Ep 60 – Appendicitis and Critical Thinking: “I Have a Client Who …” Pathology Conversations with Ruth Werner

0:00:00.0 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology, is a highly regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this groundbreaking resource serves up a comprehensive review of the pathophysiology signs, symptoms, and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.

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0:01:11.7 Ruth Werner: Hi, and welcome to I Have a Client Who, pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I am Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice, and sometimes as we have all learned, that is harder than it looks. This episode of, I have a client who deals with some of my favorite themes around our relationships with doctors and our responsibility to do our own critical thinking and clinical decision-making, and it goes like this. Very early on in my career, I had a doctor send an inpatient client down to our hospital-based clinic for a massage. I assumed she was going to be a post-natal mom until she walked in wearing a gown and she told me she had active appendicitis.

0:02:29.7 RW: I went through trying to set my boundaries and explain what I knew about contraindications, but her insistence that the doc cleared her felt more powerful than my training and experience, so, I proceeded to work with her. Once on the table, I could tell she had a fever which she confirmed, despite basically doing healing touch and using my best oncology training modifications, she just felt worse and she vomited about 15 minutes in. She went back to her room, I felt awful, and then she called and asked for a refund. Needless to say, I learned an important lesson early on that continues to serve me. Doctors and clients don't have the final say or the necessary knowledge when it comes to our work from a safety standpoint. We do. And all I can say to this massage therapist is, preach it sister. Of course, I wanna give thanks to this wonderful therapist who shares this valuable story with us, and if you have a good, I Have a Client Who story about some pathological situation that came up between you and a client, I'd love to hear about it. You can get that to me at ihaveaclientwho@abmp.com. That's ihaveaclientwho, all one word, all lowercase @abmp.com.

0:03:53.4 RW: So, let's recap. This massage therapist is working in an on-site hospital-based massage clinic. A patient comes in for a massage sent by her doctor, however, this patient has an active infection with a fever, and I'm assuming she's either awaiting surgery to have her appendix removed or she is under treatment for this active infection. In neither case, is she a good candidate for massage? Now, I could take the low-hanging fruit here and dedicate the rest of this podcast to talk about appendicitis, but instead I'll just give you a thumbnail sketch about that situation so that we can explore a different topic that is a lot more nebulous. You will probably remember that your vermiform appendix, which literally means hanging thing that looks like a worm is an organ suspended from your cecum. It's made of lymphoid tissue, and at one point it probably had something to do with immune system function, but now is considered by many to be essentially a vestigial organ.

0:05:01.4 RW: It's a common circumstance for the appendix to become infected and inflamed, and of course, that is appendicitis. Sometimes appendicitis can be treated with oral or IV antibiotics, but it's often considered safer and more efficient to simply remove the organ in what is now laparoscopic surgery. Back in my day, of course, it was open surgery, and I have the scar to prove it. The danger related to appendicitis is the risk of an abscess or the whole organ rupturing, which would allow bacteria to invade the peritoneal space. So let's think about that peritoneal space, the space between all of our intestines for a moment, what's it like in there? It's dark, it's wet, and it's about 100 degrees. It is a fabulous growth medium for bacteria, and when this happens, we call it peritonitis and it is potentially life-threatening, and that's why infected appendices are usually removed.

0:06:06.0 RW: Now, it's hard for me to imagine what possessed this patient's doctor to think massage might be a good idea, unless she was just getting very stressed before her surgery and he hoped that massage might calm her down. There's actually some nice data on this, particularly in the context of cardiovascular surgeries, where we see that patients can receive massage right before their procedure, and that helps to control blood pressure and gives them an overall better sense of safety and a better experience. However, that's a really different situation compared to someone who has a system-wide infection with a fever and are risk for peritonitis. So it was a bad idea for this person to seek massage, and the real nut in this story has already been identified by a contributor. She says, doctors and clients don't have the final say or the necessary knowledge when it comes to our work from a safety standpoint. We do.

0:07:04.7 RW: I'm sad to say that this is not the first time I have fielded, I Have a Client Who stories, in which a primary care physician made a recommendation for massage that was specifically against the best interest of the patient. And it's easy to understand a massage therapist, especially if they're new in the field or maybe new to a certain kind of working environment, wanting to be cooperative and compliant with the doctor's wishes. This massage therapist is lucky that the worst thing that happened was that her client vomited and then asked for a refund. It's not terribly likely, but definitely a possibility that this person's appendix might have ruptured during her session through no fault of the massage therapist, but this is why a person with appendicitis is in the hospital to begin with. Now, during this crazy COVID year, I've had the opportunity to put a lot of thought into what critical thinking means in the context of massage therapy, because we've had to do a lot more of that kind of thinking than maybe we have had in the past.

0:08:10.9 RW: As a pathology educator for massage therapists, I always encourage people to think about risks versus benefits for their work to see if there's a way they can offer the benefits of massage therapy without incurring or exacerbating any risks for the client. In some circumstances, this simply isn't possible, including the situation described by today's contributor. It isn't always easy to identify all of the possible realistic risks that any given client might bring to us, and this is why it's a good idea when we're not sure about safety to have a conversation with the client's healthcare provider, particularly in this setting, where it's very likely that someone who could address the therapist's concerns about fever and active infection was probably close by. In the olden days, which is to say, back when I was in massage school, we were told that if we ever had questions about our client's health or safety, we should call their doctor. Hah, that is obviously not a realistic solution to this problem. We were also told or it was certainly implied that a doctor's clearance for massage would ensure that our work was safe.

0:09:29.1 RW: What this meant then was that massage therapists were expected to ask for clearance or permission when we had clients whose health or constitution was in some way compromised, and we were concerned that massage therapy might be an iffy choice. What a different world we live in today. I do still see people suggesting that a doctor's clearance would be helpful in some complex situations, and I really wanna push back on this idea. I've said it before, I'm sure I will say it again about a bajillion times, but it is not a doctor's responsibility to know what your massage is. And a doctor is in no position to determine whether the massage that you do is safe or not for this client. Primary Healthcare Providers are wonderful, wonderful resources when we wanna get more information so that we can make safe clinical decisions on behalf of our clients, but that is such a different kind of conversation than asking Dr. X for permission or clearance to work with client Y.

0:10:35.8 RW: I'm gonna be working on an article for massage and bodywork, specifically about critical thinking clinical decisions and the intersections between massage therapy and clients who have pathologic conditions. This I Have a Client Who case is a great example of why massage therapists need to be well-educated about potential risks and also educated in how to ask the right kinds of questions so that they can do critical thinking and defend their decisions even when they are not in alignment with the doctor's recommendations. If you have had experience where you have had this kind of conflict, you are not alone. I invite you to contact me with your situations because as our profession is further and further integrated into the field of traditional and conventional healthcare, the need to establish the best and most functional relationships between the members of the healthcare team is just going to grow. And one of the ways we can step up to that challenge is by using the experiences of each other to build our critical thinking skills as this massage therapist has done for us today.

0:11:49.2 RW: Hey everybody, thanks for listening to I Have a Client Who, pathology conversations with Ruth Werner. Remember, you can send me your I have a client who stories to ihaveaclientwho@abmp.com. That's ihaveaclientwho, all one word, all lowercase @abmp.com. I can't wait to see what you send me and I'll see you next time.

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