The patient is typical: a school-aged boy with abdominal pain and vomiting. Your examination is suggestive but not classical. True, the patient winces every time you palpate the right lower quadrant, even when you try to distract him with talk about school, sports, and video games, but there is not much guarding and no rebound tenderness.
You explain to his mother that you will need to order some tests, and that you would like to have her son examined by your colleague, the surgeon on-call. She tells you she understands, and then asks the question: “Doctor, when can he have something for pain?”
You shuffle your feet, and tell her that he will be given pain medication as soon as possible. What you don't tell her, however, is that in your hospital, the timing depends as much on the surgeon on-call as anything else. So, you check the call schedule, and your heart sinks. Dr. Gustophson (the nurses call him Grumpy Gus) is the surgeon of the day. He is strictly old school, right down to the butch haircut. He does not believe in pain medication until after the diagnosis. In fact, he might not believe in pain medication at all!
Thankfully, scenarios like this are increasingly rare. There are now several articles in the medical literature that demonstrate that pain medication does not significantly alter the diagnostic accuracy of the physical examination in abdominal pain, and yet the myth that pain medications are contraindicated in patients with abdominal pain still persists among some practitioners.
‘Gorked Out on Pain Meds’
The literature shows that pain medication does not significantly alter the diagnostic accuracy of the physical examination in abdominal pain
Sadly, this is not limited to older physicians like Grumpy Gus. Not too long ago, I overheard an Ob-Gyn resident admonishing one of the emergency medicine residents not to administer pain medication to a patient before his chief had examined her because he did not want her “gorked out on pain meds” before the work-up was complete. For those of us who think that this practice is inhumane, the medical literature has recently provided a little more ammunition. Last year, a group of Finnish investigators published the results of a trial comparing oxycodone with placebo in children with “undifferentiated” abdominal pain. (Arch Pediatr Adolesc Med 2005;159:320.)
The investigators screened 104 children ages 4 to 15 for inclusion in their study. To meet enrollment criteria, patients had to have had abdominal pain for less than seven days and a pain score of at least 5 cm on standard 10 cm visual analog scale. Excluded were those who did not meet these criteria, whose pain was secondary to trauma, and who had unstable vital signs, asthma, allergy to oxycodone, and history of analgesic use prior to arrival. Sixty-three children met the inclusion criteria, and were enrolled. These children were randomized to receive 0.1 mg of injectable oxycodone (10 mg/ml) or an equivalent volume of normal saline administered into their buccal mucosa.
Investigators and patients were blinded to which agent was administered. Patients were reassessed every 30 minutes for three and a half hours. Any patient who had a pain score above 5 during reassessment received one or two additional doses of the study drug. At each reassessment point, the nurses also recorded the patients' oxygen saturations and vital signs, and noted any adverse events related to the medication.
Each patient was examined by one of three investigators, all surgeons. Surgical evaluations were conducted before administration of pain medication, at three and a half hours after the first dose of pain medication, and if necessary, at six and nine hours after initial evaluation. The surgical evaluation was standardized so that all clinical findings were recorded on a data collection form. Each surgeon then made a provisional diagnosis of acute appendicitis, nonspecific abdominal pain, or other. He also assigned a provisional disposition (operation or continued observation).
Finally, the surgeon recorded the presence or absence of abdominal guarding. For study purposes, the authors defined guarding as “voluntary contraction of the abdominal muscles when palpatory pressure was exerted on the abdomen.” Patients who had discrete pain in the right lower quadrant and those who had more diffuse pain with palpation of the right lower quadrant and other abdominal areas were said to have guarding.
All patients were placed in the hospital for further observation or surgery. Patients who did not undergo surgery were followed until their symptoms resolved. Those who were diagnosed with nonspecific abdominal pain received a follow-up phone call four weeks after discharge to determine whether a significant illness had been missed. Finally, the investigators reviewed the inpatient records for each admission to determine the final diagnosis. Next month I will present the results of this study.