need4speeduk

iTrader: (26)

I do not agree that someone who was fine the previous day, went to bed fine, woke up with back pain should be prescribed a injection of voltarol, voltarolo supositories, diazepam, & oamorph as a first line and initial treatment after a 7 minute assessment, no, sorry I dont.

I am happy and confiedent with the clinical presentations of pneumonia and a PE. As for diagnosis a PE the only way you can really do that would be via a CTPA, of which neither of us have access to and therefore niether of us could make a definitive diagnosis. As for an AA then probably not if I am being honest. In all honesty though, how long have you been practising, how many patients have you seen with back pain, how many of them have come in for an initial assessment where there first clinical presentation of something being not right was back pain that you then correctly dianosed a AA.

Dingdongler

I'm trying my best to be laid back about this thread because I can see how my rather strong feelings on this matter may come across in the wrong way.

But then you go and make one of those ridiculous statements again (see bolded)

How can you possibly say or think that?? NO you don't have a reasonable in depth understanding of acute medicine, how on earth could you?

You don't have what I would call formal medical training.

You've never done an acute medical rotation.

You've never had to take responsibility for acutely unwell patients on their first presentation to a hospital (either as a doctor or triaging nurse)



This 'in depth understanding of acute medicine' doesn't just happen by magic. It comes after dealing with thousands of patients presenting with all sorts of different diseases in all sorts of different ways.

Honestly, you've got to stop making such off the cuff and profoundly incorrect statements. It's becoming ridiculous.

Lisawrx

iTrader: (1)

Well let this be a lesson to you

Anyhow, all the arguing to one side, how is she doing now?

john banks

Boxst I hope she is improving.

It is quite common to find non musculoskeletal causes of back pain, but your case mix might not reflect that if a GP is filtering them (hopefully). The issue with suspected PE is that someone needs to identify them as candidates for CTPA when they do not give a classic presentation, in my work it is more relevant to be suspicious of alternate diagnoses than it is to be able to differentiate between causes of non surgical mechanical back pain. The last AAA I diagnosed from finding a pulsatile abdominal mass and admitted immediately presented back ache. The last pancreatitis presented with back ache.

I have completely different priorities in managing back ache as you may appreciate.

john banks

To those reading this thread and puzzled over the drama, it is self evident if the unqualified make pronouncements without evidence or credentials. Do you think the docs on here should just ignore derogatory and sometimes harmful misinformation? It stops me getting back to cutting up my cow shed in the cold, so that achieves something.

Dingdongler

Have you ever done it?

Have you ever been the first person to see a patient that presents to hospital acutely short of breath? And then taken a history, examined the patient, ordered investigations, interpreted the investigations and then decided whether it is a PE, MI, acute arrhythmia, pneumothorax etc.

And then started treatment based on your findings and followed the patient through to see whether they live or die?

Of course not! So how on earth can you say you are confident in doing so when YOU HAVE NEVER DONE IT??

Seriously, I'm going to bow out of this thread because you are deluded and nothing I say is going to change your mind. I said it before and I'll say it again, you need a massive slice of reality pie

need4speeduk

iTrader: (26)

There you go JB. Below is the PM I was trying to send. See how polite I was being.

Hello John,

I am not sure why you wan't to continue this ridiculous debate. If you insist on continuing in then perhaps we should do it via PM, phone or in person rather than cluttering up peoples threads.

With hand on heart, I think you know that for someone with no history of back pain, no mechanism of injury, that went to bed fine and woke up with back pain, as a first line treatment/prescription of an injection of voltorol, a voltolrol suspository, diazipam, and oramorph is totally OTT.

If you don't then I am honestly glad I am not your patient, and I really don't intend that sound as disrespectful as it does.

If you went to bed fine, woke up with back or neck pain would you go into work and self administer the same cocktail to yourself? Hand on heart? I think we both know you would not.

I don't need to be a doctor to know something about acute back pain management. You may disagree, which is fine, but I can assure you I really don't. As I said, I discussed this with the two spinal specialists I work with, one who is a doctor, and another doctor. I didn't say I'd been having a debate etc etc, I just asked what they thought. All said it was OTT, as the OP of the thread confirmed by saying his wife was off her face the following day.

