# is a broken arm an ALS or BLS call?



## DrParasite (Oct 27, 2009)

Very simple question, please do not over think or over analyze:

is a broken radius/ulna, just the arm and nothing else, simple fx, an ALS or BLS call?

ok, follow up: if you are on a A/BLS crew (medic and EMT) would the medic treat, or the EMT (going back to ALS or BLS)?


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## Simusid (Oct 27, 2009)

*Bls*

My daughter had a very classic Colles' fracture a few years ago when she was about 12.  Thinking about her MOI, her mental status, her presentation and subsequent treatment, I cannot think of any way to elevate her case to ALS.  YMMV 

Now her mom on the other hand... wow!  At the mention of possible surgery by the nurse, she nearly passed out.


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## eveningsky339 (Oct 27, 2009)

Most of the time, it's a BLS call.  However, there have been times where I've called in a fly car for a broken arm.  If the patient is experiencing debilitating pain (to the point where we can't get a pulse without the patient screaming), pain meds appear to be in order.

The pain management aspect aside, splinting is a technique that every EMT has in his or her bag of tricks.


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## EMSLaw (Oct 27, 2009)

A closed fracture of the arm with no complications?  Sounds like a pretty classic BLS call to me.  ALS might be able to do something about the pain, but I don't think they'd give morphine for this sort of thing.  One of our medics can chime in, I'm sure.


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## Shishkabob (Oct 27, 2009)

Too many variables for such a simple question.


How was it broken?
What type of pain is the pt experiencing?


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## JPINFV (Oct 27, 2009)

Depends if pain management is needed.


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## EMSLaw (Oct 27, 2009)

JPINFV said:


> Depends if pain management is needed.



I know local protocols can vary on this, but under what circumstances do medics generally give pain medication?  I know this is a broad question, but I've seen plenty of people complaining of 10/10 pain from various causes, and have yet to see anyone get narcotics from the medic.  

Obviously, NJ is known for its restrictive protocols, but it makes no sense to wait five minutes for medics just to have someone "checked out" with no pain relief, when you might instead be at the hospital in ten minutes.  That doesn't do the patient any good, since we are supposed to be, in whatever way we can, alleviating their suffering.


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## Sasha (Oct 27, 2009)

ALS. There is no reason to leave your patient in pain. Medics can splint too. ALS call.


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## karaya (Oct 27, 2009)

EMSLaw said:


> A closed fracture of the arm with no complications? Sounds like a pretty classic BLS call to me. ALS might be able to do something about the pain, but I don't think they'd give morphine for this sort of thing. One of our medics can chime in, I'm sure.


 
Side stepping pain management is an issue that is a constant problem in EMS. Fentanyl is an excellent choice for pain management with it's rapid onset and it does not impact the patient's hemodynamics, GCS or SpO2.


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## JPINFV (Oct 27, 2009)

EMSLaw said:


> I know local protocols can vary on this, but under what circumstances do medics generally give pain medication?  I know this is a broad question, but I've seen plenty of people complaining of 10/10 pain from various causes, and have yet to see anyone get narcotics from the medic.
> 
> Obviously, NJ is known for its restrictive protocols, but it makes no sense to wait five minutes for medics just to have someone "checked out" with no pain relief, when you might instead be at the hospital in ten minutes.  That doesn't do the patient any good, since we are supposed to be, in whatever way we can, alleviating their suffering.



Ideally, if the patient is in pain, then pain control should be considered. If the patient is going to receive pain medication in the hospital, then why not start prehospitally? Of course, as with everything else, consider transport vs response times when considering it. That said, it's not like you're going to get to the hospital and hand over care to an ER tech because the 'physician couldn't be bothered.' At the very least, that patient is still going to be treated by a PA or NP, who do have it in their powers to use pharmaceutical pain management.


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## Epi-do (Oct 27, 2009)

Again, like with the drunk patient post, it depends upon the patient.  I have no qualms giving pain meds to a patient with a fracture, and most times do.  However, I have also had patients refuse pain meds.  If that is the case, and they are otherwise ok, then there is nothing wrong, IMO, in letting my basic partner take the patient in.  He can do comfort measures just as easily as I can.


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## Sasha (Oct 27, 2009)

Epi-do said:


> Again, like with the drunk patient post, it depends upon the patient.  I have no qualms giving pain meds to a patient with a fracture, and most times do.  However, I have also had patients refuse pain meds.  If that is the case, and they are otherwise ok, then there is nothing wrong, IMO, in letting my basic partner take the patient in.  He can do comfort measures just as easily as I can.



The difference there is there is ALS and BLS on your truck. Many areas run BLS ambulances with ALS flycars or ambulances. If anything changes, you guys can simply switch. not possible in a BLS truck.


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## karaya (Oct 27, 2009)

EMSLaw said:


> ...but I've seen plenty of people complaining of 10/10 pain from various causes, and have yet to see anyone get narcotics from the medic.


 
JPINFV is right on about pain management pre-hospital. Even if you wait a few minutes for ALS, that is a few minutes earlier that the patient will begin to feel the effects of the pain management drug. You experiencing medics not giving any pain management to 10/10 patients is a tremendous problem in EMS today. I travel throughout the U.S. riding with various EMS providers and I unfortunately see this all the time. From my observations, this is due to lazy, uncaring medics who don't want to fool with the narcotic paperwork afterwards. A terrible shame!


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## Aidey (Oct 27, 2009)

Sasha said:


> ALS. There is no reason to leave your patient in pain. Medics can splint too. ALS call.



 This.   I tend to be on the more liberal side when considering pain meds. If the injury warrants it, I will let the patient know I can give them something for the pain, and see what they want and go from there. Some patients it is a given you are going to have to give them pain meds just to move them, but like someone else mentioned, I have had people refuse them too.


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## EMSLaw (Oct 27, 2009)

karaya said:


> JPINFV is right on about pain management pre-hospital. Even if you wait a few minutes for ALS, that is a few minutes earlier that the patient will begin to feel the effects of the pain management drug. You experiencing medics not giving any pain management to 10/10 patients is a tremendous problem in EMS today. I travel throughout the U.S. riding with various EMS providers and I unfortunately see this all the time. From my observations, this is due to lazy, uncaring medics who don't want to fool with the narcotic paperwork afterwards. A terrible shame!



It's interesting, since before I started in EMS, I thought that one of the benefits to paramedics was that they /did/ have access to pain medicine.  It does have an impact on your transport decision (not the ultimate outcome, obviously, but whether you wait for medics) if the only pain relief the patient will receive is at the hospital.


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## Shishkabob (Oct 27, 2009)

Now here's an interesting question:

Say you're in a tiered system with medics in fly cars.  

Do you take an ALS resource off the road during a busy day to provide ~5min of pain relief for a broken arm?  Or do you keep the medic out for something else happening?


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## Medic744 (Oct 27, 2009)

It really depends on alot of variables but when I offer pain managment to my pts I dont start with the narcotics unless the injury warrants it.  Our first line analgesic is Toradol.  We rarely give Morphine, we rarely even hint at having it on the truck to give.  In my opinion when you are in true horrible pain you will take anything that is meant to ease it.  When you refuse the NSAID and starting demanding the Demerol and an exact dose (actually had that pt) then its for sure "This is what I have to give you otherwise I dont have anything."


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## medichopeful (Oct 27, 2009)

Technically, it is a call that a BLS crew can treat.  So in that aspect, it is a BLS call.

However, I would want to have ALS on scene to ease the suffering of the patient.  Fracture can be very painful and uncomfortable.  No point in making them suffer.


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## medichopeful (Oct 27, 2009)

Linuss said:


> Now here's an interesting question:
> 
> Say you're in a tiered system with medics in fly cars.
> 
> Do you take an ALS resource off the road during a busy day to provide ~5min of pain relief for a broken arm?  Or do you keep the medic out for something else happening?



Keep the medic out.  I would only call for them on this call if it wasn't going to put anybodies life in danger.  I would rather have my patient suffer than another patient die.  I don't mean that to sound cold.


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## Jon (Oct 27, 2009)

eveningsky339 said:


> Most of the time, it's a BLS call.  However, there have been times where I've called in a fly car for a broken arm.  If the patient is experiencing debilitating pain (to the point where we can't get a pulse without the patient screaming), pain meds appear to be in order.
> 
> The pain management aspect aside, splinting is a technique that every EMT has in his or her bag of tricks.


If I was in a MICU setting (Medic/EMT truck), it would probably be a BLS call. If the pain was significant, I'd ALS it, and per PA protocol (6003, isolated extremity trauma), can give pretty liberal doses of Fentanyl, MS, or Nitrous without needing to call for orders.


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## bunkie (Oct 27, 2009)

So is the question more ?

Is the PT in Pain> YES > Want meds?> YES> ALS

Is the PT in Pain> YES/NO> Want meds?> NO> BLS


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## Seaglass (Oct 27, 2009)

I'm with everyone else--it's a basic call unless pain management is needed. 



Medic744 said:


> In my opinion when you are in true horrible pain you will take anything that is meant to ease it.



This opinion's left me in pain a few too many times. I have a lot of drug allergies, and have occasionally been in too much pain to do more than semi-coherently refuse everything I'm allergic to and ask for something I'm not. Even after indicating allergies, I've had providers tell me I must not be in serious pain or I'd take whatever they gave me.


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## karaya (Oct 27, 2009)

Medic744 said:


> It really depends on alot of variables but when I offer pain managment to my pts I dont start with the narcotics unless the injury warrants it. Our first line analgesic is Toradol. We rarely give Morphine, we rarely even hint at having it on the truck to give.


 
Why?  Do you believe all of your patients are drug seekers?


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## bunkie (Oct 27, 2009)

Seaglass said:


> I'm with everyone else--it's a basic call unless pain management is needed.
> 
> 
> 
> This opinion's left me in pain a few too many times. I have a lot of drug allergies, and have occasionally been in too much pain to do more than semi-coherently refuse everything I'm allergic to and ask for something I'm not. Even after indicating allergies, I've had providers tell me I must not be in serious pain or I'd take whatever they gave me.



ITA. There are a lot of things I can't take and I just plain do not like having drugs in my body. I've rejected many many pain meds in many different situations. Though mostly my providers are just distressed to see me in pain and a bit confused, they aren't mean about it. As soon as I explain away my reasoning they nod their heads and go about their business. I have been fortunate in that aspect.


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## karaya (Oct 27, 2009)

medichopeful said:


> Keep the medic out. I would only call for them on this call if it wasn't going to put anybodies life in danger. I would rather have my patient suffer than another patient die. I don't mean that to sound cold.


 
You seem to contradict yourself.  In one thread you responded to call in ALS, "Fracture can be very painful and uncomfortable. No point in making them suffer."  And yet, here you state let the patient suffer.


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## Epi-do (Oct 27, 2009)

medichopeful said:


> Keep the medic out.  I would only call for them on this call if it wasn't going to put anybodies life in danger.  I would rather have my patient suffer than another patient die.  I don't mean that to sound cold.



Yes, I know you were responding to a specific question regarding a tiered system during the busy part of the day, but seriously?  We can only run one call at a time, and if your patient can benefit from analgesics, get them for him/her.  With this thought pattern you are trying to play the odds game.  What are the odds of another run coming out and that run being a more serious patient than the one that I have?

You don't need to be worrying about the "potential" patients that may call while you are tending to a fracture.  You need to worry about the patient you have.  What happens when that more serious run doesn't go out and your patient has now needlessly suffered because you decided the patient that doesn't even exist is more deserving of the medic and their care than the real patient that is in front of you?  

The system will deal with whatever comes its way.  As a whole, EMS sucks at pain management.  As a whole, we need to do better at using analgesics, when warranted.  *Treat the patient you have, not the one that the next crew might get.*


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## karaya (Oct 27, 2009)

Epi-do said:


> Yes, I know you were responding to a specific question regarding a tiered system during the busy part of the day, but seriously? We can only run one call at a time, and if your patient can benefit from analgesics, get them for him/her. With this thought pattern you are trying to play the odds game. What are the odds of another run coming out and that run being a more serious patient than the one that I have?
> 
> You don't need to be worrying about the "potential" patients that may call while you are tending to a fracture. You need to worry about the patient you have. What happens when that more serious run doesn't go out and your patient has now needlessly suffered because you decided the patient that doesn't even exist is more deserving of the medic and their care than the real patient that is in front of you?
> 
> The system will deal with whatever comes its way. As a whole, EMS sucks at pain management. As a whole, we need to do better at using analgesics, when warranted. *Treat the patient you have, not the one that the next crew might get.*


 
Excellent points!


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## medichopeful (Oct 27, 2009)

karaya said:


> You seem to contradict yourself.  In one thread you responded to call in ALS, "Fracture can be very painful and uncomfortable. No point in making them suffer."  And yet, here you state let the patient suffer.



Yes, I realize that.  But this was in response to this question from Linuss:



> Now here's an interesting question:
> 
> Say you're in a tiered system with medics in fly cars.
> 
> Do you take an ALS resource off the road during a busy day to provide ~5min of pain relief for a broken arm? Or do you keep the medic out for something else happening?



All I'm saying is that, if the area is very busy and there are not very many medics, I would rather keep the medics out on the road to respond to a more serious call than a broken arm.  Yes, pain relief is a VERY important thing.  I never said it wasn't.  Rather, I am saying that if it comes down to either taking ALS away from somebody who may not survive without it, or letting somebody be in pain for a little bit, I would choose the first option.

Now, this is NOT something that I would want to do.  It's a lose-lose situation.  If you choose one option, somebody will get pain relief, but somebody else may die because they were stuck with a BLS crew.  On the other hand, somebody may get an ALS crew, but somebody else may be in pain.  It's not an easy situation.


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## medichopeful (Oct 27, 2009)

Epi-do said:


> Yes, I know you were responding to a specific question regarding a tiered system during the busy part of the day, but seriously?  We can only run one call at a time, and if your patient can benefit from analgesics, get them for him/her.  With this thought pattern you are trying to play the odds game.  What are the odds of another run coming out and that run being a more serious patient than the one that I have?
> 
> You don't need to be worrying about the "potential" patients that may call while you are tending to a fracture.  You need to worry about the patient you have.  What happens when that more serious run doesn't go out and your patient has now needlessly suffered because you decided the patient that doesn't even exist is more deserving of the medic and their care than the real patient that is in front of you?
> 
> The system will deal with whatever comes its way.  As a whole, EMS sucks at pain management.  As a whole, we need to do better at using analgesics, when warranted.  *Treat the patient you have, not the one that the next crew might get.*



As Karaya said, excellent points.  

Yes, I would LOVE to have my patient get pain management ASAP.  I would not want them to suffer in the least.  When I was responding to the theoretical question, I was thinking about the situation that is around where I go to school: very few ALS trucks to cover a few towns, at least one of which is a fairly good-sized city.  If there is a day where the ALS units keep getting called for serious problems (cardiac, respiratory, etc.), than I would say there is a good chance that they will continue to be busy.  Someone with a broken arm can wait, at least for a bit.

Now remember, the question Linuss posed had a very short transport time (around 5 minutes).  If there was a long transport time, I would be more likely to call for ALS.

I would call for ALS in a heartbeat for pain management.  The only time I wouldn't would be when resources were stretched thin.  If need be, somebody with pain can survive for 5 minutes.  Somebody who absolutely needs ALS may not be able to.

It's not an easy situation, and it's not one to take lightly.  Also, my answer is very situational dependent.

This wouldn't be a question if every truck had at least 1 paramedic on it.


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## EMSLaw (Oct 27, 2009)

Just remember that in a system with tiered response, if the medics give pain medication, they have treated the patient and have to ride the call in, especially if they have started an IV (since BLS can't transport a patient, generally, with an active IV).  

So, by the time they treat, ride to the hospital, report, and get back in service, the time is longer than five minutes. 

But, that being said, I agree you should treat the patient in front of you and not wonder about the "what-ifs".  My only concern would be tying up an ALS unit if they really couldn't do anything, for example if the patient's only ALS-level complaint was pain and the medics were unable or unwilling to give analgesics.  Since that's been my experience (and we've discussed why this is bad, but it's the way things are in this neck of the woods, apparently), I'd be more inclined to ride the call in BLS.


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## JPINFV (Oct 27, 2009)

EMSLaw said:


> So, by the time they treat, ride to the hospital, report, and get back in service, the time is longer than five minutes.



So? It's not like the ambulance reaches the hospital and the patient immediately gets pain control.


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## Medic744 (Oct 27, 2009)

karaya said:


> Why?  Do you believe all of your patients are drug seekers?



Idont believe all my pts are drug seekers, but I am highly suspicious of the ones who are "allergic" to everything but one specific narcotic and demand that one and refuse all others even if they don't claim an "allergy" to it.


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## Medic744 (Oct 27, 2009)

Seaglass said:


> I'm with everyone else--it's a basic call unless pain management is needed.
> 
> 
> 
> This opinion's left me in pain a few too many times. I have a lot of drug allergies, and have occasionally been in too much pain to do more than semi-coherently refuse everything I'm allergic to and ask for something I'm not. Even after indicating allergies, I've had providers tell me I must not be in serious pain or I'd take whatever they gave me.



But they can tell you are in pain, there's a difference between that situation and one where a pt is laughing, joking and moving the ext. or the injured area and not complaining until you remind them that they are supposed to be hurt and then the Oscar winning performance comes out.


