# For 'newer' medics and students... abdominal pain management



## RRTMedic (Nov 14, 2016)

What are your thoughts on administering analgesics to patients experiencing abdominal pain? Is there evidence to support withholding narcotics to someone in obvious pain? How has technology changed this? I know my answer, but I'm curious what they're teaching in school nowadays.


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## RocKetamine (Nov 15, 2016)

Well most of the newer medics I've been around still consider abdominal pain a contraindication for narcotic analgesia. They're still teaching (at least in my area) the "ER won't be able to assess" BS.


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## VentMonkey (Nov 15, 2016)

RocKetamine said:


> Well most of the newer medics I've been around still consider abdominal pain a contraindication for narcotic analgesia. They're still teaching (at least in my area) the "ER won't be able to assess" BS.


...


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## StCEMT (Nov 15, 2016)

I would give it assuming I didn't find anything that contraindicated it or made me question it. I don't buy the "they can't assess in the ER" deal. Otherwise, heck yea I will give some pain meds. Now I have heard that while I was in medic school, but that is a belief I chose to disregard once I was no longer under a preceptors oversight. Actually, one of the some kind of chiefs where I did my school advocated us not being stingy and treating pain appropriately if the patient is hurting. So I would say it still exists, but the idea is changing.


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## medichopeful (Nov 15, 2016)

I'm still in medic school, but once I finish and start functioning as a paramedic, unless my protocols forbid it, I see no reason to withhold analgesia for abdominal pain.  

Honestly, I don't remember what they taught me in medic school (maybe I just ignored that part if I didn't agree with it).  But through my experience working in the hospital, I can say that analgesics are not going to effect imaging results, or lab results.  Dulling the pain but not snowing the patient will also allow an assessment to continue.  Or, better yet, just do the assessment well then give the pain meds.

TL;DR: no reason to withhold them except for outdated practices and laziness.


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## Tigger (Nov 15, 2016)

The whole "interfering with the ED's assessment thing" seems to be pretty debunked. I'm not going to intentionally snow someone, but if you're hurting, I am going to try and put a dent in that. I might hold off on the Ketamine if I don't think I can adequately coach you, but really there are few contraindications to fentanyl and morphine here. Maybe be vary of opioid induced constipation, but aside from that...


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## DesertMedic66 (Nov 15, 2016)

My medic school stressed if they are in pain then medicate them. We viewed pain as an additional vital sign. 

My company does not care how much pain meds we give or what we give it for. 

Our company limits us to just isolated extremity trauma. We have to contact the base hospital for non-extremity pain or non traumatic pain. It really depends on the Doctor on duty that day. Some will let us while others won't.


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## harold1981 (Nov 15, 2016)

The days that we refused analgesics for the sake of abdominal assessement are over. If the patient is in pain he gets 1G of IV acetaminophen, and either fentanyl (up to 4mcg per kg) or esketamine (up to 0.375mg/kg) until his painscore is lower than 5. We don´t carry more flavors.


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## ParamedicStudent (Nov 15, 2016)

Can someone please explain to me why abd pain is a contraindication for analgesics?


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## RRTMedic (Nov 15, 2016)

ParamedicStudent said:


> Can someone please explain to me why abd pain is a contraindication for analgesics?



Hey so there is a adage traditional in the EMS world that patient's with abdominal pain should not receive analgesia because it may "mask" the assessment made by the physician. I.e. once the patient gets to the hospital they are no longer in any pain, soooo lets send them home. Not a good idea, right?

Although this practice may have had some merit back in the day, there is a number of pieces of literature that state there is no evidence for withholding analgesia in patients with abdominal pain.

A lot of this change in practice is due to the fact that our imaging technology has become some diagnostic and advanced. The use of ultrasound guided assessment has truly changed emergency medicine and done away with ideas such as withholding analgesia for the sake of a physical assessment.


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## RRTMedic (Nov 15, 2016)

harold1981 said:


> The days that we refused analgesics for the sake of abdominal assessement are over. If the patient is in pain he gets 1G of IV acetaminophen, and either fentanyl (up to 4mcg per kg) or esketamine (up to 0.375mg/kg) until his painscore is lower than 5. We don´t carry more flavors.



I'm always worried when we consider ketamine solely for pain management... call me what you may, it just seems like there are a number of mental side effects that are unnecessary that go along with ketamine. 

My experience with ketamine has been with patient's not tolerating bipap in the ER... give some ketamine and viola, you can ventilate them.

Anyone have more anecdotal evidence or success with ketamine solely as an analgesic? Did it impair the patient's ability to answer questions and interview well?


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## RRTMedic (Nov 15, 2016)

RocKetamine said:


> Well most of the newer medics I've been around still consider abdominal pain a contraindication for narcotic analgesia. They're still teaching (at least in my area) the "ER won't be able to assess" BS.



