# 21YOM - Back pain



## Melclin (Jan 3, 2012)

You respond at 02:30am on the eve of the non-denominational annual winter festival of celebration and general contentment, to a 21 year old bloke with back pain. 

O/A: at a camp site on a warm night (its summer here remember), you find a young bloke lying on the ground in a sleeping bag surrounded by concerned looking attractive blonds wearing not much. 

His name is Jack and he tells you with a bit of a slur that he was drinking the evening away (about 9 beers in all) when he suddenly felt a nasty pain in his back and felt unable to move properly without causing further pain (nil trauma). He waddled back to his sleeping bag to lay down where he was found an hour later by one of the beauties who called an ambulance to "cover herself" (evidently the irony of saying that while dressed in the smaller half of a handkerchief was lost on her, as was my giggling). 

O/E: BP 115/70, Pulse 98, RR 20, GCS 15, Temp 36.8

6/10 pain, central lumbar region, with pain shooting down both legs when he tries to move too much.  

Both legs have normal colour, movement, temperature, sensation and distal pulses. 

Nils meds or allergies. 

Has a hx of two episodes of back pain like this, seen in hospital once. Does not recall them telling him what it was but says they did a lot of tests, none of the medications they gave him helped and it went away after a few hours of rest (a day of bed rest on the first occasion).

You have the basics, further info on request. Shoot.

*All are welcome, even if its just, "protocol tells me...", oddly enough I'm actually quite interested in what the EMT-Bs among you are supposed to do with this case. ALS/BLS upgrade/downgrade, trauma centre/local/GP/home and all that.*


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## rmabrey (Jan 3, 2012)

Did he specify if the pain was down the front or back of the legs? First thought is Sciatica, in which case transport BLS, O2 NC for pain (silly med nec.), to whatever hospital he chooses. 

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## Underoath87 (Jan 3, 2012)

Double post


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## Underoath87 (Jan 3, 2012)

Yeah, it sounds like some sort of pinched/compressed nerve issue (maybe from an old injury).
I'd just transport to the nearest ER in a position of comfort.


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## usalsfyre (Jan 3, 2012)

Screw the guy with the back pain, are we sure the blondes don't have an urgent medical condition? 

Seriously, as a medic, pain control and transport for non-traumatic back pain. Back when I was a basic it would have been the same, minus the pain control. It's unfortunate, but I fear systems that tier ambulances in the US simply wouldn't send a medic unit for pain control, no matter how barbaric it may be. One of the many failings here.


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## Melclin (Jan 3, 2012)

Are you all sure there is nothing else you'd ask or do? What if there is something nasty brewing deep down in my highly medicated but still slightly unstable mind?

On the other side of the coin, why do you want to transport...and to what kind of hospital?



> Screw the guy with the back pain, are we sure the blondes don't have an urgent medical condition



Well, their bloke was clearly out of action for the rest of the night. I see no reason why a handsome young paramedic couldn't or shouldn't offer his services in the boneration+/-everlasting love department.


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## Melclin (Jan 3, 2012)

rmabrey said:


> Did he specify if the pain was down the front or back of the legs? First thought is Sciatica, in which case transport BLS, O2 NC for pain (silly med nec.), to whatever hospital he chooses.
> 
> Sent from my Desire HD using Tapatalk



No he didn't and I didn't ask. Why do you ask?


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## Epi-do (Jan 3, 2012)

Is the pain midline, or off to the sides of the spinal column?

At this point, I have to agree with everyone else - transport and pain meds, if available.


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## mycrofft (Jan 3, 2012)

*This being EMTLIFE and all* I'd be looking for a problem with the descending aorta or a spinal aneurysm. 

If this were House MD, I'd be saying "paraneoplastic syndrome".

If it were STNG, I'd be saying "subspace containment field of the temporal rift Q continuum".

