk better, but I would still wake up in the morning with a lot of pain and have to go through numerous rituals to be able to stand up straight.
Then I got a reference to an Osteopath. After one week, I had found "god". I could stand up straight, walk well, even the pain was lessening. I worked with the Osteopath for about two years. During the time he did weekly, then biweekly, then monthly manipulations of my back, and had me doing daily exercise regimens at home specifically meant to strengthen my back...ligaments and muscles...and to force my ligaments and the disc into the places they were supposed to be each day. I also slept in a particular way with a specialized pillow between my legs (which is fine, because it's the way I like to).
At no time did I get any kind of injections of the kind described above, so I can't speak to that. I received back manipulations that were more intense than the kinds of manipulations that one might receive with a Chiropractor. He used both X-rays and visual comparison of my back with previous records to see how straight my back was and whether more manipulation was required. And he could press sections of my lower back and upper buttocks to tell also where manipulation in my spine would be needed (you can feel the pain where the spine needs manipulating, because the nerves move through those sections on their way to/from the spine).
My Osteopath is a kind, friendly doctor who never dissed fellow Chiropractors or Doctors of Sports Therapy. He felt (as I do) that when different parts of the body are affected, they need different ways of being handled. If we're talking muscles, Chiropractors might be more the way to go. Broken bones might call more for Sports therapy. And ligaments would call more for an Osteopath.
The way that Elf writes about this guy, he comes off as arrogant and, worse, acting as though Osteopathy is the "medicine to cure everything" which it is most decidedly not. It is not a good medicine to use with injured musculature, for example.
Having had the experience I've had with Osteopaths before, it's probably a good thing I wasn't on the jury
no subject
Date: 2008-05-24 02:25 pm (UTC)I had a very similar experience, only with a chiropractor being the ultimate salvation (and no help whatsoever from traditional medicine). I'm so glad we have all the options that we do!
Here's to diversity in medicine!
no subject
Date: 2008-05-25 06:12 am (UTC)