Thank you to edwinleap.com for mentioning my post about pain medication for children with broken bones in this week's edition of Grand Rounds. Grand Rounds is a weekly compilation of health care posts from around the web compiled by a host, who goes to great lengths to make the collection informative and entertaining.

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Pain Management in Children for Broken Bones

Pain management is a hot topic in medicine in general and certainly in medicine for the outdoors. Injuries in particular, and many illnesses, cause pain, which in turn causes the victim to suffer. To a great extent, pain is subjective, but regardless of whether your pain is a "1" or a "10," it can be disabling and even dangerous, particularly if it causes you to be distracted in a situation of risk (e.g., climbing, swimming, walking along a ridgeline).

Broken bones usually hurt a great deal. It's commonly believed that the pain is always of a severity to require the administration of "strong" pain medicine, notably, something containing a narcotic compound. This may not be true. In an article (Annals of Emergency Medicine 2009;54:553-560) entitled "A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen With Codeine for Acute Pediatric Arm Fracture Pain," Amy Drendel, MD and colleagues compared the treatment of pain in children with arm fractures by using ibuprofen in a dose of 10 milligrams per kilogram (2.2 pounds) of body weight versus acetaminophen with codeine in a dose of 1 milligram per kilogram (based on the codeine component of the medication). The children were assessed for three days after discharge from an emergency department. Two hundred forty four patients were analyzed in this study.

The authors concluded that ibuprofen was at least as effective as acetaminophen with codeine for children ages 4 to 18 years with arm fractures treated as outpatients. What is also very interesting is that the children receiving ibuprofen had significantly fewer adverse effects, and both the children and their parents were more satisfied with ibuprofen. The proportion of children who had any function (play, sleep, eating, school) affected by pain was significantly lower for the ibuprofen group.

What to make of all this? The known side medication side effects measured were nausea, vomiting, drowsiness, dizziness, and constipation. Ibuprofen appears to be clearly superior in this study population. This is an eye opener for me, because I am a bit surprised (and now enlightened) by the data. I would have expected these broken bones to require more potent pain medication (e.g., a narcotic), but I see that this is not necessarily the case. In the future, I will recommend ibuprofen (if there is no contraindication) as an initial medication for many more types of pain situations, and wait to see if a more potent "rescue drug" is necessary only as needed, rather than as first choice. If remaining alert and fully functional in an outdoor setting is a priority, this makes double sense.

broken arm image courtesy of bbc.co.uk

Tags: pain management, ibuprofen, broken bones, wilderness medicine, outdoor medicine, healthline

Labels: acetaminophen with codeine, arm fracture, broken arm, broken bones, fracture, ibuprofen, pain management

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Haiti, January 28, 2010

We found out today that we are going to ship out tomorrow. My feelings are certainly mixed. There is an incredible amount of work to be done here – we have only contributed to the first wave of what is necessary. This may sound strange, but I cannot remember the details of much of what we did the first three days, when we were functioning on hyperdrive in a battlefield setting. My recollections become detailed after the third day, when we were able to see only four or five patients at a time, and we stopped triaging amputees to the operating room.

Now the hospital has been substantially augmented. Teams of foreign (to Haiti) surgeons have left to go home, because the operations to be performed now are largely orthopedic and plastic surgery, as well as specialty cases. Sadly, there are scores of patients with spinal fractures who are paralyzed, and little can be done for them this far out from the initial injury. Children continue to break our hearts. I had a small child who is a triple amputee offer me his cracker with his remaining hand. One can only pray that the memories he carries of this tragedy are erased swiftly, that he is assisted in his rehabilitation, and that his life improves. All of these will, of course, be hard to achieve.

I visited one of my favorite patients, the young woman who danced ballet professionally before she lost her leg below the knee. She had a revision of her stump yesterday, so she was asleep, recovering from anesthesia, when I saw her. Today, she was bright and alert, and gave me a big smile when I walked to the side of her stretcher bed within a very hot tent. She motioned me to come closer, and we exchanged contact information. I will do everything possible to stay in touch with her.

Many of our interpreters are living outside in enormous congregations in parks. I gave my tent to one of these persons and am distributing everything that might be useful to victims of the earthquake and to medical persons who have just arrived to take over where those leaving left off. There are plenty of medical supplies – the Haitian people need shelter, food and water. Soon, they must begin to rebuild and take what was a feeble economy and turn it into something. This will be no small undertaking.

At our compound, I handed over the reigns today to someone who will assume my role as the chief medical coordinator of all NGO activity. I said goodbye to many persons with whom I have become close under the most dire circumstances. These are wonderful people. In a meeting of the leadership present, I told them that I have never been so proud to be among such an incredible collection of talent and dedication.

Just after noon, when the meeting ended, my body finally told me to stop. I was exhausted and queasy, and so went to our headquarters and lay down on the ground. The nurses started an IV in my arm, and it took 9 full liters of IV fluid before I was able to sit up and have the lights go back on. As my wrestling coach in high school used to say, “Paul, you don’t need to win, just don’t get pinned.” I lifted by right shoulder up and chuckled. My coach would have been proud of me.

Bodies are still being pulled out and it is not a pretty site. The involuntary reflex, which I certainly possess, is to vomit, so I need to walk away. Off site, bodies were pulled out in poses like Greek statues, and I heard that many were then incinerated. I’m grateful that I did not witness that.

