TALK IS CHEAP!
Glance at the faces of patients receiving treatment in the typical emergency room and you may see expressions of anxiety.

Reassuring conversations can help ease their concerns. Talk is a very effective sedative for most victims of an acute injury.

Physicians sometimes forget to talk to their patients, perhaps because they are so intent upon selecting the right suture and placing it correctly. Meanwhile, the patient doesn't know what's coming next or what the outcome will likely be. Family members and friends waiting outside may erroneously believe the injury is serious, perhaps even life threatening!

Don't make this error. Learn to sedate your patients with simple reassuring conversation.

Skilled physicians learn to maintain a dialogue with their patients while they treat them. Sometimes the conversation centers on the problem at hand - queries about the nature of the injury or illness, its onset and manifestations. At other times, especially when treatment decisions have been made and explained, the conversations should turn to other subjects that will divert the patient's attention away from the problem.

Almost any subject is acceptable - even politics and religion - if handled with discretion. However, there is one major exception: the details of other patient's injuries.

DRUGS FOR THE ACUTELY INJURED
Regrettably, many physicians have bought into the common misconception that narcotics, sedatives and for that matter nearly all drugs, are unsafe for most victims of traumatic injury.

This principle is valid for victims with multiple-system injuries. It is not appropriate for patients with localized wounds.

Don't withhold pharmacologic assistance for those patients. Do check for signs of intracranial trauma, but if there are none, give your patients the benefit of sedation and pain control.

SEDATION
When a patient has an acute injury, give all drugs intravenously. Intramuscular injections are less effective and an unnecessary cruelty. With an IV, additional drugs can be easily added later if need be. This book cannot include a complete survey of pharmacologic alternatives. Suffice it to say that simple drugs are probably preferable.

Of course you must always ask about allergies and prior experience with drug intolerance before you give anything to a patient.

In addition, always allow time for a sedative to take effect before administering the local anesthetic. The anesthetic will be far more effective if it is superimposed on an adequately sedated patient.

ANALGESICS
A sedative like Nembutal is only that - a sedative. It is not an analgesic. If a patient is experiencing pain, or you anticipate that he will, then something must be prescribed to control pain - preferably a narcotic.

Either morphine or demerol is appropriate. Use whichever drug you are most accustomed to; however, if a patient has experienced nausea or other adverse reactions to one of these, then use the other.

RELAXANTS
In addition to a sedative and an analgesic, patients can also benefit from a short-acting relaxant like Valium, best given immediately before the local anesthetic is given.

PRECAUTIONS
Beware of the older patient who may only need to read the label on the ampule to achieve a full sedative effect. Administer smaller doses to anyone you think might be particularly sensitive to a sedative or a narcotic.

Conversely, be prepared to give extra-large doses to those who have developed drug tolerance. Again, remember to ask about prior sensitivity or tolerance. Don't try to give one drug for all purposes. Some physicians give only Valium before forging ahead. However, Valium isn't a sedative or an analgesic. It is a wonderful relaxant after Nembutal and a over-sedated or narcotized patient:

If you think that too much barbiturate has been administered call for skilled assistance, give supplementary oxygen, and avoid further medication. You may want to postpone wound repair until the patient is more stable.

If you suspect excessive narcotics have been administered, give Narcan^TM 4 mg immediately, then more as needed. Remember that Narcan^TM is very short-lived. Don't just give one dose and send the patient home. Also remember that Narcan^TM reverses all of the narcotic's effect - the analgesia as well as the respiratory depression.

PARTING SHOT
Your goal should be appropriate treatment of your patient's injury as well as the creation of a positive feeling about the way he's been handled in your office or Emergency Room. Allow IV medications to help you achieve patient equanimity.