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Opiates & the Acute Abdomen

tony joseph trauma-list@trauma.org
Sat, 12 Apr 2003 11:38:10 +1000


At 07:08 PM 10/04/03 -0700, you wrote:
>-I can;t believe we are having this discussion.
Analgesia does not mask the signs of peritonism.
Tony Joseph
Sydney


 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
>literature.
>
>>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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