Abdominal pain analgesia

The article by Thomas and colleagues in the January 2003 issue is a good, though unsatisfying, attempt to address a difficult, multivariate question. As a physician who has long held to the “withhold analgesia” school, perhaps I simply remain “ignorant of the pertinent literature.” But the current study fails to address some serious questions involved in this issue, yet appears to answer them in its broad conclusions. Unfortunately, I fear this article will only fuel the “literature” that our emergency physicians push toward surgeons in their desire to treat abdominal pain before surgical consultation. The real issue is not about masking the diagnosis in patients with abdominal pain. The issue is in masking the diagnosis in patients with a surgical abdomen. The most common setting for this is in the patient with a possible appendicitis. The authors state that “expert statistical opinion holds that more than 1,000 patients would be necessary to power a study searching for outcomes differences.” In the table listing ultimate diagnoses, only seven patients had a diagnosis of appendicitis. None of the other diagnoses warranted urgent surgery, such as perforated diverticulitis or a perforated peptic ulcer. These, in fact, are the patients in question. My personal experience has been that the use of analgesics in the emergency room has masked the presence of peritoneal signs in patients with these conditions. This study does not adequately address this subgroup specifically, yet the conclusion that analgesics can be given to emergency department patients with abdominal pain is automatically ascribed to this subgroup. I fear that with this kind of “data” in hand, Dr Cope’s fears might be more frequently realized. As another side issue, I wonder about the adequacy of the dose of morphine given in the study patients if it did not result in any significant changes in examination from those patients receiving a placebo. If it was not strong enough to change the findings, was the dose strong enough to change anything? The practice in our emergency room is for analgesics to be given in successive doses until a satisfactory analgesia level is achieved. This usually has resulted in my coming to consult on patients who are fairly heavily sedated. Detecting subtle peritoneal findings in these patients can be quite difficult. My own philosophy has been, and remains unchanged by this article, that when a surgical emergency is a possibility, analgesia should be withheld until the surgeon has had the opportunity to assess the patient. After all, a delay in diagnosis in these patients can be catastrophic. The surgeon is the one likely to be held liable. I would like to see a study in which large numbers of patients admitted to the emergency department with “rule out appendicitis” were evaluated with their methodology. I would also like to see examinations performed by emergency room physicians and surgeons, before and after administration of analgesia, and these results compared. Until then, I suspect general surgeons will continue to be even more often frustrated by early administration of analgesics to these patients than they are now.