Med control for Morphine?

[rhan101277]

So i was at clinicals today discussing with a RN about paramedic procedures on a pain medications since we were just getting through giving some. She said even a paramedic must call med control before administration of a narcotic. We can administer it without med control though so I decided not to argue.

Further discussion occurred later in the day about pre-hospital diagnose which she basically said was hogwash. I explained that one must be developed so we can decide which protocol to follow and left it at that.

I don't know if this RN was having a bad day, the rest were fine and all, but I decided I am not going to discuss any medication administration or procedures unless I absolutely need to. Most RN's are great, this one seemed to have a dislike for paramedics and/or their ability to make decisions with little supervision. <_<

 

[Lifeguards For Life]

So i was at clinicals today discussing with a RN about paramedic procedures on a pain medications since we were just getting through giving some. She said even a paramedic must call med control before administration of a narcotic. We can administer it without med control though so I decided not to argue.

Further discussion occurred later in the day about pre-hospital diagnose which she basically said was hogwash. I explained that one must be developed so we can decide which protocol to follow and left it at that.

I don't know if this RN was having a bad day, the rest were fine and all, but I decided I am not going to discuss any medication administration or procedures unless I absolutely need to. Most RN's are great, this one seemed to have a dislike for paramedics and/or their ability to make decisions with little supervision. <_<

I too have been put in many similar situations and am under the impression may rn preceptors i have had do not wish to have a student, and few seem too incompetent to have a student. I have had many paramedic preceptors that did not seem to know a whole lot.

And our medical director is pretty aggressive, we can give narcs in the field without consulting medical control as well.

 

[FFMedic75]

Alright guys, here is the deal with the nurses. Remember the majority of them (with some exceptions i.e. flight nurses, NP, etc.) do not make decisions, they simply do what the doctor says. The old adage in EMS that we don't diagnose as medics is BS. Why do we do 12 Leads or take BGLs? We diagnose symptoms and in many cases make definitive diagnoses prior to arriving at the hospital. One example of this is transporting STEMI patients directly to the Cath Lab. Many of the Nurses you will encounter are jealous of this. Lots of others are just plain burnt out. Having said that while doing clinicals you are there to practice specific skills like medication administration and IVs. The majority of your patient assessment skills and clinical decision making will come when you do field internships. The Paramedic Preceptors will be much more prepared and understanding to teach this. My best advice now and throughout your career is not to piss off the nurses just go there practice your skills and be proactive.

 

[Lifeguards For Life]

Alright guys, here is the deal with the nurses. Remember the majority of them (with some exceptions i.e. flight nurses, NP, etc.) do not make decisions, they simply do what the doctor says. The old adage in EMS that we don't diagnose as medics is BS. Why do we do 12 Leads or take BGLs? We diagnose symptoms and in many cases make definitive diagnoses prior to arriving at the hospital. One example of this is transporting STEMI patients directly to the Cath Lab. Many of the Nurses you will encounter are jealous of this. Lots of others are just plain burnt out. Having said that while doing clinicals you are there to practice specific skills like medication administration and IVs. The majority of your patient assessment skills and clinical decision making will come when you do field internships. The Paramedic Preceptors will be much more prepared and understanding to teach this. My best advice now and throughout your career is not to piss off the nurses just go there practice your skills and be proactive.

very well said. i

 

[rhan101277]

Thanks for the advice. Where I will be working after class won't be in this area though. I still want to make friends, so I will just do what I am told and try to get in there and get stuff done. I have only been successful on 3 out of 13 total IV's attempted, most were hard sticks, hopefully I will get better.

 

[downunderwunda]

Whats Med Control?

Waste of time.

You have the training, you have the knowledge, you should not have to talk to some Doctor to get permission to provide pain relief.

 

[rhan101277]

Whats Med Control?

Waste of time.

You have the training, you have the knowledge, you should not have to talk to some Doctor to get permission to provide pain relief.

And you don't, just an RN getting grumpy.

 

[mycrofft]

As a former EMT and current RN....(harrrumph)

1. Some nurses are very status/pecking order oriented, and an EMT seems easy pickings. Or Peckings.
2. Some EMT's come in very self-inflated with their boots and their windshield punches and their stethoscopes around their necks and do not do what the receiving staff want, which is bring the pt in pumping with the data the staff needs, then get out. Sometimes stuff goes missing.
3. Some nurses or EMT's are not good at precepting anyone, and there is probably a rotation set up for who will watch the student that shift. I have met EMT's and RN's who refuse to help new people.
4. Some EMT's or Nurses are simply having a very cruddy day or life and you are the closest harmless thing to biff around.

