# Als dispatch for possible Appendicitis



## njemtbvol (Sep 9, 2011)

We had a discussion today down at the squad building about whether Als should be sent out for a possible appendicitis. The pt. chief was complaint was a stabbing pain the lower left quadrant. 10/10 no radiation
Als dispatch?


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## adamjh3 (Sep 9, 2011)

Yes, for pain management.

However, wouldn't appendicitis be lower right quadrant?


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## JPINFV (Sep 9, 2011)

adamjh3 said:


> Yes, for pain management.
> 
> However, wouldn't appendicitis be lower right quadrant?



Almost always, but it can (extremely rarely) present LLQ (situs inversus)*. *Regardless, there are other things besides appendicitis that can cause LLQ pain.


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## the_negro_puppy (Sep 9, 2011)

njemtbvol said:


> We had a discussion today down at the squad building about whether Als should be sent out for a possible appendicitis. The pt. chief was complaint was a stabbing pain the lower left quadrant. 10/10 no radiation
> Als dispatch?



As others have said ALS for pain relief.


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## LondonMedic (Sep 9, 2011)

Appendicitis is a diagnosis made on imaging or direct vision. Until that point it is an acute abdomen. Pre-hospital intervention is usually limited to analgesia but the patient may require resuscitating if they are shocked. If you need ALS to do that then, yes, it is an ALS job, if not then it's BLS.


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## mikie (Sep 9, 2011)

adamjh3 said:


> Yes, for pain management.
> 
> However, wouldn't appendicitis be lower right quadrant?



Could be Rovsing's sign


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## LondonMedic (Sep 9, 2011)

mikie said:


> Could be Rovsing's sign


How?

Rovsing's is pain in the RIF on palpation of the LIF.


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## medicsb (Sep 9, 2011)

njemtbvol said:


> We had a discussion today down at the squad building about whether Als should be sent out for a possible appendicitis. The pt. chief was complaint was a stabbing pain the lower left quadrant. 10/10 no radiation
> Als dispatch?



How well are they tolerating the pain?  We all know that some patients will state 10/10 and then pick up their phone to call someone and giggle over some youtube video of a duck eating pizza.


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## Katy (Sep 9, 2011)

Yes, you would dispatch for ALS. As already stated, for pain management and just a tip it is more likely for pain to be expressed in the RLQ for Appendicitis.


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## MasterIntubator (Sep 9, 2011)

+1 here for pain management.  

Rebound pain..... referred pain.... common points in appendicitis


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## firecoins (Sep 9, 2011)

How long is your response time to the patient? 
How long will it take for ALS to arrive?  
How far is the pt's location from the hospital?


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## DrParasite (Sep 10, 2011)

njemtbvol said:


> We had a discussion today down at the squad building about whether Als should be sent out for a possible appendicitis. The pt. chief was complaint was a stabbing pain the lower left quadrant. 10/10 no radiation
> Als dispatch?


first off, appendicitis isn't a possible dispatch criteria, because it's a diagnosis, not a complaint.  now for abdominal pain, based on the criteria set forth by NJ Depart of Health/NJ Office of Emergency Telecommunications Services (found here: http://www.state.nj.us/911/home/highlights/2009EMDGuidecards.pdf) the answer is no, they should not be sent out for a possible appendicitis on the initial dispatch.

Being familiar with NJ's ALS protocols, as well as paramedics from all over north and central NJ, with no other complaints, they probably won't give pain meds prehospitally.  Not that it won't happen, but they probably won't treat just pain, especially given the proximity to a hospital to most area.

But if you want to call, ALS, than by all means call them.  a request cannot be denied, regardless of the reason (assuming a regional ALS unit is available).  whether or not they will treat the patient is a different story


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## JPINFV (Sep 10, 2011)

DrParasite said:


> Being familiar with NJ's ALS protocols, as well as paramedics from all over north and central NJ, with no other complaints, they probably won't give pain meds prehospitally.  Not that it won't happen, but they probably won't treat just pain, especially given the proximity to a hospital to most area.



Whether paramedics should be dispatched to acute abdominal pain and whether the protocol calls for it or not are two separate issues.