Of course that eased her pain. FFS John, you could have shot her with an elephant gun and eased her pain with that combination.

I have no gripe with you as I said. I do however dislike the holier than thou attitude and total lack of respect for others continuously shown by DingleDonger. We can agree to disagree on the back pain issue and 3 minute assessment but it will not change the fact that Dingledonger is a jumped up **** that needs to come down from his ivory tower and start acting like the professional he claims to be. If his attitude towards his patients is the same as he portrays on here then god help them.

But


After your Dingledonger like response to my request to do this via PM on the other thread, you know what I now think about you too.

jef

iTrader: (13)

interesting reading. many will know my opinion differs with others in certain areas of advice by professionals- altho no way connected to this discussion.


but i still see supposed approved and wildly publisised advice that is shockingly in-accurate.
its good to read both sides of reasoning as it can provide evidence from both parties, making the reader aware to all aspects- and then able to make a semi educated assesssment of the information provided.
any kind of be- littleing diminishes credibility from any offending party imo.

john banks

Ignoring cardiac palpation and misspelling (the criticism of which on a BBS may be pedantic but which is important on a prescription and would make the pharmacist think they were forged) of the all the other drugs which you are not qualified to prescribe anyway, let's talk about the drug you did manage to spell correctly.

I would defend the right and responsibility to prescribe and administer opioids (including parenteral which is a different ball game to the non-CD status of oramorph) for severe acute back pain on the basis of the license of the product (1), NICE guidance (2) and literature to support use of opioids against a background of inappropriate concerns which do not just apply in the palliative care setting (3).

You counter this on the basis on the basis of your feelings, without experience of prescribing for acute pain situation, less so in an out of hours situation in the community, supported by a selectively out of context discussion with colleagues which we are not party to. Even if we were, it would be the lowest grade of evidence at best (4). I know if was out of context because you focussed on my allocation of approx 3 minutes to an initial back examination instead of telling me what else you would remove instead from my initial 10 minute management plan and why. I have pointed out that I'm more interested in safety and analgesia during an initial consultation than I am about a later functional diagnosis that you may be more interested in. Our roles and our priorities are different and I would not wade into your domain without good basis as you are into a primary care prescribing domain. If I did I would be very careful to cite my evidence and references, as you are not.

Using the retrospectoscope to criticise the management? The appearance of a side effect is an anticipated event in opiate prescribing and doesn't undermine the original decision.

Lastly, I do not think this debate is ridiculous. It is similar to daily debate in medical literature, albeit rather one sided intellectually it would appear.

1. BNF (2012), section 4.7.2
2. http://www.nice.org.uk/CG88
3. http://www.bmj.com/content/344/bmj.e2806
4. http://www.sign.ac.uk/guidelines/ful.../section7.html

Turbohot

+1.

This debate is not ridiculous at all. As a reader, I am finding this debate very interesting. I think this debate upon over-medicating is better in open, as it is very educational for all and sundry.

need4speeduk

iTrader: (26)

You start and finish off by trying to belittle me, again, and as usual, over some spelling errors and by referring to this as a debate as rather one sided intellectually. Is that what you meant by educating me? Or are you just here to insult me and dazzle everyone with big words to prove how amazing you are.

I won't insult you, but I will suggest if you are going to belittle someone over spelling and grammer then you could at least have the decency to ensure your own use of these are 100% bang on. Which as your last post shows they are not.

Anyway, and once again (zzzzzzzz)

We have covered the fact I am not a doctor and I cannot prescribe drugs. Honestly, the amount of time you spend banging on about those two points is nuts. It appears your whole argument is based around the fact you ar able to do something that I am not.

I am able to assess. diagnose, and treat someone with back pain, accurately. Something in your 10 minutes and by your own addmission, you are not. It apprears doctor that all you are interested in is deciding what pills you can give someone to swallow. Did you really spend 5 or 6 years at med school just to promote pill popping?