**sigh** Just another example of how EMS education is 20 years behind...


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## EpiEMS (Nov 15, 2016)

So the initial idea of not providing analgesia for the acute abdominal pain patient (apparently) dates back to 1921, courtesy of Dr. Zachary Cope, who harangued against it. Now, that may have been reasonable then, but even as late as 1987, a later edition of Dr. Cope's book said "though it may appear crude, it is really prudent to withhold morphine until a reasonable diagnosis has been made and a plan of action formulated". 

Now, we know (much) better and have better diagnostic modalities...thus we can fairly comfortably say things like: "The use of opioid analgesics in the therapeutic diagnosis of patients with [Acute Abdominal Pain] does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment."


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## DrParasite (Nov 15, 2016)

RRTMedic said:


> A lot of this change in practice is due to the fact that our imaging technology has become some diagnostic and advanced. The use of ultrasound guided assessment has truly changed emergency medicine and done away with ideas such as withholding analgesia for the sake of a physical assessment.


so now the ER doctors aren't performing a subjective assessment to treat the patient (like EMS does), they are performing imaging and lab values to objectively identiy any issues.... an interesting change in assessment and treatment strategies


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## medichopeful (Nov 15, 2016)

harold1981 said:


> The days that we refused analgesics for the sake of abdominal assessement are over. If the patient is in pain he gets 1G of IV acetaminophen, and either fentanyl (up to 4mcg per kg) or esketamine (up to 0.375mg/kg) until his painscore is lower than 5. We don´t carry more flavors.



I'm reading this on my phone and read this as "1G of IV Fentanyl" because of the way the lines were laid out. That would fix the issue!

On a more serious note, what country do you work in that you're doing those meds for pain?


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## NysEms2117 (Nov 15, 2016)

if it helps at all when i went to the hospital recently (within the past month), with severe debilitating left sided abdominal/radiating to lower back pain, i got pain meds. fentanyl to be exact, idk the dose, seemed low, just enough to take the "debilitating" factor out.


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## medichopeful (Nov 15, 2016)

RRTMedic said:


> I'm always worried when we consider ketamine solely for pain management... call me what you may, it just seems like there are a number of mental side effects that are unnecessary that go along with ketamine.
> 
> My experience with ketamine has been with patient's not tolerating bipap in the ER... give some ketamine and viola, you can ventilate them.
> 
> Anyone have more anecdotal evidence or success with ketamine solely as an analgesic? Did it impair the patient's ability to answer questions and interview well?



I've given low doses of Ketamine in the past (around 10mg if I remember correctly) for migraines and it hasn't had much of an effect on their mental status.


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## EpiEMS (Nov 15, 2016)

DesertMedic66 said:


> Our company limits us to just isolated extremity trauma. We have to contact the base hospital for non-extremity pain or non traumatic pain.



Is this a California quirk or a company decision?


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## SpecialK (Nov 15, 2016)

So tell me, is there any contraindication to treating pain? No! There may be contraindications to specific medicines, but not to pain in general.

Have you ever tried to examine somebody who is in writhing agony? I have, and it's pretty bloody hard let me tell you.  That's just examining them, let alone getting them onto the bed and down to the ambulance and drive them to hospital.

When I first started it was entonox and morphine, and ketamine had just come out; so pretty limited.  I can remember morphine plus midazolam because not everybody had ketamine.  I don't even think there was paracetamol.  Now there's almost no reason pain can't be treated between entonox, methoxyflurane, paracetamol, ibuprofen, tramadol, morphine, fentanyl, ketamine, and lignocaine blocks.

"Don't treat abdominal pain" is a relic from the decades before high-tech imaging such as CT scanning when surgeons had to rely more upon physical examination.  As an aside, my ability to examine abdomens is absolutely terrible.  I can inspect, auscultate and have a push in the 9 quadrants and have a general idea of what is in each but I'm really not very good.  Most patients with abdominal pain "bad" enough to ring ambo gets taken to ED where they'll probably get thrown through the CT scanner (maybe) so nothing I really do is going to be clinically significant in terms of a diagnosis.


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## RRTMedic (Nov 15, 2016)

DrParasite said:


> so now the ER doctors aren't performing a subjective assessment to treat the patient (like EMS does), they are performing imaging and lab values to objectively identiy any issues.... an interesting change in assessment and treatment strategies



Sadly, it seems that a blanket of lab values and radiology trumps patient history and interview


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## Nova1300 (Nov 16, 2016)

If anyone ever happens to pick me up and I neeed pre-hospital analgesia, there are only 2 things I want you to give me: 

1. Ketamine in 20 mg increments until I'm comfortable.  
Or...
2. A penthrox inhaler


Unfortunately, those are both hard to come by in the US EMS world.  
.