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## Flight-LP (Sep 10, 2011)

DrParasite said:


> first off, appendicitis isn't a possible dispatch criteria, because it's a diagnosis, not a complaint.  now for abdominal pain, based on the criteria set forth by NJ Depart of Health/NJ Office of Emergency Telecommunications Services (found here: http://www.state.nj.us/911/home/highlights/2009EMDGuidecards.pdf) the answer is no, they should not be sent out for a possible appendicitis on the initial dispatch.
> 
> Being familiar with NJ's ALS protocols, as well as paramedics from all over north and central NJ, with no other complaints, they probably won't give pain meds prehospitally.  Not that it won't happen, but they probably won't treat just pain, especially given the proximity to a hospital to most area.
> 
> But if you want to call, ALS, than by all means call them.  a request cannot be denied, regardless of the reason (assuming a regional ALS unit is available).  whether or not they will treat the patient is a different story



Yet another example of why NJ has the stellar reputation they do (*note heavy sarcasm*).

Should it be an ALS response? Yes.

Should the patient in pain have their pain needs addressed? Yes.

Should a medic that withholds analgesia on the basis of location or sheer laziness be fired and turned into the state for investigation? Yes.

Sorry, but this age old "pre-hospital analgesia isn't appropriate for abdominal pain" and the "I'm close enough to the hospital, so let our patient suffer" crap is just that; crap. Folks need to get with the times and start appropriately treating their patients.


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## Medic87 (Sep 10, 2011)

ALS for sure.If the appendix raptures it will cause a spread of infection and next thing you know you have a peritonitis on your hand,and there is possibility of pt going into a shock as well..... OOO and I forgot , if you ever had an appendix removed you probably know in what kinda pain the pt might be in , so pain therapy is indicated .


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## JPINFV (Sep 10, 2011)

To be fair, if rapture occurs, a little appendicitis is the least of our concerns.

/funny typos are funny.


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## medicsb (Sep 10, 2011)

Flight-LP said:


> Yet another example of why NJ has the stellar reputation they do (*note heavy sarcasm*).
> 
> Should it be an ALS response? Yes.
> 
> ...



ALS units are a very limited resource in NJ, therefore they are not and should not be sent/requested/dispatched to every patient with a complaint of pain (abdominal or otherwise).  Many patients in pain tolerate it pretty well.  Not all pain requires narcotic analgesia.  And unfortunately, in NJ, as is the case in most other places, it's all or nothing when it comes to pain management.    

If the pain is tolerable, then, um, yes, I don't see how it would be inappropriate for a medic to turf to BLS (or not be called at all)... even if appendicitis is in the differential.  If the appendix has ruptured or is close to rupturing, there will be more than just pain to worry about and it would be more evident than a subjective 10/10 rating by the patient.  The OP has not provided any other info about the patient's pain other than it didn't radiate and the pt. rated it 10/10.  The rating means nothing without some other indicator of pain.  

So, to be sure... pain may be a reason for ALS dispatch and treatment, but most patients with some sort of pain do not require IV narcotics and for them there is no point of a medic sticking around on some far-out "what if" scenario.


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## Flight-LP (Sep 10, 2011)

medicsb said:


> ALS units are a very limited resource in NJ, therefore they are not and should not be sent/requested/dispatched to every patient with a complaint of pain (abdominal or otherwise).  Many patients in pain tolerate it pretty well.  Not all pain requires narcotic analgesia.  And unfortunately, in NJ, as is the case in most other places, it's all or nothing when it comes to pain management.
> 
> If the pain is tolerable, then, um, yes, I don't see how it would be inappropriate for a medic to turf to BLS (or not be called at all)... even if appendicitis is in the differential.  If the appendix has ruptured or is close to rupturing, there will be more than just pain to worry about and it would be more evident than a subjective 10/10 rating by the patient.  The OP has not provided any other info about the patient's pain other than it didn't radiate and the pt. rated it 10/10.  The rating means nothing without some other indicator of pain.
> 
> So, to be sure... pain may be a reason for ALS dispatch and treatment, but most patients with some sort of pain do not require IV narcotics and for them there is no point of a medic sticking around on some far-out "what if" scenario.



Then maybe the system as a whole should be overhauled, the  have the 1st aid council eliminated, and then you could potentially have the resources your communities deserve.

Pain is subjective. That is a fact. Pain is exactly what your patient tells you it is. It is completely inappropriate for a Paramedic to try to quantify another individual's pain. It also completely innappropriate for a Paramedic to pretend he / she is a CT scanner. You don't know if it is or will soon be ruptured. If they hurt, you should advocate for your patient and provide them analgesia.

Can you stand up before a jury of your peers and make the factual statement that your patient "didn't require IV narcotics"?


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## medicsb (Sep 11, 2011)

Flight-LP said:


> Then maybe the system as a whole should be overhauled, the  have the 1st aid council eliminated, and then you could potentially have the resources your communities deserve.
> 
> Pain is subjective. That is a fact. Pain is exactly what your patient tells you it is. It is completely inappropriate for a Paramedic to try to quantify another individual's pain. It also completely innappropriate for a Paramedic to pretend he / she is a CT scanner. You don't know if it is or will soon be ruptured. If they hurt, you should advocate for your patient and provide them analgesia.
> 
> Can you stand up before a jury of your peers and make the factual statement that your patient "didn't require IV narcotics"?