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## johnrsemt (Oct 27, 2009)

The reason of  "they don't get pain meds as soon as they get to the ED"  is a prime reason of giving Pain management on the street.    If you don't, not only are you delaying pain relief for transport,  they then have to wait at the ED for relief.
    Our job is to treat the patient that we have NOW;  not the one we may have in 10 minutes.

   If it was you or a family member;  wouldn't you want the pain gone?

   My old medical director told us that the reason that they were slow about changing our protocols was that we didn't use what we had.     Pain manage-ment is prime example:  when we went from having to call in for pain control to having the written protocols to give relief  (1st by Morphine,  then Fentanyl) for any pain,  (Including head and abdominal);  our usage of Narcotics dropped 30% the first year.    Too many medics were 'afraid' of using something that they had been using for years,  they just didn't have to call in anymore.

     If it is available,  use it;  patients call us for help and relief,  why is it so hard for us to give it to them.

   If you are worried about someone becoming addicted to Narcotics from Prehospital:  there is an ongoing study  (if I can find the info I will add it later):  at the University of Chicago  for the last 4 or 5 years on people that came into the ED with prehospital pain management in place.  they are over 10,000 people so far:   they have had 3 (not 3%) patients become addicted;  and they all stayed in the hospital for at least 2 weeks.     that is good odds in our favor.

    someone mentioned that the person may be a drug seeker:    So what?   the next cardiac symptom patient may not be having a MI;  but we still treat it as such.    if a patient says they are in pain:   treat it.   not our job to judge.     if a patient tells you that they are allergic to certain drugs,  believe them.      they may have developed the allergy recently.   If I have a patient that tells me that they have allergies to Toradol  and have to have Fentanyl.  I will give them Fentanyl.    I trust my patient,  even if they are a frequent flyer and I remember their past history.    what if it changes?     My allergies have changed over the years.


    In my old service I had the reputation of being 'too liberal' with pain meds:  but everyone coworker that ever told me that    also told me that they wanted me as their medic if they were hurt.     Had a supervisor go to our medical director to tell him how liberal I was:    I was told by the MD to double what I was using  after that.


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## Smash (Oct 27, 2009)

A lot of good answers. If the patient requires pain relief they get pain relief. If this means ALS intercept then so be it.  Resourcing is not my concern, treating patients is and I won't provide substandard treatment to cover for my service providing substandard coverage. 

Epi-do's quote sums it up perfectly. 

Pain relief is something that is recognized as being done extemely poorly in emergency care (both pre- and in hospital) and yet it is one of the most important things we can do for our patients.  Failure to treat pain in the field leads to ongoing failure to treat pain in hospital (they take cues from us) and leads to a greatly increased likelihood of the patient developing chronic pain disorders.

Johnrsemt raises some very good points about some if the myths of prehospital pain relief.  We need to be ever vigilant about poviding appropriate care and that includes pain relief.


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## Dominion (Oct 27, 2009)

Without reading the other posts I say BLS until proven otherwise.


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## medichopeful (Oct 27, 2009)

Somebody brought up the idea of it being a family member.  If it was my family member, I would definitely want them to have pain management.

I thought about it after I posted my last post, and I can see that yes, I was wrong.  Unless there is some major catastrophe (plane crash, etc.), or I knew for a fact that ALS would be needed by somebody else soon, I think I would request ALS for pain management.  But like I said, it would be situation dependent.

This is exactly how this site should work.  Somebody should post a question, and people should give their input.  Everybody should be open to other's suggestions, comments, etc..  I know for a fact that I learned something from this thread.  So to those who were conversing with me, thanks!


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## Luno (Oct 27, 2009)

Well, unfortunately, my home county generally does not treat for pain management.  That being said, with ski patrol, an uncomplicated ulna/radius break is regularly treated as splint to POV transport, without pain management for 30+ minute transportation times.  You usually won't see ALS here unless there is significant Loss of Consciousness, bilateral femur fx, acute chest px with suspected cardiac origin, decompensated shock, respiratory distress to failure, or some other extreme...  While I don't particularly agree with that, we play the hand we're dealt.  While I am currently practicing in the famous "King County" and our paramedics are phenomenal, I do think that we need an intermediate level of care that would allow minor interventions, including being able to treat for pain management.


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## Dominion (Oct 27, 2009)

Luno said:


> Well, unfortunately, my home county generally does not treat for pain management.  That being said, with ski patrol, an uncomplicated ulna/radius break is regularly treated as splint to POV transport, without pain management for 30+ minute transportation times.  You usually won't see ALS here unless there is significant Loss of Consciousness, bilateral femur fx, acute chest px with suspected cardiac origin, decompensated shock, respiratory distress to failure, or some other extreme...  While I don't particularly agree with that, we play the hand we're dealt.  While I am currently practicing in the famous "King County" and our paramedics are phenomenal, I do think that we need an intermediate level of care that would allow minor interventions, including being able to treat for pain management.



Our intermediates (and as I suspect most EMT-I's) are not allowed to do pain management.  Technically we have pain management protocols which are paramedic specific but my service doesn't carry pain meds.


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## VentMedic (Oct 27, 2009)

Luno said:


> I do think that we need an intermediate level of care that would allow minor interventions, including being able to treat for pain management.


 


> Our intermediates (and as I suspect most EMT-I's) are not allowed to do pain management.


When you get into pain management with the meds and assessment that goes along with it, you need to be advanced in your education and skills. You do not need to be an EMT with a couple extra tricks in your bag by way of a few hours of extra training which is essentially what the Intermediate level is.


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## Luno (Oct 27, 2009)

Vent, as I figured, you'd pop up on here...  Anyway, what I really want to see is better paramedic coverage in the area that would allow ALS response for pain management.  I don't see that as a reality here however.  That being said, our paramedics are far more advanced in scope and education than NREMT-Ps in general, and I'd almost question if we need a NREMT-P level in King County, and then the Medic One paramedics.  I entirely agree that it is more than a couple of tricks, however the way that King County recognizes paramedics is entirely different then most of the country.  A NREMT-P is only recognized in King County as a BLS provider.  Given that lens, I'm not sure that it is a true 'intermediate' provider in the sense of EMT-I, rather it is an intermediate between strictly BLS and Medic One.


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## wyoskibum (Oct 27, 2009)

DrParasite said:


> broken radius/ulna, just the arm and nothing else, simple fx, an ALS or BLS call?



BLS.  In my experience, proper immobilization and cryotherapy in most cases negate the need for pain management.


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## Seaglass (Oct 27, 2009)

Medic744 said:


> But they can tell you are in pain, there's a difference between that situation and one where a pt is laughing, joking and moving the ext. or the injured area and not complaining until you remind them that they are supposed to be hurt and then the Oscar winning performance comes out.



They can tell I'm in pain, but telling the severity of someone else's pain can be tough. Some patients will be crying and howling over a splinter, and I've seen a patient with double femur fractures who was straight-faced, coherent, and rating his pain as 10/10. If they're new and they've had the old "people in pain will take anything" saw drilled into their heads, I can see where their training would lead them not to take me as seriously.


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## DrParasite (Oct 7, 2010)

bumping an old thread to see if new blood thinks differently.

oddly enough, the poll is 22 BLS 7 ALS, but the majority of posters who commented in the thread (to my eye anyway) seem to think that it should be ALS all the way.


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## Jay (Oct 7, 2010)

Without overanalyzing I would have to say that it is a BLS call unless the PT presents with at least one of the following:

1.  Pain 7/10 or above.
2.  No or weak extremity pulse or sensation.
3.  No capillary refill being present or refill being >2-3 sec.
4.  Severe bleeding secondary to a complex fracture (or edema if justified).
5.  PT is presenting that they are having those rare but sometimes founded cardiac complications due to the fracture, i.e. clotting that is causing some kind of a blockage in which ALS intervention will be critical.
6.  I am sure that I can think of others but these are the basics that would justify getting ALS on-scene. Pain alone can be called in to the hospital along with a preliminary report (they can have MS or Dilaudid on standby) if not too debilitating (0-6/10) but severe pain or complications would definitely justify the intercept.


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## slb862 (Oct 7, 2010)

I truely believe that Fentanyl should be in the drinking water.  :blink:





J/K


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## 18G (Oct 7, 2010)

On the basis of pain management calls for fractures should be ALS. I don't believe a patient should have to suffer and remain in pain without any relief until they get to a hospital. 

If it were me with a fracture I would want analgesia ASAP and the same if it were one of my kids. If its a nasty fracture that is causing a lot of pain... think of the increase in pain through splinting, moving to the ambulance, and bumpy transport. 

In my county however, most fracture calls are BLS only.


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## akflightmedic (Oct 7, 2010)

Jay said:


> Without overanalyzing I would have to say that it is a BLS call unless the PT presents with at least one of the following:
> 
> 1.  Pain 7/10 or above.
> 2.  No or weak extremity pulse or sensation.
> ...



While I appreciate some points in your response, I would like to add a few of my thoughts for different perspective purposes and to stimulate discussion.

1. So the patient has to be a 7 before you consider calling for ALS? Pain is subjective and everyone handles it differently. A guy could calmly tell you he is an 8 with minor grimacing upon movement and this would prompt you to call for ALS versus the person who is squirming and crying but states the pain is only a 5??? Would you tell them they need to hurt "some more" so you can call for ALS and pain relief? 

See the lack of logic in setting a number that would prompt you to call for help? Pain is pain and if we can treat it prehospitally, then we should.

2. Would this make you wait on ALS or would it prompt you to hurry up and BLS it all the way to get to more definitive care? In a few systems, they would benefit from ALS care, but this is a get to a hospital now situation, so technically it is BLS.

3. See #2

4. Bleeding control is a BLS skill, even severe bleeding. Now if they are getting hypotensive, tachycardic, pale, etc...all the signs and symptoms of shock (all from a fx arm mind you) then maybe call for ALS intercept if none of the BLS remedies are working, but still is a BLS call for the most part.

5. Well this is no longer a fx arm call is it? It is now chest pain or shortness of breath...so its a moot point in this discussion.

6. Doesn't every hospital have pain meds "on standby"?   I doubt they would have it out of the locked cabinet and locked and loaded ready to inject without first conducting an assessment and checking them in. 

So in short, ANY pain from an isolated fracture justifies ALS intervention.


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## Aprz (Oct 7, 2010)

Jay said:


> Without overanalyzing...
> 
> 1.  Pain 7/10 or above.


Well, he did say without overanalyzing, but when I saw this, I thought "What about guys that don't want to admit they are in pain or something is wrong?" I don't know why, but I am one of those guys, and I just do it. I am sure there are plenty others like me who don't admit or show what they are really feeling.


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## MrBrown (Oct 7, 2010)

*Brown breaks down and cries uncontrollably alternating between sobbing between sadness and blind rage

If only ALS has pain management then its an ALS job


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## TransportJockey (Oct 7, 2010)

For me I'd say ILS/ALS for pain control (In NM ILS is allowed narc's for pain control with an online order)


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## MrBrown (Oct 7, 2010)

jtpaintball70 said:


> For me I'd say ILS/ALS for pain control (In NM ILS is allowed narc's for pain control with an online order)



In Kiwi we have

BLS (EMT) - Methoxyflurane/entonox
ILS (Paramedic) - morphine
ALS (Intensive Care) - midaz and ketamine

.... so take your pick really


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## medicRob (Oct 7, 2010)

I'd have to answer this with another question, I'm afraid. 

Does this have arterial involvement? A patient spurting bright red blood at a steady rate could be ALS, whereas a simple break would be BLS, but wait... 

That's right, we do not have X rays on the ambulance, so unless we see the bone protruding through the skin, we can't really say whether or not it is a simple fracture, etc.


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## usalsfyre (Oct 7, 2010)

This is why every patient deserves an ALS assesment, but may not  necessarily need an ALS intervention. First line of pain control SHOULD be splinting and ice. If that takes care of the problem (or at least makes it bearable with a somewhat comfortable patient) then I have no problem with a basic riding it in. If further assesment reveals the need for IV opiates then we will control it that way. 

What's important is that pain control is high on the list of priorities. I recently got to be an EMS patient who between the ambulance and the ED got to spend the better part of an hour and a half immobilized with painful injuries and NO pain control. There's a lot I don't remember about that day due to a concussion, but I do remember the pain. This made a fairly ardent suppouter of pre-hospital pain control into a dyed-in-the wool believer. "Pain never killed anyone" is NOT an acceptable excuse anymore.


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## akflightmedic (Oct 7, 2010)

medicRob said:


> Does this have arterial involvement? A patient spurting bright red blood at a steady rate could be ALS



Does this still make it ALS? 

I mean a tourniquet is a tourniquet be it a medic or EMT who places it, no?

And not many ALS providers routinely carry FFP or packed RBCs, so, does a spurt make it that much different? I think not..  

(just stirring the pot folks, don't mind me)


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## medicRob (Oct 7, 2010)

usalsfyre said:


> This is why every patient deserves an ALS assesment, but may not  necessarily need an ALS intervention. First line of pain control SHOULD be splinting and ice. If that takes care of the problem (or at least makes it bearable with a somewhat comfortable patient) then I have no problem with a basic riding it in. If further assesment reveals the need for IV opiates then we will control it that way.
> 
> What's important is that pain control is high on the list of priorities. I recently got to be an EMS patient who between the ambulance and the ED got to spend the better part of an hour and a half immobilized with painful injuries and NO pain control. There's a lot I don't remember about that day due to a concussion, but I do remember the pain. This made a fairly ardent suppouter of pre-hospital pain control into a dyed-in-the wool believer. "Pain never killed anyone" is NOT an acceptable excuse anymore.



Pain level should be treated as another vital sign, in my opinion. It should be assessed just as often as one takes a blood pressure. Usually this is only the case with Chest Pain and Burns. Pain management is a big part of prehospital medicine now. Could you imagine enduring a 30 minute flight to a trauma center with severe burns (with some nerves still intact) without Fent or Morphine. Yikes.


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## medicRob (Oct 7, 2010)

akflightmedic said:


> Does this still make it ALS?
> 
> I mean a tourniquet is a tourniquet be it a medic or EMT who places it, no?
> 
> ...




I am basing this off of the fact that most EMT-B cannot even start an IV. If a patient was losing blood, you would at least want a line until you could get them to the appropriate level of care. Moreover, what if the patient has been bleeding for a while and lost enough blood to go into decompensated shock (example, hiking trip in a rural area where it takes providers upwards of an hour to get there). I understand that this is a big, "What if", but I am only stirring the pot as well. 

I do, however understand what you are saying akflightmedic. There are a lot of variables to consider.

Also, if I have a broken arm, I want pain meds and lots of them.


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## Sassafras (Oct 7, 2010)

I don't think there is a one answer fits all.  I've broken bones.  Ibuprofen was fine in spite of having multiple fractures.  I could have easily made it to the hospital without ALS.  But other breaks are going to be more complex or present more pain and need more intervention.  

Regarding the patient who won't admit their pain level, well, I can't really help that.  I can only go off of information given me sadly and then infer what I think best at the time.


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## usalsfyre (Oct 7, 2010)

medicRob said:


> Pain level should be treated as another vital sign, in my opinion. It should be assessed just as often as one takes a blood pressure.



Amen, absoloutely.  



> Could you imagine enduring a 30 minute flight to a trauma center with severe burns (with some nerves still intact) without Fent or Morphine. Yikes.



Yikes indeed. 

There's probably something to be said for sedating this type of patient  (midazolam would be a wonderful choice) in addition to massive amounts (protocols allow 2mcg/kg of fent? nows a great time...) pain control. While you can't ensure retrograde amnesia, at least they might forget the circumstances surrounding the pain.


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## Aidey (Oct 7, 2010)

medicRob said:


> Also, if I have a broken arm, I want pain meds and lots of them.



I know earlier in this thread I voted for ALS because of the pain med issue, but I do have a personal anecdote to add. 

I've had two broken arms, 10 years apart. The first one involved tripping and falling with a concussion to boot.* School called my mom, my mom picked me up and drove me to our family doc's office. I don't think I was given Rx pain meds. The second one was from slipping and falling on ice in college. I walked around for 3 days before I got it x-rayed (urgent care center) and it was fractured in 2 places (stable fractures). I got T3 for that one. 

Anyway, so the point of this is is that some fractures don't need the emergency medical system, let alone ALS just for pain meds. When I think of medicating fractures, I'm thinking of the obvious deformity types.


* Had this event occurred today I would have been back boarded and probably gotten a CT to rule out any bleeds. Since I actually had LOC, I may have even been admitted for observation.


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## Sam Adams (Oct 7, 2010)

Jay said:


> Without overanalyzing I would have to say that it is a BLS call unless the PT presents with at least one of the following:
> 
> 1.  Pain 7/10 or above.
> 2.  No or weak extremity pulse or sensation.
> ...



Without over analyzing? You have 6 bullet points!?! :lol:



DrParasite said:


> Very simple question, please do not over think or over analyze:
> 
> is a broken radius/ulna, just the arm and nothing else, simple fx, an ALS or BLS call?
> 
> ok, follow up: if you are on a A/BLS crew (medic and EMT) would the medic treat, or the EMT (going back to ALS or BLS)?



This is a BLS call. 

Unless the pt tripped and fell because he was running away from a swarm of Africanized Killer Bees and is now in anaphylactic shock with subsequent cranial nerve damage and he's very upset due to Pluto no longer being a planet.


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## EMS/LEO505 (Oct 7, 2010)

I'd have to say that it's a BLS call unless, certain extreme conditions are present.