As I see everyday, you really aren't concerned with whats causing someones pain, just treating it. Pain is a symptom, sure you may relieve the symptom but you are doing nothing for the cause, which means the symptoms will persist until the cause is treated. Unless you intend on them popping pills for the rest of their lives?

It's all well and good quoting guidelines my friend, and evidence based practice is what it is all about, I agree. But these guidelines are also not infallible, as the recent issues with LCP prove. As for my colleagues opinions being 4th grade evidence. The two spinal specialists I work with have over 40 years of clinical back pain experience between them and will have forgot more about back pain than you or I will ever know. I would much rather take their opinion on board as to how to assess and treat a back than someone who's main priority is dosing someone up to their eyeballs on medication.

As I showed earlier in this thread, you are not even capable of measuring leg length accurately so how on earth can you say your way is the right or best way of assessing and treating something as complex as a acute back?

And you didn't answer my question.

If you went to bed fine, woke up with back or neck pain would you go into work and self administer the same cocktail to yourself? Hand on heart? I think we both know you would not.

hodgy0_2

Interestingly the Americans have a very powerful medical establishment and they seem to have left the vast majority of amercians (that can afford it) addicted to a plethora of pills

You have to litteraly crane the fat fvckers onto a yacht, complete with massive "Treat packs" full of crisps etc

They then proceed to pop slimming pills like they are smarties

They then attack the hypertension pills - ad infinitum

Unbelievable, but sadly true

yellowvanman

That huge chip on your shoulder can't be good for your back mate.

dpb

Lol

need4speeduk

iTrader: (26)

If that is directed at me, then there is no chip on my shoulders I can assure you.

You can and will read into this thread whatever you like. That is your perogative.

All I have stated is the original precription was an over kill. If you disagree that is also your right.

If push came to shove though and you had the choice of popping pills for pain relief or having the cause of said pain treated effectively so you no longer had to take pills, I think the choice is obvious.

nik52wrx

My wife has one of those crappy biomedical degrees you refer to. She is doing very well for herself as a lab manager with her crappy degree.

You tosser

yellowvanman

Yes it was. Sorry but it does come across as you having an issue with doctors.

I'm not qualified to judge if the original prescription was correct or not, but having been in a similar position, I can tell you when the Dr. arrived the first thing I wanted was to deal with the pain. Once able to move again, then dealing with the underlying condition is obviously the next step.

GlesgaKiss

Precisely. I think the point has been lost somewhere along the way.

GlesgaKiss

The original point of contention was whether the pain relief given was appropriate. It had nothing to do with finding the route cause of the pain.

Whose opinion should we listen to regarding the administering of pain relief? An anaesthetist or a spinal specialist? When a patient has acute pain, do the nurses call a spinal specialist, or does an anaesthetist come to sort it out?

need4speeduk

iTrader: (26)

Pain relief is obviously a priority.

However, a mild analgesia and anti inflammatory would have been more appropriate as a first intervention and then assessed for effectiveness prior to to starting someone on the stronger stuff listed in the original post.

john banks

In a severe acute pain situation (not just back pain) I'm interested in immediate life threatening or life changing diagnoses that can have their course changed by immediate interventions. Then I'm interested in relieving the pain. At subsequent review(s), if they occur at all, I'm interested in the less immediate underlying causes for those that haven't settled. If you quibble with those priorities it is because you again misunderstand my role, and I would be interested to see how you would prioritise it differently and why.

If I went to bed fine and awoke with back or neck pain of the severity where I would be considering giving opiates to a patient I would not be able to mobilise and would appropriately request my GP to visit. You are dramatically underestimating the distress and pain a patient can experience in this situation if you find this or the use of opiates surprising. This doesn't even consider General Medical Council guidance on treating yourself, your safety when unwell to treat patients, or your safety to drive to work when unwell or medicated, they are separate issues outside the sensible scope of this discussion, although very important.

The questions you ask betray your lack of realism in the primary care situation, which is not surprising given your lack of qualifications or experience in this area, again as you agree you are not a doctor. These patients are in too much pain to examine to determine the underlying cause of their pain apart from to check things that will immediately change their management. They won't see you in this state, they will see a doctor.