Being the sod I am, I'd palpate along the spine (any spot-tenderness or palpable protuberances or depressions or masses?), have him raise each leg without pointing his toes (keep foot-ankle at 90 deg angle) and ask about pain, test for differential weakness to resisted raising (straight knee)  and pushing (straightening a bent knee), in the ambulance; not much I'm going to be able to do onsite and the guy's in hurting status. PLUS, as I always say, the belly (well, torso) is a dark and terrible place, and we forget that the back is just the other side of the torso. Observe voluntary position of greatest comfort. (Bet it is knees up). On-scene: ask if anyone else is sick. Oh, and safely percuss by the kidneys.
History: ask about BM's, urination, recent activities, prior occasions of similar discomfort. 
Continue VS while transporting. If I was working ALS or has a nurse, draw bloods for labs, get urine if possible and dip with 10 panel stick (especially looking for blood, and if it is haemolyzed, non-haemolzed, or both; if it sits, it will all be haemolyzed), always check fingerstick glucometry. Maybe cautiously palpate belly; if anything is unusual, auscultate.


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## Nattens (Jan 3, 2012)

Melclin said:


> Well, their bloke was clearly out of action for the rest of the night. I see no reason why a handsome young paramedic couldn't or shouldn't offer his services in the boneration+/-everlasting love department.



I had a similar situation on the weekend. As the saying goes "What happens on the island, stays on the island "

As far as protocol goes transport with pain relief, depending on transport time methoxy should do the trick however it might be worth getting access for pain relief or going up the nose depending on the transport time.


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## nwhitney (Jan 3, 2012)

Any bite or puncture marks?


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## mycrofft (Jan 3, 2012)

No, they were NICE ladies...


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## rmabrey (Jan 3, 2012)

Melclin said:


> No he didn't and I didn't ask. Why do you ask?



It's not really relevant to the treatment, back of the leg makes me think sciatica, front of the leg has me thinking femoral nerve, and Injury to the back, such as degenterative disc could cause both. 

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## downunderwunda (Jan 4, 2012)

Given the intoxication (can we really believe it is only 9 beers) I would also suspect some drug use (we get raves in local state logging forests), namely exctasy & a high probability of an unknown or unrealized trauma leading to the pain he now realises. This is due to the fact he is coming down from MDMA. 

I would pain manage him, fluids ESP if there is any suggestion of MDMA, as well as full spinal precautions. 

The other thing to remember is cultural. The Aussie male is inherently hopeless in admitting to anything in the presence of 1. Beautiful women & 2. Anyone medical.


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## Veneficus (Jan 4, 2012)

or acute choliecystits, pancreatitis, or hepatitis


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## Aidey (Jan 4, 2012)

Or he is lying about the trauma. He could have pulled a muscle or slipped a disk...entertaining...the ladies.


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## mycrofft (Jan 4, 2012)

(used without permission, from this  web page):

http://anatomynotes.blogspot.com/2006/10/referred-pain.html


These should be a sticky


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## firetender (Jan 4, 2012)

I'm looking for a complete assessment here, which the OP has not provided. Mycrofft began asking the right questions. Is what you gave us what you'd report to the Doctor in the ER, OP?


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## Handsome Robb (Jan 4, 2012)

Aidey said:


> Or he is lying about the trauma. He could have pulled a muscle or slipped a disk...entertaining...the ladies.



I was waiting for someone to suggest this one  If this turns out to be the case, my hat's off to him!

Does he remember what they said about his previous episodes or only that "the medications don't work"?

Anything observed on the back? Pain on palpation? Muscle rigidity noted? Guarding? I know it's his back but he could still "guard" it. 

I see no evidence of drug use so I won't be entertaining the ecstasy theory. Plus that's not quite how it works, they aren't clumsy idiots and would notice some sort of trauma although with the ETOH on board it IS possible but not likely. People will argue that there is evidence but I will preface those arguments with ETOH is not reliable evidence of drug use. 

Has he urinated? Any abnormalities in color, difficulty or smell? Pain? The kidneys are right there and some sort of inflammation could put pressure on nerves although I don't think this theory has any real foundation either. 

Has he been drinking any water over the past couple of days or just partying? How about eating? Muscle cramps due to electrolyte imbalances seems plausible and with his Hx I'd be willing to bet that sensitive areas of the past would be the first that he would feel or notice. 

firetender I'm wondering what else you would be able to tell the ER?? I'm not big on poking and prodding at someone who is in pain any more than I have to.


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## firetender (Jan 5, 2012)

There's no reason to be shy about a little palpating. Would a head-to-toe exam be inappropriate and a report in that form being reported to the doc? It certainly would show the doc that you were thorough.

Perhaps a bit far-fetched, yet couldn't a twisted neck send out referred pain to the lower extremities? I'm thinking leave no stone unturned, especially since the pt. didn't seem willing to give much up on his own.