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## ERDoc (Nov 16, 2016)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070812/


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## StCEMT (Nov 17, 2016)

Nova1300 said:


> If anyone ever happens to pick me up and I neeed pre-hospital analgesia, there are only 2 things I want you to give me:
> 
> 1. Ketamine in 20 mg increments until I'm comfortable.
> Or...
> ...


Come to St. Louis, I'll get ya that special k.


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## SpecialK (Nov 17, 2016)

Penthrox (penthrane) aka methoxyflurane is very common in Australia so much so they've withdrawn entonox.  We still have entonox but also have MOF for an alternate when you can't give somebody entonox such as suspected bowel obstruction.

I haven't used it, truth be told I can't even remember how to do it, it's fiddly and painful to put together.

And in case you are wondering' "methoxyflurane" is a combination of parts of the IUPAC name: 2,2-dichloro-1,1-di*flu*oro-1-*methoxy*eth*ane*.


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## VentMonkey (Nov 17, 2016)

SpecialK said:


> Penthrox (penthrane) aka methoxyflurane is very common in Australia so much so they've withdrawn entonox.  We still have entonox but also have MOF for an alternate when you can't give somebody entonox such as suspected bowel obstruction.
> 
> I haven't used it, truth be told I can't even remember how to do it, it's fiddly and painful to put together.
> 
> And in case you are wondering' "methoxyflurane" is a combination of parts of the IUPAC name: 2,2-dichloro-1,1-di*flu*oro-1-*methoxy*eth*ane*.








Or as my wife envious-restricted-American-paramedic self likes to call it..."The Magic Whistle".


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## SpecialK (Nov 17, 2016)

Yes it's also referred to as "the green whistle" because the little inlet at the top can be covered with a finger is stronger analgesia is required; i.e. you are not also inspiring oxygen with the MOF.  

I have never used it as I said, but we use entonox like it's going out of fashion and having MOF means even for people who can't have entonox (for whatever reason) they still have something to breathe for pain relief if they a) do not need IV pain relief, or b) the ambulance doesn't have a Paramedic or ICP onboard.  

As an aside, now that oral tramadol has been introduced for EMTs the combination of paracetamol, ibuprofen and tramadol in addition to entonox or MOF means not only better pain relief options for EMTs (and the patient at the end of the day!) but also I would imagine sometimes no longer need to call for backup which is great because most ambulances with only an EMT (and either an FR/EMA or another EMT) are out in the country where backup can be a decent while away.


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## EpiEMS (Nov 17, 2016)

Having entonox would be a huge, easy value add for us...but we've got nothing. Isolated extremity fracture hurts? Well, I either have to call a medic or drive - that's all I've got for ya (plus splinting, cryotherapy...).


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## SpecialK (Nov 17, 2016)

So get entonox?


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## EpiEMS (Nov 17, 2016)

SpecialK said:


> So get entonox?



Would if I could - it's not the kind of thing that's going to be quickly implemented in my neck of the woods, especially with our profusion of medics and conservative administrations.


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## Handsome Robb (Nov 17, 2016)

SpecialK said:


> So get entonox?



The reason a lot of places stopped using nitronox here is because no one was manufacturing a mixer that was FDA approved for a long time. 

My old service had it but we couldn't ever get parts to fix our equipment. 


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## NomadicMedic (Nov 17, 2016)

SpecialK said:


> So get entonox?



Curious how you track potential abuse?


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## MackTheKnife (Nov 17, 2016)

RRTMedic said:


> What are your thoughts on administering analgesics to patients experiencing abdominal pain? Is there evidence to support withholding narcotics to someone in obvious pain? How has technology changed this? I know my answer, but I'm curious what they're teaching in school nowadays.


You give analgesics for pain. Even in Abdominal Compartment Syndrome.


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## RocketMedic (Nov 17, 2016)

RocKetamine said:


> Well most of the newer medics I've been around still consider abdominal pain a contraindication for narcotic analgesia. They're still teaching (at least in my area) the "ER won't be able to assess" BS.



I've noticed a lot of that. It's very disappointing- especially how people think that these people think that everyone with abdominal pain is "faking it" due to assumptions based on locale and demographics...


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## SpecialK (Nov 17, 2016)

DEmedic said:


> Curious how you track potential abuse?



We don't.  Honestly, the idea somebody would mischievously huff entonox is pretty far out there no?

I can't think of a way you could do but I can't see why you'd need to.  

Morphine, fentanyl, and ketamine are tracked and audited but nothing else because don't need to.