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## jjesusfreak01 (Oct 7, 2010)

I didn't get pain meds at any point when I broke my arm. If the pain is bad, give the meds, but don't overmedicate just because you can. Usually a BLS call IMHO.


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## medic417 (Oct 7, 2010)

It is ALS because it is about patient care.  If patient needs pain relief they need it.  If you are a basic only ambulance patients suffer.  There is no excuse to cause a patient to suffer.


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## CAOX3 (Oct 7, 2010)

Mechanical fall with isolated extremity fracture is going to get a BLS response here, upon arrival extenuating circumstances exist an ALS truck can be summoned.


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## akflightmedic (Oct 7, 2010)

jjesusfreak01 said:


> I didn't get pain meds at any point when I broke my arm. If the pain is bad, give the meds, but don't overmedicate just because you can. Usually a BLS call IMHO.



Why have any pain at all?

Remember the pain scale? It is 0-10...ZERO as in no pain being the goal.

We are not talking about snowing them into a coma, but if you have the ability, why not take the edge off?


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## aewin90 (Oct 7, 2010)

medic417 said:


> It is ALS because it is about patient care.  If patient needs pain relief they need it.  If you are a basic only ambulance patients suffer.  There is no excuse to cause a patient to suffer.



This is the stupidest thing I've seen on the internet.

Pain control is an extremely important part of EMS.  Pain is the 5th vital sign.  But when someone stubs their toe and has a 2/10 on the pain scale, you really want an ALS rig to be pulled out of service?  

Heck, why not just call a chopper?  They can get to that big trauma center faster.  We can't let our stubbed-toe patient suffer in a small ER.


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## medic417 (Oct 7, 2010)

aewin90 said:


> This is the stupidest thing I've seen on the internet.
> 
> Pain control is an extremely important part of EMS.  Pain is the 5th vital sign.  But when someone stubs their toe and has a 2/10 on the pain scale, you really want an ALS rig to be pulled out of service?
> 
> Heck, why not just call a chopper?  They can get to that big trauma center faster.  We can't let our stubbed-toe patient suffer in a small ER.



What in the heck are you talking about?  The case presented is a broken arm.  Any broken bone including a toe would justify a Paramedic for pain management.  

Now your stubbed toe are you sure that is all?  Are you sure they do not have a mental problem?  Are you sure its not actually referred pain in a diabetic having a cardiac event.  See I can act stupid to.    Please refrain from attacking someone until you have enough education to debate with.


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## 46Young (Oct 7, 2010)

ALS. Whether or not the pt needs pain management is a decision for the paramedics, resulting from their paramedic level assessment. We all know that a dispatch for an isolated extremity Fx can be much more upon arrival, just like the report of a multi system trauma can be a simple superficial lac and a bruise or two. There's no way of knowing the pt's presentation until we're there. Besides, if it's really a minor injury regarding pain, and blood loss, you can always turf the pt to the BLS for txp.

I'm not a big fan of the EMD system that's used by dispatchers w/o any EMS experience. Too many calls get over triaged. However, in the case of a potential pain management situation, such as a Fx or Hx strongly suggesting the possibility of kidney stones, then it should be an ALS dispatch. Ideally, the call would be BLS with a medic chase car so the pt would have prompt access to pain management and the proper level of asessment that comes with that.

It sounds like I'm putting down BLS, but understand that I did 911 BLS for three years. I've worked countless injuries where the pt winced or screamed with each attempt at slinting them and packaging them. Our ALS at the time couldn't use pain management for injuries, only morphine for CX pain and APE, and those weren't even standing orders. Now that I can give pain meds on standing orders, I use them quite frequently, so long as I'm not suspicious of the pt being a drug seeker. I use fentanyl and zofran for their respective symptomatic relief on a regular basis.


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## Veneficus (Oct 7, 2010)

I think this a broken arm is like a mercedes. 

You don't need a paramedic, but you want one. 

a boy scout with a stick and triangular bandage can stabilize an uncomplicated fx. But, if you hurt, you probably don't want to continue hurting.


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## 46Young (Oct 7, 2010)

aewin90 said:


> This is the stupidest thing I've seen on the internet.
> 
> Pain control is an extremely important part of EMS.  Pain is the 5th vital sign.  But when someone stubs their toe and has a 2/10 on the pain scale, you really want an ALS rig to be pulled out of service?
> 
> Heck, why not just call a chopper?  They can get to that big trauma center faster.  We can't let our stubbed-toe patient suffer in a small ER.



See my previous post. What's dispatched and what's found onscene can vary greatly. To use your stubbed toe example, most pain management protocols and guidelines refer to long bone Fx's, not digits. The debate is on long bone Fx's, and the potential insult to bodily systems and appropriate pain management. How does a stubbed toe qualify as a comparable case when compared with a long bone Fx? Also, a stubbed toe wouldn't fit the criteria for a medevac. Flying out the stubbed toe to the big trauma center is an obvious strawman argument. 

Let's see how it is when you're the one experiencing the pain or maybe a parent or child of yours. 

Stay in your lane and refrain from overtly insulting other member's posts, as in "This is the stupidest thing I've seen on the internet". Telling someone that their post is stupid is not the way to effectively argue your point.

Edit: I could have made mention that you haven't even completed your EMT training yet, and that the extent of your medical education is that of a CNA. Actually, I just did make mention of it. But you get the point.


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## Dutch-EMT (Oct 7, 2010)

Well, I can tell you that the ambulances don't show up for only a broken arm in the Netherlands. (Only when an ambulance is dispatched to an accident on the streets (by emergency call), an broken arm will be seen by the ambulancecrew.)
A broken arm isn't life-threatening and the dispatcher will tell you to bring on a sling and drive with the patiënt to the nearby physician or hospital.


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## aewin90 (Oct 7, 2010)

medic417 said:


> What in the heck are you talking about?  The case presented is a broken arm.  Any broken bone including a toe would justify a Paramedic for pain management.


You didn't comprehend my post.  Let's try this again:



> *Pain control is an extremely important part of EMS. Pain is the 5th vital sign.* But when someone stubs their toe and has a 2/10 on the pain scale, you really want an ALS rig to be pulled out of service?


You've basically reiterated what I said about the importance of pain management, *assuming the pain is strong enough to require pain medication.*  Not every fracture results in a 8/10+ on the pain scale.



> Now your stubbed toe are you sure that is all?  Are you sure they do not have a mental problem?  Are you sure its not actually referred pain in a diabetic having a cardiac event.


Sure, the toe pain can be any number of things, which would necessitate ALS response.  But more than likely it is what it is-- toe pain secondary to a stubbed toe.  A BLS call if there ever was one.  A taxi call, more like it.

If BLS arrives and the toe pain turns out to be something else, that's what ALS intercepts are for.



> Please refrain from attacking someone until you have enough education to debate with.


:lol:


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## 46Young (Oct 7, 2010)

Dutch-EMT said:


> Well, I can tell you that the ambulances don't show up for only a broken arm in the Netherlands. (Only when an ambulance is dispatched to an accident on the streets (by emergency call), an broken arm will be seen by the ambulancecrew.)
> A broken arm isn't life-threatening and the dispatcher will tell you to bring on a sling and drive with the patiënt to the nearby physician or hospital.



How accurate is the dispatcher's information? Here in the U.S. many dispatch centers use the EMD flip chart. These dispatchers typically have no medical experience and can only ask questions, refer to the appropriate page, ask a few more questions, and then arrive at the appropriate call type. Too many calls are given a higher level dispatch classification. Also, the dispatchers here don't have the authority to triage over the phone and deny the caller an assessment by the ambulance crew.

For example, if you trip and fall, and injure your ankle, you may call 911. The dispatcher, in using the EMD manual, must ask a whole array of questions, such as "Do you have difficulty breathing?" and such. The pt, in dealing with the pain, may in fact be breathing heavily. Now it's an ALS call. Same thing for someone with a productive cough that's sore from days of dealing with the cough. Now, instead of a BLS sick call, it's now an ALS chest pain. The pt may be 20 years old with no other inclusion criteria suggesting a cardiac event, just the "chest pain."


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## medic417 (Oct 7, 2010)

aewin90 said:


> You've basically reiterated what I said about the importance of pain management, *assuming the pain is strong enough to require pain medication.*  Not every fracture results in a 8/10+ on the pain scale.
> 
> If BLS arrives and the toe pain turns out to be something else, that's what ALS intercepts are for.



Never wait for 8/10 pain.  If they hit 3/10 sometimes less based on presentation they get pain meds.  It is easier and safer to low dose pain meds early rather than trying to catch up later.  And the pain may not be there at the start of transport so BLS crew cancels ALS then driver hits bump and wow pain is extreme now but basic can do nothing.  That is why it should have ALS.  

ALS intercepts are a bad idea.  I do not want you splinting my broken bones until I get pain meds on board.  And if a BLS ambulance shows up then I have to lay there screaming in pain while you request ALS and wait for them to get there.


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## aewin90 (Oct 7, 2010)

46Young said:


> What's dispatched and what's found onscene can vary greatly.


And thus, the fly car was born.  



> To use your stubbed toe example, most pain management protocols and guidelines refer to long bone Fx's, not digits.


Well, I see you've taken everything I said seriously.  I'm not the only one who "needs more education" evidently, but I suppose I can humor you.



> The debate is on long bone Fx's, and the potential insult to bodily systems and appropriate pain management. How does a stubbed toe qualify as a comparable case when compared with a long bone Fx? Also, a stubbed toe wouldn't fit the criteria for a medevac. Flying out the stubbed toe to the big trauma center is an obvious strawman argument.


I... um... yeah, you took everything I said seriously.  Let's keep it simple then:

-The opening post of this thread states this is a simple fracture, no serious complications.

-Therefore, unless the pt is in pain to the point where pain management is necessary, this is a strictly BLS call.



> Let's see how it is when you're the one experiencing the pain or maybe a parent or child of yours.


Well let's see here.  There was that laceration I had when I was younger, an easy 8/10 on the pain scale, no pain meds.  My wife in intense back labor, 10+/10, no pain management because the nurses couldn't start an IV.  My mother's occasional migraines that were so painful she was unable to walk, no pain meds, just lay down in a dark room...  I could actually go on for a while with this. 



> Stay in your lane and refrain from overtly insulting other member's posts, as in "This is the stupidest thing I've seen on the internet". Telling someone that their post is stupid is not the way to effectively argue your point.


It was incredibly stupid, and frankly I see no need to argue "my point".  Anyone who has read a protocol book know that this is a BLS call.



> Edit: I could have made mention that you haven't even completed your EMT training yet, and that the extent of your medical education is that of a CNA. Actually, I just did make mention of it. But you get the point.


Sorry buddy, my CNA certification is the result of 240 hours of combined classroom and clinical experience in a variety of clinical environments.  You can push the education point all you want, but I have twice as much education as most EMT-B's.


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## aewin90 (Oct 7, 2010)

medic417 said:


> Never wait for 8/10 pain.  If they hit 3/10 sometimes less based on presentation they get pain meds.


I never would wait for 8/10 pain.  I would ask the patient to rate their pain on the scale and ask if they would like some pain relief, even if it's as low as 2 or 3.  It's the patient's emergency and the patient's body.

So let's leave it at this: if this is a fracture with no additional complications, it is a BLS call unless the patient requests pain relief.


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## medic417 (Oct 7, 2010)

aewin90 said:


> ISo let's leave it at this: if this is a fracture with no additional complications, it is a BLS call unless the patient requests pain relief.



Let's not.  Pain levels can change.  It's ALS as potential for pain management is there.


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## 46Young (Oct 7, 2010)

medic417 said:


> ALS intercepts are a bad idea.  I do not want you splinting my broken bones until I get pain meds on board.  And if a BLS ambulance shows up then I have to lay there screaming in pain while you request ALS and wait for them to get there.



On several occasions I've had to medicate a pt before moving them. It could be the knee or long bone injury from a football play, it could be the elderly female that just popped out her recently done hip replacement, to name a couple of examples. 

Actually, the football injury is a good example. It came over as a 12 y/o that twisted their ankle on a play. When we got there, his ankle was fine, and we strongly suspected a distal femur fx. We needed to give 0.5mcg/kg of fentanyl just to move him. Besides his screaming on our initial attempts to place an air splint, the parents were asking us to make him comfortable. The fent decreased the pain from a 10 to a 2. We were expecting to do a quick pillow splint job, ice and txp. Instead, he "stubbed his toes" on the turf, so to speak, lodged his foot there, and ended up fracturing his distal femur. This was confirmed by the attending at the ED later on.


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## aewin90 (Oct 7, 2010)

medic417 said:


> Let's not.  Pain levels can change.  It's ALS as potential for pain management is there.



Nevermind then.  Hopefully there's another ALS unit around who will take care of the heart attack across the street.


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## medic417 (Oct 7, 2010)

aewin90 said:


> Nevermind then.  Hopefully there's another ALS unit around who will take care of the heart attack across the street.



There is because we run nothing but ALS.


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## Veneficus (Oct 7, 2010)

*respectfully*



aewin90 said:


> Well let's see here.  There was that laceration I had when I was younger, an easy 8/10 on the pain scale, no pain meds.  My wife in intense back labor, 10+/10, no pain management because the nurses couldn't start an IV.  My mother's occasional migraines that were so painful she was unable to walk, no pain meds, just lay down in a dark room...  I could actually go on for a while with this.



Are you citing an example of poor care as an excuse to deny others care?

I don't really buy the "man up don't be a baby" argument myself. Consider also cultural aspects of pain. In some Asian cultures people need permission to complain about pain. It doesn't mean they don't have pain. Sometimes most grevious. 

Likewise, in some other cultures, it is encouraged to express pain and is often done so disproportionately to the injury. 

Pain isn't a vital sign, that is a very poor cliche. (I know you didn't start it) A vital sign is an objective finding. Pain is a subjective finding.

Treating pain is one of the earliest tennants of medicine. In my opinion, deciding for a patient what is painful and how bad it should be is poor patient care. Evidence of pain should be recognized and addressed.  



aewin90 said:


> Anyone who has read a protocol book know that this is a BLS call.



Is a doctor a BLS provider?

Using the argument that a physician is a definitive provider means that a patient can not be referred to a higher level of care and not be seen by a doctor. Clearly this is not the case. Otherwise even mid level providers would have to refer up. 

Even among physicians it is commonplace to refer patients to somebody more educated or experienced when they are available. To do otherwise is not utilizing the best resources for the patient. As an example, an Emergency physician is more than capable of reducing a fx, splinting it, and referring the pt to an ortho follow up. But if there is an available orthopod in the facility, readily available, there is really no reason not to refer the patient. So what if an unstable injury might happen at any moment?

For a more EMS based example, if all ALS units are busy or otherwise unavailable, chest pain or any other call suddenly becomes BLS, with transfer to a higher level as soon as possible. That may mean BLS all the way to the hospital. 



aewin90 said:


> Sorry buddy, my CNA certification is the result of 240 hours of combined classroom and clinical experience in a variety of clinical environments.  You can push the education point all you want, but I have twice as much education as most EMT-B's.



If your advanced education makes you a more capable care provider, why would you decide or advocate that a patient should not be worthy of a more advanced one? 

Just some food for thought.


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## 46Young (Oct 7, 2010)

aewin90 said:


> And thus, the fly car was born.
> If a fly car is dispatched, then it isn't just a BLS dispatch, is it?
> 
> Well, I see you've taken everything I said seriously.  I'm not the only one who "needs more education" evidently, but I suppose I can humor you.
> ...


Still a far cry from a paramedic's level of education, the lowest level of education that qualifies to make a field determination to start pain management or withhold it. With all the three to five month medic programs, the paramedic level of medical education is arguably weak. What does that say about a CNA's level of education regarding pt assessment and decisions regarding pain management?

If my child were injured, and pain management was indicated, they better be getting it. I wouldn't sue for most things, but if you're going to intentionally hurt my child, by withholding available, indicated pain relief, I'll be going after your job and I'll also see you in court.


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## 46Young (Oct 7, 2010)

aewin90 said:


> I never would wait for 8/10 pain.  I would ask the patient to rate their pain on the scale and ask if they would like some pain relief, even if it's as low as 2 or 3.  It's the patient's emergency and the patient's body.
> 
> So let's leave it at this: if this is a fracture with no additional complications, it is a BLS call unless the patient requests pain relief.



Wouldn't you have to be ALS to be able to offer pain management? If it's just a BLS call, then there's no medic onscene to offer that.


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## aewin90 (Oct 7, 2010)

Thanks for the civil response, Vene.  I have no problem with liberal pain management but the "ALS Everything" crowd irks me, especially when this is a thread regarding a fracture of a BLS nature.  And the OP was very clear it was BLS.

At the risk of attracting more butt-hurt medics like flies to a bright light, I withdraw my presence from this thread.  :usa:


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## Dutch-EMT (Oct 7, 2010)

46Young said:


> How accurate is the dispatcher's information? Here in the U.S. many dispatch centers use the EMD flip chart. These dispatchers typically have no medical experience and can only ask questions, refer to the appropriate page, ask a few more questions, and then arrive at the appropriate call type. Too many calls are given a higher level dispatch classification. Also, the dispatchers here don't have the authority to triage over the phone and deny the caller an assessment by the ambulance crew.



The dispatchers are mostly (former) ambulancenurses, (former) ambulancedrivers or former ER/CCU/ICU-nurses. They have authority to triage over the phone and can deny the caller an assessment by ambulance-crew.


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## 46Young (Oct 7, 2010)

aewin90 said:


> Nevermind then.  Hopefully there's another ALS unit around who will take care of the heart attack across the street.



