Resistance to pain medication

[Melclin]

Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?

I think the 80-100 x stronger is generally quoted. My experience is that its more towards the 80 end of the spectrum.

Who said it even needed to be severe pain? I picked a bloke up the other day from a local hospital with an incarcerated hernia. He was still uncomfortable after 12.5 mg morphine given at the hospital. I gave him a total of 100mcg of fent, bringing him down from uncomfortable to comfortable. While I'm sure incarcerated hernias are not lovely, 60% BSA burns they are not. But its still pain. Far from becoming becoming comatose, resp depressed and the world generally falling apart, on arrival at hospital, he stepped down off the stretcher, I took him to the toilet, after which we walked to his waiting hospital bed, while chatting about lunch plans.

Fent especially is easy to titrate. With the addition of a little common sense, its a pretty easy game. Honestly, if my grandmother is trusted to titrate her PO opiate analgesia, surely a healthcare professional can manage a little IV fent or morph.

 

[johnrsemt]

We had a doctor that used to give radio/phone orders for Morphine (above written protocols): "give them 5mg every 5min until they stop breathing; then bag them". When they are unconscious pain is pretty much gone.
Never went to that extreme; but my goal is always: Pain is gone, patient feels better; and gets better faster.

My father's doctor told him to take 2 percocet every 4 hours for pain from a DVT: due to "if your body is fighting the pain, it can't fight the insult/injury to it".


I hate working with medics who won't give pain meds "because I am afraid that I will get the patient addicted to it"

 

[KellyBracket]

We had a doctor that used to give radio/phone orders for Morphine (above written protocols): "give them 5mg every 5min until they stop breathing; then bag them". ...

Something for me to aspire to!

And by the way, with all due respect to the experience of usalsfyre, nobody should feel responsible that they'll cause a patient to get trached. Far from it - the evidence suggests that more patients should be trached, and earlier. It's more comfortable, and seals up nice when it's no longer needed!

 

[jwk]

Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?

My thought is you're wrong. Fentanyl most certainly can produce significant respiratory depression.

 

[jwk]

Burn unit nurses might as well be CRNAs...they're about as good at providing proper analgesia as anyone else in the hospital.

Seriously? There's FAR more to anesthesia than pushing a few narcs. You're wayyyy outside your area of expertise.

 

[Hellsbells]

Our guidelines are generally Morphine 5mg q 5mins to 20mg, 5mg q 15min thereafter.

Or fentanyl 50mcg q 5mins to 200mcg, 50mcg q 15min thereafter.

If these narcs arnt cutting it, then we can go to Ketamine or toradol as well.

 

[Shishkabob]

How do I deal with this and approach it?

Tell them you are your own Paramedic, and that you treat YOUR patients how YOU decide is best.

 

[jjesusfreak01]

Seriously? There's FAR more to anesthesia than pushing a few narcs. You're wayyyy outside your area of expertise.

I'm not talking about myself here. I have a friend who is a BSN in a burn unit, and they go through specific training about how to provide proper analgesia, which they then get to put into practice every day they are working. While doctors write the orders, the nurses are responsible for seeing how the patients react to the medications and ensuring that the patients pain is being adequately managed. In the end, its years of experience that teaches any provider how to properly manage pain, not classes or degrees.

Also, burn units don't just "push a few narcs". Their patients are very frequently intubated, so they are pushing narcs, dissociatives, sedatives, hypnotics, and paralytics. It appears treatment in burn units is outside of your expertise.

 

[Farmer2DO]

Burn unit nurses might as well be CRNAs...they're about as good at providing proper analgesia as anyone else in the hospital.

Seriously? There's FAR more to anesthesia than pushing a few narcs. You're wayyyy outside your area of expertise.

I'm not talking about myself here. I have a friend who is a BSN in a burn unit, and they go through specific training about how to provide proper analgesia, which they then get to put into practice every day they are working. While doctors write the orders, the nurses are responsible for seeing how the patients react to the medications and ensuring that the patients pain is being adequately managed. In the end, its years of experience that teaches any provider how to properly manage pain, not classes or degrees.

Also, burn units don't just "push a few narcs". Their patients are very frequently intubated, so they are pushing narcs, dissociatives, sedatives, hypnotics, and paralytics. It appears treatment in burn units is outside of your expertise.

I think everyone needs to realize that you guys are talking about 2 completely different job descriptions here. I agree, burn nurses (in general) are pretty damn good at managing pain. They "get" the big picture, and for the most part, aren't afraid to use a lot of meds to help their patient. Doses that would usually be far outside the comfort zone of most nurses, even many ICU nurses. That does not by any means, however, equate to them being a CRNA, or even close. Completely different job. That's a nurse practicing anesthesia (I have my own opinions about the whole topic), not a nurse doing bedside care. One year at my last employer, where we ran about 35.000 jobs a year, I was 70% of the controlled substance administrations, company wide. That fact alone does not make me nearly a CRNA.

 

[systemet]

In the end, its years of experience that teaches any provider how to properly manage pain, not classes or degrees.

You have to have both academic preparation and clinical experience, in my opinion. If your options for pain control are pretty much give one of more or morphine, fentanyl, demerol, lorazepam, diazepam, midazolam, toradol or ketamine, following a suggested guideline -- that's very different from having a wider range of agents available and having skills like spinal or epidural anesthesia, or the ability to provide nerve block, etc.

