Go Ahead

Morphine for undifferentiated abdominal pain. I’ve written about it. I’ve advocated for it. But until yesterday, I hadn’t ever given it. At our last regional council meeting we approved the use of .05 mg/kg for undifferentiated abdominal pain on standing orders. .05 mg/kg is half the regular morphine for pain dose. It is a “judicious amount” in the new terminology that advocates relief of suffering. The literature on the issue is clear. Morphine does not hinder the diagnosis of abdominal pain. To quote the conclusion of the most recent study:

“Although administration of intravenous morphine to adult ED patients with acute abdominal pain could lead to as much as a 12% difference in diagnostic accuracy, equally favoring opioid or placebo, our findings are most consistent with the inference that morphine safely provides analgesia without eroding clinically important diagnostic accuracy. These data are congruent with the aggregate weight of evidence accumulated from previous studies examining this question during the past 20 years.”
-Randomized Clinical Trial of Morphine in Acute Abdominal Pain
Gallagher, Esses, Lee, Lahn, Bijur
Annals of Emergency Medicine
August 2006

When I read that at the MAC meeting, it was a slam dunk. Who can speak against such a statement?

Still, the old ways are hard to change. It was grilled in us 15 years ago. NEVER give Morphine for abdominal pain, unless you can make a clear case that the pain is caused by kidney stones. Never. Every now and then you would hear of someone calling in and asking to give it. Such a beating they received. People would talk behind their backs for years. There’s the moron who tried to give a patient morphine for abdominal pain.

For months I have been anticipating giving it. Until our protocols are rolled out, I am required to call for orders if I want to give it for abdominal pain. I have played out the scenario in my head. I call and am denied. The doctor says on the radio. See me when you get here. He says it in the way a principle says “To my office.” To my office back in the days of corporal punishment. I imagine everyone staring at me when I come in. People looking at me in amazement. All this time they all thought I knew what I was doing and here I have gone and asked for morphine for abdominal pain. Scandal. Gossip. But in my imagination I am prepared. I go toe to toe with the MD. You need to read the literature, I say. I start spouting. Annals of Emergency Medicine. Latest edition of Cope’s Early Diagnosis of the Acute Abdominal. Aggregate evidence of the last twenty years. Get with the program. I slap down the studies on the tray by the bedside. The doctor is flustered. The staff looks at me. Well, all right then. A new sheriff in town.

So here’s what happened. 86 year old male, pale as a sheet, comes walking out the front door, holding his stomach. While we spread a clean sheet on the stretcher; he says he has had the pain for four hours. He has vomited twice. There is in fact dried vomit on his shirt. No diarrhea. Once we get him on the stretcher I examine his abdomen. Soft, non-tender. No pulsing masses. His pressure is 200/100. Heart rate in the 80’s inching up to the nineties. I put in a line and hang a bag of fluid. He looks really uncomfortable. He is irritated at me when I ask questions. The pain is dull and diffusive and goes into the back. No, it is not tearing. He says he has never had pain like this before.

I’m not certain what is going on. Maybe an ischemic bowel? I don’t know. I think about morphine, but I also think, maybe I don’t want to mask the diagnosis. I know, I know. I’ve read the studies. Everything for the last twenty years. Still. It is deeply ingrained. We are enroute now. My partner is taking the long way – a way he thinks is the shortest, but I know to be at least ten minutes linger, particularly at this time of day – afternoon rush hour. We aren’t going lights and sirens. The patient looks really, really uncomfortable. I am thinking this is no normal belly ache. We are at least twenty minutes from the hospital. I ask him how bad his pain is. He is annoyed by the question. He finally snaps, “I’ve never had pain this bad.” “That would be a ten then, “I say. “Ten,” he says through gritting teeth.

He is in pain. He is suffering. He needs something. Okay. I pump out my chest, run my hand through my hair. Here goes. I make the call. I give as detailed a patch as I have given for years, and then I say, “I’d like to give a judicious amount of morphine for pain relief – 3 mg IV.” I say.

“Go ahead, 3 mg MS IV,” the doctor says. Since the radio is scratchy I can’t pick up the tone, but it clear. I got the go ahead. They said yes.

Easy enough. I give the patient the morphine, and while it only makes the pain go down to an 8, he seems much more comfortable. His heart rate goes down to the 60’s.

At the ED, they put him in a medical alert room so he gets immediate treatment by two doctors. They order a stat ultrasound. I ask the doctor to sign my narcotics sheet. He does so without a problem. “Excellent job,” he says.

All right then.

3 Comments

  • denvermedic says:

    no surprise, we face the same issue with morphine for abd. pain. those who give it without a call in can expect some contact from the medical director. that said, those who call in usually get the order. makes me wonder if urban ems will begin to swing back to morphine being an acceptable analgesic for abd. pain. i would argue that most people that have the potential for something serious going on get a ct scan or ultrasound anyway, so the concern that it is masking something more serious only holds true if the receiving hospital doesn’t take your report of post-morphine symptoms as the truth.i would have been happy to give that guy morphine. if i had a patient that was a drug seeking abdominal pain (which is a whole other grey area, but it’s one of those intuition things), i wouldn’t be providing morphine (or any narcotics, for that matter) to that one.

  • PC says:

    pain management is fascinating topic. I’ve been reading about how failure to treat acute pain can lead to chronic pain. The typical drug seeker also falls into several different catagories. Drug seekers who are in true acute pain. Drug seekers who are in severe chronic pain who are seeking the drugs because they are undertreated for their pain, drug seekers who are often in pain, who lie about their current pain so they will have a supply when they need it, drug seekers,m who plan to sell their drugs to others. I will write more about this in a full column after I have learned more. ABD pain is one of the areas that drug seekers typically claim because it is hard to diagnose.

  • denvermedic says:

    i’d be interested to read what you have to say on the topic. where have you been reading about the failure to treat acute pain leading to chronic pain? i’d be interested to know.i’d like to think that i’m not on the top of the list of people who never give out pain meds, but i’m definitely not on the top of the list of people who do.last pt. i can think of that struck me as a drug seeker w/abd. pain was someone i was on the fence about. i thought about giving him some narcs and then for some reason asked him if he had been to the hospital recently. i come to find out he just got done kicking a morphine habit. maybe i’m playing god, but it didn’t make sense to me to be the one responsible for renewing his habit.hmmmm.

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