Medical myth: Analgesia should not be given to patients with an acute abdomen because it obscures the diagnosis

A Machine Learning Model for Predicting Unscheduled 72 h Return Visits to the Emergency Department by Patients with Abdominal Pain

Seventy-two-hour unscheduled return visits (URVs) by emergency department patients are a key clinical index for evaluating the quality of care in emergency departments (EDs). This study aimed to develop a machine learning model to predict 72 h URVs for ED patients with abdominal pain. Electronic health records data were collected from the Chang Gung Research Database (CGRD) for 25,151 ED visits by patients with abdominal pain and a total of 617 features were used for analysis. We used supervised machine learning models, namely logistic regression (LR), support vector machine (SVM), random forest (RF), extreme gradient boosting (XGB), and voting classifier (VC), to predict URVs. The VC model achieved more favorable overall performance than other models (AUROC: 0.74; 95% confidence interval (CI), 0.69–0.76; sensitivity, 0.39; specificity, 0.89; F1 score, 0.25). The reduced VC model achieved comparable performance (AUROC: 0.72; 95% CI, 0.69–0.74) to the full models using all clinical features. The VC model exhibited the most favorable performance in predicting 72 h URVs for patients with abdominal pain, both for all-features and reduced-features models. Application of the VC model in the clinical setting after validation may help physicians to make accurate decisions and decrease URVs.

Myths and social structure: The unbearable necessity of mythology in medical education

CONTEXT

Myth busting engages scholars in the critical examination of commonly accepted but poorly evidenced claims with the goal of instilling quality and trust in knowledge making. The debunking of such knowledge "myths" and associated misguided practices purportedly serves to avert resources and attention from wasteful and dangerous scholarship. We address the myth that "all myths in medical education deserve to be busted".

METHODS

Using a critical narrative approach, we searched the medical education literature for orientations to myths and myth busting, and reviewed this literature analytically drawing from the sociology of science and Merton's concepts of manifest and latent functions. The results of this analysis are presented in the form of a narrative that deploys the articles reviewed to explore the utility of myth busting for medical education reform and begins with a brief exploration of the etymology of "myth" and how meaning making is related to symbols, practices and storytelling.

RESULTS

Our analysis revealed the important function of myths in the social practice of medical education and practice. A deconstruction of five salient examples of the contemporary myth in medical education (the myth of the "ideal candidate", the myth of "cut-throats", the myth of "cadaver stories", the myth of "learning styles", and the myth of "patient information leaflets") demonstrates that myths continue to have material effects even after they have been busted.

CONCLUSIONS

Our analysis makes evident that myth busting disrupts, renegotiates and reconstitutes socio-epistemic relationships rather than simply correcting falsehoods. We also argue that myths play important and inescapable roles in the social practice of medical education and the negotiation of values, and in constructing the conditions for group change and transformation. Imperatives related to humanism, compassion and patient engagement offer a healthy humanising counter-mythologising that we suggest must survive any contemporary myth-busting endeavour aimed at improving medical education practice.

Preoperative pain treatment in acute abdomen in Osogbo, Nigeria: a randomized double-blind placebo-controlled study

Background

Withholding analgesics in acute abdomen for fear of masking clinical features and impairing diagnosis and decision-making is still being practiced despite recent evidence to the contrary. This study assesses the effect of preoperative analgesia on clinical findings, clinical diagnosis, and decision-making in patients with non-trauma acute abdomen.

Method

This is a randomized, double-blind, placebo-controlled study using Tramal, a brand of tramadol, at the ED of LAUTECH Teaching Hospital Osogbo, Nigeria. Ninety-five patients between 18–60 years received Tramal (n = 46) or placebo (n = 49). The pain score, clinical findings, provisional diagnosis, and treatment plan were noted before and 15–20 min after administration of the analgesic or placebo. The final diagnosis arrived at after adequate investigation or operation was considered the gold standard. The pain scores, diagnosis, treatment plan, and decision between the two groups were compared. Statistical analysis was by SPSS 16. Results were considered statistically significant at p < 0.05.

Results

Demography and case distribution were similar in both groups. The improvement in pain was greater in the Tramal group (p = 0.001). The abdominal palpation findings were also better in the Tramal group (p = 0.02). There were more changes in the diagnosis after use of Tramal (p = 0.01). There were more changes in the decision in the Tramal group (p = 0.03). Most of the changes in diagnosis and decision in the Tramal group were for the better.

Conclusion

The preoperative use of Tramal in acute abdomen improved the experience of pain and did not adversely affect the accuracy of the diagnosis or decision-making.

Impact of Liberalization of Protocols for the Use of Morphine Sulfate in an Urban Emergency Medical Services System

OBJECTIVE

To investigate the impact of liberalization of paramedic management protocols for the use of morphine sulfate (MS).

