Red Flags For Low Back Pain, Or Clinical Decision Making?

It’s only happened a couple of times in my career.

You know that feeling you get when something just isn’t right? You’re not quite sure what it is, but something just seems off?

Twice I’ve had people come in where their pain and limited mobility had me questioning if they needed a trip to the emergency room. In one instance I called a family member who took the patient in, and everything checked out fine.

The other instance, the persons low back pain was so extreme, it just didn’t add up. There was no history of trauma or anything else that suggested the hospital was necessary, but I could barely touch the patient during the treatment because their low back was so sensitive. Afterward, I recommended seeing a doctor, or emergency room, but they refused. I never saw them again, so I’m not sure what the outcome was.

So how do we know when low back pain is an emergency, or just really painful?

Traumatic Injuries And The RTC

In old First Aid terms, there were criteria we would use at the scene of an accident to quickly decide if a patient had to have spinal immobilization used and if they needed to be immediately sent to the hospital. 

It was called the RTC (Rapid Transport Category), and it was a simple list which made it easier to decide how to provide the appropriate care to a patient. While this isn’t as useful in a clinical setting, it could be invaluable in a sport, or outreach setting if some type of emergency were to happen and you are required to provide care. In a clinical setting, it would be helpful during your patient interview in case you weren’t quite sure why a patient is having the issues they are presenting with.

The RTC criteria include quite an extensive list of things to watch for. Not all of them would be applicable to us, but here are some that would be:

  • Mechanism of injury
    • Fall from greater than 20ft
    • High-speed accident
    • Pedestrian struck at speeds higher than 30 km/hour
    • Broken windshield damaged steering wheel, or airbags deployed
    • A rollover accident
    • Severe crush injuries
    • Any other people involved in the accident that result in a fatality
    • Electrical injuries (we always assume spinal damage with electrocution)
  • Anatomy of injury
    • Severe brain injury
    • Penetrating injuries to anything but the limbs
    • Depressed skull fracture
    • Pregnant woman with fairly moderate trauma
  • Findings in the Primary Survey
    • Decreased level of consciousness
    • Cardiac arrest
    • Suspected heart attack
    • Poisoning
    • Status Epilepticus

Particularly for us in the clinical setting the mechanism of injury should be one category to take note of. Hopefully, if someone has been through an accident that traumatic, they have already been to the emergency room, or at least a doctor to be checked out, but this doesn’t always happen. Sometimes a patient may play it off and just think they need to see a chiro, physio, or massage therapist and book in with you before ever seeing a doctor, or even calling 9-1-1 after an accident.

I’m sure we all see patients on a regular basis who have been in a car accident. Knowing those above criteria and being able to ask some of those specific questions in your interview may give you a better idea as to how severe their injuries could be. Or, if they played it off and haven’t been checked out, you may want to refer them to a doctor just to be safe.

Whenever I teach a first aid course we talk about the signs and symptoms of a heart attack. This is where there could be a bit of a red flag, as it is quite common for women to experience back pain associated with a heart attack. However, it would be back pain combined with other symptoms like chest pain, nausea and vomiting, sweating, and shortness of breath.

This is certainly part of our role as healthcare professionals to recognize and help our patients if this is happening. 

Photo by: Lucina Medina

The Red Flags Of Low Back Pain

There seems to be a wide array of information on the red flags of acute low back pain.

Most of the concern is driven toward four issues:

One red flag that is unrelated to specific disease was the onset of pain in patients under 20 years old. However, one study actually calls this a “dubious distinction” and shows that age alone combined with pain is not enough to be considered a red flag, as most of the participants in the study were diagnosed with non-specific mechanical spinal pain.

When we look at the risk factors associated with spinal fractures, most information cites major or significant trauma, age, a history of osteoporosis, and the use of corticosteroids as the red flags to look out for. A systematic review showed that all of the above combined with the presence of a contusion brought the probability of a fracture up from 4% to a range between 9 and 62%. An Australian study showed that when three red flags (female, over 7o years of age, severe trauma, and use of corticosteroids) were all present, the chance of a fracture went from 4% to 90%. So, when looking at red flags for fractures, one red flag alone is not likely an issue, but a combination of the red flags is more likely to result in a fracture.

The commonly used red flags for infection were:

  • Fever/chills
  • Use of corticosteroids or immunosuppressant therapy
  • IV drug use
  • Pain worse at night
  • Night and rest pain
  • Tenderness over the spinous process

But the same systematic review showed that there is a lack of standardization with these red flags, and the risk of serious disease in patients with low back pain is less than 0.1%.

The same can be said for malignancy, as the one big red flag, in this case, is a history of cancer. Yet “history of cancer” isn’t clear enough as it doesn’t specify how long ago the person was diagnosed or the type of cancer they had. There are several cancer types that apparently put a person at greater risk for spreading to the spine, but if the person didn’t have one of those types, or had it 20 years ago, the likelihood of spinal malignancy is probably a lot less than someone diagnosed recently.

The two most common red flags with Cauda Equina were saddle anesthesia (perineal numbness)  and sudden onset of bladder dysfunction. Either way, I’d be referring out for that!

One thing that came out of most of the studies I could find was one resonating point. Clinical decision making and judgment of the therapist to determine if the patient needs to be referred out is more reliable than the list of red flags. So in other words, when in doubt, refer out! There are some other things to take into account with this whole red flag discussion and one review makes a great point as to why screening for red flags isn’t reliable. As practitioners, we don’t actually screen, we manage low back conditions. They actually encourage watchful waiting for changes in symptoms, as evidence is showing that early intervention with low back pain may actually be more harmful.

One thing I hadn’t ever heard of was “yellow flags,” however, I found it encouraging that it was mentioned in a paper from rheumatologists. They listed these yellow flags as:

  • A belief that back pain is harmful or disabling
  • Fear of pain and movement avoidance
  • Tendency to low mood and withdrawal from social interaction
  • Expectation of passive treatments rather than believing active participation helps

Biopsychosocial approach anyone? It’s great to see these “yellow flags” being mentioned with the same importance as the dreaded red flags.

Overall, it is probably good to be aware of those red flags to help guide your clinical decision making, but they aren’t the be all end all like we once thought they were. The valuable thing will be your judgment call and also making sure to monitor your patients progress. If your spidey senses start tingling, and something doesn’t seem right, don’t hesitate to refer out, it’s better safe than sorry.

Putting Your Safety As A Massage Therapist First

It was the strangest thing to happen in my career to that point.

Something just felt off, right from the introduction to a new patient. I couldn’t explain it, it just felt off.

The patient came in and was very demanding. Telling me over and over again, “deep pressure is the only thing that works for me, it HAS to be deep pressure.”

Fair enough, I weigh around 215lbs, I should be able to put enough pressure into this.

After they got on the table, I went to work. As I pushed in with more pressure, I would continually check in to make sure they were satisfied with the pressure.

Then about 15 minutes into the treatment the patient abruptly said: “this isn’t working for me, I want to stop!”

I quickly asked if I had done something wrong?

“No, I just want this to stop now, it’s not working for me.”

I ended the treatment and said I would meet them outside when they were ready. As the patient exited the room, their hand reached out with a credit card in it. I said there would be no charge as it was only a 15-minute treatment (they were booked in for 45) and were also dissatisfied with it. But they refused and paid for the treatment.

I sat there even more confused (although happy I would have the next 1/2 hour to figure out what just happened).

As they walked out the door, the patient turned back and said: “thanks a lot for making me feel safe.”

Now, I was even more confused (and convinced the person had been sent in as a test or something), but even in the confusion, there was something that I was concerned with even more.

What about MY safety?

Right Of Refusal

This is where things can get a bit tricky.

When I look at our provincial bylaws (I’m just going to assume most other places are about the same) under the code of ethics there is a wide range of topic and wording that apply to us in practice. And that wording can be read a couple of different ways, depending on your interpretation.

To highlight a few that are applicable to the point of this post:

  • Massage therapists must set and maintain appropriate professional boundaries with a patient.
  • Despite section 23(iii), a massage therapist may immediately terminate the therapeutic relationship with any patient that:
    • sexualizes or attempts to sexualize the treatment or environment, or
    • threatens the massage therapist or otherwise endangers the massage therapist.
  • Massage therapists must protect and maintain personal and professional integrity.
  • Massage therapists must maintain a safe and healthy treatment environment.

Now granted, the colleges responsibility is to protect the public and most of these are probably in place with that thought in mind, as opposed to protection of a therapist.

The reason I bring all of this up is because of the story I mentioned in the beginning but also because, most of the time when I hear of someone who has been falsely accused of something (these are just things I’ve heard in passing, not from anyone directly who has been accused), I also hear, they regret not ending the treatment themselves because something just felt “off.”

Since we are to maintain appropriate professional boundaries with a patient, the responsibility lies with us. If the patient is going beyond a boundary it is up to us to end and or alter the treatment.

As laid out, we can terminate a therapeutic relationship if a patient threatens or otherwise endangers us as a therapist. In this case, I’m sure the intent was if a patient was actually threatening or physically endangering us. But what about when they are doing something that could possibly endanger your career, your mental health, or your overall well being? If something during the treatment happens and our gut tells us something isn’t right, we should have the full right to end that treatment. It won’t be easy to do, but in the long run, it could save not only a career but also mental anguish. This is also a way we can protect and maintain our personal integrity.

Since we are also expected to maintain a safe and healthy work environment, have we taken the time to think how that affects us as opposed to our patients?

In my past career before becoming an RMT, I worked in an industrial setting dealing with health and safety. The one thing that always came up was our right as employees to have a safe work environment. Part of those rights was the ability to deny unsafe work. If you were told to do a job but considered it to be unsafe, you had the right to deny doing it.

While you had to give sound reasons for why you considered it unsafe, the company could not force you to do it until the safety concerns were rectified.

In this case, if a patient is doing something that is setting off some red flags for you, it is your right to demand a safe workplace environment and in turn should be able to deny treatment to a patient if you think your safety is at risk.

Photo by: JESHOOTS

Working Alone

This is another one of those areas that is often overlooked because we are either self-employed or work as contractors.

There was an article being circulated a month or so ago, which highlighted a massage therapist getting killed on the job as she was doing mobile, home care work (I think it later came out that she was working under less scrupulous employment) with no one else around.

If someone was working as a mobile therapist by themselves, or even working alone in a clinic, there are certain safety guidelines set out through WorkSafe or department of labour that stipulate conditions that are to be met to protect someone in this case.

Some of the guidelines that are set out in order to protect someone working alone or in isolation are as follows:

  • Develop and implement a written procedure for checking the well-being of a worker assigned to work alone or in isolation.
  • Procedure for checking a worker’s well-being must include the time interval between checks and the procedure to follow in case the worker cannot be contacted, including provisions for emergency rescue.
  • A person must be designated to establish contact with the worker at predetermined intervals and the results must be recorded by the person.
  • Time intervals for checking a worker’s well-being must be developed in consultation with the worker assigned to work alone or in isolation.

So, if you are a clinic owner, think of how this applies to some of the people working in your clinics. Are there times in the day when they are at the clinic alone? Is anyone calling in to check on them? Are there emergency procedures in place if something were to happen to one of them?

How about for those of you who do mobile massage on your own? Do you have a check in system before and after your treatments? Does someone know your schedule for the day and the addresses you’ll be working at? Do you have a contact in case of emergencies?

This doesn’t have to be an expensive complicated endeavour, even if it is regular contact throughout the day to a loved one or co-worker, who can regularly check in with you, as long as there is constant contact with someone.

However, there are companies out there who offer this kind of check in service. When I used to work alone I would have to call in to a company every two hours. If they didn’t hear from me, they would try to make contact. If contact failed they would dispatch emergency help to come and check on me (fortunately this never happened). There are now even some phone apps available like this one to handle these types of scenarios. The whole point of this post was not intended to scare anyone, but as self-employed people, we rarely take the time to think about possible safety issues within our work. We are trained to constantly think about what is safe and appropriate for our patients, when in reality isn’t our safety just as, if not more important?

Therapeutic Exercise And Inversion Ankle Sprains

When she came in, you could see the pain on her face.

Wincing with each step toward the treatment room, her limp was noticeable as she was protecting the ankle.

As I helped her sit down, of course, my first aid protocols popped into my head first, so I ran through the typical questions:

“What happened?”

“Did you hit your head at all?”

“Did you hear a pop in your ankle?”

“How are your pain levels?”

Fortunately, she didn’t hit her head and there was no “pop.”

She had just rolled her ankle and had a pretty typical inversion sprain, the swelling was already noticeable. What made it worse for her was the stress and worry of whether she could run as it was her favourite thing to do.

She wanted to get that ankle back to her normal activities ASAP.

Helping Protect The Injury

As I mentioned, the first thing I thought of was the first aid protocols when it comes to an injury.

This particular incident was obviously in the acute stage, so all the RICE protocols are the first thing I thought of. While there has been lots of debate online about using ice and rest, I still believe that in the acute stage it’s the best way to go.

Where I have changed my opinion is how long to use RICE.

In the past, we would use ice and rest for way longer (at least I did) than was probably appropriate. During the inflammation phase, (which is the first 48 hours) it is important to rest and support the tissues involved in the injury but still, keep up with some movement and continue to load the tissue within pain tolerances.

Since most of you probably already know how to rest, ice, and elevate I thought we would go over the compression portion and demonstrate how to properly wrap and inversion sprain, to give it some support and help control swelling over that first 48 hours.

Properly wrapping an ankle like this can give it that little bit of extra support (and confidence) in order to help the patient continue to move and also help with pain management.

Loading The Tissue

More and more over the past few years, we have been hearing and seeing more research on the importance of loading tissues post injury.

I’m sure we’ve all heard the stories about how they get patients up and moving almost immediately after surgeries.

Research is showing that loading the tissue or causing mechanical tension (muscular force) is actually a way to help influence wound healing. As the injury enters into the repair phase we can start to load the tissue even more.

This, of course, depends on pain and weight bearing abilities. If the patient can do full weight bearing pain-free you should be able to load the tissue more than if they can’t do full weight bearing. If they can’t bear full weight, giving the patient something to hold for balance will help decrease the amount of weight we are loading into the tissue and help with a decrease in pain, but still have the ability to move and load the tissue.

Here is an example of how you can begin some weight bearing exercises and load for an inversion sprain.

Once the patient feels more comfortable and pain has decreased, you can then progress them to this kind of exercise in order to load the tissue more:

As the patient continues to progress, here is a 3rd progression you can use to load into the injury more:

It is important to work within your patients pain tolerance when doing any kind of exercise, but one study showed that doing isometric contractions actually helped to decrease pain in patients with a tendinopathy. While an inversion sprain isn’t a tendinopathy, we can use it as a reminder that it is okay to load the tissue early in the healing process. So, in addition to doing some massage therapy, actually loading the tissue will not only help strengthen the area but also assist in decreasing pain for the patient. However you decide to set up your treatment plan, these are movements that can be taught in the clinic and incorporated into your treatment but also given as homecare exercises to help the patient progress. For those of you who don’t have “exercise” in your scope of practice, let’s just call it “therapeutic movement!”

What Is Really CI’d With Hypertension?


Was it 140/90 or was it less than that?

Wait, 160/95 is what’s too high?

I always had a hard time remembering what was CI’d and what wasn’t. Positioning, heat, which blood pressure numbers were too high?

Many of these CI’s were based on massage increasing circulation, making it too hard on the heart when blood pressure was already too high.

But what about now that we know that massage doesn’t increase circulation and move fluids around like we once thought?

Are these things still a contraindication?

And do we really need to take every patients blood pressure before treatment?

Do We Really Need To Take Blood Pressure?

Part of the problem with hypertension is that it quite often goes unrecognized.

It has been called the “silent killer” because of the damage it can cause to the blood vessels, heart, brain and kidneys before any other noticed symptoms occur.

Where we need to pay attention is the degree of hypertension the person is experiencing.

  • Normal blood pressure: 120/80
  • Prehypertension: between 120-139 systolic over 80-89 diastolic.
  • Stage 1 high blood pressure; 140-159 systolic over 90-99 diastolic.
  • Stage 2 high blood pressure; 160 or higher systolic over 100 or higher diastolic.
  • Hypertensive crisis, a medical emergency; 180/110 or higher.

Looking back over my notes from college, we were told that 160/95 was contraindicated for a massage. This is probably true in the case of someone who doesn’t know they have hypertension and should see a doctor. If they are under the care of their doctor, they’re probably coming to see you for help with this very thing.

Which leads us to why we should be taking a patients blood pressure in the first place.

One paper examined the role of manual therapists taking blood pressure prior to treatments as an aid to their clinical reasoning, risk assessment, and vascular profiling. The paper presents three case studies where patients were having either neurological or musculoskeletal pain in the neck and/or thoracic chest area.

In each case blood pressure was taken, two of the cases were abnormally high, and one was low. Once the patients were referred out to appropriate care and the issues causing the rise or drop in BP was corrected, the issues they were experiencing decreased and manual therapy could continue.  The only way these issues would have ever been recognized was by the manual therapist taking blood pressure readings as part of their treatment protocols.

Also important is another study which showed a difference in blood pressure measurement depending on the position the patient was in. Systolic blood pressure decreased in semi-fowlers and sitting positions compared to being taken when the patient was supine. This stressed the importance of making sure measurements were being taken with the patient in the same position before and after treatment to get a true reading on whether therapy was effective.

If you took the initial measurement when the patient was sitting before the treatment started, then took a second measurement at the end of the treatment while they were laying on your table, your comparison before and after treatment wouldn’t be accurate.

So even if you think the patient you’re treating doesn’t fit the profile of someone who would be dealing with high blood pressure, it should still be part of your routine, especially if it’s the first time you’re seeing someone.

Photo by: Gadini

Shortening Strokes And Positioning

As we have discussed on this blog before about massage and circulation, many of the contraindications we learned in school probably aren’t as applicable anymore.

We were taught to shorten our strokes when it comes to hypertensive patients, but as research has shown, we aren’t increasing total body circulation, there is just a bit of circulation increase locally to the tissue we are working on. So, we probably don’t need to worry about specifically shortening our strokes with a hypertensive patient.

We were also told that positioning of the patient on the table could be a concern as well, we were instructed to not leave the person in the prone position for extended periods. Looking back through the textbooks and notes as I wrote this article, there was some good advice from one of the texts, the gist was that if the person could sleep in this position (eight hours sleeping compared to an hour on your table), they’re probably fine. Keeping communication open with that patient would be important, to see if they start feeling dizzy, or lightheaded during the treatment, but otherwise, you’re probably safe.

One study showed that just lying prone can actually help decrease blood pressure just as much as lying prone with a massage (however this study was done on healthy people and those with hypertension were excluded from the study).

Another systematic review(1) showed that massage therapy combined with antihypertensive drugs was more effective than just using the drugs alone. While researching for this, I found several articles and studies that show massage therapy to be an effective complimentary treatment for hypertension.

So with all this evidence, it’s safe to say there is a lot we can do to help patients with hypertension. Keeping in mind a few different things, like when pressure is high enough to dictate an emergency, communication with your patient and knowing that a regular length stroke is okay, there shouldn’t be too many issues with your treatment. As we continue to try and gain respect as healthcare professionals, this is one easy step we can use to add to our clinical reasoning and risk assessments when dealing with our patients. If one of your patients is coming in for this specifically, take their blood pressure before and after the treatment (with them in the same position), so you can prove what you are doing is helping them, and communicate that information with their family doctor as well. I guess I’ll have to go buy one of those digital blood pressure cuffs now, they’re probably more accurate and less of a chance I’ll screw it up when using it.


  1. Xiong X, Li S, Zhang Y. Massage therapy for essential hypertension: a systematic review. Journal Of Human Hypertension [serial on the Internet]. (2015, Mar), [cited July 10, 2017]; 29(3): 143-151. Available from: MEDLINE with Full Text.

Treating A Diabetic Reaction In Your Massage Clinic


It was a few years ago and we were having a great conversation about our favourite topic, hockey.

Being a big Jets fan, he excitedly told me the news that Winnipeg was approved to get their team back.

You could feel the excitement come across the phone: “did you hear the Jets are coming back!?”

Not 30 seconds later, he said it again: “did you hear the Jets are coming back!?”

Umm yeah, we just talked about that.

Then he repeated it again, this time his speech was a little slurred.

Something was off.

Then I clued in and asked: “did you take your insulin this morning?”

“Why would I do that”, his speech was getting more slurred.

“When was the last time you ate?”

“Why would I do that, I don’t need anything!?”

I hung up and started phoning every extension in the office, no one was answering.

I drove to the office and found him slumped over his desk, looking and sounding very confused.

The small sugar drink he had taken wasn’t working, or more likely just wasn’t enough.

I ran next door to the coffee shop and grabbed some food, Coke and orange juice.

When I got back, I held everything up and asked what would work best.

He pointed at the Coke.

I took the top off, handed it to him and he took a sip. He sat up a little, then took another drink. The third drink perked him up some more, with each drink his condition improved.

Then he looked at me and said: “what the hell were we talking about!?”


“Oh yeah, did you hear the Jets are coming back!?”

Understanding Types Of Diabetes

I’m sure we all know someone and have at least a few patients who have diabetes. However it is important to know which type of diabetes they have.

There are two different classifications, although one kind doesn’t get talked about or recognized as much.

  • Diabetes Insipidus:
    • Results because of dysfunction of the posterior pituitary.
    • Causes defects in antidiuretic hormone (ADH) receptors or can’t secrete it.
    • Neurogenic Diabetes Insipidus makes too much ADH because of a brain injury.
    • Nephrogenic Diabetes Insipidus the kidneys do not respond to ADH which results in too much urination leading to dehydration.
    • This type of diabetes is typically treated with hormone therapy.
  • Diabetes Mellitus:
    • The more common form of diabetes, with classification of Type 1 and Type 2 resulting from an inability to make or use insulin.
    • Type 1 referred to as juvenile diabetes or insulin dependent, the persons immune system destroys the beta cells in the pancreas, so they don’t produce insulin.
    • People with Type 1 typically have to take insulin injections to deal with the condition.
    • Type 2 aka: non-insulin dependent diabetes or adult onset diabetes most commonly caused by cells becoming less sensitive to insulin.
    • Type 2 diabetics may need insulin injections but it is typically managed with checking blood sugar and regulating with diet.

Diabetes Mellitus is the condition we are most likely going to be faced with in our clinic, so it is important for us to understand what is happening and how to deal with this if we are ever faced with someone having a diabetic emergency before or after a treatment.

If someone who requires the use of insulin takes too much (hyperinsulinism) this can cause the body to use up any extra glucose in the blood (hypoglycemia), which then deprives the brain of the sugar it needs.

When this happens the brain cannot function properly and the body begins to shut down.

If someone is having this kind of a diabetic reaction, it can eventually lead into a diabetic coma and eventually death if it is not dealt with appropriately.

It is then our responsibility as healthcare professionals to be able to recognize and deal with this, preventing the coma and reversing the reaction.

Signs And Symptoms Of A Diabetic Reaction

If we have a patient with diabetes, chances are it is going to be Type 1 or 2.

Those with Type 2 typically manage their blood sugar with diet and monitoring blood sugar levels (sometimes they use insulin as well). This comes on later in life, usually past the age of 35.

However those with Type 1 (who use insulin) can end up suffering from hyper or hypoglycemia.

If they are experiencing hyperglycemia, there is sugar in their blood, but not enough insulin to allow their cells to be receptive to the sugar.

When this happens the body attempts to get the sugar from other sources, such as fats from within the body. This produces increased waste in the body and knocks pH balance off and the person starts to feel ill.

When the person is experiencing hypoglycemia (not enough sugar), the sugar in the body is used up and in turn affects brain function which can be life threatening.

