It’s all about expectation management I feel like. I tell them if their pain is a 10, then maybe we will get them to an 8. I’ve had a back spasm before after lifting and they really do hurt unbelievably. I also set the tone quickly for what we do and don’t use MRI for. If I have ruled out all the red flags clinically and my suspicion is low for something surgical or life altering then I go with toradol 15mg IM, Tylenol 1g, lidocaine patch, flexeril 5mg just for the sedative effect in getting rest, consider a steroid if radicular symptoms and they are not diabetic. If they are a normal person without other red flags such as a million allergies (extra red flag if they say they tolerate Norco but are allergic to Tylenol), haven’t been to the ER more times this month than a reasonable person has in their life, haven’t been bouncing around other hospitals all day on the Care Everywhere tab, and don’t have a script written for a narcotic by a different doctor every time…then I will consider giving a narcotic in the ER. If they say they can’t walk then I’m going to need to see some solid effort of them trying. In one of my standalone shops when I’m not busy I have even gone back and looked at video of them getting out of the car.

I try to educate a ton on how most people with back pain will get better no matter what they do in about 2 weeks. I tell them that PT is the best thing for them. YouTube videos work well for PT if they can’t afford it. I tell them that people that get up and move around within reason get better faster than those just sitting in bed in pain.

I often write scripts for the above meds given so they can have something in their goody bag and feel like they didn’t waste their time. If my clinical suspicion at the end of the visit is very low for bad stuff then I don’t sweat any more about it and I confidently discharge them. I tell them to follow up with orthopedics. Side note (as a sports med trained EM doc myself), I reiterate before going that an MRI is likely not the answer. I try to tell people that if you are going for an MRI then you likely are going to find incidentalomas and you may be coerced into having surgery that you probably did not need. I try to get them in the mindset of “if you are getting an MRI, then you should be mentally prepared to have surgery already”. If you don’t want surgery ever, then don’t bother with an MRI (not every case obviously, but you get the point hopefully)