In essence, though, treatment would be the same; provide comfort and stability and transport.


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## Handsome Robb (Jan 5, 2012)

firetender said:


> There's no reason to be shy about a little palpating. Would a head-to-toe exam be inappropriate and a report in that form being reported to the doc? It certainly would show the doc that you were thorough.
> 
> Perhaps a bit far-fetched, yet couldn't a twisted neck send out referred pain to the lower extremities? I'm thinking leave no stone unturned, especially since the pt. didn't seem willing to give much up on his own.
> 
> In essence, though, treatment would be the same; provide comfort and stability and transport.



True. A good physical exam will definitely help the doc out especially if you are providing analgesia. I still wont advocate causing a pt unnecessary pain though. If I've checked the complaint area thoroughly once I'm not going to keep poking at it.

I don't see a twisted neck causing referred pain to the lower extremities. I would expect it to present as altered sensation and motor skills rather than pain. I'm no neurologist though. 

Coming from someone who experienced a severe cervical injury I have never had referred pain in my lower extremities but thats n=1. I had a mid-to-high cervical insult and have occasional pain and spasms in my shoulders, neck and sometimes down into my hands (mostly thumbs) along with tension headaches.


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## MedicPatriot (Jan 6, 2012)

Assuming no aortic issues suspected...

.1 mg/kg Morphine up to 20mg titrated to pain
all else BLS


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## Melclin (Jan 6, 2012)

mycrofft said:


> *This being EMTLIFE and all*
> Being the sod I am, I'd palpate along the spine (any spot-tenderness or palpable protuberances or depressions or masses?), have him raise each leg without pointing his toes (keep foot-ankle at 90 deg angle) and ask about pain, test for differential weakness to resisted raising (straight knee)  and pushing (straightening a bent knee), in the ambulance; not much I'm going to be able to do onsite and the guy's in hurting status. PLUS, as I always say, the belly (well, torso) is a dark and terrible place, and we forget that the back is just the other side of the torso. Observe voluntary position of greatest comfort. (Bet it is knees up). On-scene: ask if anyone else is sick. Oh, and safely percuss by the kidneys.
> History: ask about BM's, urination, recent activities, prior occasions of similar discomfort.
> Continue VS while transporting. If I was working ALS or has a nurse, draw bloods for labs, get urine if possible and dip with 10 panel stick (especially looking for blood, and if it is haemolyzed, non-haemolzed, or both; if it sits, it will all be haemolyzed), always check fingerstick glucometry. Maybe cautiously palpate belly; if anything is unusual, auscultate.



No spot tenderness on palpation, no depressions or masses, can raise each leg without pointing toes. No one else is sick (I assume, I didn't ask, but given the worry on the face of the caller, I'd say she'd mention that fact that there were 12 others like him in the next tent). He was able to urinate before he came and lay down. Hasn't tried a bowel movement, doesn't need to go. 

Didn't do glucose and don't have bloods.



NVRob said:


> Does he remember what they said about his previous episodes or only that "the medications don't work"?
> 
> Anything observed on the back? Pain on palpation? Muscle rigidity noted? Guarding? I know it's his back but he could still "guard" it.
> 
> ...



Doesn't remember anything about what they've said previously. He also had an MRI spine and abdo U/S that were NAD. 

He seems "straight" and there is no evidence of drug use, its all a pretty low key affair. The property is owned by an ex-copper. 

Urination was normal. Was at home until a few hours ago, hasn't been partying extensively.


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## Melclin (Jan 6, 2012)

So interesting answers. 

Are people so keen to transport because they have to, because they assume he wants to go or because its EMTlife and they're worried about 1/10000000 alien egg sack adhered to spine?

I didn't take this guy to hospital.

To me he had what was probably some kind of musculoskeletal issue, it any case it had happened before, had been extensively investigated by the sounds of it with nothing horrible being found. Pain relief seemed ineffective and the problem was ultimately self resolving. Whats more, if they could't figure it out in the big city with their fancy scannermajigs, what are they going to do for him in a small rural ED? Furthermore, the guy was pretty happy with the idea of staying put. We had him test his mobility (didn't wanna come back for lift assist 2 hours later), and he could move without pain. He happy to "stretch it out". If he's happy, I'm not going to kidnap him. 

Shoot.


