Don't believe medication myth
Patients with abdominal pain are at high risk for being inadequately managed for pain, argues William Mallon, MD, FACEP, associate professor of emergency medicine at University of Southern California Medical Center in Los Angeles. "People are aggressive about managing chest pain, but abdominal pain is one of the worst managed conditions of all. I think we can do a lot better job than we do," he says.
ED physicians may hold off on pain medications because they know the surgeon will be against the idea, says Mallon. "Surgeons tend to be conservative with pain management across the board, but the literature is completely at odds with that concept," he insists.2,3
"This is a tremendous controversy," emphasizes Stephen Colucciello, MD, FACEP, clinical services director and trauma coordinator for the department of emergency medicine at Carolinas Medical Center in Charlotte, NC. "The traditional thinking is that narcotic pain medicine obscures findings of the physical exam and makes surgical examination more difficult. This myth has been perpetuated for decades," he says.
Studies have repeatedly shown that the use of medication does not obscure the need for surgery, but the misconception persists, says Colucciello. "In general, the studies show that narcotics do not interfere with the medical exam. However, many surgeons still believe it does. There is a lot of tradition that keeps physicians from ordering medication," he says.
Patients who obviously need surgery should be medicated. "If free air is seen on the patient's X-ray, that's an automatic laporotomy. So, the patient should get pain medicine since it's not an issue of whether the abdominal exam shows the need for an operation," says Colucciello. Medication should be given in small amounts and titrated intravenously, rather than IM, he adds.
Nurses should present alternatives if physicians are resistant. "You can suggest non-narcotic approaches to pain," says Colucciello. "Toredol is useful for biliary colic, and droperidol alleviates both the pain and nausea of pancreatitis. Or, in the case of narcotics, the surgeon can always give Narcan to reverse the narcotics if they are worried about obscuring the physical exam. However, this seems to be a heartless approach to me."
If a patient comes in with a pain of 8 on a scale of 1 to 10, a reasonable goal is to reduce his or her pain by half, says Mallon. "The literature says when you do that, the patient is able to localize pain better, so the ability to identify the source of pain gets better, not worse," he explains.
Having patients self-report pain may prompt physicians to give pain medication, Mallon suggests. "If the physician is resistant to giving pain medication, inform them that the patient's pain is a 9 out of a 10," he says. "That can work both as a prompt-both while the patient is in the ED and when they are discharged."
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