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Opiates & the Acute Abdomen

caesar ursic trauma-list@trauma.org
Thu, 10 Apr 2003 19:08:02 -0700 (PDT)

--- ecthompson <ecthompson@msn.com> wrote:

> American Journal of Surgery isn't the best journal
> that we have.  So,
> you're already standing on shaky ground.

Hmmmm....did you even read the article?  Seems like
you're committing a variant of the Ad Hominem fallacy
here.  The paper should stand or fall on its own
merits, not your perception of what a good journal is.
 And, pray tell, what makes the American Journal of
Surgery not so good (in your opinion, of course)?

> It may not be based on great science but it seems to
> be the right thing.
> Patients writhing in pain while ER resident, a
> surgery intern, a surgery
> 3rd year and a surgical chief exam them can't be in
> the patient's best
> interest. 

Of course not.  I hope that in your institution, as is
the case in ours, such scenarios are rare.  But that's
not really the point of the article (again, did you
read it?)  The point is that there is no good data
that proves that premedicationg these patients does
not affect the surgeons ability to render an accurate
diagnosis.  And since the overwhelming trend these
days is to premedicate (and literature is quoted to
support this practice) we might want to re-examine the
validity of the conclusions drawn from this

>With our increased reliance on radiologic
> imaging, I'm not
> sure what the problem is.  Have you missed a
> diagnosis or delayed
> treatment because of a couple of milligrams of
> Morphine?  I can say with
> my retrospectoscope that I have not delayed or
> missed a diagnosis
> because of morphine, to the best of my knowledge. 
> Do you really believe
> that your patients are being harmed?

Sounds like you are saying that physical exam isn't
that important in this day and age of CT scans.  Do
you trust your CT scan to diagnose intestinal
ischemia?  How about perforated viscus?  If so, can
you back up that contention with good data?

> Outside of the ivory tower, I can tell you that 95%
> of patients with an
> acute appendix will get a CT scan or ultrasound or
> both.  Average time
> from when the ER doc calls for a surgical consult to
> when the surgeon
> arrives is 30 minutes to 3 hours.  

Again, I think you've commited the fallacy of Appeal
to Common Practice.  Just because 95% of the RLQ pains
in YOUR hospital get scanned doesn't invalidate the
role of a good abdominal exam to diagnose those
patients with clear signs that do not need CT scan.

> Finally, if this is really bugging you, you could
> without too much
> trouble study this topic in a prospective manner in
> your institution.  

I think, as do the authors of the study, that such a
project would need to be multi-institutional so as to
recruit enough patients to make it valid.

C.M. Ursic, M.D.
Dept. of Surgery
UCSF-East Bay
Oakland, California

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