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## DrParasite (Jan 7, 2012)

Melclin said:


> I didn't take this guy to hospital.
> 
> To me he had what was probably some kind of musculoskeletal issue, it any case it had happened before, had been extensively investigated by the sounds of it with nothing horrible being found. Pain relief seemed ineffective and the problem was ultimately self resolving. Whats more, if they could't figure it out in the big city with their fancy scannermajigs, what are they going to do for him in a small rural ED? Furthermore, the guy was pretty happy with the idea of staying put. We had him test his mobility (didn't wanna come back for lift assist 2 hours later), and he could move without pain. He happy to "stretch it out". If he's happy, I'm not going to kidnap him.
> 
> Shoot.


unfair answer (even though that's what you did).

did you determine he didn't need to go to the hospital (essentially refused to transport him because he didn't need it), or did he tell you he didn't want to go so you had him sign an RMA?  Those are two different outcomes.

Outside of a loss of bladder or bowel control, nothing seemed life threatening.  If he called 911, and wanted to go to the hospital, than we take him to the hospital, with the treatments provided in reply 2.  If he doesn't want to go, sign the RMA.  

When you hear hoof beats, think horses not zebras or water buffalo.


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## Melclin (Jan 7, 2012)

Well its not a bloody competition. Where does fair come into it? I wasn't trying to get people to get "the right answer", I was interested in what other systems do with this kind of pt.

Rarely does it have to be one or the other in regards to transport. I explain their situation and what course of action would be most appropriate depending on what they wanna achieve. Many people who call here will ask whether or not we think they need to go and will are happy to accept our opinion on what the best option is. Its not a matter of "refusing transport" to a person who wants to go or singing out AMA.

With this guy it went something like, "We can take you down to hospital if you want, but I think its very unlikely that they're ganna be able to do much more than they have in the past. If the pain is bothering you beyond panadol etc then we can help you out in that regard but then we'll have to run you down to hospital, its really up to you, you're the only person who knows how much pain you're in."

Happy to run him down and put him in the waiting room, its not out of my way, but at the same time, I didn't really think he needed to go to hospital via ambulance. It wasn't as simple as him refusing to go from the outset, but that was the conclusion we came to in the end after discussing his options.


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## Melclin (Jan 12, 2012)

Really? Nobody? 

I can see by some of the responses that many thought it was an EMTlife "who dunnit". It wasn't. I thought I made that reasonably clear. I apologise if I didn't.

Really though, it wasn't meant to be a trick question. Nor one to demonstrate the superiority of one system or another (I know sometimes I/others bang on about how much we're allowed to do or how awesome one system is over another).

*I was genuinely interested in what the thought process was in diagnosing/risk stratifying/transporting this guy... EMTlife noggin scratchers aside. Non-transports are, I think, the area where we make the most mistakes and potentially do the most good for all of the many stakeholders.* As such, its an area of intense interest for me.

Having said this, I'm interested to know why everyone transported in this case. I think I noted that it wasn't actually him who called the ambulance. This is a classic non-transport for use. *Lets put aside the fact that its EMT life*. Is it that he rated his pain highly? Are people routinely asking if their pts actually want to go to hospital? Did you genuinely suspect a pathology that needed to be treated at the local ED? Did you hold a high enough index of suspicion that it was something nasty? Do you HAVE to transport? 
*I'm actually interested to know, please do comment again.*

Don't be afraid to change your positions, treatments etc..Its not a pissing contest, and the scenario may have changed compared to how it was perceived originally due to my deficiencies in describing it.


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## mycrofft (Jan 12, 2012)

Well then, if I were not on duty, I'd casually question him and bystanders as to his physical activities that evening, and just before the onset, and maybe the day before if nothing so far had seemed likely to be MOI for musculoskeletal injury. I'd suggest he get a ride to see a doc if no serious activity had preceded, like alcohol plus strip-Limbo or swimsuit-Twister.

Engaging our dangerous mind reading capacities, if the situation was serious and precarious, like renal or major vascular, then his MD would have acted more strongly or even put him on meds and/or performed surgery.

Of course, a "simple musculoskeletal" (shorthand for "it's not me that has it") back injury could be a precursor to permanent disability, pain, etc. The spine being the tilting tower it is, anything that casual would be risking the pt...but no more than he was willingly risking himself.

I'm saying "off duty" because if I were on duty I'd be professionally held to look for those zebras.