Say to your preceptor "I am feeling that I am not doing anything right. Can you tell me specifically what I have to do better?". Write down their answer, or get it in writing and time and date it. If the answer is "Nothing, you're doing fine", it's your choice to talk about it or go to your instructor and ask for another preceptor. If the feedback seems odd or not real, take it to your instructor and talk about it. If the corrections are at all realistic, thank your preceptor and ask more questions about how you are doing.
If the preceptor says "You aren't cut out for this", consider it for a second, then talk to your instructor.

Been there done that.

As for the drug issue, learn your protocols but make sure the count is right at the beginning end and whenever you take out a narc, and when you are leaving shift you count the actual narcs to the oncoming person who looks at the book (or whatever), or you both count and read together. NEVER change shift by allowing the offgoing staff to hold the book and have the count read to them (too easy to say "good count" and instantly put it on the oncoming shift).

 

[daedalus]

Ugh. I HATE the direction these threads go sometimes. While there may be very few RNs that envy being out in the field (I assure you, very few of them really want to be out on a rig when they could be making much more cash in the ED), there are many more paramedics I know who envy the RN's job. I say from experience, a lot of my paramedic partners have plans on going the RN route for better job stability, better benefits, better pay, better family friendly job.

Also, very few RNs work under the old prejudices people have of them. They do not silently wait for orders from an MD and than go carry them out. Please shadow an RN in a modern ED or ICU/PICU/NICU/CCU if you do not believe me.

In one nearby trauma center, the RNs typically have "ordered" most lab work before the doc sees the patient, and the MD/DO/PA just signs off on it. If you cannot do this competently, you will not last in that ED.

Also, common. RNs require a college education. We do not. Automatic trump. As painful as it is to admit, we have to fix this.

OP, I have encountered your situation as well. Keep your mouth shut and skate through your clinical and than in the field you will get to give all the morphine you want without calling base, and you can smile about it. You get what I mean.

 

[VentMedic]

Alright guys, here is the deal with the nurses. Remember the majority of them (with some exceptions i.e. flight nurses, NP, etc.) do not make decisions, they simply do what the doctor says. The old adage in EMS that we don't diagnose as medics is BS. Why do we do 12 Leads or take BGLs? We diagnose symptoms and in many cases make definitive diagnoses prior to arriving at the hospital. One example of this is transporting STEMI patients directly to the Cath Lab. Many of the Nurses you will encounter are jealous of this. Lots of others are just plain burnt out. Having said that while doing clinicals you are there to practice specific skills like medication administration and IVs. The majority of your patient assessment skills and clinical decision making will come when you do field internships. The Paramedic Preceptors will be much more prepared and understanding to teach this. My best advice now and throughout your career is not to piss off the nurses just go there practice your skills and be proactive.

Here we have another one who has absolutely no hospital experience and knows absolutely nothing beyond the back of an ambulance or fire truck. Yet, he feels the need to spout such crap to bash RNs to make up for whatever inadequacies exist in EMS and in himself.

The major difference between RNs and those in EMS, besides the education, is that they know who they are and what they are capable of. They also know when, why and how to gain more education and respect in medicine. EMS still believes a few hours of training and their ability to drive real fast with their L&S automatically gives them respect.

There are many EMS services such as Washington DC that didn't have access to even valium or morphine until recently. I believe the morphine is still on a very limited basis with lots of hand holding from medical control. There are some EMS services in the U.S. that don't start any type of IV medications or fluids without medical control. There are also some areas such as California that just can not do much of anything due to their very limited state scope of practice which is why RNs are used on the CCTs and Flight teams.

One of the reasons RNs and RRTs are utilized for Specialty teams is their ability to have very extensive scopes of practice extended to them by their states since they do have an established educational foundation that is consistent for the minimum and based on a college degree not a trade school diploma stating a few hundred hours. Thus, their job description can be as broad as necessary to get the job done. Even working on a flight team as a Paramedic with a fairly progressive scope of practice, I am still very limited when compared to my RN partner. In the ICUs and other nursing areas, there is no comparison as the RNs have extensive protocols to follow which fill books much larger than almost any Paramedic system in this country.

