What happens when we subject dogma to scientific scrutiny? Kelly Grayson and Gene Gandy will answer that question in this new series, as each month they challenge some of EMS’ most closely held beliefs and practices to meet the standards of evidence-based medicine. It’s time to drag a few sacred cows to the slaughterhouse!
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 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.