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## MackTheKnife (Nov 26, 2016)

Another point- analgesics do not necessarily mask an evaluation by the ER provider. A dose of opiods is not going to totally shut down peristalsis ot abdominal sounds. Think of the various abdominal etiologies and their associated bowel sounds (hyopactive, hyperactive, etc.) And someone with rebound tenderness with a hot appy ain't gonna change the dx if they got some joy juice.


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## SpecialK (Nov 26, 2016)

I remember being taught to stop testing for "rebound tenderness" years ago no? .....


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## StCEMT (Nov 26, 2016)

SpecialK said:


> I remember being taught to stop testing for "rebound tenderness" years ago no? .....


I am fresh out of medic school and we were taught it. Now I am not just gonna press as hard as I can or anything ridiculous, but I would at this point in my career do a light test for it.


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## Handsome Robb (Nov 26, 2016)

StCEMT said:


> I am fresh out of medic school and we were taught it. Now I am not just gonna press as hard as I can or anything ridiculous, but I would at this point in my career do a light test for it.



Or markle's sign. That's an easy one too. 


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## NomadicMedic (Nov 26, 2016)

Handsome Robb said:


> Or markle's sign. That's an easy one too.
> 
> 
> Sent from my iPhone using Tapatalk



I was just going to say that! Or, the hop test.


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## StCEMT (Nov 26, 2016)

Handsome Robb said:


> Or markle's sign. That's an easy one too.
> 
> 
> Sent from my iPhone using Tapatalk


Huh, I just learned something new. Good to know.


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## SpecialK (Nov 26, 2016)

StCEMT said:


> I am fresh out of medic school and we were taught it. Now I am not just gonna press as hard as I can or anything ridiculous, but I would at this point in my career do a light test for it.



From memory the rationale for not using it is because it doesn't have any specific diagnostic value that will change what we do to the patient.

As I said previously, my abdominal examinations are pretty rubbish but I do have a quick palpate of their tummy.  If they have a peronitic, rigid hard abdomen it's going to be quite obvious when I have a feel no?

Abdo pain in general is a pain in the, well, abdomen, I guess.  It can be really hard figuring out if these patients need immediate referral somewhere or are safe to remain in the community with delayed referral or self-care.

Unless they have an obviously non-significant and well-manageable problem such as uncomplicated gastroenteritis or something I will generally recommend they go to ED, or at the very least, see their GP in the morning AND make an appointment with them while at the house.  Most GP's also don't seem to like abdominal pain and their default is "unless it's minor they go to ED".  Which I think is honestly best for the pt.


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## Handsome Robb (Nov 26, 2016)

SpecialK said:


> Unless they have an obviously non-significant and well-manageable problem such as uncomplicated gastroenteritis or something I will generally recommend they go to ED, or at the very least, see their GP in the morning AND make an appointment with them while at the house.  Most GP's also don't seem to like abdominal pain and their default is "unless it's minor they go to ED".  Which I think is honestly best for the pt.



I don't disagree. An acute abdominal complaint with an unknown cause is a high risk scenario. 


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## MackTheKnife (Nov 26, 2016)

SpecialK said:


> I remember being taught to stop testing for "rebound tenderness" years ago no? .....


Still an assessment tool in nursing.


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## StCEMT (Nov 26, 2016)

SpecialK said:


> From memory the rationale for not using it is because it doesn't have any specific diagnostic value that will change what we do to the patient.
> 
> As I said previously, my abdominal examinations are pretty rubbish but I do have a quick palpate of their tummy.  If they have a peronitic, rigid hard abdomen it's going to be quite obvious when I have a feel no?
> 
> ...



I haven't ever actually had a patient with appendicitis, so I don't know. But then again, if memory serves right it starts out periumbilical and moves to where McBurney's point is? So I guess there are times where that would be true.

Same here, abdominal pain leaves so many doors I don't really go too crazy with trying to play doctor and find an answer in the 7 minutes I have them in my truck.


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## VentMonkey (Nov 26, 2016)

StCEMT said:


> *I haven't ever actually had a patient with appendicitis, so I don't know.* But then again, if memory serves right it starts out periumbilical and moves to where McBurney's point is? So I guess there are times where that would be true.
> 
> Same here, abdominal pain leaves so many doors I don't really go too crazy with trying to play doctor and find an answer in the 7 minutes I have them in my truck.


You'll "_just know"._They're typically doubled over in pain with no reasonable suspicion that they are "med seeking", have had copious bile in their vomit, and/ or have been dry heeving.

I agree with what most of the seasoned medics have posted on here (I know the op wanted newer paramedics' input), acute abdominal pain with any reason for suspicion to me gets antiemetics and pain control/ fluids, no real ifs ands or buts. I could care less what the ED staff does or doesn't think of my differentials.