I defend my legal right and responsibility to use opiates safely and appropriately for my patients. They thank me for it and a review of opiate prescribing I conducted for the primary care trust attracted praise. To put into context, I give an injection of an opiate for back pain about once every 2 years (getting through about 5 injections of morphine a year for all causes such as renal colic, biliary colic, severe recurrent headache where everything else has been tried, acute MI, acute cardiac failure, palliative situations), diazepam for acute back spasm about once a fortnight, cocodamol 30/500 and/or diclofenac for acute back pain about once a week.

john banks

Not for someone in severe pain. They will be screaming or whimpering at your with a look of terror in their eyes. Sometimes only an opiate will do, acutely, before anything else.

Medics are trained on this stuff at 3am dealing with patients in cardiac failure typically. Diamorphine (along with oxygen, furosemide etc) does a lovely job of settling them. You recognise that look of terror and pain later and know when to use the opiate. You simply don't have that first hand experience or responsibility to criticise here.

Your stance against proper pain management has something irrational behind it. Post Shipman, bad experiences with doctors, anti-medication, or over-emphasis on your own techniques/treatment methods?

Patients need doctors who take their pain seriously and one of the duties of a doctor is to "take steps to alleviate pain and distress whether or not a cure may be possible". (GMC, Good Medical Practice).

This debate isn't new to me, it is one of the topics I discuss with our medical students. I encourage them to argue with me, I want them to be able to justify their actions to their patients and their peers, know their responsibilities and practice safely as well as effectively. When they see me prescribe an opiate I ask them what they would have done and to justify it. I also discuss opiates daily with patients, it is my bread and butter. Yes I have things to learn, but not from this thread...

cster

I must be thick, as I can't make sense of this at all.
The OP case was an acute emergency call out, not some routine visit to the GP.
As such, you reference to popping pills for pain is without context.
I gather you are not qualified to treat people using prescribed drugs.
Yet you state that the original prescription is overkill.
Not opine - but state.
I suppose it doesn't really matter, as in either case (since you are not qualified) whatever you have to say is irrelevant.
IMO
Your comments are out of order.
You seek to big yourself up by use of continued attempts to denigrate the GP who made the call-out. Do you think this is the way one health "professional" should behave towards another?
Other than that, carry on. You are a credit to the NHS

need4speeduk

iTrader: (26)

And you are right, that was the original point of contention.

But when someone claims another professional doesn't have a clue just because they aren't a doctor, it's kind of disrespectful. Especially when that doctor doesn't even know how to measure something as simple as leg length. Doesn't say much for their clinical skills really does it. Also when they start claiming how much they can do for back pain and then state they physically examine someone in 3 minutes it does become a bit farcical.

I'm not a doctor, but I'm also not a radiologist. That doesn't mean I can't interpret xrays ct scans etc. I have nothing against doctors. They study long and hard and are rightly held in high regard. That however does not mean they are always right and other professionals with clinical experience in a certain area are clueless just because they happen to belong to a different progression.

Anyway, this has got a tad silly now and gone way off course so I'm bowing out.

john banks

You're mistaking roles again. My requirement to measure leg length is nowhere near as important as yours (I send mechanical back pain to physios), and your requirement to use medication to relieve acute pain is nowhere near as important as mine.

It would be interesting though (since this is more your area it seems) if you have any evidence to support measuring leg length in the context of mechanical back pain from the greater trochanter to the lateral malleolus rather than ASIS to floor. What if the joint space is narrowed in the hip or ankle due to OA? You'd miss it with your method, but not mine. Yet in terms of back pain you'd have a tilted pelvis and a scoliosis.

john banks

Link supporting ASIS to floor: http://books.google.co.uk/books?id=f...leolus&f=false

Best we call it lower limb BTW, since leg to me anatomically means knee to ankle.