Well run depts will acheive proper staffing and deployment objectives. Pain management is a function of the ALS level of pt care, as is the management of retrosternal cx pain. Who gets the first ambulance dispatched to their location is decided by the agency's protocols for call types. In all cases, I would think, a cardiac cx pain would receive a higher priority than cx pain. We all know this. 

In addition, we could be dispatched to someone that said they have cx pain just to get a timely response, when they have anything but, in reality. There could be a cardiac arrest a block away. Once, this actually happened. We heard the arrest job come over, and then told the pt that someone is probably going to die because we're here because of your fraudulent cx pain claim, and the next available ALS is greater than 10 minutes away. At least in the case of the pain management case, we're providing legitimate ALS.

Another strawman argument.


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## Sassafras (Oct 7, 2010)

Hmm, considering the only ALS unit around here keeps 2 crews total and many times end up having to run BS BLS runs because there are so few other units around here...we are probably not going to call ALS.  However, there is an over dependance on ALS from other units and the medic unit is starting to complain that they can't help the serious needs due to running non stop BLS calls.  

WIth that in mind though, I think whoever mentioned asking the patient may be on the right track.  If the patient is fine with their pain level, who am I to force medication on them?  However, again, if they request it, then I should call for back up.

Reminds me of the transport we did recently though.  We were only BLS capacity interfacility transport.  Hosp to nursing facility post fall that fx 3 ribs.  Intense pain.  Refusal to open eyes pain.  Hosp said not due for more meds.  We said 'she seems to need it'.  Hosp said nursing home will dose at due time.  Luckily it was a 5 minute transport but station was 30 minutes away so access to our medics was not there.  She cried the whole way there and we started rooting through her paperwork looking for her last dose as soon as we could and told the nurses there what time the last dose was so they knew to help her ASAP.  Hosp was lazy.  She was due for more meds, and simply refused.  Luckily nursing home got to her as soon as she was admitted and settled in bed.  

She needed medication.  

My 3 bones broken in my hand did not.

I think this all goes back to watch your patient, assess and reassess.


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## 46Young (Oct 7, 2010)

aewin90 said:


> And the OP was very clear it was BLS.
> No, the OP asked if it was BLS or ALS, which is the nature of the whole discussion.
> 
> At the risk of attracting more butt-hurt medics like flies to a bright light, I withdraw my presence from this thread.  :usa:


Apparently you haven't read my signature: 
When the debate is lost, slander becomes the tool of the loser."
— Socrates


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## 46Young (Oct 7, 2010)

Dutch-EMT said:


> The dispatchers are mostly (former) ambulancenurses, (former) ambulancedrivers or former ER/CCU/ICU-nurses. They have authority to triage over the phone and can deny the caller an assessment by ambulance-crew.



That would be highly desireable in our country. The problem is, we live in a severely litigous society. It's difficult to find any medical directors that would put themselves at risk for denying ambulance txp. It takes only one pt with an untoward outcome to derail any attempts at a telephone triage program. Tort reform would be necessary to do this.


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## lightsandsirens5 (Oct 7, 2010)

Linuss said:


> Too many variables for such a simple question.
> 
> 
> How was it broken?
> What type of pain is the pt experiencing?



That ^

It all depends on what is going on. 

Caused by a crushing injury, took 30 minutes to extricate, open fracture, major blood loss, pt screaming in pain? Maybe a medic would be a good thing. 

Caused by slipping on a puddle of water in the kitchen, no deformity, slight swelling, pt in some pain, but not debilitating? Prolly just a BLS call.

Just my $0.02


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## rbromme (Oct 7, 2010)

After reading all these replies and starting off with the "I don't know crap" since I just got my cert, is there any call that is not an ALS call?  Following some of the arguments one here, it would seem that EMT's should only be allowed patient contact after the medic has said so and maybe to take vitals at the medics direction.  I will be the first to say that EMT training is very very basic and needs a huge upgrade in knowledge level.  I am just wondering how anyone learned to do anything before medic school.


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## 18G (Oct 7, 2010)

What route does everyone prefer when giving a pain med in the case of an isolated fracture? Do you just give an IM injection or do you always start a line?

I prefer to start a line in case of an adverse reaction or nausea. Granted Zofran can be given IM as well but an IV will save the patient an extra stick if they need it.


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## TransportJockey (Oct 7, 2010)

18G said:


> What route does everyone prefer when giving a pain med in the case of an isolated fracture? Do you just give an IM injection or do you always start a line?
> 
> I prefer to start a line in case of an adverse reaction or nausea. Granted Zofran can be given IM as well but an IV will save the patient an extra stick if they need it.



For a little pedi, I'll consider IM, or some companies here are experimenting with IN fent. For adults, I'll usually go for a line


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## Veneficus (Oct 7, 2010)

rbromme said:


> After reading all these replies and starting off with the "I don't know crap" since I just got my cert, is there any call that is not an ALS call?  Following some of the arguments one here, it would seem that EMT's should only be allowed patient contact after the medic has said so and maybe to take vitals at the medics direction.  I will be the first to say that EMT training is very very basic and needs a huge upgrade in knowledge level.  I am just wondering how anyone learned to do anything before medic school.



Part of the issue is that EMT-B at one time was meant to identify and make basic decisions about treatment and transport in a time when ALS was not as independant as it is now. 

What is now going to be the 2 prior revisions of the EMT curriculum, in order to make the class shorter and easier to pass for the purpose of cheaply increasing the number of providers, a "skills" based curriculum was put in place.

Compared to many of the original programs this new "advancement" took away a lot of educational components such as more advanced classroom clinical science and a field internship that was 50% or more of the the entire current EMT-B program. 

With the skills approach also came the evolution that the EMT-B is best suited for rendering aid in the most extreme of emergencies. These types of emergencies are less than 5% of the total responses. That means the EMT has skills that will help in only a minority of situations they are called to respond to. 

When you add in ALS response, it marginalizes the EMT-B even more. In tiered response systems and more rural areas, the EMT-B is still a primary contact for medical care, but these opportunities are becomming more scarce. Making a decent living at it even more remote. (not to say it can't be done, only that it can be done in a handful of places)

By default a paramedic is becomming the minimal level of training required to be employed or functonal in prehospital care from the practical point of view in modern US society.

That is why more and more, having any "experience" as an EMT prior to becomming a medic doesn't carry the benefit it once did. 

In all societies as the collective knowledge of man increases so does the minimal education required in order to be of benefit to society, and therefore value.

In short, when EMTs became skill based, they basically eliminated themselves from the market.


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## 46Young (Oct 7, 2010)

rbromme said:


> After reading all these replies and starting off with the "I don't know crap" since I just got my cert, is there any call that is not an ALS call?  Following some of the arguments one here, it would seem that EMT's should only be allowed patient contact after the medic has said so and maybe to take vitals at the medics direction.  I will be the first to say that EMT training is very very basic and needs a huge upgrade in knowledge level.  I am just wondering how anyone learned to do anything before medic school.



It depends on the area. Some systems are all ALS. Others are tiered to varying degrees. In NYC for example, a stable asthmatic can be BLS, a serious one is ALS. OD/intox - BLS, unconscious - ALS. Abd pain and sick jobs are BLS, Cx pain and the hypotensive are ALS. Injury major/minor are BLS, the confirmed multi trauma can be ALS. EDP's are BLS. AMS is ALS. An allergic reaction is BLS. The anaphylaxis is ALS. MVA's are BLS. The pin job will deploy ALS.


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## DrParasite (Oct 7, 2010)

46Young said:


> If my child were injured, and pain management was indicated, they better be getting it. I wouldn't sue for most things, but if you're going to intentionally hurt my child, by withholding available, indicated pain relief, I'll be going after your job and I'll also see you in court.


You can sue all you want, you can try to get me fired; you will lose in court, and you will get laughed out of my bosses office when you want me fired because of it.

Pain management is still new in EMS.  no, let me rephrase that; having ALS there solely for pain management is new to EMS.   If your medical director tells me that I should have one for an arm fx, then I'm sure that can be arranged.  And if it's indicated (and I think we can disagree on what indicates prehospital pain management based on local protocols and local customs), and you withhold it, then the medic will have some explaining to do.

I guess the answer I would give to the question (since I am the OP after all), if you are an all ALS system, and you have the pain meds available to you, by all means give them.  but if you are in a tiered systems, which a lot of the busier systems are, then I wouldn't be requesting a medic simply for pain control, when their skills can be better used treating the chest pain or asthmatic.



46Young said:


> How accurate is the dispatcher's information? Here in the U.S. many dispatch centers use the EMD flip chart. These dispatchers typically have no medical experience and can only ask questions, refer to the appropriate page, ask a few more questions, and then arrive at the appropriate call type. Too many calls are given a higher level dispatch classification. Also, the dispatchers here don't have the authority to triage over the phone and deny the caller an assessment by the ambulance crew.
> 
> For example, if you trip and fall, and injure your ankle, you may call 911. The dispatcher, in using the EMD manual, must ask a whole array of questions, such as "Do you have difficulty breathing?" and such. The pt, in dealing with the pain, may in fact be breathing heavily. Now it's an ALS call. Same thing for someone with a productive cough that's sore from days of dealing with the cough. Now, instead of a BLS sick call, it's now an ALS chest pain. The pt may be 20 years old with no other inclusion criteria suggesting a cardiac event, just the "chest pain."


you are getting off topic.... It's pretty clear you don't like EMD.  fine, we get it.  have you ever dispatched?  I'll take a 12 hour shift on the road in medium speed system dealing with maybe 14 patients, to a 12 hour dispatch shift dealing with close to 100+ patients, many screaming at you trying to get help, and all you can do is tell them the ambulance is on the way.  If you think you can do a better job, by all means you can have my seat.  Also, while I agree with you that that question causes a lot of unnecessary upgrades to ALS dispatches, I will say that more educated people than you and I wrote those questions, and your boss and my boss approved those cards, and your dispatchers are told to follow them.  And if they do deviate from the cards, and send BLS on what turns out to be a patient needing ALS, then the dispatcher gets hung out to dry by the dispatch agency, as well as the medical director and company who makes the cards.

and the question isn't do you have difficulty breathing, it's "are you breathing normally."  same results occur.  but back to the topic at hand....





medic417 said:


> Never wait for 8/10 pain.  If they hit 3/10 sometimes less based on presentation they get pain meds.  It is easier and safer to low dose pain meds early rather than trying to catch up later.  And the pain may not be there at the start of transport so BLS crew cancels ALS then driver hits bump and wow pain is extreme now but basic can do nothing.  That is why it should have ALS.


woooow.  I have had patients with a stubbed toe who said their pain was 10/10.  ditto a broken swollen finger.  or abdominal pain.  or a headache.  or an ear ache.  it's always 10/10 on the pain scale.  I guess they needed pain meds, going by your thinking





medic417 said:


> ALS intercepts are a bad idea.  I do not want you splinting my broken bones until I get pain meds on board.  And if a BLS ambulance shows up then I have to lay there screaming in pain while you request ALS and wait for them to get there.


see, I guess that shows what type of a provider you are.  you let your patient's dictate how you are going to treat them. If I show up to your broken arm, and you tell me you are just going to just lay there screaming in pain until I request ALS and they give you pain meds, I am either going to pull up a chair and wait for your to grow up, tell you "if you want to be treated, you need to let me treat you, or can can just lay there the pain", and if you still don't want me going anywhere near you, I am going to say "sign the RMA," and next time, have the cops and a supervisor respond when you call again.  If you are going to let the patient dictate how you are going to treat him (not his condition based on your assessment, his desires), than you are a drug seekers dream medic.

I broke my wrist, my brother broke both his arms due to stupidity (one after the other), and we never called 911.  and if I did break my arm, unless it's at a 90 degree angle, I'm probably going to end up walking to the ambulance once it has been splinted and secured in a position of comfort, and that is if I call for an ambulance at all.  I might prefer to just drive myself to the ER, or even better, to my PMD's office


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## Outbac1 (Oct 7, 2010)

Wow !! 10 pages for a simple question. 

 A simple closed arm fx w/o complications could be managed by someone with a first aid card and car. Doesn't mean thats the best way to manage it. 

 Here you would get the closest available unit, BLS or ALS. Keep in mind our BLS is not the same as the USA.  Pain management needs to be a consideration and be properly assessed. I've had pts tell me they are in 10/10 pain(for whatever) and show absolutly no signs of being in pain. Conversly I've had pts with 4/10 that were obviously in agony. Pts need proper assessment and then appropriate treatment. If they need pn management, they need it, sooner not later. 

 How soon can they get the appropriate tx. Pts may wait in the ER a long time before being seen and treated. Perhaps it is better to have ALS intercept and give the pn management before the pt gets to the hosp and waits in line. 

 Should you pull in an ALS unit to intercept? Sure, the call you have always beats the call you might get. 

 Here just because an ALS unit gives pain meds does not mean they have to stay with the pt. Our BLS crews routinely transport pts with pain meds on board.


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## medic417 (Oct 7, 2010)

DrParasite said:


> If I show up to your broken arm, and you tell me you are just going to just lay there screaming in pain until I request ALS and they give you pain meds, I am either going to pull up a chair and wait for your to grow up, tell you "if you want to be treated, you need to let me treat you, or can can just lay there the pain", and if you still don't want me going anywhere near you, I am going to say "sign the RMA," and next time, have the cops and a supervisor respond when you call again.



And you would lose in a court of law.  You are showing yourself not to be very knowledgeable.  

Pain management is not a new thing in EMS maybe in your area but not the rest of the country.  We used to even administer pain meds, splint the broken arm, confirm good pulses and cap refill, verify no adverse affects to pain meds, then send them with their family or friend to the hospital or doctors office.  

As to determining who gets pain meds since when have you been given the ability to see if I am actually in pain or just a drug seeker?  How do you determine?  Is it because of their skin color?  Is it because they are poor?  Is it because they have tattoos?  Is it because they look like a biker?  What?  Pretty much unless they tell you they just want a fix it is not your place to withhold pain meds.  You do not know how a person responds to pain.  What I might say is a 1/10 you might call an 8/10.  My vitals do not fluctuate the way many claim they should when I am in severe pain.  In fact when I got hurt on a job another medic thought I was faking until the x rays and cat scans were done at the hospital.  

So if I am the drug seekers friend you must be the worst ems person ever.


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## Flight-LP (Oct 7, 2010)

DrParasite said:


> You can sue all you want, you can try to get me fired; you will lose in court, and you will get laughed out of my bosses office when you want me fired because of it.
> 
> Pain management is still new in EMS.  no, let me rephrase that; having ALS there solely for pain management is new to EMS.   If your medical director tells me that I should have one for an arm fx, then I'm sure that can be arranged.  And if it's indicated (and I think we can disagree on what indicates prehospital pain management based on local protocols and local customs), and you withhold it, then the medic will have some explaining to do.
> 
> ...



I'd love to be in that courtroom when you boast your uneducated BS. You are WRONG on all levels. 

You will lose in court.

You will lose if reported to your responsible regulatory agency.

You will lose if pursued through an employer.

This exact issue has been proven time and time again. Pain is subjective, if the means to address an issue is available, then it is to be given. While you weren't addressing me in your post, I can tell you exactly the type of provider I am. I do let my patients dictate their treatment, why wouldn't I? Give me one good reason.

If I was this hypothetical patient, you will call for ALS, I will get a competent exam with treatment options discussed, and you will get off of your lazy pompous *** and treat me with the respect and dignity that all patients deserve. Or you will not continue to practice in your minimalistic medical position. Your attitude towards treating human beings in absolutely disgusting. You are not qualified to make an objective assessment of another humans suffering. If you cannot possess or acquire some compassion for your fellow man, you have no business being on an ambulance.

Quit while you are ahead, you are giving your fellow EMT's a bad name with the ignorance you are spouting.


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## medic417 (Oct 7, 2010)

Flight-LP said:


> This exact issue has been proven time and time again. Pain is subjective, if the means to address an issue is available, then it is to be given. While you weren't addressing me in your post, I can tell you exactly the type of provider I am. I do let my patients dictate their treatment, why wouldn't I? Give me one good reason.
> 
> If I was this hypothetical patient, you will call for ALS, I will get a competent exam with treatment options discussed, and you will get off of your lazy pompous *** and treat me with the respect and dignity that all patients deserve. Or you will not continue to practice in your minimalistic medical position. Your attitude towards treating human beings in absolutely disgusting. You are not qualified to make an objective assessment of another humans suffering. If you cannot possess or acquire some compassion for your fellow man, you have no business being on an ambulance.



Excellent reply.


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## usalsfyre (Oct 7, 2010)

I'm sorry, I can't let this go. 




DrParasite said:


> Pain management is still new in EMS. no, let me rephrase that; having ALS there solely for pain management is new to EMS


 Pain management is not new in *MEDICINE*. Whether  medicine is practiced in a doctors office, a hospital or the patients living room is irrelevant. 



> And if it's indicated (and I think we can disagree on what indicates prehospital pain management based on local protocols and local customs.


 *PAIN* indicates pain management. It may be as simple as positioning and an ice-pack. A good portion of pain doesn't need IV narcotics, but if the patient is in pain, it needs to be adressed. 



> I guess that shows what type of a provider you are.  you let your patient's dictate how you are going to treat them.



You bet your sweet @ss I am going to let the individual patient presentation dictate how I treat them. Why would I waste my time doing an assesment otherwise?