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## DrParasite (Jan 12, 2012)

Melclin said:


> Having said this, I'm interested to know why everyone transported in this case. I think I noted that it wasn't actually him who called the ambulance. This is a classic non-transport for use. *Lets put aside the fact that its EMT life*. Is it that he rated his pain highly? Are people routinely asking if their pts actually want to go to hospital? Did you genuinely suspect a pathology that needed to be treated at the local ED? Did you hold a high enough index of suspicion that it was something nasty? Do you HAVE to transport?
> *I'm actually interested to know, please do comment again.*


The job of EMS, at it's most basic level is to take the patient to the hospital, and prevent the patient from getting worse (if possible).  taking everything else out of the equation, and what people might want EMS to become in the future, and all the skills, that's the basic job of ems.

Do I think the patient in your example NEEDED to go to the hospital by ambulance?  absolutely not.  Then again, I don't think the person who had 15 beers in the past hour needed to go to the hospital either, nor the 20 year old with a fever for the past 2 days, nor the person in the MVA who has minor neck pain from a fender bender.  However, if they want to go to the hospital, despite me thinking they don't need an ambulance, let's go for a ride.

Similarly, if the 65 year old man who is grossly diaphoretic, complaining of weakness, and a little chest pain is adamantly refusing to go to the hospital (his wife called because he didn't look right to her), and is competent to make his own decisions, than I also don't HAVE to transport him.  He has every right to make his own decisions, and I cannot force him not to make a stupid decision.


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## TbArbie (Jan 12, 2012)

Well again to reiterate EMS tells us to look at the problem at hand and expect the worst...So 1 you have a possible intoxicated man, 2 there is a half clothed women next to him, 3 hes deemed stable...if it was me, id first off back would know that alcohol may act as an muscle relaxant in some people, it could be also cause muscle spasms in others and that these muscle spasms could be causing the pain. so his fun with the female could be the contributing factor of the pain as well. Id offer transportation to the pt/ and give him o2 via NC 4l/min and quickly assess him and apply ice to the affected area.


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## mycrofft (Jan 13, 2012)

Never heard of ETOH causing muscle spams before. I know drunks will overexert sometimes until injured, or ignore an extant pain until it nail them.,
About 2 AM. When they suddenly can't get out of bed to use the toilet. In a single-wide mobile home. In the rain, and no sidewalks.


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## TbArbie (Jan 13, 2012)

mycrofft said:


> Never heard of ETOH causing muscle spams before. I know drunks will overexert sometimes until injured, or ignore an extant pain until it nail them.,
> About 2 AM. When they suddenly can't get out of bed to use the toilet. In a single-wide mobile home. In the rain, and no sidewalks.



Well they believe ETOH can cause muscle spams due to it that has affects on nerve impulses...for example some people who are intoxicated who get into fights and get punched dont usually feel the pain till the following morning. ETOH disrupts the natural conduction of nerve impulses.


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## mycrofft (Jan 13, 2012)

Yeah, that's what IU'm talking about. The ETOH doesn't cause the spams and injury, it allows you to engage in those activities.
(I worked detox ward for six years).


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## TbArbie (Jan 13, 2012)

mycrofft said:


> Yeah, that's what IU'm talking about. The ETOH doesn't cause the spams and injury, it allows you to engage in those activities.
> (I worked detox ward for six years).



i think what they were trying to get at is, since the ETOH is affecting the nerves which can cause a spasm, since your not having normal impulses i guess if you move or be naughty your introuble:rofl:


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## mycrofft (Jan 13, 2012)

Some folks get some pretty abnormal impulses while under the influence.


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## TbArbie (Jan 13, 2012)

yes very, i have a friend when she drinks she looks like shes constantly winking!


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## mycrofft (Jan 13, 2012)

She's into you, dude!


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## TbArbie (Jan 13, 2012)

:rofl:: so i guess my new motto should be..if you cant find your winking gf, shes prolly in the back on my stretcher haha


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## Handsome Robb (Jan 13, 2012)

I think that would be a "he's into girl!" not visa versa.

Just a guess


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## mycrofft (Jan 13, 2012)

Sorry, Mel, it's late on our time zone..


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## TbArbie (Jan 13, 2012)

haha i should be sleeping but im keeping an eye on my sister she had a tonsillectomy, so im making sure she doesnt have trouble breathing


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