Our two-tent E.R. continued to be busy. The doctor teams were swift, efficient and resourceful. We added service for HIV patients, and the number of patients with tuberculosis increased to the point that we created an isolation tent. These patients are coughing and cachectic. On the opposite side of the compound, the population in the pediatric tents in growing rapidly. Unless there is a concerted effort to create an off-site location to house patients that can be discharged from the hospital, there will once again be space problems.

I am so proud of my Stanford colleagues and all the other doctors present in the compound who have worked tirelessly for the past two weeks. The teams from California, Hanover, Boston, New York, Switzerland, Norway, Canada, Spain, and many other locations all pulled together in a model for collaborative behavior. There are always a few people more interested in citing their credentials than in getting the work done, and media people looking for the sensational angle, but they stood out in stark contrast to the dedicated and tireless people who rolled up their sleeves coming in and hugged going out. Take it from someone who was, as someone suggested to me, in the belly of the beast that when the memories finally register, they will be indelible and life-altering. I wish the people of Haiti every good fortune from this point forward and hope that you will find it in your hearts and schedule to assist these people, and others in need, in some fashion.

Labels: earthquake, Haiti

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from Haiti, January 27, 2010

We've been here working at the University Hospital in Port au Prince for nearly two full weeks, and it is shaping up. The care being delivered is remarkable given the circumstances since the earthquake. There are two operating rooms running 4 beds each, a tented medical unit for our sickest patients, a fully stocked pharmacy, a satellite pharmacy, an increasing laboratory testing capability, and more tents. Still, this is not a hospital as we have become accustomed to in the U.S. It is a medical facility under tents, and the conditions are not sterile in the sense of sterility in "clean facilities." What I am trying to convey is that while the situation is improving, and we have optimism that it will continue to improve, for the patients who have suffered bad injuries, they are certainly not yet all out of the woods.

I find myself going back to visit a few patients, like the young woman professional dancer who lost her leg. She was returned to the O.R. today for a revision of her stump, so was postoperative and asleep when I saw her. In the crowded tent, she was covered with flies, so I sat by her for a while and fanned them away with a small notebook. In another tent, I watched a mother bathe an emaciated infant. The baby will not make it through the next two days. One tent over, a woman shouted out in pain during childbirth.

The garbage is being picked up and we should have upright portable bathrooms tomorrow. That is a triumph towards which I have struggled for days. Once again, the U.S. military showed its compassion and coordination when nearly 50 patients were evacuated to more advanced care. More will follow tomorrow. In our central wooded area, the crowd is thinning as some persons have found locations out of the hospital where they may live and rest while they recover. That all may change if it begins to rain or the ground shakes again.

Yesterday the generator went out for many hours, so we could not run the O.R., or so I thought. A team of resourceful surgeons wore their headlamps and made it through some of their cases.

We got word today that we may be going home soon. I have mixed feelings about that. It will be difficult to leave, but all signs point to it approaching the right time. Emotionally, I am OK, but my legs are a bit wobbly. I wake up as tired as I was when I went to sleep. The people here deserve fresh legs.

Tomorrow we will finalize coordination of sanitation, electrical, tent placement, number of physicians needed to carry us through the next two weeks, and how to accelerate the return of Haitian physicians and nurses. There is much work to be done.

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Haiti, January 26, 2010

On the 10th full day in Haiti, we find ourselves at the transition point where we must work extremely hard carrying out our duties, but beginning to transfer responsibility to the persons who will assume our roles upon our departure. Some of our team have begun to "hit the wall" physically and emotionally. I am fine emotionally, but these old muscles are aching for sure. However, every time I walk past a young Haitian child who has lost an arm or leg, yet still smiles and tries to give me a wave, I am energized. It will be very difficult to leave, but I know that within a few days, we must get our batteries recharged.

The hospital complex is really taking shape now. The tents are wall-to-wall and all filled with patients. We have arranged for electricity and sanitation. We have oxygen bottles and new stretchers. Yet, we are still missing critical sterilization equipment for surgical instruments, modes of transportation, phones, and sufficient supplies to call this a complete medical operation.

I was visited today by a contingent from the US Armed Forces and Department of Defense officials responsible for supporting the military-civilian interface. I gave them a tour and they pledged to help us solve some of our most pressing problems related to space and supplies. I believe that this will be invaluable to our efforts and am enormously grateful for the support.

Some of my new friends from other NGOs have begun to rotate out, and I miss them already. We have become close "under fire," in a way that is not possible in any other venue. We would trust each other with our lives.

Three of us shared a common experience today, individually, as we walked down the road past the crushed nursing school and towards the Swiss surgery tent compound. We all noticed for the first time a beautiful flowering bougainvillea that had been completely overlooked when we marched head down along what was only a week ago a thoroughfare of death. We smelled the cooking from the street, and walked past tents of injured persons singing, trying to be happy, trying to begin to get back to normal. They are so brave and so deserving of all that we can give them.

Our group has adopted in a certain way the young 5 year old boy who was pulled from the rubble after a week. He comes to visit us, and clings to the nurse who was most attentive to him during his resuscitation. His parents are lost now and he is an orphan. He is like thousands of children in Haiti now. The orphanages are filled or filling, I am told, and reconstruction cannot occur fast enough to avoid enormous tent cities, housing many tens of thousands of persons in each location.

Stop for a moment and think what you might do to help anyone, anywhere. Hug your children, visit someone in the hospital, and be kind to everyone you meet. Life is a precious commodity. Most of all, appreciate what you have, and consider sharing it with persons who are less fortunate than yourself.

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