> If I show up to your broken arm, and you tell me you are just going to just lay there screaming in pain until I request ALS and they give you pain meds, I am either going to pull up a chair and wait for your to grow up, tell you "if you want to be treated, you need to let me treat you, or can can just lay there the pain", and if you still don't want me going anywhere near you, I am going to say "sign the RMA," and next time, have the cops and a supervisor respond when you call again.  If you are going to let the patient dictate how you are going to treat him (not his condition based on your assessment, his desires), than you are a drug seekers dream medic.


 I would rather be a drug seekers dream medic, then let severe pain go untreated in one patient because I thought they were seeking. How do you know the patient in question is faking? As was stated before cultural factors play a role in response to pain. Are you going to let him hurt because his response to is distasteful to you? In addition, your pain tollerance is not this guy's. Unless you can do the Vulcan mind-meld with your patient, you have no way of knowing whether he's faking, or just has a really low pain tollerance. 



> I broke my wrist, my brother broke both his arms due to stupidity (one after the other), and we never called 911.  and if I did break my arm, unless it's at a 90 degree angle, I'm probably going to end up walking to the ambulance once it has been splinted and secured in a position of comfort, and that is if I call for an ambulance at all.  I might prefer to just drive myself to the ER, or even better, to my PMD's office



Again, YOUR response to a similar situation should not affect how the patient is treated. 

DrParasite, I have worked in busy systems with a high load of abusers. I understand, it's easy to get jaded. What's truly lost if you medicate a chronic system abuser who doesn't need it? Are they going to call more? Doubtful. Patient condition? Most EMS service don't give narcotic doses that would even begin to produce respiratory depression. Some narcotics? Most narcotics are generic and dirt-cheap. I respect that your system has chosen a tiered model. However please stop using this to defend the absoloutely pitiful state of pain management in US EMS. It need to be fixed and telling folks the equivelent of "grow some" is not gonna help the situation.


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## Aidey (Oct 7, 2010)

I would say that behavior is a good indicator of med seeking, I don't know where you got all that other stuff from. 

I think Vene put it well, you might want a paramedic, but you don't necessarily need one. I also agree that you need to ask your patient, because for 2/10 pain they may not want pain meds. I can't force them to take them just in case it gets worse. If it gets worse, and they change their mind, that is their option.


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## 46Young (Oct 7, 2010)

DrParasite said:


> You can sue all you want, you can try to get me fired; you will lose in court, and you will get laughed out of my bosses office when you want me fired because of it.
> Regardless, whether it was at my old hospital, or down here in Virginia, that protocol violation would result in a pt care restriction and mandate a re-education. It would remain on the employee's permanent record, and would cause future pt care issues to be dealt with more severely.
> 
> Pain management is still new in EMS.  no, let me rephrase that; having ALS there solely for pain management is new to EMS.   If your medical director tells me that I should have one for an arm fx, then I'm sure that can be arranged.  And if it's indicated (and I think we can disagree on what indicates prehospital pain management based on local protocols and local customs), and you withhold it, then the medic will have some explaining to do.
> ...



EMD is akin to cookbook paramedicine. It works for anyone, since you don't have to think much, just follow the algorithm blindly. Dispatch ought to be much more than that, as should a paramedic's field treatment.


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## Aidey (Oct 7, 2010)

Would it not be cookbook medicine to give everyone with pain of 1/10 or higher fentanyl automatically? That is the only option I have, which sucks. It leaves me stuck with an all-or-nothing approach. 

Honestly, here is how I look at it. Pain management is important. However, if fentanyl is your my option it means that if I medicate all pain, I end up giving a potent narcotic to someone who could have benefited more from a different medication. If medical directors/hospitals/etc want us to be more aggressive with pain management, then we need to be given more options so that we can give appropriate pain management. For me, it isn't that I don't want to manage my patient's pain, I don't want to manage it inappropriately. And when all you have is fent, it is a crappy situation.


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## medic417 (Oct 7, 2010)

Aidey said:


> Would it not be cookbook medicine to give everyone with pain of 1/10 or higher fentanyl automatically? That is the only option I have, which sucks. It leaves me stuck with an all-or-nothing approach.
> 
> Honestly, here is how I look at it. Pain management is important. However, if fentanyl is your my option it means that if I medicate all pain, I end up giving a potent narcotic to someone who could have benefited more from a different medication. If medical directors/hospitals/etc want us to be more aggressive with pain management, then we need to be given more options so that we can give appropriate pain management. For me, it isn't that I don't want to manage my patient's pain, I don't want to manage it inappropriately. And when all you have is fent, it is a crappy situation.



Man I feel bad for you and your patients.  Do they at least let you adjust dosage?  We have multiple types and choices.  What is funny is that most pain meds are dirt cheap so cost should not play a part in deciding what to carry.  I hope you can work with your medical director to increase your options.  

I never force pain meds.  If they say they hurt I explain that I would like to administer X ( drug I feel is best based on all factors I am aware of ) for pain.  Surprisingly some patients that are even 9/10 will so no to pain meds. Now if they change there mind later I am still there so I then give them what is needed.


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## Aidey (Oct 7, 2010)

The dosage is variable, but as it is fentanyl, low doses don't seem to do one bit of good. Even in small patients 25mcg doesn't seem to have much (if any) affect. I've had to give some larger patients the max dose just to get them to the hospital. I would LOVE to have a variety, a longer acting opiate, a non-opiate or two, nitrous, a muscle relaxant. That way I could actually treat my patients appropriately. 

Aside from abuse/misuse concerns, there is the fact that our protocols apply to the county, including all the non-transport FDs. While our agency's doctor would probably be open to adding stuff, it won't happen unless the FDs all agree, and the regional EMS council. Anytime we try and add stuff the FD's don't have/don't get to use there are issues.

I think that may be part of the issue in this debate, no one is discussing what pain management options they have. So for me, I'm highly unlikely to end up doing pain management beyond BLS on a simple fracture, but that is because all I have is fent. If I had other options, I would be more likely to medicate becuase I could medicate appropriately.


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## medic417 (Oct 7, 2010)

Aidey said:


> The dosage is variable, but as it is fentanyl, low doses don't seem to do one bit of good. Even in small patients 25mcg doesn't seem to have much (if any) affect. I've had to give some larger patients the max dose just to get them to the hospital. I would LOVE to have a variety, a longer acting opiate, a non-opiate or two, nitrous, a muscle relaxant. That way I could actually treat my patients appropriately.
> 
> Aside from abuse/misuse concerns, there is the fact that our protocols apply to the county, including all the non-transport FDs. While our agency's doctor would probably be open to adding stuff, it won't happen unless the FDs all agree, and the regional EMS council. Anytime we try and add stuff the FD's don't have/don't get to use there are issues.
> 
> I think that may be part of the issue in this debate, no one is discussing what pain management options they have. So for me, I'm highly unlikely to end up doing pain management beyond BLS on a simple fracture, but that is because all I have is fent. If I had other options, I would be more likely to medicate becuase I could medicate appropriately.



Don't hold back because Fentanyl still helps take the edge off which is better than nothing.  In some patients it lets them sleep away their pain.  A big plus in trauma is it usually does not bottom them out.  

I agree more choices would be helpful.  I would hate to be in a situation like yours where everyone gets stuck with basically nothing because a few can not comply.


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## Aidey (Oct 7, 2010)

I miss having more options, I used to have morphine, valium and nitrous. Between valium, versed and ativan I feel that the valium was the best for relieving muscle spasms, which helped significantly in dislocations. The nitrous was awesome because I could use it until the morphine kicked it, or use a lower dose of morphine overall. I also used it several times in patients who were adamant about no needles.


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## jjesusfreak01 (Oct 7, 2010)

Two things to remember: Your patient could be a drug seeker, or your patient could be an ex addict. Giving drugs to the former of these without evidence they are in pain is bad, and giving meds to the latter of these without helping them make an informed decision is much much worse. All drugs have side effects, and all drugs have aftereffects. Overmedication is one of the bigger medical problems we face in the United States now, better not to compound the problem if you can help it. Be compassionate and make informed treatment decisions based on what a patient needs.


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## Jay (Oct 8, 2010)

Sam Adams said:


> Without over analyzing? You have 6 bullet points!?! :lol:



LMFAO 

Go back and read a handful of my posts and you will sadly come to the realization that for me this is not over-analyzing.


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## Jay (Oct 8, 2010)

Aprz said:


> Well, he did say without overanalyzing, but when I saw this, I thought "What about guys that don't want to admit they are in pain or something is wrong?" I don't know why, but I am one of those guys, and I just do it. I am sure there are plenty others like me who don't admit or show what they are really feeling.


If they are not admitting pain and don't appear to be in pain than it is definitely BLS. I used 7/10 as an example because local hospitals use this to expedite triage because pain management is a primary concern however if the PT is complaining of severe pain, regardless of the number than ALS would be warranted. Aside from the number you would have other indicators using OPQRST to determine the severity of the injury and how much pain they *should* be experiencing even if they only report little or no pain. I had a PT a couple of weeks ago that was in bad shape, he is on chemo and has stage 4 kidney failure, severe right sided pedal edema and a hernia that would not go back in. He was grimacing and looked like he was in pain but initially said that he had no pain, then he reported 3/10, I bluntly told him that we can make him more comfortable and to stop lying to me and then he finally reported 6 or 7. By that point, once he jumped from 0 to 3, ALS was already in route. It's a common sense thing and not really a numbers thing but my initial response was more in the lines of who would get expedited via triage due to the severe pain and thus also would warrant to be expedited in the field. It should be noted that I gave him 12 LPM via NRB and his pain went down to a 2 in about 5 minutes!!! We also repositioned him and it helped as well. Both are BLS interventions which should be noted. Another indicator is elevated BP, pain tends to do that to a person, his was 200/120 and I knew there was no way that his pain wasn't *severe*. 

In this case, did the BLS interventions work? Absolutely. 

Was ALS also warranted? Yes.

Just my $0.02 on the numbers.

...and after all this, I was trying not to over-analyze like on previous posts


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## Charmeck (Oct 8, 2010)

How far from the hospital are you?  Pain management?


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## akflightmedic (Oct 8, 2010)

Charmeck said:


> How far from the hospital are you?  Pain management?



1. Does it matter? Pain is pain and if you have the ability to treat it do you delay/deny care based on how close you are to a facility or do you provide the level of care expected and capable of regardless of distance?

2. Yes, pain management. Is there more to this?


***I have to expand in regards to #1 above and I find it amusing how many times people do not consider the time delays.

Injury occurs-clock starts
911 activated- 0 minutes to 10 minutes on average
Dispatch/Ambo response  Let us be kind and say 10 minutes on scene....now post injury 20 minutes
Assessment/Hx Isolated fx, so we can knock this down to 5 minutes (for greetings, SAMPLE, pmhx, etc)

Now decision time...hospital is 5 minutes away (to go with the close facility theory)
Load patient/store gear/check compartment doors/drive away 2-5 minutes
Transport time  5 minutes

We are now 35 minutes post injury for those counting

Unload at ER and wait to give report--- 5 minutes to ...unknown  (Peak season in Orlando, Florida has created wait times of up to 2+ hours)...but lets be nice and say 10 minutes

You hand off care and leave.

Nurse does intake assessment and then uses standing orders or gets doc to ok some pain relief  5-15 minutes  (we will say 10)

Nurse starts IV (cause we kept this BLS), then gets meds and verifies orders---this could be 10 minutes to 30 minutes on a good day.

Pt finally gets pain meds...1+ hours POST Injury

Now...had this been ALS...pt would have been receiving pain relief in less than 35 minutes post injury.

You tell me which is the better outcome for the injured? And this was only a 5 minute trip to the hospital and in a non-busy ER where the RN is able to do everything right away for this 1:1 ratio they maintain in all ERs (sarcasm).


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## Aidey (Oct 8, 2010)

Jay said:


> If they are not admitting pain and don't appear to be in pain than it is definitely BLS. I used 7/10 as an example because local hospitals use this to expedite triage because pain management is a primary concern however if the PT is complaining of severe pain, regardless of the number than ALS would be warranted. Aside from the number you would have other indicators using OPQRST to determine the severity of the injury and how much pain they *should* be experiencing even if they only report little or no pain. I had a PT a couple of weeks ago that was in bad shape, he is on chemo and has stage 4 kidney failure, severe right sided pedal edema and a hernia that would not go back in. He was grimacing and looked like he was in pain but initially said that he had no pain, then he reported 3/10, I bluntly told him that we can make him more comfortable and to stop lying to me and then he finally reported 6 or 7. By that point, once he jumped from 0 to 3, ALS was already in route. It's a common sense thing and not really a numbers thing but my initial response was more in the lines of who would get expedited via triage due to the severe pain and thus also would warrant to be expedited in the field. It should be noted that I gave him 12 LPM via NRB and his pain went down to a 2 in about 5 minutes!!! We also repositioned him and it helped as well. Both are BLS interventions which should be noted. Another indicator is elevated BP, pain tends to do that to a person, his was 200/120 and I knew there was no way that his pain wasn't *severe*.
> 
> In this case, did the BLS interventions work? Absolutely.
> 
> ...



This was an ALS call for about 5 reasons besides pain management.


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## FDNYRescueMedic (Oct 8, 2010)

In the NYC 911 system a broken arm will come in as a priority 5 call, non-critical injury and automatically dispatched as a BLS call. When the EMT's arrive and start treating the pt. they can request ALS response for pain management.


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## Outbac1 (Oct 8, 2010)

akflightmedic said:


> 1. Does it matter? Pain is pain and if you have the ability to treat it do you delay/deny care based on how close you are to a facility or do you provide the level of care expected and capable of regardless of distance?
> 
> 2. Yes, pain management. Is there more to this?
> 
> ...



 Exactly!


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## medic417 (Oct 8, 2010)

Outbac1 said:


> Exactly!



I agree.  We can speed time to relief and proper care by what we do in the field.


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## DrParasite (Oct 8, 2010)

medic417 said:


> And you would lose in a court of law.  You are showing yourself not to be very knowledgeable.


please cite cases where EMS personnel have been sued and found civilly liable for not giving pain medications prehospitally.  I haven't heard of any, but if you actually have the information (as opposed to just posturing and saying you can and will lose) I am sure others would like to hear as well.  I mean, after all, you are the knowledgeable one, not me


medic417 said:


> Pain management is not a new thing in EMS maybe in your area but not the rest of the country.  We used to even administer pain meds, splint the broken arm, confirm good pulses and cap refill, verify no adverse affects to pain meds, then send them with their family or friend to the hospital or doctors office.


where?  I have NEVER heard that, and would love to speak to a medical director who allows this, so I can give the info to my medical director so we can do the same thing.  I would love to be able to take a traumatic injury, call for an ALS to give pain meds, and then be able to just send them to their PMD, it would take a huge burden off the ERs.


medic417 said:


> As to determining who gets pain meds since when have you been given the ability to see if I am actually in pain or just a drug seeker?  How do you determine?  Is it because of their skin color?  Is it because they are poor?  Is it because they have tattoos?  Is it because they look like a biker?  What?


So you are implying only poor people with a certain skin color who look like bikers and have tattoos are the only ones who are drug seekers?  sounds pretty racist of you to make that determination, but hey, you said it not me.  


medic417 said:


> Pretty much unless they tell you they just want a fix it is not your place to withhold pain meds.  You do not know how a person responds to pain.  What I might say is a 1/10 you might call an 8/10.  My vitals do not fluctuate the way many claim they should when I am in severe pain.  In fact when I got hurt on a job another medic thought I was faking until the x rays and cat scans were done at the hospital.


gotcha.  I'm going to your area next time I want to get high, to complain of pain, so you can shoot me up until I am higher than a kite.  Since you won't refuse to give them.


medic417 said:


> So if I am the drug seekers friend you must be the worst ems person ever.


Well, you are a drug seekers friend, but I'm far from the worst EMS person ever.


usalsfyre said:


> I'm sorry, I can't let this go...*PAIN* indicates pain management. It may be as simple as positioning and an ice-pack. A good portion of pain doesn't need IV narcotics, but if the patient is in pain, it needs to be adressed.


so you just supported my point, and for that I do thank you.  Sometimes positioning and an ice pack are all you need to manage the pain, not narcotics which everyone wants to push.


usalsfyre said:


> You bet your sweet @ss I am going to let the individual patient presentation dictate how I treat them. Why would I waste my time doing an assesment otherwise?


see, that wasn't what I said.  I said you are going to let the patient dictate what happens to them; you just told me that you are going to assess the patient and treat accordingly.  Those are two completely different things.  In the first case, the patient says "give me drugs because I say so", while in the second, you give drugs because you think they are warranted.  There is a distinction there, and if you don't see it, then it's not worth me explaining it to you.


usalsfyre said:


> DrParasite, I have worked in busy systems with a high load of abusers. I understand, it's easy to get jaded. What's truly lost if you medicate a chronic system abuser who doesn't need it? Are they going to call more? Doubtful.


I'm sorry what? if a chronic junkie gets pain meds every time they call for the ambulance, you honestly think they aren't going to call more?  Like anytime they want a fix and don't have the money to buy some, just call 911 and say their arm is broken and they need pain meds?  and if you think that won't happen, then I question what type of busy system you have worked in.


usalsfyre said:


> Patient condition? Most EMS service don't give narcotic doses that would even begin to produce respiratory depression. Some narcotics? Most narcotics are generic and dirt-cheap. I respect that your system has chosen a tiered model. However please stop using this to defend the absoloutely pitiful state of pain management in US EMS. It need to be fixed and telling folks the equivelent of "grow some" is not gonna help the situation.


