I had the 2nd ambulance ride of my life recently.The ambulance was overkill. Four strong bodies, duct tape and a door would have been more appropriate, and cheaper too.
Alas there was no intermediate alternative. I was unable to stand or crawl with mere ibuprofen and canes, and that becomes a problem over time. Since nobody will prescribe narcotics and valium over the phone this left me with only one route to medical care -- a back board.
The ED got adequate control over the back spasms with modest doses of IV valium and morphine . I was a pathetic sight hobbling out of the ED on two canes to lie flat in an emptied van, but six hours later, after continuous ambulation, I walked a mile without difficulty using a single cane as a psychological aid. I was on the way to rehab. 
I'll have a bit more to say in a later post on the pointless cost of this episode vs. the intelligent alternative, but this particular post is about three very simple things that the ED didn't do. I had them covered myself, but without them I'd still be in the hospital.
So these interventions matter. The important question is why did I have to take care of them?
Now I think I was the guest of a quite good rural ED, and I felt feel confident that ER doc who took care of me seemed confident and competent (and comely too!), so I suspect these are common omissions:
- a cold pack and a neoprene waist belt to provide continuous cold therapy to the acutely spasmed back
- two canes to enable ambulation
- a urinal to enable sleep at home
- (see more here)
The ED had no canes, but I could never have done my pathetic totter out of the facility without them. They did have a walker I could test my gait with, but a walker isn't designed to support body weight while in motion. They didn't think to train me on how to use a cane (I knew how), but any significant back pain requires days of cane use. (If your acute musculoskeletal back pain doesn't require a cane, do you really need an ED?)
Continuous cold therapy during the acute episode is an key part of most therapeutic recommendations. I realize reactions differ, but cold therapy is essential for me. I had to bring my own neoprene cold pack belt, and I had to request ice (they had no cold packs).
In the end everything worked, but acute back pain is hardly a rare ED event. Why didn't they have the key ingredients in place?
I'd like to see someone do a survey article on what percentage of EDs provide these 3 items on discharge, in addition to whatever else they do:
- local cold therapy (an ace wrap and an Rx for a neoprene belt would do - total cost $4)
- canes with usage instructions ($10 each at Walmart - crummy but effective)
- a disposable urinal for men (free, since you keep the one you use in the ED).
So why hasn't the study been done? If it has been done, why aren't payors making these steps a part of their quality measures used to justify reimbursement? If this stuff isn't in the standard ED guidelines, then we have an even more interesting set of "why" questions.Understanding these "why" questions would tell us a lot of interesting things about health care and where money is spent.
 The cognitive effect of the "morphine" was so modest I wondered if it was saline placebo (which would have been fine really -- anything that works!). I think they were just doing small incremental dosing
 Once the pain is under some control, and improvement has begun, the rehab process has a certain appeal. Every day actions are a bit like mountain climbing, with the same need for concentration, precision, and planned motion. Also, the same sense of risk with error. It appeals to a certain twisted mind.