Saturday, June 28, 2008

ED treatment of acute back pain - what's missing and why

[There's something messed up with how Scribefire and Blogger are formatting this post, but for the life of me I can't fix it! So, there are no real paragraphs. I'm going to forego use of Scribefire with FF3 until I sort this one out.]

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 [1]. 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. [2]

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 urinal is key for the first day or two at home, yet I had to keep reminding the staff that it needed to go with me.

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:

  1. local cold therapy (an ace wrap and an Rx for a neoprene belt would do - total cost $4)
  2. canes with usage instructions ($10 each at Walmart - crummy but effective)
  3. a disposable urinal for men (free, since you keep the one you use in the ED).
My guess is that less than 10% of EDs meet this standard, and the result is a horrendous waste of money nationally.

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.

[1] 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

[2] 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.


Coldone said...

Very interesting comments by a patient with severe back pain.

As the manufacturer of Coldone Brand Ice Compression wraps, we have experienced a great degree of interest in Cold Therapy by orthopedic surgeons and clinics. It is universally accepted that icing and compression work quickly to stop pain and stop inflammation to soft tissue injuries, however the MDs also have to balance the therapeutic affects with the costs acceptable by the insurance carriers. Those without health care insurance have to carry the cost burdens themselves.

The combination of icing and compression in a single product is safe, affordable, and effective. The hospitals are seeing a reduction of time in the hospital and a reduction of pain meds when cold compression therapy is implemented.

Random studies are hard to come by but patient response is overwhelmingly positive for cold compression therapy. Studies are an efficient means of documenting the repeatable results for the medical community, but they are expensive and time consuming.

There are limited studies to refer to and mostly they document cold therapy on total knee replacement or knee surgeries. Unfortunately there are backs, torn rotator cuffs, carpal tunnel syndrome and many other injuries for which there is not a body of studies to evaluate.

Let's hope these studies can be performed.

Anonymous said...

Canes?! No one has ever told me to use canes for my severe back pain. Ditto for cold compression--they always apply HEAT.

JGF said...

If I don't have a cane, I don't get vertical. There's no doubt about that. I usually need one for 1-3 days, but this one is bad, I still need one cane to get vertical in the am.

Maybe my back pain is more extreme than I'd imagined.

There's a stunning lack of data around heat and cold therapy. I believe there's more variation in back injury than we can currently discriminate, so it's actually hard to study these therapies so we don't know what we're treating.

For me it's definitely ice -- partly for anesthesia, partly for therapy.

My mental model is that after 30 years of episodic acute back pain (1-2 times /year) my lower back has a lot of scarring. At some point (sitting, weight gain, lack of exercise) a scar tears. Bleeding induces spasm. I try to get the darned thing to clot, so I use cold therapy and avoid advil in favor of tylenol. Then I try to stretch the surrounding tissues.

My rehab program (starting as soon as I survive the next 1,000 miles lying flat in back of the van) will involve a LOT of exercise, a lot of flexibility, and I'm dropping down to 175 (I'm 6 foot) or bust. I'll be doing that program with medical supervision for a change -- my 30 year self-care program has clearly come to the end of the line.

JGF said...

Oh, and in reply to coldone.

Cold therapy is dirt cheap. Sorry!

My neoprene wrap (see links in original post) cost me about $10 several years ago.

Conventional therapeutic cold packs cost $1 to $3. I cheat and use the illegal freezer packs too -- they can cause fatal tissue necrosis in people with compromised blood flow but my back does not lack for blood.

JGF said...

I followed up with the national experts re: Anonymous comment on cold compression.

Details in an update here:

Basically, it's all cold therapy nowadays. Hot is not!