If the EMS system is broken, then get your MD, become a medical director, get on various national level steering committees and push for change.


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## medic417 (Oct 8, 2010)

Parasite you are a parasite.  No point in wasting time with you.  Have a great day.


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## LonghornMedic (Oct 8, 2010)

aewin90 said:


> Thanks for the civil response, Vene.  I have no problem with liberal pain management but the "ALS Everything" crowd irks me, especially when this is a thread regarding a fracture of a BLS nature.  And the OP was very clear it was BLS.
> 
> At the risk of attracting more butt-hurt medics like flies to a bright light, I withdraw my presence from this thread.  :usa:



Moot point since the system I live and work in is all ALS. Thank God I don't live in areas with fly cars, intercepts, BLS only, etc. As a sufferer of many a kidney stone, I've been on the receiving end of EMS on more than one occasion. It chills my blood to read some of the responses here. If you have meds, give it. You aren't paying for it. It's there for a reason, so use it. I've had partners over the years, mostly they were real young or older medics who were burned out, who would rarely give pain meds because they were just too lazy(burned out medics) or the "patient can suck it up"(newer young medics). Please, if any of you get to this point in your career.....get out. 

Rare is the patient who isn't medicated *BEFORE *I start immobilizing, splinting and moving. If someone is sitting on a baseball field with a fractured arm, they get medicated right where they are sitting and then we do the rest.


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## LonghornMedic (Oct 8, 2010)

jjesusfreak01 said:


> Two things to remember: Your patient could be a drug seeker, or your patient could be an ex addict. Giving drugs to the former of these without evidence they are in pain is bad, and giving meds to the latter of these without helping them make an informed decision is much much worse. All drugs have side effects, and all drugs have aftereffects. Overmedication is one of the bigger medical problems we face in the United States now, better not to compound the problem if you can help it. Be compassionate and make informed treatment decisions based on what a patient needs.



Your not serious are you?


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## jjesusfreak01 (Oct 8, 2010)

LonghornMedic said:


> Your not serious are you?



About what, that overmedication is a problem in the US? That is absolutely true. I'm not saying that it is a problem in pre-hospital medicine, but it is a huge problem nonetheless in general medicine, and I would hate to see it spread to the pre-hospital setting. Just because we only treat patients for a short time doesn't make the interaction any less important in their overall care. 

Drug seekers and addicts are also something commonly faced in EMS that we have to be aware of. All i'm advocating is that we use good judgement when injecting people with foreign substances and avoid treating with a "just because we can" methodology. Field IVs are prone to infection at a higher rate than hospital IVs (though it is not a very high rate), so do you want to go before your medical director and defend your starting an IV on an immunocompromised patient so you could give a little pain medication for their stubbed toe? Every invasive treatment on a patient involves inherent risks, and it is often a risk that is warranted,  but sometimes it isn't.


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## medic417 (Oct 8, 2010)

Many meds are way over prescribed but pain management is way underutilized.   Again we have no way to verify.  It is their pain treat it.


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## usalsfyre (Oct 8, 2010)

DrParasite

Since you misinterpreted my post, let me explain one final time. You can't feel a patient's pain. If they say the hurting, unless there is obvious behavior to suggest otherwise, I believe them. Very often, the treatment of choice for pain is IV (or IN) opiate medications, in my system it's Fentanyl. 

Fentanyl, as reported by surveys of users, gives a poor high, with noticeably less euphoria, ect than other narcotics. It also has a very short half life, meaning a "fix" will likely have less "high" and less duration than whatever their drug of choice is. So given the choice between calling EMS for a crappy high, or obtaining a normal high through buying, stealing or other illegal activities they are likely to go with the normal methods.

Jjesusfreak, listen, this applies in your argument to. Withdrawl HURTS. Users are physically dependent on narcotic medications for normal physiologic function of their bodies. If they don't have it, pain, nausea, vommiting and other illness symptoms honestly appear. Don't believe me, withhold grandma's Vicoden for a day and see what happens. Is this patient somehow less deserving of treatment? Is a patient with the flu not worthy of treatment. Addiction does not make on less human. 

The last busy truck I worked I considered "busy" averaged around 16 calls per 24 hours. A busy day was 25+. A large low-income, minority and homeless population and the associated problems with it. 

The EMS system *IS* broken. Ask most people with a real EMS background. Some of us are trying to make it better, MD or no MD. I am extremely fortunate to work for a medical director that believes in aproprite pain management and sedation as needed. These are probably more important to patient care than all the cardiac arrest drugs in the world.


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## LonghornMedic (Oct 8, 2010)

DrParasite said:


> I guess the answer I would give to the question (since I am the OP after all), if you are an all ALS system, and you have the pain meds available to you, by all means give them.  but if you are in a tiered systems, which a lot of the busier systems are, then I wouldn't be requesting a medic simply for pain control, when their skills can be better used treating the chest pain or asthmatic.
> 
> 
> 
> ...



What an :censored::censored::censored::censored::censored::censored::censored: you are. It's medics like you who give us all a bad name. Who are you to determine if someone with ABD pain isn't having 10/10 pain? And just because you were "man enough" not to call 911 for your FX wrist doesn't mean that someone else may not need pain control. 10/10 headaches aren't deserving medications? Migraines can be debilitating for some people.


This statement right here tells me exactly what kind of jaded, burned out EMT you are-

_If I show up to your broken arm, and you tell me you are just going to just lay there screaming in pain until I request ALS and they give you pain meds, I am either going to pull up a chair and wait for your to grow up, tell you "if you want to be treated, you need to let me treat you, or can can just lay there the pain", and if you still don't want me going anywhere near you, I am going to say "sign the RMA," and next time, have the cops and a supervisor respond when you call again.  If you are going to let the patient dictate how you are going to treat him (not his condition based on your assessment, his desires), than you are a drug seekers dream medic._

Guys like you last a couple months where I work. And I work in a busy as hell EMS system. But they expect you to be courteous to the patient. Our "business" is providing care and showing compassion. If one of our Paramedics talked to someone like you say you do, you'd be fired. No joke, you would be out the door. If you tell a homeless guy to go F-off, you're gone. Our Medical Director is big on customer service. The patients are our customers and they deserve the right to excellent pre-hospital care. And we're not even a private service worried about contracts, we're a county run 3rd service with about as much of job security as one can get.


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## LonghornMedic (Oct 8, 2010)

jjesusfreak01 said:


> About what, that overmedication is a problem in the US? That is absolutely true. I'm not saying that it is a problem in pre-hospital medicine, but it is a huge problem nonetheless in general medicine, and I would hate to see it spread to the pre-hospital setting. Just because we only treat patients for a short time doesn't make the interaction any less important in their overall care.
> 
> Drug seekers and addicts are also something commonly faced in EMS that we have to be aware of. All i'm advocating is that we use good judgement when injecting people with foreign substances and avoid treating with a "just because we can" methodology. Field IVs are prone to infection at a higher rate than hospital IVs (though it is not a very high rate), so do you want to go before your medical director and defend your starting an IV on an immunocompromised patient so you could give a little pain medication for their stubbed toe? Every invasive treatment on a patient involves inherent risks, and it is often a risk that is warranted,  but sometimes it isn't.



I've started literally thousands of IV's. I've yet to be called in for a bad one. If you follow proper procedures, you'll be fine. And this whole "stubbed toe" scenario is so stupid. No medic is going to medicate that. But if someone is complaining of severe pain, I'm going to offer and give meds. I'm don't know if the patient is an addict. Maybe he is. Most importantly, maybe he isn't. How would YOU feel if you were in dire pain and some burnout medic responded and treated you like crap and withheld meds and left you in pain? All I have ever worked in is busy EMS systems in large cities. I can only think of a few times where I have encountered chronic 911 abusers looking for pain meds. You and your partner get to know who they are over time. Dispatch notes on the MDT usually will indicate a patient with high risk on it. If I get one I am familiar with and know they are seeking, then I may not give meds. But I have to be pretty darn sure of it before I go around refusing meds because I worry too many people may be addicts.


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## DrParasite (Oct 8, 2010)

LonghornMedic said:


> And this whole "stubbed toe" scenario is so stupid. No medic is going to medicate that. But if someone is complaining of severe pain, I'm going to offer and give meds.


why not? it hurts when you stub your toe, even worse if you slam your hand in the car door.  heck, my mom kicked a railroad tie once and broke her toe, would you not give her pain meds?  or are you selectively withholding pain meds? [/QUOTE]





LonghornMedic said:


> What an :censored::censored::censored::censored::censored::censored::censored: you are. It's medics like you who give us all a bad name. Who are you to determine if someone with ABD pain isn't having 10/10 pain? And just because you were "man enough" not to call 911 for your FX wrist doesn't mean that someone else may not need pain control. 10/10 headaches aren't deserving medications? Migraines can be debilitating for some people.


abd pain is different, as in a mirgrane.  this is about a broken arm.  

out of curiosity, would you give meds for abd pain?  most medics I know won't, because they don't know what is causing the pain.  not that it isn't painful, only that without knowing the underlying cause, people are hesitant to push pain meds.  oh and as for your 10/10 migranes, I'm sure they are painful, but how do you know they aren't a bleed or an undiagnosed head injury?  There is a reason doctors run tests and perform an assessment before they start giving pain meds.  and contrary to what some people think they have more training and more tools at their disposal before they say "ok lets give some narcotics to take the edge off."

btw, next time I hurt my back, I am going to call for a paramedic unit to give me pain meds.  much easier than waiting for the ER to give them to me.  after all pain is pain right?


LonghornMedic said:


> This statement right here tells me exactly what kind of jaded, burned out EMT you are-
> 
> _If I show up to your broken arm, and you tell me you are just going to just lay there screaming in pain until I request ALS and they give you pain meds, I am either going to pull up a chair and wait for your to grow up, tell you "if you want to be treated, you need to let me treat you, or can can just lay there the pain", and if you still don't want me going anywhere near you, I am going to say "sign the RMA," and next time, have the cops and a supervisor respond when you call again.  If you are going to let the patient dictate how you are going to treat him (not his condition based on your assessment, his desires), than you are a drug seekers dream medic._


actually no.  That shows that I am going to treat my patient based on my assessment, not on what he wants.  I will treat the patient based on my assessment (and yes, his pain complaints is one of those vital signs, one of a larger picture).  I will not let the patient bully me (which is exactly what the patient is doing when they say they are not moving until I do something they want to and I don't think they need) into doing something.  If following my assessment I determine that medicinal pain management is needed, that is one thing.  but no, I do not let the patient demand I do something because they want me to.  and if you do, well, I don't really know what to say.


LonghornMedic said:


> Guys like you last a couple months where I work. And I work in a busy as hell EMS system. But they expect you to be courteous to the patient. Our "business" is providing care and showing compassion. If one of our Paramedics talked to someone like you say you do, you'd be fired. No joke, you would be out the door. If you tell a homeless guy to go F-off, you're gone. Our Medical Director is big on customer service. The patients are our customers and they deserve the right to excellent pre-hospital care. And we're not even a private service worried about contracts, we're a county run 3rd service with about as much of job security as one can get.


I'm pretty sure my system is busier, but that's irrelevant.  

I am courteous to all my patients.  I won't tell a homeless guy to F-off, nor did I ever say I would (despite what you tried to imply).  My operations director as well as my medical director are both big on customer service; however, they both know that the patients should be treated based on what they need, not what they want.  They can want morphine, fentynal, and oxycotin, and any other pain med you can name.  if it's warranted, then they should (and do) receive it.  And still, I have yet to be called into the office for not requesting an ALS unit to provide pain control for a broken arm....

I know this might shock some people, but customer service doesn't mean the customer is always right, but rather doing what is best for the customer.  

I guess some places are willing to give the "customer" whatever they want, regardless of if they need it or not.  I am curious is the response to the question "why did you give that drug" is "well, the patient demanded that I give it to him, and with customer service, the customer is always right" what would your bosses or the legal system think of it


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## DrParasite (Oct 8, 2010)

btw, the poll says 35% think it's an ALS call, and 65% say BLS.

Maybe the more vocal minority is wrong?  and the majority of people (ie, leading in the poll), think BLS is perfectly acceptable, but they don't want to get accused of being harsh jaded EMS providers by a small but vocal providers?

just a thought.


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## JPINFV (Oct 8, 2010)

...alternatively the majority can easily be lacking something that the minority has. Medicine isn't based on a majority vote.


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## medic417 (Oct 8, 2010)

We give pain meds for abdominal pain.  Only systems that are stuck in the 70's don't.


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## medicRob (Oct 8, 2010)

If you have read your textbooks, you would see that you cannot tell whether a patient's pain is real or not and you are not to withhold medications because you "think" the patient is lying to you. 

Don't forget that before "Medic" In your title comes, "PARA" meaning, "in a secondary or accessory capacity". 

Also in response to earlier posts, we treat patients based on our clinical findings. This is not Cookbook medicine or "One size fits all".


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## LonghornMedic (Oct 8, 2010)

DrParasite said:


> I'm pretty sure my system is busier, but that's irrelevant.



Unless your agency or company is handling over *110,000 EMS 911 only* calls a year, you have me beat. Considering there isn't even a city remotely the same size as where I work in NJ, I doubt it.


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## LonghornMedic (Oct 8, 2010)

medic417 said:


> We give pain meds for abdominal pain.  Only systems that are stuck in the 70's don't.



Exactly. We also give meds for patients with a history of migraines. Not sure what kind of back @sswards systems some people work in.


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## lampnyter (Oct 8, 2010)

i think that pain deffinitly determines whether you give pain meds but if people are saying a broken arm is an ALS call then what is a BLS call? Some people make it seem like everything is an ALS.


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## medic417 (Oct 8, 2010)

lampnyter said:


> i think that pain deffinitly determines whether you give pain meds but if people are saying a broken arm is an ALS call then what is a BLS call? Some people make it seem like everything is an ALS.



Everything has the potential to be ALS so it should have a ALS response.


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## MrBrown (Oct 8, 2010)

The American obsession with ALS vs BLS is laughable and utterly ridiculous.

That is not a reflection on individual providers or systems and should not be taken as such but as an overarching concept it has all but been abandoned in other countries as it is outdated and not found anywhere else in medicine.

Lets see, if you go to the ER you get seen by a doctor (eventually) and have access to a Consultant physician, if you go to the dentist you get seen by a dentist, and so on.  But in the US, if you call an ambulance you might get a 120 hour wonder who can take your blood pressure and give you some oxygen.  If ALS turns up they might be able to give you 5 or 10mg of morphine and then have to call the doctor to ask for more, which might get denied.  If your pain does not respond to traditional narcotic analgesia you probably won't get combination analgesia such as morphine+midazolam or ketamine, dilaudid, nubain/foratol or even bloody methoxyflurane/entonox so guess what you're out of luck.  

By saying oh so and so is a BLS call it really does show the limited scope of American EMS' thinking and reflects a lack of appreciation for wider concepts in medicine and international trends within EMS.  It also highlights the poor quality of knowledge being given to providers generally because it is so limited.

Its depressing that after nearly fifty years the American system still advocates a basis of "limited training" with "medical direction" as being acceptable (EMS Agenda for the Futures words not mine)


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## TransportJockey (Oct 8, 2010)

MrBrown said:


> The American obsession with ALS vs BLS is laughable and utterly ridiculous.
> 
> That is not a reflection on individual providers or systems and should not be taken as such but as an overarching concept it has all but been abandoned in other countries as it is outdated and not found anywhere else in medicine.
> 
> ...



Too bad there's a large body that helps control EMS that is against a lot of improvements since it would increase education times


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## Akulahawk (Oct 8, 2010)

There are other ways to treat pain than IV pain meds. Is a simple broken arm an ALS call? Maybe. Maybe Not. Then again, I don't try to blot out your pain. I want to make you comfortable, and your pain tolerable, but not completely gone. Why? I want you to remember to keep still... If you're still moving around because it no longer hurts, you risk further damage to all the structures in the area of the Fx. Of those, I worry most about neurovascular damage...


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## MrBrown (Oct 8, 2010)

jtpaintball70 said:


> Too bad there's a large body that helps control EMS that is against a lot of improvements since it would increase education times



You could just say the IAFF/IAFC/volunteers/Parathinktheyare's/Medicfighters.

They probably know who they are anyway


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## TransportJockey (Oct 8, 2010)

MrBrown said:


> You could just say the IAFF/IAFC/volunteers/Parathinktheyare's/Medicfighters.
> 
> They probably know who they are anyway



I was trying not to point fingers  Besides, a lot of people here know my thoughts on that


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## MrBrown (Oct 8, 2010)

Momma Brown said it was rude to point


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## DrParasite (Oct 10, 2010)

LonghornMedic said:


> Unless your agency or company is handling over *110,000 EMS 911 only* calls a year, you have me beat. Considering there isn't even a city remotely the same size as where I work in NJ, I doubt it.


you got me there.  We do between 100,000 and 70,000 responses, depending on how you calculate numbers.  But we do between 14 and 20 jobs in a 12 hour shift, and are always in the top 10 for busiest EMS systems (per unit).  Can you say the same?

FDNY does 1.1 million EMS calls a year; however in an 8 hour shift, you might do 6 calls on a BLS truck, and 2-4 on an ALS one.  

Our units still run more than they do, despite them having a greater overall call volume.


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## JPINFV (Oct 10, 2010)

I'm going to enjoy these proverbial **** measuring contests based on call volume once I start residency. "Ok...and I'm managing several patients at the same time for periods longer than 15 minutes. Beat that!"


