At least once in just about everyone's childhood, there came a time when your mother asked you why you did something foolish. You may have been drinking fingernail polish or jumping in front of cars to hear their brakes squeal, but you probably remember the incident or the stories that were told as you grew older.
As I write this article (Oct. 4, 2012), people in Tennessee, North Carolina, Florida, Virginia and Maryland have contracted a rare form of meningitis, with people in 18 additional states potentially impacted. This meningitis outbreak has (as of this hour) killed four people with at least 27 in critical condition.1 [Click here for current outbreak information from the CDC.]
The fungal infection can cause "massive tissue death in the brain stem, inflammation in the blood vessels" and even stroke. Some of those are expected to pull through; some are not. Others will be six months to a year in recovery. Authorities expect to "see many more cases spread across the country." This appears to be a similar scenario to another outbreak of fungal meningitis that occurred 10 years ago, but this is on a much larger scale.2-4
This type of meningitis didn't spread from contact with people who had it. These people were apparently infected when they received a steroid injection for their back pain. While officials are not making any firm statements about the source of the outbreak, they suspect a compounding pharmacy that has since ceased operations, closed its doors, taken down its Web site and stopped answering the phone. Because no one knows the scope of the outbreak, the hospitals involved have their PR people making guarded statements. The medical doctors have not yet been interviewed.
What makes this entire tragedy ironic is the poor evidence that these steroid injections would have relieved their back pain in the first place. As Dr. Warren Hammer stated in his article on the topic last year, "the evidence recommending steroid injections is still unclear." Dr. Hammer cited a seminal study and quoted an editorial from the British Medical Journal that stated, "Thirty-five controlled studies on the subject have failed to provide a definitive answer regarding the efficacy of epidural steroid injections and it is unlikely that future trials will do so."5-7
The above brings into question the wisdom of seeking the right to inject nutritional supplements, steroids or other substances into patients. This debate has been front and center in several states over the years, with heightened emotions on both sides.8-9 The reality is that anytime you break the skin (let alone inject into the spine) and introduce any substance into the body, you run the risk of also introducing bacteria, fungus, poisons and other dangerous contaminants as well. This was the situation last year in Alabama, when nine people died and another 10 became ill when they were "given an intravenous nutritional supplement that investigators have found was contaminated by bacteria."10
For almost 120 years, chiropractors have practiced a very conservative form of care that has an extremely remote chance of harming our patients. Decisions to add injection and prescription rights change our risk profile. And while this will likely have an actuarial impact on our malpractice insurance, how that can impact our practices is the issue at hand.
If you ask most MDs about the prognosis for their patients, they will tell you that most patients get better, some don't and some die. This is their reality and they have been trained to accept it. I think most DCs would find that environment a hard way to practice. I would. The current outbreak of meningitis is an opportunity to stop and consider just how far this profession wants to go in the effort to expand our scope toward the medical model. The same question should be asked about your practice specifically.
In the time it took to write this article, one more person died, 13 more people were hospitalized and one more state reported casualties from the outbreak. Tomorrow will likely be even worse. If one of these tragedies involved your patient and their condition was the result of your decision to inject steroids, would you still feel good about being a doctor of chiropractic?
- "FDA Finds Fungus in Steroid Shots, Meningitis Toll Rises." Yahoo News, Oct. 19, 2012.
- "Framingham's New England Compounding Center Linked to Deadly Meningitis Outbreak." WCVB Boston, Oct. 4, 2012.
- Grady D. "In Outbreak, Meningitis Is Reported in 5 States." The New York Times, Oct. 3, 2012.
- "'Rapidly evolving' Meningitis Outbreak Sickens 26, Kills 4." CBS News, Oct. 4, 2012.
- Hammer W. "Epidural Steroid Injections: What Current Evidence Suggests." Dynamic Chiropractic, Nov. 4, 2011.
- Iversen T, Solberg TK, Romner B, Wilsgaard T, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomized controlled trial. BMJ, 2011;343:1-15.
- Cohen SP. Epidural steroid injections for low back pain. (Editorial) BMJ, 2011;343:1-2.
- "To Inject or Not to Inject? Hearing in Florida Polarizes Chiropractors." Dynamic Chiropractic, Jan. 14, 2002.
- Taylor M. "How Are We Doing After 20 Years of Chiropractic INP? The Oklahoma Story." Dynamic Chiropractic, Jan. 14, 2002.
- Sack K, Williams T. "Deaths of 9 Alabama Patients Tied to Intravenous Supplement." The New York Times, March 30, 2011.
Click here for more information about Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher.