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It’s OK to Relieve Abdominal Pain
At 74 Nora looked 20 years younger. She was in excellent health and great physical shape, riding her bicycle daily and playing golf twice a week. She felt wonderful. That is, until one Saturday night after dinner, when she developed a dull pain in the pit of her stomach. This, she thought, is not right.
Soon she felt nauseated and vomited. After that she felt better but tired and just not up to par, so she went to bed early and had no trouble falling asleep. But at 0500 a nagging pain in her lower right abdomen woke her up. It was dull at first, but by 0600 it had become sharp and, when she moved, caused her to almost cry out.
Her first thought was to call her doctor, but it was Sunday morning. She decided to take some Pepto-Bismol and see if it would go away. But just walking to the bathroom caused her great pain, so she retreated to bed and called her friend, Sally, next door. Sally, a retired nurse, said she would be right over. Arriving 10 minutes later, Sally immediately decided Nora needed to go to the hospital. “Do you still have your appendix?” she asked. Nora said she did. “Well, darling, I think you may have appendicitis. Let’s call 9-1-1.”
Medics Susan and Jared got the call and responded in less than 10 minutes. After hearing the history from Nora and Sally and doing an appropriate physical exam, they agreed it was very likely Nora had appendicitis. She had classic signs and symptoms, and her history fit the picture perfectly. They lifted her gently onto the stretcher and started for the ambulance. When the stretcher wheels bounced over the threshold of the front door, Nora cried out in pain. Once in the ambulance she got into the fetal position, which seemed to help, but was still hurting terribly. As Jared began the drive to the hospital 36 miles away, Nora asked Susan if there was anything she could give her for pain. Susan replied, “Unfortunately not. Since you have abdominal pain, we are prohibited from giving you pain relief until after the surgeon sees you in the hospital.”
Later Nora described it as the most horrible ride of her life. She had never experienced such agony before, and the agony continued long after she arrived at the hospital. The only available surgeon was in the OR fixing the liver and kidney of a motorcycle collision victim and could not get to her for more than three hours. She writhed in pain the whole time.
Why, you ask, is it necessary to keep patients with abdominal pain in agony while they wait for surgical evaluation? The answer: It’s not, but in many places it is still the practice.
The History
The prohibition against analgesia for patients with undifferentiated abdominal pain goes back almost 100 years if not longer. In 1921 Sir Zachary Cope published Cope’s Early Diagnosis of the Acute Abdomen, possibly the most famous and influential surgical text of all time. In it he recommended pain medications not be given to patients with undiagnosed abdominal pain until a surgeon had evaluated them. This tenet has been adhered to religiously by physicians and surgeons for many decades. But times have changed.
In 1921 CT scanners, bedside ultrasound and MRI machines did not exist. Surgeons used their knowledge of anatomy, their hands and elegantly refined assessment techniques to arrive at a diagnosis. Naloxone (Narcan) was not developed until the 1960s, and there was no way to reverse an opioid overdose effectively in 1921. Doses were usually not titrated to pain relief, and dosing to the point of sedation could occur. In 1921 IM injections of 30 mg of morphine were common.
Today, however, although physical assessment skills are still very important, modern radiographic studies make diagnosis much easier, and opioid effects can be reversed readily if desirable. Few surgeons, if any, will bring a patient to the operating room based upon physical diagnosis alone, making potential masking of symptoms by opioid administration a moot point.
For the last 30 years, editions of Early Diagnosis have been edited by William Silen, MD, of Harvard University. In the latest edition, the 21st, he wrote:
The patient cries out for relief, the relatives are insistent that something shall be done, and the humane disciple of Aesculapius is driven to diminish or banish the too-obvious agony by administering a narcotic. The realization, likely erroneous, that narcotics can obscure the clinical picture has given rise to the unfortunate dictum that these drugs should never be given until a diagnosis has been firmly established. With the numerous layers of triage nurses, medical students, residents and attending physicians in modern emergency units, and with the addition of time-consuming tests often done before an adequate history and physical examination, the suffering patient is sometimes forced to wait for many hours before any relief is offered. This cruel practice is to be condemned, but I suspect it will take many generations to eliminate it because the rule has become so firmly ingrained in the minds of physicians. A recent prospective randomized trial has shown that the early administration of morphine to patients with acute abdominal pain does not obscure the correct diagnosis or delay appropriate treatment.1
Some argue that a patient given opioids will lack the mental capacity for informed consent for treatment. This argument does not hold water unless the patient is medicated to the point of sedation. If the patient has the cognitive ability to understand her circumstances, understand an explanation of what is proposed to be done and rationally evaluate those two items and come to a rational judgment about treatment, then there is no problem. Unlike in decades past, opioids may now be given intravenously and titrated to pain relief, and if the patient is given so much medication that rational consideration is not possible, reversal is an easy option.
It can just as easily be argued that a patient suffering excruciating pain may be as unlikely to make a rational decision as a medicated patient. Indeed, the hurting patient may feel coerced into consenting to a procedure.2
The Studies
Numerous studies have examined the effects of opioids on the ability of physicians to diagnose abdominal pain.