However you are correct that the Paramedic preceptors should be better prepared to explain how it is in EMS. Most nurses will have a difficult time understanding how someone can do x but can not do y or how some don't even see that x and y should go together. Essentially, the limiting recipes of EMS make no sense to hospital staff who are about total care of the patient and providing all the meds necessary when needed and not "just this much". Sedation and RSI are good examples when the patient is given just enough to p** them off when procedures are attempted and not enough to do any good.

My other message to you is not to attempt to bash other health care professionals in an attempt to hide the problems that exist in EMS. Maybe if you address the problems that give rise to such discussions about EMS providers amongst other health care providers, there would be little need for threads like this.

 

[mycrofft]

I need to correct my last response!

1. If you are coming on, YOU count the narcs while the offgoing reads the sign out/balance book to you, point being never accept a book count without personally correlating the actual eyes-on narcs to the count.
2. I am told I am still in the 19th century with that means of passing on control of controlled substances. Oh, well, so it goes...

We nurses need to recognize professionalism in whomever we meet when it is exhibited, whether it is a new MD, a medical assistant or technician, or the guy who refills the O2 cylinders. Actually, that's a good rule to live by period.

 

[triemal04]

We nurses need to recognize professionalism in whomever we meet when it is exhibited, whether it is a new MD, a medical assistant or technician, or the guy who refills the O2 cylinders. Actually, that's a good rule to live by period.

Actually, that should just read "We," not just nurses. But I agree with the overall sentiments completely. Unfortunately, as can be seen with a couple of posts in this thread, it won't happen anytime soon.

To the OP: don't worry about it. Just as not every medic knows the in's and out's of each in-hospital care provider, not everyone of them will know about what we do. It's not a bad idea to (politely and appropriately) explain why something that has bee said is wrong, but if you can't...meh. It's not always possible with the various personalities you'll encounter.

 

[MSDeltaFlt]

So i was at clinicals today discussing with a RN about paramedic procedures on a pain medications since we were just getting through giving some. She said even a paramedic must call med control before administration of a narcotic. We can administer it without med control though so I decided not to argue.

Further discussion occurred later in the day about pre-hospital diagnose which she basically said was hogwash. I explained that one must be developed so we can decide which protocol to follow and left it at that.

I don't know if this RN was having a bad day, the rest were fine and all, but I decided I am not going to discuss any medication administration or procedures unless I absolutely need to. Most RN's are great, this one seemed to have a dislike for paramedics and/or their ability to make decisions with little supervision. <_<

Rhann, since we are both from Mississippi, let me explain it from first hand experience.

Mississippi EMT's have to sign a jurisdictional Medical Control agreement. If your offline med control has not restricted your scope of practice, then you write "none" in the restriction section. If you have any restrictions, then the restrictions will be written there and what they are. There are those that have that written and some some that probably should have it written.

With regards to narcotic administration: if you're hospital-based some on-line med controls may not want agressive narcotic adminstration prehospitally regardless of what your protocols, or even your off-line med control, may or may not allow you to do. If your not hospital-based, once your pt is in your ambulance they fall under your off-line med control's orders, not the receiving's orders.

Your pain management protocol probably says you can give so much morphine every so often up to a point then you have to call med control. If that's what it says, then do that.

What a lot of RN's tend to misunderstand is that protocols are like standing orders. RN's have standing orders all the time. You're doing what your standing orders (protocols) tell you to do just like they do. However, they're stnading orders are just not as broad as our's are in the field.

You follow your protocols. Those that try to tell you how to do your job when they really don't have all of the necessary information just need a little patience.

If there's anything else I can do to help just ask.

 

[FFMedic75]

Here we have another one who has absolutely no hospital experience and knows absolutely nothing beyond the back of an ambulance or fire truck. Yet, he feels the need to spout such crap to bash RNs to make up for whatever inadequacies exist in EMS and in himself.

The major difference between RNs and those in EMS, besides the education, is that they know who they are and what they are capable of. They also know when, why and how to gain more education and respect in medicine. EMS still believes a few hours of training and their ability to drive real fast with their L&S automatically gives them respect.

