Missed Diagnosis of the Past…

Let’s take a trip back to an innocent time when I was being bored to death in pathology class at the Los Angeles College of Chiropractic.  The anatomy and physiology department was stocked with Egyptian medical doctors from the University of Alexandria, who had all escaped religious persecution to come to America (They were Christian).  I’m imagining that the City of Alexandria, having given us the greatest library of the ancient world, probably produced spectacular Medical doctors but our professors were unable to practice medicine in their new home.

In what I imagine was a lateral if not downward trajectory to their careers they were relegated to teaching medical courses inside of a Chiropractic College whose campus used to be an old High School.

“Saved by the Bell”, the Welfare years.

The instructor continued in his thick Egyptian accent:

“Mucopolysaccharides Type IH is the deficiencyof the alpha-L iduronidase enzyme. It results in the buildup of large sugar molecules, glycosaminoglycans (AKA GAGs, or mucopolysaccharides) in lysosomes. The inability to break down these molecules results in a damage to several different organ systems, including but not limited to the nervous system, skeletal system (He pronounced it like “Skel – eaT – ul), ocular system, and cardiovascular system.”

“Yo, why the fuck do we have to know this?” I asked my friend sitting next to me.

“Shhh, Im trying to learn.” – Said my friend equally as bored.

“No Talking!” barked our professor.

“Seriously, Joe, stop interrupting the class.” I whispered to my friend.

Our professor continued: “Mucopolysaccharides, also called Hurler’s syndrome or Gargoylism, occurs once in every 100,000 patients.”

“I’m never going to even see this.” I muttered to myself.

Shortly before Christmas 2014 a father and mother drove their 7-year-old son several hours to our clinic in Surabaya.  They had been to several medical specialists who had offered no explanation for their son’s condition.  Hunched back, with long spindly legs and a distended pot belly he lumbered into my office with a facial expression that resembled those afflicted with mental retardation.

7 Years Old. Hurlers Syndrome.

The parents described a normal first few years until he started to get scoliosis.  The perplexed medical doctors recommended over head exercises with dumbbells and swimming for the two-year-old patient. The next five years before visiting my office offered equally futile answers and no hope for clarity.

I could offer answers and no hope.  But I didn’t want to be the bearer of bad news.

“I’m going to send these x-rays to a specialist in America to be read.  In the meanwhile get a urine test for your son, I want to check sugar levels.”  

When the parents left, my assistant came up to me to probe for answers.

“Dr. Marc can you help him?”

“No.  He’s got hurlers syndrome.  He only has about 3-5 more years before he dies.”  I said in a “matter of fact” manner.

I pulled up Gargoylism on google and showed my assistant.

I reviewed with my assistant what I had learned a decade earlier, back when the odds of me being a Chiropractor in Indonesia were up there with acquiring Hurlers syndrome at birth.  The chance that a Chiropractor would see a case in the west is next to impossible, despite its rarity ANY medical doctor would know what Hurlers was. They would never wander into a Chiropractors office looking for answers.

This is not to make lite of the education that a Medical Doctor gets in Asia, but they probably don’t have the rarest of the rare conditions drilled into them like a western medical education.  When those local doctors start going into the more remote villages that barely exist in an urbanized west you can see the limitations they work with.

Good thing I was (kinda) paying attention in Pathology class.

I was paying even less attention in the X-ray classes.

“Why is the spinous process of C1 jammed into the foramen magnum” I asked myself while reviewing the most recent x-rays of my 16-year-old patient who hadn’t been able to rotate his neck to the left in months.

(Now’s as good a time as any for a spinal anatomy review. The spinous process (sometimes called the neural spine) projects posterior and centrallyfrom the vertebra and are the prominent “bumps” when palpating the spine.  Every vertebra has a spinous process, except for the one I was looking at, the atlas. C1 has a posterior arch, not an SP.)

Before and Post Surgical – Atlas Dislocation

Poring through MRI’s and reports I was trying to figure out how this was missed. I decided to have a DACBR (Diplomate of the American Chiropractic Board of Radiology) read the X-Rays, paying him for knowledge that was free when he was a resident in the radiology department on the tail end of my time at LACC.

“Hi Marc

THAT IS A CRAZY ATLAS AND THEY NEED TO BE STABILIZED – COLLAR, WHATEVER, BUT EVENTUALLY SURGERY.

I’ll email you a report within an hour, but this is emergent – they could die if action is not taken now!!

no joke.  just want to get this out asap.  more later”

So despite temporarily forgetting that atlases have posterior arches I was correct about the Atlas and even the Spina Bifida’s.

The other doctors had missed them.  Ultra sounds of the neck, Catscans of the brain, MRI’s etc. someone had missed the X-ray with an atlas dislocated by a space occupying lesion.

As one mentor who was teaching at IMU in Kuala Lumpur stated a Chiropractor from the states would be better at diagnosis than many Medical practitioners in Asia.

Now telling an Asian MD they misdiagnosed is another thing.  Due to the concept of “saving Face” I would have to sugar coat things:

“Thank You Doctor, the work you did was the foundation from which we were able to find the correct diagnosis.” Which sounds better than “Bro, how the fuck did you miss this.  I wasn’t even paying attention in class and I caught this.” (New Yorkers have no such cultural inclinations to “Save Face”.) 

Now cultural sensitivities are important wherever you go but it’s doubly important in Asia especially practicing with the Large Chiropractic Groups.

The advertisements attracting patients can be, if not disingenuous, lacking in clarity on what we are actually doing.  After the “No Drugs, No Surgery” there is a litany of what Chiropractic “can” help with.  Well it “can” help with anything and everything when we are discussing the recuperative abilities of the body but that’s not what the message is conveying.

15 Year Old Girl – 

Patients are thinking of the western medicine paradigm of “curing” the problem. If you are advertising for scoliosis you know damn well the population thinks “Chiropractic will straighten my spine.” Which is well within the realm of possibility for a Chiropractor specializing in corrective care. But I’ve also had parents walk in saying that their previous Chiropractor said that he could straighten their child’s spine faster than the local doctor, as if healing could be negotiated.

On the converse side many patients, who had been to Orthopedic surgeons and were told to try “Physical Therapy”, another nebulous term in many of these places, before being referred to surgery came to me as a “last hope” when I discovered that their cases were relatively mild by US standards and surgeons would be a LOT more conservative stateside.  I had even worked side by side with surgeons stateside something that doesn’t seem as likely in South East Asia.

There has always been a tenuous history between Medical Doctors and Chiropractors, which has improved in recent decades in the west, although many straights will say this came at the cost at compromises in our philosophy. While that may be true that is a discussion for another day.

In the meanwhile, Chiropractors must realize that Medical doctors have something we have never grasped in the west, cultural authority, and it’s something that we don’t even have amongst other “Natural Healthcare practitioners” indigenous to the Asian population.

Again, this presents us with a Golden opportunity, one I hope we haven’t forever forfeited in the west, to declare what it is that we do that is separate, unique and distinct from all other forms of healthcare while cooperating with the larger medical communities.

This requires us to, yes, diagnose as a patient population comes to us seeking answers, which we may not have, while not making outlandish claims of cures when that’s never been what our philosophy was about.  

In other words, we must know our history so that we are not doomed to repeat it…

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s