As far as palpating the abdomen, I usually start from the farthest quadrant from their pain, and if it hurts there, I stop. I wouldn't want someone poking at my stomach for some quasi-reliable test if I have an acute abdomen.

I would think much like any half way decent paramedics, most ED docs and nurses worth a dime don't need to have some "sign" be the defining factor in a clinically diagnosed abdominal complaint...and most don't.


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## StCEMT (Nov 26, 2016)

VentMonkey said:


> You'll "_just know"._They're typically doubled over in pain with no reasonable suspicion that they are "med seeking", have had copious bile in their vomit, and/ or have been dry heeving.
> 
> I agree with what most of the seasoned medics have posted on here (I know the op wanted newer paramedics' input), acute abdominal pain with any reason for suspicion to me gets antiemetics and pain control/ fluids, no real ifs ands or buts. I could care less what the ED staff does or doesn't think of my differentials.
> 
> ...


I don't doubt I could put 2 and 2 together and reach 4, its just the various tests that I don't know how certain they are or really if even necessary. At least not with appendicitis, others might be a bit more useful.


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## NysEms2117 (Nov 26, 2016)

VentMonkey said:


> As far as palpating the abdomen, I usually start from the farthest quadrant from their pain, and if it hurts there, I stop. I wouldn't want someone poking at my stomach for some quasi-reliable test if I have an acute abdomen.


As an idiot asking this... Isn't appendicitis a rebound pain? which is oddly distinct? please don't maul me if this is a stupid question


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## VentMonkey (Nov 26, 2016)

StCEMT said:


> I don't doubt I could put 2 and 2 together and reach 4, its just the various tests that I don't know how certain they are or really if even necessary. At least not with appendicitis, others might be a bit more useful.


This was more generalized so that others may understand my rationale as well. I'm sure you know 2 and 2 doesn't equal 10, etc.


NysEms2117 said:


> As an idiot asking this... Isn't appendicitis a rebound pain? which is oddly distinct? please don't maul me if this is a stupid question


As far as the signs for me, again, I personally don't get too caught up on their reliability in the prehospital setting. Most of them are "nice to know", but I have yet to think of a time I have relayed to an EM physician a specific "sign" to correlate with my treatment modalities
and it being a defining moment in their decision-making. I don't know how pertinent they truly find it, but would guess it varies from doc to doc.


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## StCEMT (Nov 26, 2016)

VentMonkey said:


> This was more generalized so that others may understand my rationale as well. I'm sure you know 2 and 2 doesn't equal 10, etc.
> 
> As far as the signs for me, again, I personally don't get too caught up on their reliability in the prehospital setting. Most of them are "nice to know", but I have yet to think of a time I have relayed to an EM physician a specific "sign" to correlate with my treatment modalities
> and it being a defining moment in their decision-making. I don't know how pertinent they truly find it, but would guess it varies from doc to doc.


Probably doesn't change much for them. Guess I feel better knowing I don't walk in like "yea his stomach hurts like a sumbitch, he didn't like moving much....so yea....don't do that". But who knows, most of my abdominal stuff has been nursing home GI bleeds that they already know the problem.


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## rescue1 (Nov 29, 2016)

NysEms2117 said:


> As an idiot asking this... Isn't appendicitis a rebound pain? which is oddly distinct? please don't maul me if this is a stupid question



It can be, but rebound pain doesn't = appendicitis. The current guidelines for acute appys tate "no physical exam findings, together or alone, can confirm a diagnosis of appendicitis". All these patients are getting imaged, so don't stress over an in depth assessment of the abdomen. Don't ignore the assessment either, but keep in mind many of the physical exam signs for abdominal pain have pretty low sensitivity and/or specificity so while you'll still see them done, they can only nudge you in the right direction, not tell you definitively what's going on.


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## NysEms2117 (Nov 29, 2016)

rescue1 said:


> It can be, but rebound pain doesn't = appendicitis. The current guidelines for acute appys tate "no physical exam findings, together or alone, can confirm a diagnosis of appendicitis". All these patients are getting imaged, so don't stress over an in depth assessment of the abdomen. Don't ignore the assessment either, but keep in mind many of the physical exam signs for abdominal pain have pretty low sensitivity and/or specificity so while you'll still see them done, they can only nudge you in the right direction, not tell you definitively what's going on.


I've been told rebound is the "go to" field test(physical) for it though. I understand as soon as they get into the ER most likely before they even see a doctor they are getting imaged. Are there any other "quick and easy" tests for appendicitis?


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## StCEMT (Nov 29, 2016)

NysEms2117 said:


> I've been told rebound is the "go to" field test(physical) for it though. I understand as soon as they get into the ER most likely before they even see a doctor they are getting imaged. Are there any other "quick and easy" tests for appendicitis?


That bump test that was mentioned earlier in the thread. Markle's sign I think it was called.