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## MrBrown (Oct 10, 2010)

As if call volume should be an indicator of care quality .....


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## Veneficus (Oct 10, 2010)

MrBrown said:


> As if call volume should be an indicator of care quality .....



In my experience call volume is inversely proportional to care quality.

In fact the busiest system I ever worked for (strangely enuogh it was a 3rd service EMS agency.)had the worst quality of care and worst medics I have seen anywhere.

Though it pains me to say, I have never seen a FD with care that poor either.


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## Epi-do (Oct 10, 2010)

LonghornMedic said:


> And this whole "stubbed toe" scenario is so stupid. No medic is going to medicate that



Well, you can now officially call me "no medic" because I have done almost exactly this.  While that particular pt had no obvious deformity or swelling, there was significant bruising across the top of her foot, and she was unable to bear weight on it.  She was crying and was very protective of the foot.  ...and it all happened when she stubbed her toe on a filing cabinet.

I am sorry, but the original question isn't "simple".  It is all about _properly_ assessing your patient, and treating them according to that assessment.  Do all simple fractures require pain management?  Of course not!  (When I was 10, I broke my arm, but had absolutely no pain until 3 days later, while playing with the dog.  It wasn't until then that I was even taken to the family doctor to be evaluated.)  However, if your patient is in pain and you can do something about it, use the tools your medical director has given you to improve your patient's condition.  

And after re-reading this, I guess it really is simple after all...treat the patient that you have in front of you, *not the one that you think should be in front of you* based upon their complaint.


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## 46Young (Oct 10, 2010)

MrBrown said:


> You could just say the IAFF/IAFC/volunteers/Parathinktheyare's/Medicfighters.
> 
> They probably know who they are anyway



You forgot to include each and every employer that chooses to hire employees without degrees, and also those that give no hiring preference to degreed medics, either. That's maybe 90% of the employers out there. Along with the FD's you have all those hospitals, privates, and muni third services.

Here's one of the best, according to popular opinion:

http://www.wakegov.com/NR/rdonlyres/7B908EBF-1571-4D37-98FA-B0ACD9EA9817/0/Paramedic.pdf

No degree requirements there, just the typical cert, alphabet cards, and an acceptable driving history.

What have they done to advocate increased educational requirements in EMS, namely making a degree as the minimum requirement to be employed? What about other like systems? Just sayin'. All delivery models share the blame, not just the fire service.


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## 46Young (Oct 10, 2010)

MrBrown said:


> You could just say the IAFF/IAFC/volunteers/Parathinktheyare's/Medicfighters.
> 
> They probably know who they are anyway



You forgot to include each and every employer that chooses to hire employees without degrees, and also those that give no hiring preference to degreed medics, either. That's maybe 90% of the employers out there. Along with the FD's you have all those hospitals, privates, and muni third services.

Here's one of the best, according to popular opinion:

http://www.wakegov.com/NR/rdonlyres/7B908EBF-1571-4D37-98FA-B0ACD9EA9817/0/Paramedic.pdf

No degree requirements there, just the typical cert, alphabet cards, and an acceptable driving history.

What have they done to advocate increased educational requirements in EMS, namely making a degree as the minimum requirement to be employed? What about other like systems? Just sayin'. All delivery models share the blame, not just the fire service.


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## JPINFV (Oct 10, 2010)

...because minimum requirements are the end-all, be-all of requirements and guarantee getting hired?

The requirement for almost all medical schools is 90 semester units of undergrad, not an undergraduate degree. However, 99+% of accepted students have an undergrad degree and something like 30% (IIRC) have some type of graduate degree upon starting medical school. How can this be considering that the minimum requirement isn't even a bachelors degree?


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## 46Young (Oct 10, 2010)

JPINFV said:


> ...because minimum requirements are the end-all, be-all of requirements and guarantee getting hired?
> 
> The requirement for almost all medical schools is 90 semester units of undergrad, not an undergraduate degree. However, 99+% of accepted students have an undergrad degree and something like 30% (IIRC) have some type of graduate degree upon starting medical school. How can this be considering that the minimum requirement isn't even a bachelors degree?



Like I said, preference isn't really given for advanced education in a majority of places. Although these employers may not be hiring at the bare minimum, they're also not requiring degrees. We're talking about using degree requirements for employment to increase the standard for the profession as a whole. We're not talking about gving hiring preference to those with experience, a degree in a different field, interviewing well, etc. If more employers, at least the ones worth working for were to be uniform in requiring degrees to be hired, then many would get that degree, to be eligible to work for the choice employers. Other depts and agencies, being left with an inferior hiring pool, would follow suit at some point. My point is that no one is doing this, at least outside of Oregon.


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## princessretard (Oct 10, 2010)

bls i think. emts can treat and splint fractures. if pt experiences nausea, vomiting, maybe even shock because of the fx, well...they can treat for that too and then do a rapid transport to the hospital. so bls.


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## medic417 (Oct 10, 2010)

princessretard said:


> bls i think. emts can treat and splint fractures. if pt experiences nausea, vomiting, maybe even shock because of the fx, well...they can treat for that too and then do a rapid transport to the hospital. so bls.



What can bls do for shock, nausea, pain?  Nothing.


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## princessretard (Oct 10, 2010)

medic417 said:


> What can bls do for shock, nausea, pain?  Nothing.




trendelenberg position, give high flow 02, rapid transport to hospital...that's all a basic can do i guess. not much i know but its a broken bone. there are other traumatic calls where yeah als should definitely be called for intercept. but this one sounds like you can bls it to the ER.


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## TransportJockey (Oct 10, 2010)

princessretard said:


> trendelenberg position, give high flow 02, rapid transport to hospital...that's all a basic can do i guess. not much i know but its a broken bone. there are other traumatic calls where yeah als should definitely be called for intercept. but this one sounds like you can bls it to the ER.



Trend has been shown to basically be useless, but other than that diesel is the only thing BLS can do for a trauma call that is useful.


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## princessretard (Oct 10, 2010)

jtpaintball70 said:


> Trend has been shown to basically be useless, but other than that diesel is the only thing BLS can do for a trauma call that is useful.



ah. gotcha.


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## EMS/LEO505 (Oct 10, 2010)

jtpaintball70 said:


> Trend has been shown to basically be useless.



They don't even teach it in NM anymore for that reason haha


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## lampnyter (Oct 10, 2010)

they taught us trend in my recent basic class for shock.


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## EMS/LEO505 (Oct 10, 2010)

lampnyter said:


> they taught us trend in my recent basic class for shock.



What state?


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## lampnyter (Oct 10, 2010)

Ct.


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## JPINFV (Oct 10, 2010)

lampnyter said:


> they taught us trend in my recent basic class for shock.



EMS isn't exactly known for being up to date on things like this. After all, I'm willing to bet that your course also taught you that supplemental oxygen was harmless, so give it early, often, and in copious amounts.


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## princessretard (Oct 10, 2010)

EMS/LEO505 said:


> They don't even teach it in NM anymore for that reason haha



wait, so why exactly is it useless to put someone in trendelenberg? just so i know. 'cause i took my emt course about a year ago and they were still teaching us that. maybe having the blood flow to your center/heart is not so true??? i dont know.


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## EMS/LEO505 (Oct 10, 2010)

lampnyter said:


> Ct.



Big difference from the south west lol


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## DrParasite (Oct 10, 2010)

princessretard said:


> wait, so why exactly is it useless to put someone in trendelenberg? just so i know. 'cause i took my emt course about a year ago and they were still teaching us that. maybe having the blood flow to your center/heart is not so true??? i dont know.


PHTLS no longer teaches to put people in Trend, now it's lay them supine, and transport them to the er so they can receive IV fluids or blood.


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## JPINFV (Oct 10, 2010)

princessretard said:


> wait, so why exactly is it useless to put someone in trendelenberg? just so i know.


There's no evidence that it works. The handful of studies done are generally small in size, fairly weak and with varying patient populations (sometimes healthy adults, sometimes adults immediately after giving blood, etc), but they've all consistently failed to show (and, by "show," I mean like they might get one subject to have an increase in BP, without evidence of an increase in cardiac output, otherwise no real change, little less a statistically significant change) any increase in blood pressure between laying supine and being in trendelenburg. They have shown, though, increases in intercranial pressure, and an increase in work needed to breath (shifting abdominal contents), among other adverse effects.

Another problem is that different studies test different things. There's a difference between trendelenburg (defined as a full body, head down tilt. Essentially unheard of in prehospital care), and passive leg raising (just the raising of the legs; commonly called "trendelenburg"), but again, regardless of what was tested no difference was found.


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## TransportJockey (Oct 10, 2010)

EMS/LEO505 said:


> They don't even teach it in NM anymore for that reason haha



Yep, it was being phased out when I was in Mike's class in the end of 07


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## 46Young (Oct 10, 2010)

JPINFV said:


> There's no evidence that it works. The handful of studies done are generally small in size, fairly weak and with varying patient populations (sometimes healthy adults, sometimes adults immediately after giving blood, etc), but they've all consistently failed to show (and, by "show," I mean like they might get one subject to have an increase in BP, without evidence of an increase in cardiac output, otherwise no real change, little less a statistically significant change) any increase in blood pressure between laying supine and being in trendelenburg. They have shown, though, increases in intercranial pressure, and an increase in work needed to breath (shifting abdominal contents), among other adverse effects.
> 
> Another problem is that different studies test different things. There's a difference between trendelenburg (defined as a full body, head down tilt. Essentially unheard of in prehospital care), and passive leg raising (just the raising of the legs; commonly called "trendelenburg"), but again, regardless of what was tested no difference was found.



Hey, I'm not trying to call you out, but I'd like to be able to quote studies to others at my dept as to why trendelenberg (passive leg raising, I like that) is ineffective. Would you have any links to studies in regards?


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## Smash (Oct 10, 2010)

JPINFV said:


> There's no evidence that it works. The handful of studies done are generally small in size, fairly weak and with varying patient populations (sometimes healthy adults, sometimes adults immediately after giving blood, etc), but they've all consistently failed to show (and, by "show," I mean like they might get one subject to have an increase in BP, without evidence of an increase in cardiac output, otherwise no real change, little less a statistically significant change) any increase in blood pressure between laying supine and being in trendelenburg. They have shown, though, increases in intercranial pressure, and an increase in work needed to breath (shifting abdominal contents), among other adverse effects.
> 
> Another problem is that different studies test different things. There's a difference between trendelenburg (defined as a full body, head down tilt. Essentially unheard of in prehospital care), and passive leg raising (just the raising of the legs; commonly called "trendelenburg"), but again, regardless of what was tested no difference was found.



This. Trendelenberg position was never intended to be used for shocked patients. It was (and is) a means of moving the abdominal contented during surgery to better get at the bits that need chopped. Or at least the bits that the surgeon wants to chop 

Sing RF, O'Hara D, Sawyer MAJ, Marino PL Trendelenburg Position and Oxygen Transport in Hypovolemic Adults Ann Emerg Med March 1994; 23:564-567

Miyabe M, Namiki A The Effect of Head-down Tilt on Arterial Blood Pressure After Spinal Anesthesia Anesth Analg 1993;76:549-552.

Sibbald WJ, Paterson NA, Holliday RL, Baskerville J The Trendelenburg Position: Hemodynamic Effects in Hypotensive and Normotensive Patients Crit Care Med 1979;7:218-224

Reuter DA, Felbinger TW, Moerstedt, Kilger E, Lamm 
P, Goetz AE Trendelenburg Positioning After Cardiac Surgery: Effects on Intrathoracic Blood Volume Index and Cardiac Performance Eur J Anaesthesiol 2003;20:17-20.


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## TransportJockey (Oct 10, 2010)

46Young said:


> Hey, I'm not trying to call you out, but I'd like to be able to quote studies to others at my dept as to why trendelenberg (passive leg raising, I like that) is ineffective. Would you have any links to studies in regards?



Ive got one that kinda states that :
http://www.cjem-online.ca/v6/n1/p48


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## JPINFV (Oct 10, 2010)

No worries... I normally try to post sources for those posts anyways.

Good first stop for prehosptial evidence based medicine is the Dalhousie University EMS evidence based medicine site: 

http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=207#Trendelenburg

Also:
"Use of the Trendelenburg Position as the Resuscitation Position: To T or Not to T? "

Fairly good review even though it's starting to get a little old (published in 2005).
http://ajcc.aacnjournals.org/cgi/content/full/14/5/364


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## EMS/LEO505 (Oct 10, 2010)

jtpaintball70 said:


> Yep, it was being phased out when I was in Mike's class in the end of 07



Yup, now its all about the MAST pants haha


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## TransportJockey (Oct 10, 2010)

EMS/LEO505 said:


> Yup, now its all about the MAST pants haha



Please tell me you're joking. They were falling out of favor back when I was in class for anything but pelvis stabilization. Hell, most services in NM don't even carry them, even if they are on the NMPRC stocking list.


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## EMS/LEO505 (Oct 10, 2010)

Well there's a debate on them, mike has a couple people help him in lab and they're from sandoval, tijeras. They use them a lot out there, but not much here so idk lol


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## Babalu (Oct 10, 2010)

Linuss said:


> Now here's an interesting question:
> 
> Say you're in a tiered system with medics in fly cars.
> 
> Do you take an ALS resource off the road during a busy day to provide ~5min of pain relief for a broken arm?  Or do you keep the medic out for something else happening?



This pretty much sums up my EMS system, but with a few extra details. The nearest hospital is about 15-20 mins away, which also provides an ALS fly car for the surrounding area which carries 2 medics so typically one rides with PT and the other goes back. Because they only provide one fly car, ALS can be tied up very easily. While it would be unfortunate if the PT had to endure considerable pain during transport, it's wiser in my situation to avoid the mentality that anything and everything must have ALS. Of course there are exceptions to these kinds of things, compounding injuries such as soft tissue injuries like deglovings would make ALS more appropriate.


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## TransportJockey (Oct 10, 2010)

EMS/LEO505 said:


> Well there's a debate on them, mike has a couple people help him in lab and they're from sandoval, tijeras. They use them a lot out there, but not much here so idk lol



Are you in Mike F or Mike V's class (I was in F's class)? And yea, SVFD does tend to use them a lot, but they've gotten some of CNMs last few medic classes, so hopefully that will start to go away. As for Tijeras... I don't know a lot about that area other than it's on the edge of BCFD and AAS response areas... and neither of those services carry PASG


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## LonghornMedic (Oct 10, 2010)

Babalu said:


> This pretty much sums up my EMS system, but with a few extra details. The nearest hospital is about 15-20 mins away, which also provides an ALS fly car for the surrounding area which carries 2 medics so typically one rides with PT and the other goes back. Because they only provide one fly car, ALS can be tied up very easily. While it would be unfortunate if the PT had to endure considerable pain during transport, it's wiser in my situation to avoid the mentality that anything and everything must have ALS. Of course there are exceptions to these kinds of things, compounding injuries such as soft tissue injuries like deglovings would make ALS more appropriate.



So if you were a patient having 9/10 pain, you'd be okay with no pain meds for the 20 min drive in? Keep in mind you've already waited 10 minutes from the time 911 was activated, 10 minutes sitting on scene doing the assessment and another 10-15 minutes to get into an ER bed, see a doc and get meds. By the time you finally get pain meds on board it has been roughly an hour. Let's say in that hour your ALS fly cars did nothing more than watch TV. Still think it was a good idea? Treat what you have now, not what may(or may not) happen.


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## JPINFV (Oct 10, 2010)

^
...but remember, pain medication doesn't decrease mortality, therefore it's useless and paramedics shouldn't be used at all! [remove tongue from cheek]


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## Scott33 (Oct 10, 2010)

Don't assume that there will be a nurse waiting for the patient to arrive, with pain meds already drawn up. I have seen people wait for quite a while for pain relief. "10-15 minutes" is a little ambitious.

Pain scale is an important factor in determining the ESI category, but usually a simple, uncomplicated extremity fracture in a patient with no risk factors will be an ESI-4 (as with strains and sprains which can be equally as painful). This puts them behind about 75% of every other patient in the ED, or roped in with everyone else in fast-track.

It all depends what else is going on, but I think it is reason enough to consider giving pain relief prehospitally whenever possible / applicable.


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## MrBrown (Oct 10, 2010)

46Young said:


> You forgot to include each and every employer that chooses to hire employees without degrees, and also those that give no hiring preference to degreed medics, either. That's maybe 90% of the employers out there. Along with the FD's you have all those hospitals, privates, and muni third services.



That is a problem, however even the two year EMS Degrees seem to have been watered down with a bunch of management or general education requirements which means you spend maybe half your time learning what is already an inadequate amount about the praxis of prehospital medicine.

In the countries that require Bachelors and Advanced Degrees for Paramedic or Intensive Care level we focus specifically on Paramedicine and specalise from semester one of year one with maybe one general education class required across the three years of the degree.  Mind you this is a feature of all our degrees because we do thirteen years of high school at least in NZ and I believe in all Commonwealth countries.



JPINFV said:


> ...99+% of accepted students have an undergrad degree and something like 30% (IIRC) have some type of graduate degree upon starting medical school. How can this be considering that the minimum requirement isn't even a bachelors degree?



In Australia where graduate medical education co-exists with the traditional six year courses they require a Bachelors Degree.



princessretard said:


> bls i think. emts can treat and splint fractures. if pt experiences nausea, vomiting, maybe even shock because of the fx, well...they can treat for that too and then do a rapid transport to the hospital. so bls.



