21YOM - Back pain

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.
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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.
 
Assuming no aortic issues suspected...

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

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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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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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.
 
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.
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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.
 
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.
 
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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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.
 
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.
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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.
 
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.
 
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.
 
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.
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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.
 
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).
 
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).
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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:
 
Some folks get some pretty abnormal impulses while under the influence.
 
yes very, i have a friend when she drinks she looks like shes constantly winking!
 
She's into you, dude!
 
: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
 
I think that would be a "he's into girl!" not visa versa.

Just a guess ;)
 
Sorry, Mel, it's late on our time zone..
 
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