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## VentMonkey (Nov 29, 2016)

As one can see, there's a slew of "signs" that can cue you to lower quadrant abdominal ailments, none of which are exactly accurate or definitive.

http://emedicine.medscape.com/article/773895-overview#a1

Just my take, and why if I palpate the farthest quadrant from their complaint I cannot rule in or out a specific diagnosis, only treat them accordingly with what I have. 

I rely more on other findings such as obvious signs of pain, copious N/V/D leading to volume depletion, fevers, chills, etc.; to me this is usually enough to paint a clinical picture as to how I should treat their otherwise vague complaint until relinquishing care to the ED and passing on what I may have found pertinent.


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## EpiEMS (Nov 29, 2016)

AHRQ has a comparative effectiveness review of diagnostic tools for RLQ pain. Page 25 has a nice little table with sensitivity and specificity figures for clinical signs. Their conclusion is pretty unequivocal: "Clinical symptoms and signs and laboratory tests have relatively limited test performance *when used in isolation*." [Bold text mine]


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## EpiEMS (Nov 29, 2016)

Also, FWIW, you can calculate 7 of 10 of the Alvarado score points prehospitally (only 3 points come from lab metrics that I don't think I can get in a usual BLS service).


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## Handsome Robb (Dec 3, 2016)

VentMonkey said:


> As one can see, there's a slew of "signs" that can cue you to lower quadrant abdominal ailments, none of which are exactly accurate or definitive.
> 
> http://emedicine.medscape.com/article/773895-overview#a1
> 
> ...



I just like the word "markle".


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## RoadRat (Dec 20, 2016)

I'm a 4-month-old medic. 

In class and in the ambulance we were hounded to never give narcotics for abdominal pain. 
Zofran, yes. 
Morphine or fentanyl, no.

Our instructors and even field preceptors went on, and on about referred pain and how the abdomen is essentially a black hole which cannot be correctly assessed due to the peritoneum.

Which is correct as long as the patient is isolated to care within an ambulance. I've had some blind arguments against abdominal pain management, but have since learned better. 


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## EpiEMS (Dec 20, 2016)

RoadRat said:


> In class and in the ambulance we were hounded to never give narcotics for abdominal pain.





RoadRat said:


> Our instructors and even field preceptors went on, and on about referred pain and how the abdomen is essentially a black hole which cannot be correctly assessed due to the peritoneum.



Wow, I didn't imagine that this kind of "knowledge" was still being passed down. Have you been personally properly treating pain despite the preceptors?


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## RoadRat (Jan 1, 2017)

EpiEMS said:


> Wow, I didn't imagine that this kind of "knowledge" was still being passed down. Have you been personally properly treating pain despite the preceptors?



Now that I'm on my own, I do treat abdominal pain properly, but at the disgust of my coworker. I've had two separate EMTs report me to higher-ups for improper patient care due to administering painkillers for abdominal pain. The supervisors they report me to also disagree with pain management for abdominal pain. 

But, I keep going against the grain without any consequence other than the doubt of my coworkers. 

It's a sad world out here. 


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## StCEMT (Jan 1, 2017)

Well they can go piss up a rope. Pretty sure you can easily use research to show that they're being idiotic. Hopefully your future partner(s) aren't quite that obnoxious.


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## DrParasite (Jan 2, 2017)

RoadRat said:


> I've had two separate EMTs report me to higher-ups for improper patient care due to administering painkillers for abdominal pain. The supervisors they report me to also disagree with pain management for abdominal pain.


What does your medical director think?  After all, you are working under his license,so it's only his opinion and direction that really matters. 

On an unrelated topic, I have 0 respect for any EMT who whines to the higher ups about a paramedic treating a patient who was in pain.


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## RoadRat (Jan 3, 2017)

DrParasite said:


> What does your medical director think?  After all, you are working under his license,so it's only his opinion and direction that really matters.



The protocol states the typical "consider pain management" line even for abdominal pain. We never actually have face-to-face or even electronic/radio contact with our medical director, so we can only assume he approves of abdominal pain management. 

The private company's CEO (a critical care medic of 20+ years) counseled me due to the complaints by partners and after 10 minutes of discussion he agreed with my methods. A supervisor was also present to witness the discussion, so it's known that I'm correct in my habits. But that doesn't change that I make my coworkers uncomfortable with my pt care choices. 

They're reacting naturally, but not logically. 

... I'll also add I'm a bit abrasive to EMTs who question my choices. My pride is overdeveloped, and so when they ask why I administered pain meds I don't explain my thoughts in a calm manner. I can't really blame them for complaining to an ear who will listen. 


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## DrParasite (Jan 3, 2017)

RoadRat said:


> The protocol states the typical "consider pain management" line even for abdominal pain. We never actually have face-to-face or even electronic/radio contact with our medical director, so we can only assume he approves of abdominal pain management.