Do you seriously believe that every patient that rates their pain 10/10 should get IV narcotics?  If you do, then... :rofl:  I agree pain is subjective, but it is not purely so.  Many physical signs indicate the presence of pain.  

A decent assessment can determine whether IV narcs are appropriate.  And there is no pretending that one has X-ray vision here.  There is also no pretending that there is anything for a medic to do other than stare at the patient when only modest pain is present.  Pain in and of itself does not indicate appendicitis specifically, it is just one of many many other pathologies in the differential.  Again, a good assessment will reveal if the patient needs IV narcotics, an anti-emetic, or fluid resuscitation for sepsis, dehydration, or hemorrhage.   The presence of pain, in and of itself, is not necessarily an indicator of the need of a paramedic.  

I'm pretty confident with my assessment skills, so I'll take my chances with the jury, thanks.


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## usafmedic45 (Sep 11, 2011)

> Almost always, but it can (extremely rarely) present LLQ (situs inversus). Regardless, there are other things besides appendicitis that can cause LLQ pain.



Also, but it can also start out with midline pain and in pregnant women will tend to present with RUQ pain.


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## bigdogems (Sep 11, 2011)

Well seeing how there is so much concern about possible rupture. Now that you loaded your pt up with narcotics hope that they have someone who can give consent if they need surgery.


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## LondonMedic (Sep 11, 2011)

bigdogems said:


> Well seeing how there is so much concern about possible rupture. Now that you loaded your pt up with narcotics hope that they have someone who can give consent if they need surgery.


Seriously?

So, not only would you be unable to use an appropriate amount analgesic but you would actively withold pain relief from someone (someone who is willing to be treated by _you_) on the grounds that they might be required to sign a form in the next few hours.

That sounds cruel and unusual to say the least.


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## njemtbvol (Sep 11, 2011)

*allow me to clarify*

If the pain was LRQ medics would have been called.
Hospital is about 5-7 mins away l/s
I ask the pain scale the may my instructor taught me. As 1 is a normal headache, 10 I'm actively cutting off limbs with a chainsaw.

Als is about 4-5 mins out.


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## bigdogems (Sep 11, 2011)

From everything I've seen I have to say the UK has some very different ways things are done. But as a standard I've never worked anywhere that narcotic pain management was used in acute abd pain. Ortho injuries sure. But for how many possible things could cause abd pain I rather let the doc do his exam without pain being masked by pre hospital pain management. Im not sure about the UK but "pain control" has been pushed so much in the US that people have come to expect that they shouldnt ever have to have pain. I have seen countless pts with 10/10 abd pain yet they are eating a bag of chips when the get to the waiting room or can sleep perfectly comfortable

But for the OP. No, if working in a system that has both ALS and BLS it would be acute abd pain and be a BLS response. When in a system that has limited ALS units sending them to abd pains would probably completely overload the system


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## LondonMedic (Sep 11, 2011)

bigdogems said:


> From everything I've seen I have to say the UK has some very different ways things are done. But as a standard I've never worked anywhere that narcotic pain management was used in acute abd pain. Ortho injuries sure. But for how many possible things could cause abd pain I rather let the doc do his exam without pain being masked by pre hospital pain management.


This has been shown, time and again, to be unacceptable practice. Good analgesia actually enables a proper assessment and allows the clinician to take a clearer history and elicit signs on examination. If someone is too busy screaming or writhing on the trolley then none of this is possible.

Read the Cochrane Review.



> Im not sure about the UK but "pain control" has been pushed so much in the US that people have come to expect that they shouldnt ever have to have pain. I have seen countless pts with 10/10 abd pain yet they are eating a bag of chips when the get to the waiting room or can sleep perfectly comfortable


Then that is part of managing people's expectations and that is as important a comms skill as taking a history or breaking bad news.


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## STXmedic (Sep 11, 2011)

bigdogems said:


> From everything I've seen I have to say the UK has some very different ways things are done. But as a standard I've never worked anywhere that narcotic pain management was used in acute abd pain. Ortho injuries sure. But for how many possible things could cause abd pain I rather let the doc do his exam without pain being masked by pre hospital pain management.



Then you should reevaluate the places you've worked at. I'm in Texas also, and have never worked in a system that doesn't allow narcotics for abdominal pain. I won't go into why as London said it fairly well.