There are many EMS services such as Washington DC that didn't have access to even valium or morphine until recently. I believe the morphine is still on a very limited basis with lots of hand holding from medical control. There are some EMS services in the U.S. that don't start any type of IV medications or fluids without medical control. There are also some areas such as California that just can not do much of anything due to their very limited state scope of practice which is why RNs are used on the CCTs and Flight teams.

One of the reasons RNs and RRTs are utilized for Specialty teams is their ability to have very extensive scopes of practice extended to them by their states since they do have an established educational foundation that is consistent for the minimum and based on a college degree not a trade school diploma stating a few hundred hours. Thus, their job description can be as broad as necessary to get the job done. Even working on a flight team as a Paramedic with a fairly progressive scope of practice, I am still very limited when compared to my RN partner. In the ICUs and other nursing areas, there is no comparison as the RNs have extensive protocols to follow which fill books much larger than almost any Paramedic system in this country.

However you are correct that the Paramedic preceptors should be better prepared to explain how it is in EMS. Most nurses will have a difficult time understanding how someone can do x but can not do y or how some don't even see that x and y should go together. Essentially, the limiting recipes of EMS make no sense to hospital staff who are about total care of the patient and providing all the meds necessary when needed and not "just this much". Sedation and RSI are good examples when the patient is given just enough to p** them off when procedures are attempted and not enough to do any good.

My other message to you is not to attempt to bash other health care professionals in an attempt to hide the problems that exist in EMS. Maybe if you address the problems that give rise to such discussions about EMS providers amongst other health care providers, there would be little need for threads like this.

I'm actually quit familiar with how things work in the hospital. I was simply trying to point out where this particular problem may have originated. I don't disagree that EMS has its own inadequacies especially when it comes to education and I can only hope it gets fixed one day. However you can't tell me you have never run in to this situation. Yes nurses do have Standing Orders they function under in many locations. They very different from place to place just as ALS Protocols are in the field. I wasn't bashing RNs, simply the ones that think they are gods gift to everyone. I have worked with several and they are great at what they do, however when the same nurse that may be great in the ER or ICU tries to bridge and become a Paramedic, it doesn't always work. Just as I would be lost if you stuck me in the OR as a scrub nurse they lack the experience, practical knowledge and decision making skills to work in the field that Paramedics develop in their career, but they have no problem interjecting how well they think you do your job. How many times have you heard one of them say, "what no IV?" They have no clue what being one block from the ER means or the patient had no airway, I was by my self and no one would come and help. Help in the hospital is always a call away. You have a violent patient in the ER you call security, you can't get someone intubated you call Anesthesia. We are by ourselves and many of them don't get it and they think they are better than us so they just criticize. I have actually found that required field ride-alongs helps prevent some of this. Again I am certainly not talking about every nurse I've ever worked with, however this situation certainly does exist across the US, and I was providing incite to what could be the source of someone's problem. Nurses make errors just like Doctors and Paramedics, there are good one and bad ones.

 

[VentMedic]

I'm actually quit familiar with how things work in the hospital. I was simply trying to point out where this particular problem may have originated. I don't disagree that EMS has its own inadequacies especially when it comes to education and I can only hope it gets fixed one day. However you can't tell me you have never run in to this situation. Yes nurses do have Standing Orders they function under in many locations. They very different from place to place just as ALS Protocols are in the field. I wasn't bashing RNs, simply the ones that think they are gods gift to everyone. I have worked with several and they are great at what they do, however when the same nurse that may be great in the ER or ICU tries to bridge and become a Paramedic, it doesn't always work. Just as I would be lost if you stuck me in the OR as a scrub nurse they lack the experience, practical knowledge and decision making skills to work in the field that Paramedics develop in their career, but they have no problem interjecting how well they think you do your job. How many times have you heard one of them say, "what no IV?" They have no clue what being one block from the ER means or the patient had no airway, I was by my self and no one would come and help. Help in the hospital is always a call away. You have a violent patient in the ER you call security, you can't get someone intubated you call Anesthesia. We are by ourselves and many of them don't get it and they think they are better than us so they just criticize. I have actually found that required field ride-alongs helps prevent some of this. Again I am certainly not talking about every nurse I've ever worked with, however this situation certainly does exist across the US, and I was providing incite to what could be the source of someone's problem. Nurses make errors just like Doctors and Paramedics, there are good one and bad ones.

Again you are expressing ideas from what sounds like a very poorly run hospital with nurses you believe to be inadequate.