This can be caused by a few different things:

  • Takes too much insulin.
  • Hasn’t eaten enough, or regularly enough.
  • Exercise has burned off their blood sugar faster than normal.
  • Great emotional stress.

In order to recognize a possible emergency, there are similarities between the hyper and hypoglycemic conditions:

  • An altered level of consciousness, dizzy, drowsy and confused.
  • Rapid breathing.
  • Rapid pulse.
  • Feeling ill as well as looking ill.

If you know one of your patients has diabetes and starts to show any of these symptoms, it is essential to provide the appropriate care.

Photo by: stevepb

Photo by: stevepb

Providing Care During A Diabetic Emergency

There are some specific steps to take when trying to help someone during a diabetic emergency.

If you’re not sure why the person is having an issue, we do what is called a Primary Survey. Check to see if they have their ABCs (Airway, Breathing, Circulation). If they are unconscious, call 911.

If they are conscious and speaking to you, then the ABCs are present and you can go into your Secondary Survey.

During the Secondary Survey we do a quick check of the rest of the body to see if there are any injuries that could be causing the issue. It’s just a quick rapid scan of the persons body from head to toe looking for possible injuries.

This is where you could possibly find a medic alert bracelet or necklace that could tell you they are diabetic. Nowadays some people are also getting them as tattoos, so you may see this as well.

Assuming the person can talk to you, then there is a series of questions to use called the SAMPLE questions. It is just a simple mnemonic which can help you determine what is going on:

  • S – signs and symptoms?
  • A – allergies?
  • M – medications?
  • P – past medical history?
  • L – last meal?
  • E – events leading up to the emergency?

In the case of a diabetic emergency, there are a few questions that can really help you out.

If you didn’t already know it was a diabetic emergency, knowing their medication (insulin), past medical history (diabetes) and their last meal can give you great insight into what is going on.

The person might tell you right away what is wrong and ask for something to help, but just in case they don’t, asking those questions can get you the information you need.

Now that you have determined the emergency, we need to get sugar into their system.

Keeping fruit juice, candy or non-diet soft drinks in your clinic are all great resources to help someone in this condition. After they have some sugar, it will help quickly, actually it’s surprising how quickly it can turn things around.

If the person is unconscious, do not give them anything, you could end up compromising the airway and making things worse.

Just monitor their ABCs until further help arrives.

There is a bit of controversy about determining the difference between hyper and hypoglycemic conditions as there could be a concern about giving someone sugar who already has too much sugar in their system.

While this could cause some more damage, it is not going be as life threatening as it is for someone who has low blood sugar and needs to get sugar in their system.

For our purposes in a clinical setting, we are going to treat the person with sugar because it will be difficult to know which condition is causing a problem.

Since we are not authorized to give medications we don’t inject insulin for people. If this happens before a treatment, you cannot carry on with the massage even if the patient has some sugar and starts to feel better. They need to go eat a proper meal to help balance out blood sugar. It doesn’t mean they need to go to the hospital (unless they don’t start to feel better within five minutes of getting sugar in their system), remember this is something they deal with on a regular basis (if they go unconscious, call 911). Since 9.3% of the population has diabetes and a large population remains undiagnosed, as well as the prevalence of gestational diabetes affecting 9.2% of pregnant women, there is a strong chance you will have to deal with this kind of an emergency in your clinic one day. Knowing the signs, symptoms and ways to deal with it will be the biggest way you can help any one of your patients should this happen. And yes, the Jets came back and I still get to talk to my buddy about it regularly.  

Managing A Collapse In Your Massage Therapy Clinic

Like it or not, it is going to happen one day.

You do your intake with a patient, leave the room and on your return there they are, lying on the floor not breathing.

Your adrenaline rushes because you never thought you’d actually have to deal with this…ever.

But the odds are against you.

According to the heart rhythm society, in the U.S. more than 350,000 deaths occur each year because of sudden cardiac arrest, which is more than breast cancer, lung cancer or AIDS.

Sudden cardiac arrest takes an average of one life every two minutes.

Unfortunately 95% of people who suffer a cardiac arrest lose their life because of delayed treatment.