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## Flight-LP (Sep 11, 2011)

PoeticInjustice said:


> Then you should reevaluate the places you've worked at. I'm in Texas also, and have never worked in a system that doesn't allow narcotics for abdominal pain. I won't go into why as London said it fairly well.



Thanks for the interjection. 

Bigdog, studies have proven that acceptable analgesia in the pre-hospital environment has ZERO effect on most consent concerns. It is nothing more than an excuse.

I agree with poetic, you may need to look at the systems you are associated with, especially since the one in your own hometown has some of the most liberal pain guidelines around.


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## mycrofft (Sep 11, 2011)

*Search pre-hospital analgesia.*

hat debate cvhanged my mind in favor of it.

Original post:

We had a discussion today down at the squad building about whether Als should be sent out for a possible appendicitis.An acute abdomen is an acute abdomen. Put down the video game or dominoes and go.

The pt. chief was complaint was a stabbing pain the lower left quadrant. 
Internittent or steady or worsening or stable , sudden onset or insidious and over how long...go see the pt, its safer and quicker. Don't have the pt do a rebound test over the phone.

I've had every one of my relatively few appy cases recall pain in locations besides McBurney's beforehand, but the overwhelmingly greater pain there was thought by them to be different. Also, most complained of queasiness before the pain settled down and right*.

10/10 no radiation.
I think that abdo pain "refers", not "radiates", usually.

The silver lining here is that the majority of LLQ pain is related to stool or/and gas so some of those delayed pts may have gotten lucky, but the belly is a wonderous and dangerous place, as one of my instructors told us.


*As a healthy adolescent, mine started m idline with slight nausea, then LLQ, then RLQ.


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## 18G (Sep 11, 2011)

ALS for pain and nausea management.


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## medicsb (Sep 11, 2011)

njemtbvol said:


> If the pain was LRQ medics would have been called.
> Hospital is about 5-7 mins away l/s
> I ask the pain scale the may my instructor taught me. As 1 is a normal headache, 10 I'm actively cutting off limbs with a chainsaw.
> 
> Als is about 4-5 mins out.



As has been mentioned pain is subjective.  You will encounter patients who will rate their pain 10/10 (even if you try to calibrate them with a 1= X, 10=Y approach) but will pick up their cell phone to call and yell at their kids or make jokes with you while another patient may rate a pain 8/10 and be rocking back and forth, crying, grunting, with an elevated RR and HR.  

You need to look for objective signs of pain, too.  Grimacing, difficulty concentrating or answering questions due to distraction by the pain, vital sign changes (e.g. incr. HR, RR, BP), splinting, guarding, etc., etc.


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## systemet (Sep 12, 2011)

It seems that in EMS we have some sort of idea that we have to identified "drug-seeking" individuals, and with-hold narcotics from them.  Or that by giving a random citizen a small dose of IV morphine, we're risking creating a raging heroin addict, if we get them even the slightest bit euphoric.

I would argue that most of the behaviour we label as "drug-seeking" is actually people who are anxious, and having a little bit of a hard time coping with life in general.  

I think if you're a true addict, and you're going through withdrawal, maybe 5mg of morphine is worth calling EMS for, to "take the edge off".  I don't think we're going to be getting anyone who is even a little bit tolerant of opiates high off the doses we give prehospitally under most circumstances.  

[Consider for example, pain management in cancer patients --- I once received an order of 30 mg MS IVP, from a palliative care physician for a patient with breakthrough pain.  These patients are opiate tolerant, but how much more tolerant is a drug addict?]

I had a family member once present to the ER with an acute abdomen, and be labelled as a drug seeker.  Possibly because he's a little bit of a borderline personality. He has trouble communicating well, and at 0300 may have appeared to fit the "drug seeking" demographic.  And he got to sit there for several hours until someone finally did some imaging, while the staff treated him like crap.  I would rather give opiates to a hundred "drug seekers", and take the edge off a few people's opiate addictions, than try judging how much my patients "deserve" opiates, and miss a single patient who genuinely needs pain control.  I'd rather have a high false-positive rate than see this happen.


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## abckidsmom (Sep 12, 2011)

systemet said:


> It seems that in EMS we have some sort of idea that we have to identified "drug-seeking" individuals, and with-hold narcotics from them.  Or that by giving a random citizen a small dose of IV morphine, we're risking creating a raging heroin addict, if we get them even the slightest bit euphoric.
> 
> I would argue that most of the behaviour we label as "drug-seeking" is actually people who are anxious, and having a little bit of a hard time coping with life in general.
> 
> ...



Amen.


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