01 June, 2007

Broken ribs, pain, diagnoses, and the pharmocracy.

So, let's start with a quote from an article from SFGate (and we all know how conservative the Bay Area is, so it's going to be commie ranting about health coverage, but I assure it's relevant).

He was riding his motorcycle through San Francisco's Presidio on Sept. 19. It was late afternoon. Palmer was heading toward the Golden Gate Bridge and then home to Richmond.

Suddenly his brakes locked, sending the motorcycle into a slide. Palmer slammed into a guardrail. He was pretty shaken up, but he could tell he wasn't badly hurt.

A passer-by saw the accident and called for help. An ambulance arrived within minutes.

Palmer said he told the paramedics that his ribs felt banged up, possibly broken, but that he was basically OK. He said he preferred to be treated in Contra Costa County, where he lives and would probably qualify for reduced hospital rates because of his income level.

This sounds familiar. Broken ribs. It's pain, right? The only reason to go to the doctor is because you're in a shitload of pain. Ribs hurt, a lot. The rest of the article is drivel about how he was charged a lot of money because our Republic doesn't have socialized health care, et cetera, et cetera. What the important point is (and they seem to have missed or ignored) is that the only reason the guy went to the hospital is the intense pain he was in. This is a recurring theme in my "pharmocracy" rants.

So what's really surprising is there's a lot of research (including clinical trials) on treating broken ribs with what amounts to a hormone that stimulates calcium growth at break points. The stuff is called calcitonin, well documented, and naturally nobody even mentions this. Apparently, taking calcium, magnesium, and vitamin D can aid bone repair too. Did we get this at the ER? No. Of course not. Here's 24 percocet (5/325, the weakest they can prescribe), enjoy your pain.

Let's look at some other interesting quotes from another article, though:

  • Fracture of the left lower ribs is associated with splenic injuries

  • Motor vehicle crashes (most common mechanism)

  • Patient-controlled anesthesia allows adequate pain relief with minimal inhibition of respiratory drive.

  • Morphine sulfate -- Used to achieve a desired anxiolytic and analgesic effect because easily titrated to desired level of pain control or sedation



So first off, I broke ribs 3-4 on my left hand side. Nobody gave me a CT to see if my spleen is okay (hey, I'm alive, it's probably okay, right?). There are three hundred thousand cases a year of broken ribs. The vast majority of these are from auto accidents, and the patients are given things like ibuprofen, ketoprofen, tylenol 3, and the "baby percocet" I mention above. The MD who wrote the article, Christopher Doty, however, says that for analgesia and as an anxiolytic, morphine is the preferred – and patient controlled – analgesic. Because, really, you just fell off a motorcycle, had a car accident, or whatever, and your ribs hurt like hell.

But ERs, I guess in trauma centers, you're some kind of a pussy if you're hurting. When I had meningitis, they kept me on iv dilaudid q4h for an entire week. But when I show up with broken bones from a goddamn motorcycle accident, they give me enough percocet to last four days when it's clear that the injury will take between three and eight weeks to heal.

What's really frightening in addition to the "pain chauvinism" of trauma staff is the fact that there is such high mortality in rib fractures. In fact, you're more likely to die if you're female. You're more likely to die if you break low ribs (5) or high ribs (1) because you break important things under those ribs.

What nobody told me in the trauma center is that because my breathing is so shallow (it hurts to breathe, folks) fluid can build up and I could go back into pneumonia.

I'm really, really upset at the complete ineptitude of the trauma staff at the GWU Hospital ER. For the number of cases we get per year of rib fractures (at 300,000, that means .1% (Pablo gives the correction here of oh-point-one-percent, rather than one percent) of people per year receive them), they should know that there is a tendency towards pneumonia. They should know that leaving the patient with twenty-four percocet is not going to help anything. Motrin 800 is not going to help anything. What you're going to have to give these patients is something like 20-80mg of oxycontin (or Oramorph SR, or whichever) for six weeks minimum. However, as I've said before, when doctors lose the monopoly on pain, they become irrelevant. It is in the interest of the medical profession to keep the injured in pain.

This boggles my mind, and frankly makes me sick. I might go vomit except it would hurt so fucking much.

Sometimes I just really have a deep, spiteful hate for doctors. Just how many of them out there do you think are willing to adequately treat rib fractures from a motorcycle accident? A few percent maybe? What are my chances, in picking a random trauma center, that I'll get a doctor who actually understands the degree of pain suffered, the risks of the injury, and the length of time it will take to heal?

I think what happened is the asshole at GWU Trauma gave me some sort of sanctimonious "punishment" for my having the audacity to ride a motorcycle. Well, if the world works the way I hope it does, he'll be run over by a cement truck and be given ibuprofen to treat his pain. Because, afterall, he did walk in front of a cement truck, and that was stupid.

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