 I thought that was a requirement to operate under their license?  Maybe a phone call or email would be in order, provided it was passed up through the chain of command?


RoadRat said:


> The private company's CEO (a critical care medic of 20+ years) counseled me due to the complaints by partners and after 10 minutes of discussion he agreed with my methods. A supervisor was also present to witness the discussion, so it's known that I'm correct in my habits. But that doesn't change that I make my coworkers uncomfortable with my pt care choices.
> 
> They're reacting naturally, but not logically.
> 
> ... I'll also add I'm a bit abrasive to EMTs who question my choices. My pride is overdeveloped, and so when they ask why I administered pain meds I don't explain my thoughts in a calm manner. I can't really blame them for complaining to an ear who will listen.


So was the complaint that you didn't explain properly, or because you administered pain meds to the patient?  and were you counseled on your administration of pain meds, or your interactions with your partners?

As an EMT, it is not my place to decide whether my partner paramedic gives pain meds to someone, and I stand by my statement that I have zero respect for EMTs who whine about it to supervisors.  If you want to treat a BLS patient with ALS equipment and meds, it's one less chart me to to write.  

Now if you are treating your EMT partners like crap and getting all defensive because they are asking you a question about why you did something, that's a different story.  A chat with the boss was probably warranted, even if simply "hey, don't be a jerk off when they ask you a question.  Explain why you do something, and then if they still have an issue with it, then both of you should come to my office and we can discuss it together.  But tone it down with the abrasiveness, it's completely uncalled for."  

Contrary to the belief of many paramedics, paramedics do make mistakes, do miss things, and it's much easier to work with an EMT partner vs having them work for you.  But if they have an issue with giving any clinically indicated medication, and it goes up to the CEO's office, than that sounds more like a system issue.  But I have a hunch it wasn't what you said or why you did something, but rather how you said it.


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## VentMonkey (Jan 3, 2017)

DrParasite said:


> Contrary to the belief of many paramedics, paramedics do make mistakes, do miss things, and it's much easier to work with an EMT partner vs having them work for you.


Quoted for its emphatic truth.


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## StCEMT (Jan 3, 2017)

DrParasite said:


> Contrary to the belief of many paramedics, paramedics do make mistakes, do miss things, and it's much easier to work with an EMT partner vs having them work for you..





VentMonkey said:


> Quoted for its emphatic truth.



That's a big reason why I am I am chasing down a friend to start working as my partner. He knows the area, he's a good EMT, and since he is a good ways through medic school he will be someone I can bounce ideas off of.

I can understand the annoyance with people handing stuff like that when your treatment was right though[/QUOTE]


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## RoadRat (Jan 3, 2017)

DrParasite said:


> I thought that was a requirement to operate under their license?  Maybe a phone call or email would be in order, provided it was passed up through the chain of command?
> 
> Now if you are treating your EMT partners like crap and getting all defensive because they are asking you a question about why you did something, that's a different story.  A chat with the boss was probably warranted, even if simply "hey, don't be a jerk off when they ask you a question.  Explain why you do something, and then if they still have an issue with it, then both of you should come to my office and we can discuss it together.  But tone it down with the abrasiveness, it's completely uncalled for."
> 
> Contrary to the belief of many paramedics, paramedics do make mistakes, do miss things, and it's much easier to work with an EMT partner vs having them work for you.  But if they have an issue with giving any clinically indicated medication, and it goes up to the CEO's office, than that sounds more like a system issue.  But I have a hunch it wasn't what you said or why you did something, but rather how you said it.



I recognize medics make mistakes. And I welcome an experienced EMT partner's input. 

I also try to monitor my interactions with my EMTs. I realize my ego is not their problem, and they are not responsible for tip-toeing around it. I don't expect them to. 

Whenever I feel an exaggerated emotional response to a partner's pointed question, I take a moment to calm down before explaining myself through calm but gritted teeth. So, perhaps from the perspective of the EMTs, "gritted teeth" warranted being reported.

Again, I know my ego is my problem and no one else's.

But, I will say in my defense that I don't become aggravated without first being jabbed in the side. An EMT who - in front of a patient - dramatically rolls his eyes, huffs, waves his hands in a dismissive fashion, and outright argues with me about ALS care is promised to get an angry reaction. 

I was not counseled on my interaction with the partners who reported me. If how they received my demeanor was the motivating factor behind reporting me, it was never indicated to me by my supervisors or the CEO. The CEO specified that several EMTs were concerned I was inhibiting care of abdominal pain pts by giving analgesics.