However the bright side is that you can help. The odds of being able to revive someone greatly increases when you witness the collapse.

Fortunately when we have our patients in the clinic, chances are we are going to witness the collapse in case they experience a cardiac arrest.

Initial CPR

If you ever witness a collapse, or walk back into your massage treatment room and see someone unconscious, the first thing you have to do is assess if the person is breathing.

We do this by using a technique called: “look, listen and feel”.

Firstly, squeeze the persons traps and see if they respond in anyway. Then put your ear overtop the persons mouth, place a hand on their chest and look at the chest for 15 seconds.

See if you can feel a breath on your ear and watch to see if your hand on the chest rises at all to indicate breathing.

If there is no air exchange occurring, tilt the persons head back, check to see if they start breathing. If they don’t start breathing on their own keep the head tilted back and attempt to give the person two breaths.

Watch to see if the chest rises, indicating air going into the lungs.

If the chest rises, it shows that the person has an open airway, so you can begin chest compressions (if the air didn’t go in, it means something is blocking the airway so they could have choked on something).

If they had choked on something, you would start compressions as well, however the intent of the compressions now is to clear whatever the person had choked on.

To start your compressions, landmark at the persons armpit on the side of the body opposite to you. Then bring the palm of your hand up to the sternum and deliver 30 chest compressions.

Continue to deliver 30 compressions and two breaths until more help arrives.

Once you realized the person was not breathing and CPR was necessary it is important to get someone to call 911 for you, and if available get an A.E.D. (automated external defibrillator).

If you’re on your own, grab a phone, bring it back to the person and call 911. Put it on speaker phone and the 911 dispatchers will coach you on what to do.

Using An AED

People often think that an AED works like the paddles the doctors on TV shows like ER use to jumpstart a persons heart.

It doesn’t work like that.

If the heart is completely stopped and flat lined, the AED isn’t going to do anything.

There has to be a “shockable” rhythm, a tachycardia (fast rhythym) or bradycardia (slow rhythym) for the AED to do anything.

There are a few things to take into consideration when using an AED.

If you are in a wet environment (you sports therapists) you have to do a splash test.

If the ground is wet and you slap it, if it makes a splash you have to move the person before you can allow the AED to deliver a shock. If the ground is just wet and there is no splash, it’s fine to deliver the shock.

If the person has a really hairy chest, then you have to shave the chest before putting the pads on. The pads have to be in direct contact with the skin to work properly (fortunately AED kits come with a razor in them).

Also if there is any metal (ie: underwire bra, jewelery etc.) in the path of the pads, it should be removed or it will leave burn marks. Same for any kind of nicotine or medical patches, they should come off.

Then just turn the machine on and follow the directions, don’t try and jump ahead, just do what it tells you.

Make sure when the machine says “everyone stand clear”, no one is touching the patient. If someone was still doing compressions, the machine would read that as the rhythm of the heart instead of it’s actual rhythm.

Also, the second time it advises to make sure “everyone stand clear”, is when it’s about to deliver a shock. Make sure no one is touching the patient or they will get shocked as well.

If the AED detects a “shockable” rhythm it will deliver a shock and you will see the body rise up a bit.

If there is not a “shockable”rhythm it will say: “no shock advised, continue doing two minutes of CPR”.

If you have a second person with you, have them take over doing CPR, so you get a break. Then alternate with the other person every two minutes so that one person doesn’t get tired out.

It should look something like this:

This can be a pretty scary situation to have to deal with. I honestly hope you never have to. However if this ever happens and the outcome isn’t what you had hoped for, please reach out and talk to someone about it. As healthcare professionals we are constantly telling patients to do proper home care, or are referring people to get more help should they need it. This is one of those cases where we really have to take care of ourselves after an incident like this. Chances are if this happens in your clinic, you already have a therapeutic relationship (and possibly a long standing one) with your patient. Going through a shocking scenario (no pun intended) such as this can bring up some very strong and sometimes scary emotions from the person who has to perform CPR. So please reach out and get some counselling or talk to some sort of mental health professional should you ever go through this. Remember how important your own self care is.