Have you never seen a nurse run a code? Intubate? Put in central lines? Run a Rapid Response situation? And, nurses also must function outside of their hospital element every day to accompany a patient on an ER to ER transfer because the Paramedic is not allowed to take most medicated drips. They rise to occasion and go into whatever role required of them and if they have questions, they ask and seek out advice.

Have you also considered what protocols for the Paramedic in that area? Maybe they are like Washington DC where their Paramedics would never think of giving morphine with or without a doctor's order. It just isn't done and they are not the only EMS system in this country like that. I can also think of a couple FDs in Florida that got their meds taken away and weren't allowed that many to begin with.

Thus, unless you actually know this system personally, since the OP is only a student and is not working as a Paramedic, you can not say for certain if that nurse is right or wrong.

 

[FFMedic75]

You are right, I can't say the nurse is right or wrong, but to start and argument with a student over EMS scope of practice gleams of inadequacy. I have worked in 3 states actually and aside from the Flight Nurses, whom I have never had an issue with because they understand what we do, I have never seen a non specialty nurse intubate, start central lines, etc. It is not in their scope of practice in most places, and yes I can transport any medicated drip that has been established where I work. I know that isn't the same everywhere. There are lots of awful EMS systems with poor protocols but there are a lot of hospitals that are bad as well, and oddly enough I have run into more obnoxious staff in these facilities as compared to the busier Trauma Centers. It's all an attitude issue.

 

[rhan101277]

Here is our pain management protocol. They give us much lead way on such matters. All of the protocols say consider, not you must etc.

http://img5.imageshack.us/img5/3073/painalgorithm.jpg

P.S.

I like distraction procedures for pain off 6 or less. Though there is no protocol for what those procedures are.

 

[MSDeltaFlt]

Here is our pain management protocol. They give us much lead way on such matters. All of the protocols say consider, not you must etc.

http://img5.imageshack.us/img5/3073/painalgorithm.jpg

P.S.

I like distraction procedures for pain off 6 or less. Though there is no protocol for what those procedures are.

Hehehe. Yeah. Thank God you're not a first responder.

However, technically it says "up to 10mg MSO4" or "50-100ug Fentanyl" and it says to contact Med Control PRN. Meaning if one of the regimen didn't work, you'd have to call for more orders; as in add the other narcotic if the first didn't get rid of the pain adequately. Granted the odds of you maxing out either one of these dosages is remote, but the operative word here is "or".

There is a difference between giving pain medication and treating pain. I like the leeway they give you guys here. They still give you an "out" with the "contact med control" bit. Because your off line med control knows that you never say never and you never say always.

Hope this helps.

 

[downunderwunda]

And you don't, just an RN getting grumpy.

You should not have to talk to anyone. You should be autonomous enough to be able to make a decision for that patient without outside interference.

 

[VentMedic]

You are right, I can't say the nurse is right or wrong, but to start and argument with a student over EMS scope of practice gleams of inadequacy. I have worked in 3 states actually and aside from the Flight Nurses, whom I have never had an issue with because they understand what we do, I have never seen a non specialty nurse intubate, start central lines, etc. It is not in their scope of practice in most places, and yes I can transport any medicated drip that has been established where I work. I know that isn't the same everywhere. There are lots of awful EMS systems with poor protocols but there are a lot of hospitals that are bad as well, and oddly enough I have run into more obnoxious staff in these facilities as compared to the busier Trauma Centers. It's all an attitude issue.

These skills are very much in their scope of practice in most states which is why there are Flight, CCTs and Specialty RNs. If he/she is working in an area that requires intubation, there rarely an issue if there is a need. However, for the same argument of having every FF be a Paramedic and then do maybe 1 intubation per year, it is impractical for a hospital to train over 1000 RNs to intubate.

Central lines? RNs can do UAC/UVCs and PICCs. On Flight and Specialty the can do whatever is necessary to do their job. They get their training while working in the ICUs.

But then, you may only have a very limited view from the ED and don't see the full extent of what RNs can do.

As far as your drips, that could only be RL and NS with maybe one or two meds such as in CA. It is sometimes very difficult to find Paramedics that can take the drips some patients are on for IFT even if they claim to be "CCEMT-P" and then if they can, it is for watching only and they shut the IV pump off if it beeps.

Thus, few paramedics are equal with the hospital and patients getting burned if they "assume" too much from some EMS providers.