Tincture of Chicken Soup

I have been a big advocate of pain relief for patients. All the studies show that patients are consistently undermedicated both prehospitally and in the ER. Pain relief is something we can do that makes a huge difference for the patient. We can take care of their pain. I try to be as aggressive as I can be within hemodynamic bounds.

Recently I made a new protocol proposal to the medical advisory committee involving morphine. In the old days we were taught never to give morphine to patients with abdominal pain because it masked their diagnosis. Then we could give it with medical control permission if we made a good case that their probably had kidney stones.

Proposed Protocol Change # 1:
Morphine for Undifferentiated Abdominal Pain

The Change:

In the Pain algorithm under Other Pain, change the heading to “Abdominal Pain (possible kidney stone, sickle cell anemia or undifferentiated pain)” and include the following:

If patient is hemodynamically stable: Administer .05 mg/kg Morphine Sulfate (MS) SIVP to a max of 5mg.

Establish Medical Control

Possible Physican Orders:

Additional MS

Also, add the following footnote:

“This change is due to recent research that shows morphine does not hinder abdominal pain assessment, and may in fact improve diagnoisis. Thus paramedics may give “a judicious dose” of morphine (.05 mg/kg) on standing order to patients with non-traumatic abdominal pain. Additional needed morphine may be requested upon contact with medical control.”

Background:

Withholding morphine for abdominal pain in the belief that it might mask pain, delay diagnosis and contribute to mortality has been a long-standing practice in medicine despite the lack of any research supporting such a practice. As medicine has turned to evidence-based practice and with a concern toward alieviateing patient pain, as well as the presence of increased laboratory and imaging tools, there has been a paradigm shift on this issue.

“The judicious use of analgesics in the setting of acute abdominal pain is appropriate.”
-Cope’s Early Diagnosis of the Acute Abdomen
2000 Edition

“Administration of narcotics to patients with abdominal pain to facilitate the diagnostic evaluation is safe, humane, and in some cases, improves diagnostic accuracy. Incremental doses of an intraneneous narcotic agent can eliminate pain but not palpation tenderness. Analgesics decrease patient anxiety and cause relaxation of their abdominal muscles, thus potentially improving the information obtained from the physical examination. There is evidence that pain treatment does not obscure abdominal findings, or cause increased morbidity or mortality.”
-Clinical Policy: Critical Issues for the Initial Evaluation and Management of Patients Presenting With the Chief Complaint of NonTraumatic Acute Abdominal Pain
American College of Emergency Physicians, 2000

“It should be recognized that no study establishing negative outcomes (of giving MS to patients prior to surgical exam) of any sort has been published. Humane treatment of suffering should therefore be the only argument required to treat abdominal pain.”
-Pain Management and Sedation: Emergency Department Management
McGraw Hill, 2006

Studies- (Full Abstracts and Additional Related Studies attached in Science Document)

1. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial.
J Am Coll Surg. 2003 Jan;196(1):18-31, Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN, Kumar AM, Stair TO.

CONCLUSIONS: Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain. Copyright 2003 by the American College of Surgeons

2. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996 Dec;3(12):1086-92. Pace S, Burke TF.

CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients.

3. Intravenous Morphine in Emergency Department Patients with Acute Abdominal Pain Does Not Alter Disposition Decision, Acad Emerg Med Volume 12, Number 5_suppl_1 18-19, David Esses, Polly Bijur, Conroy Lee, Michael Lahn and E. John Gallagher

Conclusions: The decisions to admit or discharge patients with acute abdominal pain were comparable, regardless of the administration of morphine.

We discussed the proposal for awhile at the last meeting but couldn’t vote on it because we didn’t have a quorum. I got a good deal of support for it, and only enountered one doctor, who hadn’t read my briefing papers, who tried the old argument of his need to see the patient unmarred by morphine. We will continue our debate in September when we meet again.

Recently I have had a couple patients who told me they were allergic to morphine. One had it typed in big front, the other just said she always got really sick when she took it. I asked my medical control doctor, who is also on the medical advisory committee for the region about the possibility of us getting another drug so we can provide relief to the people with the morphine allergy. He said he would look into it, but also said that most people just got nauseous and that’s why we carried phenergan. He suggested just premedicating them with phenergan, and then giving them the morphine.

A couple days later, I had a call for a lady who fell down three stairs, severely breaking her forearm and twisting her ankle. She was crying in pain. I asked her about allergies, and whether she could take morphine. She said it always made her sick. I convinced her to let me give her some phenergan first, then then I gave some morphine very slowly. I ended up giving her 12.5 of morphine, and it helped a great deal. No nausea.

I told the doctor about it and he was happy, and he said he was still looking into another drug we could carry – maybe tramadol – to take care of the people with a true morphine allergy.

Two days ago, I did a call at an exclusive retirement community for a 100 year old lady, who tripped in the dark during the night and broke her arm. She was in great shape for a 100 year old (except for her broken humerous). She said her pain wasn’t bad as long as she wasn’t moving her arm. I asked her if she wanted any morphine and she said, quite appalled, heavens no. She was a very proper old woman who had spent her life at an upper class country club and who had quite high social standing. I felt like she was thinking who did I think she was some common street skank.