Experience can be a good teacher, provided you're willing to listen to the lessons it provides. Not everyone is, and for a lot of us, experience is just the process of providing suboptimal care on a repeated basis over a long period of time.

There's a point where your ability to provide treatment is limited by your educational background, and your scope of practice. While I'm at least a reasonably competent paramedic, I'm pretty certain that an anesthesia provider approaches pain management in a completely different manner to how I do, has a lot more options to consider, and knowledge of a lot of issues that completely elude me.

There's also an issue of autonomy here. As good as a given burn RN may be, and I accept that they're like very caring, excellent people, and could teach me plenty, how much real power do they have over how the patient is treated? Part of the difference in the scope of practice of an RN or a paramedic and a specialty physician are grounded in the physician having being exposed to a far greater concentration of patients requiring pain management and experience using a far greater range of techniques.

This isn't to trash burn nurses in any way. I have lot of respect for them, but let's be realistic here.

It appears treatment in burn units is outside of your expertise.

Are you aware of what jwk's area of expertise is? I think you might reconsider your statement.

Have you considered that there might be a medical specialty outside of burn nursing that might have substantially more education in providing analgesia and anesthesia?

 

[Veneficus]

Seriously? There's FAR more to anesthesia than pushing a few narcs. You're wayyyy outside your area of expertise.

you're right, here is the instructional video

http://www.youtube.com/watch?v=xuZl9tRqjoQ

 

[jjesusfreak01]

Have you considered that there might be a medical specialty outside of burn nursing that might have substantially more education in providing analgesia and anesthesia?

Yeah, anesthesiologists and CRNAs...probably pain management specialists as well. I never said burn nurses are the best, just that they are quite competent at analgesia, and are required to provide anesthesia to a limited degree (that is, they push the drugs and they are responsible for monitoring patients under anesthesia in the ward).

 

[Rogue Medic]

Too much morphine or fentanyl?

There is a lot of research available on the use of fentanyl, or morphine, for severe pain. Here are just some of what is out there.

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Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed - in process]

Full Text PDF Download at medicalscg.

Fentanyl Study: EMS Research Episode 9
EMS Research Podcast
Podcast

I created my own charts to highlight the effects of fentanyl from the study above -

Chart Version – Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Sun, 05 Jun 2011

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Safety and effectiveness of fentanyl administration for prehospital pain management.
Kanowitz A, Dunn TM, Kanowitz EM, Dunn WW, Vanbuskirk K.
Prehosp Emerg Care. 2006 Jan-Mar;10(1):1-7.
PMID: 16418084 [PubMed - indexed for MEDLINE]

Free Full Text PDF Download from MSTC.

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A protocol to improve analgesia use in the accident and emergency department.
Goodacre SW, Roden RK.
J Accid Emerg Med. 1996 May;13(3):177-9.
PMID: 8733653 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central

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Prehospital use of analgesia for suspected extremity fractures.
White LJ, Cooper JD, Chambers RM, Gradisek RE.
Prehosp Emerg Care. 2000 Jul-Sep;4(3):205-8.
PMID: 10895913 [PubMed - indexed for MEDLINE]

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Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients.
Bijur PE, Kenny MK, Gallagher EJ.
Ann Emerg Med. 2005 Oct;46(4):362-7.
PMID: 16187470 [PubMed - indexed for MEDLINE]

This is just an abstract, but I wrote about it in detail -

Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients
Fri, 07 May 2010

also -

Pain Management: EMS Garage Episode 85.

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Avoiding trouble when using opiates to treat patient pain.
June 2003 ACP Observer, copyright © 2003 by the American College of Physicians.
By Jason van Steenburgh
Article

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ED procedural sedation of elderly patients: is it safe?
Weaver CS, Terrell KM, Bassett R, Swiler W, Sandford B, Avery S, Perkins AJ.
Am J Emerg Med. 2011 Jun;29(5):541-4. Epub 2010 Apr 24.
PMID: 20825829 [PubMed - in process]

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Elderly Emergency Department Patients With Pain Are Less Likely to Receive Pain Medication
Tue, 16 Aug 2011

I write about some abstracts published at EP Monthly -

Practice Changing Abstracts

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Analgesia in patients with acute abdominal pain.
Manterola C, Vial M, Moraga J, Astudillo P.
Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005660. Review.
PMID: 21249672 [PubMed - indexed for MEDLINE]

AAP is Acute Abdominal Pain –

AUTHORS’ CONCLUSIONS:
The use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment.

-

 

[Handsome Robb]

Also one more question, do you think 100ug of fentanly is too much for someone in severe pain? I read that 100 of fentanyl is compared to 10mg but I think it is acceptable because it doesnt produce the respiratory depression like morphine. Any thoughts?

We routinely give 100 mcg doses. Our Pain/Sedation management protocol says "1-2 mcg/kg to a max single dose of 100 mcg q 5 minutes to a total of 300 mcg" After that we have to call for orders for more.

My partner was working an OT shift today and brought us a trauma patient and he had maxed out the fentanyl dose and told me he almost called for more.

It isn't unusual for us to hit our limit on fentanyl.

 

[systemet]

Here's a news article from the BBC, about the use of fentanyl as an illicit drug in Estonia. It's not particularly well written, especially from a scientific perspective, but I found it interesting. (Not quite sure about statements like "after fentanyl you just don't feel heroin any more", or words to that effect).

http://www.bbc.co.uk/news/world-europe-17524945

 

[d_miracle36]

Tell them you are your own Paramedic, and that you treat YOUR patients how YOU decide is best.

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