METHODS

A retrospective database analysis tallied and categorized MS use into seven conditions during two intervals--six months before (control) and six months after (study) the protocol change.

RESULTS

In the control interval, 760 of 34,020 (2.2%) patients received MS. In the study interval, 999 of 30,320 (3.3%) received the drug, a 50% relative increase in MS use. MS use dramatically increased in two assessment categories: other painful medical conditions (19.0% vs. 2.8% of transports, relative risk [RR] 6.8, 95% confidence interval [CI] 5.2-8.9) and nontraumatic abdominal pain (9.2% vs. 1.9% of transports, RR 4.8, 95% CI 3.3-6.9).

CONCLUSION

Liberalization of pain management protocols resulted in an appreciable increase in the use of MS only in medical categories, predominantly abdominal pain, with no apparent safety or misuse issues.

Critically reappraising the literature-driven practice of analgesia administration for acute abdominal pain in the emergency room prior to surgical evaluation

BACKGROUND

Classic teaching is that narcotic analgesia in the setting of an acute abdomen can alter physical examination findings and should therefore be withheld until after a surgeon's examination.

METHODS

A telephone survey of emergency medicine physicians representing 60 US hospitals was conducted to assess the current practices and opinions regarding the early administration of narcotic analgesia in this setting. Relevant literature was also reviewed for methodological errors.

RESULTS

Fifty-nine of 60 (98.3%) respondents reported that it is their practice to administer analgesia prior to surgical evaluation. Of these, only 9 of 59 (15.3%) reported always informing the surgeon prior to dosing the patient. The two most common motivations cited were that patient discomfort takes precedence (52 of 59; 88.1%) and that the literature supports the practice to be safe (51 of 59; 86.4%).

CONCLUSIONS

It is common for emergency medicine physicians to medicate acute abdomen patients prior to surgical evaluation. Numerous significant study limitations and design flaws were found that question the validity of the four clinical trials supporting this practice. Because many physicians base their clinical decisions on these trials, a careful analysis of their shortcomings, as well as our own personal experiences and practice recommendations, is discussed.

Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial

BACKGROUND

Because of concerns about masking important physical findings, there is controversy surrounding whether it is safe to provide analgesia to patients with undifferentiated abdominal pain. The purpose of this study was to address the effects of analgesia on the physical examination and diagnostic accuracy for patients with abdominal pain.

STUDY DESIGN

The study was a prospective, double-blind clinical trial in which adult Emergency Department (ED) patients with undifferentiated abdominal pain were randomized to receive placebo (control group, n = 36) or morphine sulphate (MS group, n = 38). Diagnostic and physical examination assessments were recorded before and after a 60-minute period during which study medication was titrated. Diagnostic accuracy and physical examination changes were compared between groups using univariate statistical analyses.

RESULTS

There were no differences between control and MS groups with respect to changes in physical or diagnostic accuracy. The overall likelihood of change in severity of tenderness was similar in MS (37.7%) as compared with control (35.3%) patients (risk ratio [RR] 1.07, 95% confidence interval [CI] 0.64-1.78). MS patients were no more likely than controls to have a change in pain location (34.0% versus 41.2%, RR 0.82, 95% CI 0.50-1.36). Diagnostic accuracy did not differ between MS and control groups (64.2% versus 66.7%, RR 0.96, 95% CI 0.73-1.27). There were no differences between groups with respect to likelihood of any change occurring in the diagnostic list (37.7% versus 31.4%, RR 1.20, 95% CI 0.71-2.05). Correlation with clinical course and final diagnosis revealed no instance of masking of physical examination findings.

CONCLUSIONS

Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain.

Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain

BACKGROUND

The question of whether it is safe to provide analgesia for patients with undifferentiated acute abdominal pain is marked by longstanding controversy over the possible masking of physical findings. The goal of this review is to assess the pertinent studies.

METHOD

A Medline search was performed in April 2002, using the terms 'analgesia', 'abdominal pain', 'acute abdomen' and 'morphine'. Other articles were identified using the bibliographies of papers found through Medline. All articles reporting clinical trials of analgesia and its effects on diagnosis or physical examination were reviewed.

RESULTS

A total of eight trials (one reported only as an abstract) were identified. Because of significant disparity in trial design, no formal analysis such as meta-analysis was performed. However, detailed review of the trials revealed a striking consistency in results. In no study was there an association between analgesia and diagnostic impairment or dangerous masking of the findings of physical examination.

CONCLUSION

The literature addressing early pain relief for abdominal pain is characterized by weaknesses, but there is a common theme suggesting that analgesia is safe. Pending further research, which should address some of the shortcomings of extant studies, a practice of judicious provision of analgesia appears safe, reasonable and in the best interests of patients in pain.