There is a whole group of patients out there, who are not allergic to morphine, but who think they are not hurt enough to have to get MORPHINE or that MORPHINE will turn them into crazed junkies. The 100-year old lady was in this group. Proper ladies do not partake of morphine unless they truly, truly can’t bear the pain(after hours of torture).

I think we should rename MORPHINE to Herbal Balm or Chicken Soup. I think if I said, I’ve just going to give you a little tincture of chicken soup, they would have no objections and feel quite better.

Yesterday I responded for a guy with a hernia that had popped out and he wasn’t able to reduce it as he sometimes could. He said it would have to be resewn — he knew the jargon. He was in a fair amount of pain. I thought this would be a great test case for me to call to ask for morphine for abdominal pain, but he said he would wait until the hospital. He wasn’t that bad. I felt like saying, then don’t tell me you’re in pain, and stop grimacing if you don’t want me to help you. I should have just said, I’m going to give you a little IV herbal balm
th
at will make it feel better.

I don’t want anyone to suffer.

I imagine myself as a Jewish Mother. Her young boy has scrapped his knee. Stop your crying, let me shoot you up with some morphine and you’ll be all better.

10 Comments

  • Jamie Davis, the Podmedic says:

    We added the ability to administer morphine for abdominal pain in Maryland last year for paramedics and EMT-I’s with consult. However, I have yet to get permission from medical command to do so after 5 tries this past year. It still seems to be entrenched in the minds of some docs to avoid treating this variety of pain in the field.Regardless, thanks for the posting and research. I always look forward to your new posts and I have featured your blog in my podcast, the MedicCast, several times.

  • Eric says:

    We’re allowed to give Morphine for any type of significant pain, and don’t need to call in. Our limit before we have to report it to our medical advisor is 15mg. I’ll start pre-medicating w/ Phenergan – what a great idea.

  • Anonymous says:

    Here in Tasmania, Australia, paramedics always administer an anti nausea drug (Metoclopramide) before administrating morphine.

  • Anonymous says:

    We carry demerol, mostly for the allergy issue too. Never had any orders for it, and never seen anyone use it, however.

  • Sean says:

    Just thought I’d suggest that your committee might want to consider fentanyl before getting too hardcore into tramadol. In addition to working extremely well (when dosed correctly), compared to other oft-used narcotics, it has a shorter duration of action (around 45 min) and, unlike others, very few people are truly allergic to it.About six months ago (maybe seven) NAEMSP published a position paper in which they referred to it as the ideal drug for EMS pain management [paraphrased].Best of all, typical dosing lies somewhere between 50 and 100 mcg per dose and a vial with 250 mcg costs less than $1.00.Our EMS system (38K calls annually, 200 paramedics) utilizes either morphine or fentanyl and has had very good results with each. For nausea/vomiting, we use Zofran, but it rarely gets used. Personally, I administer MSO4/fentanyl to about one patient per week and have yet to have someone complain of nausea from it… but, then again, we using 2 mg increments spaced about 3 minutes apart. It works a bit slower than the 4-5 mg, obviously, but at least they dont puke on me. 🙂

  • Anonymous says:

    Hi.Here in the United Kingdom we can administer upto 20mg Morphine without Physician permission. We also routinely give an antiemetic (Metoclopramide). It is written into our protocol to give the antiemetic before the analgesia. A lot of us also give it to patients at risk of vomiting when strapped to a spinal board for transport.We also carry Tramadol as an adjunct to morphine but it is not as effective.Our protocol used to state that we cannot administer IV pain relief “in undiagnosed abdominal pain”. This was recinded, for the reasons you have stated from EBM journals, about 4 years ago.Good luck in your fight for patient comfort.B

  • angus says:

    Situation is the same in Victoria, Australia (MAS) where we can give up to 20mg morphine without consult (in 2.5mg (elderly/paed pts) or 5mg increments). Metoclopramide is the anti-nausea medication we give if we encounter nausea but it is not given as a matter of course. Our intensive care paramedics can give fentanyl if the patient has an allergy to morphine.Interestingly, there is no mention of any issue with giving morphine to patients with abdo pain (indeed, for reasons you discuss it fits the bill perfectly). Our issue is that we must consult for morph in the patient with severe/sudden onset headache.Great site btw

  • PC says:

    Thanks for all your helpful comments! I’m on vacation and will comment more later. Thanks all.

  • Anonymous says:

    hi, I usually buy tramadol here online so I’d like to know if tramadol is addictive drug.Sam

  • Anonymous says:

    First of all I LOL when the comment about the Chicken soup and herbal balm, in addition to the Jewish mother with the knee-scraped child. Patient comfort is essential in pain management. We ultilize anything within the scope of alternative/and the medical model. However, lately we have had a patient who is allergic to Morphine and Demerol and cannot use Tramadol either with anaphalactic symtoms. For conscious sedation she did well with Fentanyl. Also another comment on Phenergan–only give it IM due to causing blood clots if given IV.(or something like that)

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