I eagerly await your reply, I would love to put in my learning plan that I changed my practice as a result of a discussion based on good logic and evidence, and this is an area you know more about than me, so please argue me into a corner and I will concede this point if you do so with skill, you'll have to fight for it though

john banks

Here are the results of a literature search since I don't leave questions like this unanswered for long as I always try to improve. This will go in my learning plan, but unfortunately I cannot double the credits for the time involved (you can if it changes your practice) since I am not changing my practice based on my reading despite your suggestion that my present method makes me incompetent (this gives me some reassurance that I am in fact not incompetent and will actually make you question your assumptions better). The evidence is not of good quality to show causal links between leg length discrepancy and low back pain, and neither is there broad agreement on which pelvic landmark to measure from (except they are pelvic not femoral), but based on what I read I would suggest you consider when assessing back pain to measure from a pelvic rather than femoral landmark and strongly consider going to the floor since that is where the patient ends and includes the ankle which is relevant.

I think I really have said enough for now. I hope you don't bow out here and look forward to the next instalment.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/
"Moreover, there are certain causes of LLD such as fibular hemimelia and posttraumatic bone loss involving the foot where a significant portion of the limb shortening is distal to the ankle mortise. Thus, it may be more accurate to measure the true length from the pelvis to the bottom of the heel as it is more easily reproducible and can account for shortening distal to the ankle."

http://www.drrmarx.com/pdf/measureme...iscrepancy.pdf
ASIS to malleoli

http://www.physther.net/content/70/3/150.full.pdf
ASIS to malleoli

http://www.ncbi.nlm.nih.gov/pubmed/22371777
Posterior superior iliac spine to floor here, emphasis on pelvic obliquity, how would you detect that by looking at the greater trochanter?

http://www.podiatrytoday.com/article/1035
Interesting article that doesn't mention measuring but comparing the iliac crest positions.

http://www.ncbi.nlm.nih.gov/pubmed/16808134
Interesting study showing no difference at a year between military trainees with 0.5cm difference, but that seems small enough to me to be physiological.

http://www.ncbi.nlm.nih.gov/pubmed/6146810
Another negative association between limb length discrepancy and low back pain.

http://www.ncbi.nlm.nih.gov/pubmed/12774997
Pelvic landmarks, another negative association with low back pain.

hodgy0_2

Hi John

Before I start, let me say I have the highest regard for the medical profession – and furthermore every single interaction I (and my rather large family) have had with the NHS has been beyond reproach and compare – simply 100%

But I made, in a previous post, an observation (based on both personal experience and anecdotal evidence*) that in the US they seem to have reached a zenith in medicalisation of every conceivable condition – from troubled children (ADHT), slimming, anxiety, sleeplessness – the list goes on and on

Every possible human condition (real and imagined) seems to have an associated set of pills

The American population seem to be addicted to medication of one form or another

What’s your take on this? - are Doctors in the US medicating too easily?

Apologies to the OP - I know this is slightly broadening the thread,

*I would be interested in actual hard statistic on drug prescription etc in the states versus life expectancy and general health

john banks

I think I'm representative of British medical opinion and value one particular aspect of our system which is that there is no incentive to prescribe medication or medicalise normal or social situations. There is a common understanding that low use of many drugs is a marker of good practice. Many doctors enjoy stopping medications, most especially but not exclusively in the elderly where polypharmacy is a big problem.

Modern patients often question prescribing, and I enjoy justifying my opinion to them if there is a rational basis for debate rather than an anti-medicine stance which ignores evidence. The more difficult argument can often be that I do not want to prescribe for mild depression, inability to cope with normal life pressures, addictive drugs to addictive personalities for dubious reasons, antibiotics for viral illnesses, repeated alcohol detox, insomnia, slimming outwith the situation of continuous monitored weight loss, and troubled children who need parenting.

ADHD does exist, but most parents that ask about it need help with parenting, not a diagnosis. Sometimes it is a cover story to obtain social benefits.

There is a whole host of "get a note from your doctor" situations that are a frank misuse of the service.

I'm a strong proponent of immunisation where the evidence is overwhelming.

Consultation rates have noticeably increased and my impression is that despite my generally decent bunch of patients, more time is being taken up with the (attempted) medicalisation of non-medical issues which I'm trying to resist.

I'd say we probably see eye to eye on this?

hodgy0_2

Thanks John,

appreciate your time to respond

and yes, we prob do see eye to eye

and i bet you get pissed off with "i have googled my symptoms and I think.............."