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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Pablo said...

That's .1%

Anonymous said...

I like your fervor with which you practice your free speech...

Your broken rib scenario is not black and white.

Broken ribs hurt every breath; in and out.

This invariability causes “guarding”: muscle stiffening that is involuntary for the most part. This means a big decrease in oxygen in the lungs and out to the body through the blood system.

So, this leaves a large chance of infection. If pain is treated, the patient will breathe deeper. So, the treatment of pain in theses cases is more than symptomatic.

Also, the less “guarding” one has during rib fracture, the faster the ribs heal. That’s just fact.

Now, atelacsis or lung collapse is another thought. It is important to make sure that there is no damage to the lung. Even if there is not a full collapse of the lung, there could still be bruising and abrasion to the lung form fracture. Any “open” area is a keyhole to infection as well.

Fractures need to be assed for the way they are fractured. Ribs can become a dagger to the lungs in one wrong movement with the right brake…

One other thing that used to get missed in chest trauma before we had cat scans or people not using them: is a part of the aorta that commonly becomes “detached”. My own grandfather lived with injury for three years before it killed him. He refused medical care. If he had not, I may know him now; albeit most die from this immediately to hours after

I honestly haven’t read all your material thoroughly; from what I have you’ve got some good points.

What I have learned, if any is interested, (you can’t give opinion that isn’t asked for or wanted and even then.) Everything has grey areas.

Every thing needs to be looked at. Not every thing will have the same answer.

The last thing is about Totalitarianism vs egalitarianism. Whether you’re talking of a whole or one: I.e. should you spend six-million on one person who has cancer or help more with the same money

I find most arguments are not started on the same element. Just like mathematics, for an answer you must first start with the same element. For answers in real life, I think we must first start on the same element.

Alex J. Avriette said...

Really, the fervor comes from seeing a solution to a problem, and yet encountering the problem over and over again. I talk about the word "pharmocracy" a lot (I thought I had coined the term, but a quick glance at google shows otherwise) because I am a pretty active guy between motorcycles, hiking, moving servers around, and general clumsiness.

It's infuriating that it is against the interest of the medical profession to cure patients. To do so would eliminate the need for the profession. The solution is to have a much less hands-on approach to medicine. For self-treatable conditions like pain, a cold (although I'm not real big on giving everyone abx...), and so on, let the patients treat themselves. Even the addicts. Addicts, largely, self-regulate.

A couple other issues bother me, but this broken ribs rant of mine gets a lot of traffic. The problem here is that there are solutions for the break itself, to reduce the time until the ribs mend. Furthermore, the doctors know how long the pain will last and prescribe inadequate pain relief. Your point about guarding is moot if the patient has had a CT and is not in any danger from breathing more deeply. The point is, it doesn't matter how long it takes to heal. It will heal, and they can help it heal in ways other than just sending you home.

They don't bother. It's elitist, and I believe I used the term "pain chauvinism." I think it's especially apt. When somebody has a subjective injury, it's difficult to gauge how much pain they are in, or even how injured they are. It's easy from the un-injured's point of view to assume that the injured is overstating or unaware of how severe (or not) their injury is. I don't know why this judgment happens. If we treated patients properly, we'd titrate them to an appropriate dose – and they would know what their appropriate dose is next tie they are injured.

I'm not even going to get into the mental health profession because this comment is almost as long as the post itself. All I can say is that I am glad people are reading it. I wish more people would. I wish people understood the fundamental flaw of (particularly American) Medicine.