As long ago as 1986, Nigel Zoltie and Michael Cust studied 100 patients in the U.K. who were given opioids for abdominal pain and concluded there was no evidence of masking of physical findings.3 Six years later a similar study resulted in similar findings.4
In 2003 a study published in the Journal of the American College of Surgeons compared 36 adult patients who were given placebos with 38 adult patients who were given morphine. The study found no evidence of masking of symptoms or differences in physical exam results and diagnosis between the two groups. It concluded that early administration of analgesics to patients with undifferentiated abdominal pain should not be contraindicated.5
Silen and Stephen H. Thomas evaluated these three studies along with several others in 2003 and concluded that “judicious provision of analgesia appears safe, reasonable and in the best interests of patients in pain.”6 However, there were some weaknesses in the studies, one of which was the limited number of patients studied.
In 2006 Sumant Ranji, et al, reviewed nine trials involving adults and three trials in children to see if the results of physical examinations were altered by opioid administration. They found that while opioid administration might alter the physical examination findings somewhat, there were no significant management errors, and no patient suffered major morbidity or mortality.7
In 2007 a Cochrane Review compared six randomized controlled trials contrasting opioid analgesia with no analgesia in adults with abdominal pain. These studies included 699 patients who were given either 5–15 mg of morphine or equivalent amounts of normal saline. The studies found no significant differences in the groups in terms of accuracy of diagnosis, alterations in physical presentations or mistakes in treatments. Two of the studies measured patient comfort and found significant improvements with opioid analgesia.8 Other studies have resulting in similar findings in the pediatric and geriatric populations.9–11
EMS providers are bound by treatment guidelines that arise from varying sources. Some are bound by state-mandated protocols and field guides that may limit pain management; some are guided by regional consortiums that adopt protocols; some are governed by hospital-based guidelines; others are free to have their medical directors provide treatment guidelines as they see fit. Standardization is difficult and probably unattainable. Yet in view of the existing evidence, a good argument can be made that lack of adequate pain management may be a breach of standard of care that can lead to claims for injury and damages. Medical malpractice lawyers are well aware of pain management standards and deficiencies and should be expected to review the pain management aspects of any case they investigate. And patients may never forget being made to suffer because of a flawed system.
Changing the attitudes of emergency providers about pain management proceeds at glacial pace. It will require the efforts of all concerned to improve our standards and remove barriers to pain relief.12 EMS providers are often the tail of the dog in pain management; some progressive EMS providers who provide good pain management have found themselves the focus of criticism by certain emergency physicians and nurses. Others simply are stuck in the mire of tradition, bound by archaic rules and unable to progress.
Bright spots exist. Practices are changing. Many progressive emergency physicians and EMS medical directors are leading the fight for better pain management, and there are many EMS providers who provide excellent pain relief.
Conclusion
In this era of iPods and digital media, EMS pain management seems stuck in the days of boom boxes and cassette tapes. It’s time we tossed the old attitudes about pain management, like those old boom boxes, into the dustbin of history.
(And kids, if you don’t know what a boom box or cassette tape is, ask your parents.)
References
1. Silen W, Cope Z. Cope’s Early Diagnosis of The Acute Abdomen, 21st ed., p. 5. Oxford, NY: Oxford University Press, 2005.
2. Brewster GS, Herbert ME, Hoffman JR. Medical myths: Analgesia should not be given to patients with an acute abdomen because it obscures the diagnosis. West J Med, 2000 March; 172(3): 209–210.
3. Zoltie N, Cust MP. Analgesia in the acute abdomen. Ann R Coll Surg, 1986; 68: 209–210.
4. Attard AR, Corlett MJ, Kidner NJ, Leslie AP, Fraser IA. Safety of early pain relief for acute abdominal pain. BMJ, 1992; 305: 554–6.
5. Thomas SH, Silen W, Cheema F, et al. Effects of morphine analgesia on diagnostic accuracy in emergency department patients with abdominal pain: a prospective, randomized trial. J Am Coll Surg, 2003 Jan; 196(1): 18–31.
6. Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. Br J Surg, 2003; 90(1): 5–9.
7. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA, 2006 Oct 11; 296(14): 1,764–74.
8. Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev, 2007; (3):CD005660.
9. Bailey B, Bergeron S, Gravel J, Bussieres JF, Bensoussan A. Efficacy and impact of intravenous morphine before surgical consultation in children with right lower quadrant pain suggestive of appendicitis: a randomized controlled trial. Ann Emerg Med, 2007 Oct; 50(4): 371–8.
10. Goldman RD, Narula N, Klein-Kremer A, Finkelstein Y, Rogovik AL. Predictors for opioid analgesia administration in children with abdominal pain presenting to the emergency department. Clin J Pain, 2008 Jan; 24(1): 11–5.
11. Güngör F, Kartal M, Bektas F, Söyüncü S, Yigit O, Mesci A. Randomized controlled trial of morphine in elderly patients with acute abdominal pain. Ulus Travma Acil Cerrahi Derg, 2012 Sep; 18(5): 397–404.
12. Motov SM, Khan AN. Problems and barriers of pain management in the emergency department: Are we ever going to get better? J Pain Res, 2008 Dec 9; 2: 5–11.
William E. “Gene” Gandy, JD, LP, NREMT-P, has been a paramedic for more than 30 years. He has testified in court as an expert witness in a number of EMS cases. He lives in Tucson, AZ.
Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator.