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## EpiEMS (Jan 4, 2017)

DrParasite said:


> As an EMT, it is not my place to decide whether my partner paramedic gives pain meds to someone, and I stand by my statement that I have zero respect for EMTs who whine about it to supervisors. If you want to treat a BLS patient with ALS equipment and meds, it's one less chart me to to write.



If my medic partner decides to not give a patient in pain treatment for pain, it's totally reasonable for me to ask after the fact why they didn't, no?



RoadRat said:


> An EMT who - in front of a patient - dramatically rolls his eyes, huffs, waves his hands in a dismissive fashion, and outright argues with me about ALS care is promised to get an angry reaction.



Absolutely. (Nothing wrong with asking afterwards, though, I'm sure you'll agree!)


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## DrParasite (Jan 4, 2017)

ok, let me see if I have this right..... 

1) you treated a patient in pain, in accordance with you agency's protocols
2) your EMT partner (actually several of them), filed complaints about your patient care with the supervisor, despite you following your medical director's clinical protocols (which everyone is aware of, since everyone has a copy of the protocols)
3) The supervisor evaluated the complaints, felt they were valid and with merit, and gave them to the CEO to initiate a disciplinary session
4) The CEO counseled you on your actions, despite agreeing that pain should be treated, despite you following the protocol from your medical director, and despite the fact the modern studies say prehospital treatment of pain does not prevent objective assessment of abdominal issues

Assuming i got that right, I have questions: assuming everything you said is 100% true, why didn't the supervisor quash these complaints immediately?  why is your CEO counseling you on anything, shouldn't the supervisor be doing it?  why didn't the supervisor (who I am assuming is a paramedic) ask you to explain your actions prior to going to the CEO?  What gives an EMT the right to argue over you wanting to provide ALS care?  I can see arguing over NOT providing needed ALS care, but if you want to treat the patient, they are throwing a hissy fit?


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## NysEms2117 (Jan 4, 2017)

RoadRat said:


> I'll also add I'm a bit abrasive to EMTs who question my choices. My pride is overdeveloped, and so when they ask why I administered pain meds I don't explain my thoughts in a calm manner. I can't really blame them for complaining to an ear who will listen.


1. glad we aren't partners lol, That wouldn't fly with me
2. they aren't complaining, they are asking you(whom the state of whomever deems you have more education in healthcare then they do) which you interpret as complaining.
3.It may benefit you to explain your thoughts in a calm manner, becuase if your like a certain person i know who works as an EMT-B, but is a physician he will then proceed to i believe the saying is "rip you a new one?"
4. What happened to the whole you never learn unless you ask questions thing? Maybe it has something to do with abd pain in LRQ instead of LLQ, but if i dont ask, how am i supposed to know?
Edit: at DR.P from my interpretation i think the EMT's asked a question, not arguing. I think they were just trying to learn why tbh. but this is my youthful ignorance as one of those pesky question asking emt's


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## RoadRat (Jan 4, 2017)

DrParasite said:


> ok, let me see if I have this right.....
> 
> 1) you treated a patient in pain, in accordance with you agency's protocols
> 2) your EMT partner (actually several of them), filed complaints about your patient care with the supervisor, despite you following your medical director's clinical protocols (which everyone is aware of, since everyone has a copy of the protocols)
> ...



You are correct in all aspects of what you have written, except for one large and overhanging concept: you assume my company's management system and structure is effective with dealing with employee complaints. I am unable to explain the faults in the management system, and am only able to relay what I have witnessed and perceived. 

It also seems that we have deviated from the topic of this forum. It's also obvious no matter how clearly and accurately I explain the situation, someone will compare it to a perfectly functioning EMS system and find suspicion. I didn't comment on this topic with the hopes of being subject to this tiring back-and-forth. 

Believe what you will. 


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## NomadicMedic (Jan 4, 2017)

Eh, this doesn't exactly sound like the whole story. I think we all know newer medics who believe in "treating all the pain". As in, "I've got a drug box and I'm gonna use it". 

Yep, I was there too. 

And those salty, jaded EMTs can be a thorn in the side of a newer medic, especially when the supervisor says something to the effect of, "Bill's been an EMT for a long time. He knows more than most medics. He'll keep you out of trouble." 

Sounds like a combo of a new medic overtreating, salty EMTs taking their role as new medic babysitter a bit to seriously and the CEO trying to smooth things over, but just making it worse (in the eyes of the OP). 

There's always three sides to every story.


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## RocketMedic (Jan 5, 2017)

I've been that guy, and mostly still am. The best answer is really just to ask yourself "is it worth it?" Sounds terrible, but now I find myself asking if my anticipated treatments are actually likely to make a difference or if they're just to make me feel better. That and I have become far less outwardly passionate about good care- you'll never change anyone who self-identifies as "salty", especially a career EMT. Not worth your time.


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