On abdominal pain

For EMS personnel, abdominal pain calls are notoriously difficult. As an emergency physician in Buffalo once said, "The problem with abdominal pain is it can be so many different things." In a nutshell, this sums up the dilemma faced by EMS. Without the advanced diagnostic tools and imaging technology available in the hospital setting, it is extremely challenging to arrive at an accurate field impression/differential diagnosis. There are definitely clues that can point you in one direction or another, and a skilled provider performing a detailed assessment can make headway, but sometimes you just don't have the resources to pin it down.

This vagueness plays out in the treatment options available to providers. The only mention of abdominal pain in the 2009 edition of New Hampshire's patient care protocols is to instruct paramedics to withhold Nitronox, a 50% nitrous oxide-oxygen gas mixture used for pain relief, from any patient with this complaint. This is not to be cruel; if the patient turns out to have a bowel obstruction, the gas can get trapped in the folds of the obstructed bowel and potentially cause a rupture. In many cases, all you can do is assess the patient to the best of your ability, provide supportive care and rapidly transport him to the closest appropriate facility (other options for pain control exist as well).

The Health section of yesterday's New York Times had a fascinating article about abdominal pain in pediatric patients. The author, physician Perri Klass, related how as a resident she and her colleagues used to "smirk" at cases of functional abdominal pain. Functional abdominal pain, which is a term previously unfamiliar to me, is evidently a diagnosis arrived at when nothing else seems to fit. Children with persistent stomachaches that cannot be explained by the presence of any disorder are often said to have this condition.

The article discussed how functional abdominal pain had previously been a throw-away diagnosis, or as Dr. Klass puts it, "A code for a troublesome patient, dubious symptoms or an anxious family." Now, though, clinicians are recognizing it as a legitimate complaint that requires serious attention and treatment.

As difficult as abdominal pain calls can be, it's nice to know that sometimes the doctors get stumped too.