Oh please stop saying things.  



princessretard said:


> trendelenberg position, give high flow 02, rapid transport to hospital...that's all a basic can do i guess. not much i know but its a broken bone. there are other traumatic calls where yeah als should definitely be called for intercept. but this one sounds like you can bls it to the ER.



Once again may I point out that the American notion of BLS vs ALS is utterly hillariously ridicoulous?


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## DrParasite (Oct 10, 2010)

Scott33 said:


> Pain scale is an important factor in determining the ESI category, but usually a simple, uncomplicated extremity fracture in a patient with no risk factors will be an ESI-4 (as with strains and sprains which can be equally as painful). This puts them behind about 75% of every other patient in the ED, or roped in with everyone else in fast-track.


question: would the person with the " uncomplicated extremity fracture" who now has a prehospital IV and is medicated in the field have a higher or lower ESI number, and would he or she be treated in front of the 75% of other patients due to now being under the influence of analgesics and with the prehospital IV already started?


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## Smash (Oct 11, 2010)

DrParasite said:


> question: would the person with the " uncomplicated extremity fracture" who now has a prehospital IV and is medicated in the field have a higher or lower ESI number, and would he or she be treated in front of the 75% of other patients due to now being under the influence of analgesics and with the prehospital IV already started?



I can't speak for the triage category question, but I have seen a study in which patients with a NOF fracture were more likely to recieve timely and adequate pain relief in hospital if they presented having already had IV pain relief in the field.  So lack of prehospital analgesia is not just a prehospital issue, it effects the entire course of care the patient receives.

Untreated acute pain leads to significant ongoing physical, psychological and emotional problems.  Adequate pain relief for any and all patients is not just some warm, fuzzy, nice to do thing so long as we have a medic who feels like doing it, it is an absolutely vital part of the overal management of patients and one of the most important things we can do in prehospital medicine.


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## Scott33 (Oct 11, 2010)

DrParasite said:


> question: would the person with the " uncomplicated extremity fracture" who now has a prehospital IV and is medicated in the field have a higher or lower ESI number, and would he or she be treated in front of the 75% of other patients due to now being under the influence of analgesics and with the prehospital IV already started?



Well, they certainly wouldn't jump to the front of the line. 

However, depending on the facility, type and dose of prehospital analgesia given, and triage nurse - they may be given a higher or lower priority. Should be noted though, that not all prehospital analgesia is opiate / opioid in nature, or requiring of an IV.  

Triage is tailored to the individual, more than just trying to slot the chief complain into an algorithm, and an isolated fracture on its own means very little. The patient who had received 60mg of Toradol IM, and is now completely pain free, will obviously be given a different priority than the patient who presents with diffuse urticaria, wheezing and angioedema after having received Morphine.

Those are the two extremes of course, but they do say, _if in doubt about the severity of a patient's presentation, then up-triage_. But it is also true that if the place is packed with ESI-2s and 3s, then it is often better to downgrade isolated injuries. 

When you hear "take them to fast-track" or "out to the waiting room", it very often means that they will be evaluated and treated a lot sooner than if they were to be allocated a bed in the main ED.


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## princessretard (Oct 11, 2010)

MrBrown said:


> That is a problem, however even the two year EMS Degrees seem to have been watered down with a bunch of management or general education requirements which means you spend maybe half your time learning what is already an inadequate amount about the praxis of prehospital medicine.
> 
> In the countries that require Bachelors and Advanced Degrees for Paramedic or Intensive Care level we focus specifically on Paramedicine and specalise from semester one of year one with maybe one general education class required across the three years of the degree.  Mind you this is a feature of all our degrees because we do thirteen years of high school at least in NZ and I believe in all Commonwealth countries.
> 
> ...





well, buddy, when you work in an area where als is hard to come by then you got no choice but to do the calls as bls. cant sit on scene waiting for the one als truck to show up to take the guy to the hospital. duh. the base i work out of has several bls trucks but only one als. so if the medics are busy and dispatch tells us als wont be able to intercept well then i guess thats that.


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## LonghornMedic (Oct 11, 2010)

Scott33 said:


> When you hear "take them to fast-track" or "out to the waiting room", it very often means that they will be evaluated and treated a lot sooner than if they were to be allocated a bed in the main ED.



I'm not sure how it works where you are, but if a patient is turfed to the waiting room, it's a safe bet they will be waiting for quite some time. We typically get bed assignments when we call in en route. But on rare days where a particular ER may be busy, patients in the waiting room will sit for over an hour.


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## Flight-LP (Oct 11, 2010)

princessretard said:


> well, buddy, when you work in an area where als is hard to come by then you got no choice but to do the calls as bls. cant sit on scene waiting for the one als truck to show up to take the guy to the hospital. duh. the base i work out of has several bls trucks but only one als. so if the medics are busy and dispatch tells us als wont be able to intercept well then i guess thats that.



Actually you do have a choice. You can bring on a change that should have occured decades ago and promote the expansion of ALS services. Alternatively, you can continue to accept the mediocrity that currently exists and be content with offering minimal services to your community. 

Your choice.

Either way, I'll add your area to my "don't get ill or injured" list.


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## Sam Adams (Oct 11, 2010)

LonghornMedic said:


> I'm not sure how it works where you are, but if a patient is turfed to the waiting room, it's a safe bet they will be waiting for quite some time. We typically get bed assignments when we call in en route. But on rare days where a particular ER may be busy, patients in the waiting room will sit for over an hour.



Now THAT is a pipe dream for us.... I can't even fathom getting room assignments over med control. The only time hospitals want us calling is if the pt needs the trauma/ resuscitation team. Also frequently the average waiting room time is well over 2, sometimes up into the 3 and 4 hour range. Not just for 1 of our hospitals, but many of them.


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## boingo (Oct 11, 2010)

Well, we can argue for the "all ALS" system where everyone gets a paramedic v.s. the "tiered" system with a lot of BLS and fewer ALS vehicles reserved for high acuity patients.  

One can claim that they always have ALS on every call, although I don't think there is any evidence suggesting that more ALS = better outcomes, although, at least in the setting of cardiac arrest, there is evidence that systems that operate in a "more BLS less ALS" configuration DO have better outcomes.  Perhaps medics that see 8 high acuity patients a shift, do in excess of 20 intubations a year make more of a difference, (at least in cardiac arrest) than medics that see 7 low acuity patients, with maybe one in need of aggressive intervention a shift, and do less than 10 intubations a year.  

If you saturate a system with paramedics you get paramedics who's learning curve is prolonged, be it EMT's and Paramedics in the U.S, Paremedics and Adavanced Care Paramedics in Canada, or any other configuration.  

The folks in Australia and New Zealand are no different.  They have fewer top end providers with more lesser (although certainly better educated than those in the U.S.) providers doing the majority of the work.  Am I wrong?

As for pain management, I wish the BLS in the U.S. could administer pain meds, I don't think you need and ACP with RSI, thrombolytics and chest tubes to treat and transport a simple fx.


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## MrBrown (Oct 11, 2010)

Last time I checked Intensive Care Paramedics made up around 10% of our workforce and I think it might have gone up a bit in recent years.

You do not need a configuration of all top-tier practitioners in order to be effective and infact many systems (particularly in AU and NZ, although to a degree in some Canadian provinces) are giving skills and knowledge that was once the domain of the advanced level officer to those below him.

In an "all ALS" model you have a large number of pracitioners competing for a limited number of opportunities to apply knowledge and skill which will not be met and people get atrophy and clinically stagnant.  By giving the necessary skill and education options to first-tier crews you reduce the number of unnecessary requests for Intensive Care (for a bit of adrenaline or morphine etc) and increase thier avaliability for complex medical emergencies.


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## clibb (Oct 11, 2010)

Lots of factors:
-CMS
-How long ago the fracture happened.
-What type of pain the pt is experiencing.

But this is usually a BLS call.


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## Veneficus (Oct 11, 2010)

*searching...*

I am still hoping somebody will explain to me if a fx is a bls event that requires so little, why a physician needs to be involved?


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## MrBrown (Oct 11, 2010)

Veneficus said:


> I am still hoping somebody will explain to me if a fx is a bls event that requires so little, why a physician needs to be involved?



Legal reasons, why else is a Doctor involved in 99% of medicine in the US?


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## EMS/LEO505 (Oct 11, 2010)

jtpaintball70 said:


> Are you in Mike F or Mike V's class (I was in F's class)? And yea, SVFD does tend to use them a lot, but they've gotten some of CNMs last few medic classes, so hopefully that will start to go away. As for Tijeras... I don't know a lot about that area other than it's on the edge of BCFD and AAS response areas... and neither of those services carry PASG



Mike F, we still have to train in them because they are still in use in this state lol


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## DrParasite (Oct 12, 2010)

Veneficus said:


> I am still hoping somebody will explain to me if a fx is a bls event that requires so little, why a physician needs to be involved?


ummm, because definitive medical care is an MD?  

It's BLS because "prehospitally" (you know, before you get to the hospital) it can be manged safely by BLS (unless you get a patient who refuses to move until you call for a paramedic, but I digress), packaged, and transported to a hospital (you know, with doctors) where X-rays can be taken, and permanent interventions can be applied, at least until their PMD can follow up with them.

Just like your medical director doesn't need to respond to the scene of a fx, and even if he does, he still wants you transported to the hospital so you can run all his fancy tests.


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## johnrsemt (Oct 12, 2010)

depends if it is your arm that is broken or not:

  I worked with medics that refused to give pain meds;  and kept telling me that I was too liberal with them;  but then would state that if they were ever hurt they wanted me to respond because they knew that I would treat their pain.

  Had a supervisor/Medic call for an intercept one day, with a manager/patient with a head injury:   the way it sounded on the radio, supervisor took run with narcotics.    when I got there, supervisor had narcs, just wasn't comfortable giving them to patient,   wanted me to give them, and then give patient care back to her.


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## 46Young (Oct 12, 2010)

I think that the reason some medics are hesitant to give narcotics is because they're either phobic of screwing up the administration, or more likely they're just lazy, and don't want to go through the process of documentation, restock, etc.


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## rhan101277 (Oct 12, 2010)

46Young said:


> I think that the reason some medics are hesitant to give narcotics is because they're either phobic of screwing up the administration, or more likely they're just lazy, and don't want to go through the process of documentation, restock, etc.



I had an opportunity to give some yesterday for a broken arm that initially I couldn't see any deformity.  But upon moving pt. to backboard it flopped around.  The patient was in pain for sure.  She had pulse,motor, sensory in the affecting extremity.  But she was geriatric, was AAOx3, heart rate of 47, blood pressure was ok, but with all of the heart meds she was on, suspicious ST depression but I only had a 3 lead so its not diagnosable. I was hesitant.  Concerned that a dramatic BP drop could occur for which her cardiovascular system may not be able to compensate for.  Thinking back I could have called med control, but we were only 8 minutes out.

It bothered me to not administer it, since no contraindications existed.  I think I made a good clinical decision though.


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## 46Young (Oct 12, 2010)

rhan101277 said:


> I had an opportunity to give some yesterday for a broken arm that initially I couldn't see any deformity.  But upon moving pt. to backboard it flopped around.  The patient was in pain for sure.  She had pulse,motor, sensory in the affecting extremity.  But she was geriatric, was AAOx3, heart rate of 47, blood pressure was ok, but with all of the heart meds she was on, suspicious ST depression but I only had a 3 lead so its not diagnosable. I was hesitant.  Concerned that a dramatic BP drop could occur for which her cardiovascular system may not be able to compensate for.  Thinking back I could have called med control, but we were only 8 minutes out.
> 
> It bothered me to not administer it, since no contraindications existed.  I think I made a good clinical decision though.



If you were using a LP 12, you can change the monitor function from "monitor" to "diagnostic." This lets you view the leads as if it were an actual 12 lead. At the minimum, you could see II, III, and AVF and assess for any ischemic changes. The morphology differs somewhat from monitor and diagnostic mode. Try it on yourself when you go back to work.

You can bolus for the BP drop. Perhaps you could have called OLMC to be safe, maybe started a conservative plan with 1 mg of MS. I'd be suprised if a mg or two would bottom out the pt. I'm assuming that her HR is controlled medically and wouldn't be able to rise in response, but still. I'd be more worried about the effect of severe pain on the pt.


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## Veneficus (Oct 12, 2010)

46Young said:


> You can bolus for the BP drop. Perhaps you could have called OLMC to be safe, maybe started a conservative plan with 1 mg of MS. I'd be suprised if a mg or two would bottom out the pt. I'm assuming that her HR is controlled medically and wouldn't be able to rise in response, but still. I'd be more worried about the effect of severe pain on the pt.



OLMC is one of my best friends 

Not to split hairs, but I don't see the purpose of extremely small doses of narcotic over time.

If you are using morphine, the recognized dose outside of easy to read EMS protocol numbers is 0.15mg/kg. 

If this elderly person weighs 50 kg. that is 7.5 mg. let's cut it in 1/2 for potential increased potency from effects of aging, gets you 3.75 call it 4 because I don't know anyone who i going to portion out 0.75 mg of MS. 

By those numbers if you gave 1mg every 2 minutes, it would take you 6 minutes to even get to the predicted level of effect. In an 8 minute ride that sort of bites.

If the BP starts to drop, since the vasculature is still a closed container, you can just add a little fluid. Probably won't even need 500ml. 

BP controlled, pain hopefully controlled, if not, decide what to do at that point based on presentation.

Personally I would rather have a person a bit snowed and feeling no pain then take the time to do all the work and get nothing out of it. 

Just the way I think.


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## 46Young (Oct 12, 2010)

Veneficus said:


> OLMC is one of my best friends
> 
> Not to split hairs, but I don't see the purpose of extremely small doses of narcotic over time.
> 
> ...



Thanks, it makes sense when you put it that way.


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## Aidey (Oct 12, 2010)

^^^ I actually prefer to give Fentanyl that way because of its shorter duration. I usually give a loading dose, and then 2-3 smaller doses after that (or more depending on transport time) so that there is a slight chance it won't wear off before the ER can give them anything.


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## 46Young (Oct 12, 2010)

Aidey said:


> ^^^ I actually prefer to give Fentanyl that way because of its shorter duration. I usually give a loading dose, and then 2-3 smaller doses after that (or more depending on transport time) so that there is a slight chance it won't wear off before the ER can give them anything.



I prefer fent as well. We have the choice.


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## Veneficus (Oct 12, 2010)

DrParasite said:


> ummm, because definitive medical care is an MD?.



Yea, I keep hearing that, but I don't know if I really believe it.   



DrParasite said:


> It's BLS because "prehospitally" (you know, before you get to the hospital) it can be manged safely by BLS



I think the point of the argument is whether or not the guy with the broken arm wants the minimum safe level or the maximum medical care available when a level higher than basic exists. 



DrParasite said:


> (unless you get a patient who refuses to move until you call for a paramedic, but I digress), packaged, and transported to a hospital (you know, with doctors) where X-rays can be taken, and permanent interventions can be applied, at least until their PMD can follow up with them.



If I could just share my experience on how this plays out?

Patient arrives at hospital (by whatever means) is examined by staff, some times a doctor, sometimes somebody else. 

If required pain is controlled chemically. If possible by PO.

xray is taken, usually for later comparison. If the fx was complex it creates a whole different event, but lets stick with simple. Whether there is a strain, a sprain, actually a simple fx, or no x-ray finings at all, the patient will receive a plaster splint, and an appointment to follow up with ortho. Then they get bounced.   

Most patients I have ever seen don't have a PCP. For those who do the PCP probably wouldn't want to see them anyway and would direct them to ortho.

Some patients actually show up for the ortho appt. There is a follow up x-ray looking for bone reforming. (scaphoid fx don't actually show up on xray, but the bone healing oes later) If there is evidence of a fx and the splint is well applied, it is left on. If not it is cut off and a circumferential plaster cast applied. 

If no signs of fx, then the splint comes off and a usually expensive commercial splint applied.

While all that sounds rather glorified, I am sure it could be handled by a NP and probably even by a PA at an urgent care.

In a few words: pain meds, xray, splint, ortho follow up, DC.

If you are going to pay for the ambulance ride, (in theory anyway) don't you think that the person would want something done? If not, what is the point of paying to staff an ambulance? 

A $300 taxi ride where nothing is done seems like a terrible waste of money. In many cities I have been, yo could get a cab before an ambulance for such a call. 

The point is though, if you want people to pay for EMS, via taxes or any other way, you have to demonstrate the value of the service. There is no value in paying for nothing. 

I know, there is a splint and o2. But the funny thing about injured people, they like to find the position of comfort and stay there. Amazingly enough the position of comfort (or relative comfort) is the position where the body is suffering the least amount of damage. That could be considered self splinting. 

What's the o2 going to do? Nothing.

Now if even a patch factory medic showed up and gave you some drugs that "helped," people might find more value in EMS. Otherwise, it is hard to convince them to support "nothing" at the prices required.

It comes down to protecting/promoting EMS jobs.

One of the reasons the FD usually has so much more than EMS is because they advertise. People actually perceive value and they pay for it.

A different perspective from pt. advocacy I know. But it sounds better than "all you need," "all you deserve," and "the minimum required."


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## jjesusfreak01 (Oct 12, 2010)

46Young said:


> I think that the reason some medics are hesitant to give narcotics is because they're either phobic of screwing up the administration.



I don't get that. In a worst case scenario if you overdose a patient you can just titrate with naloxone, right? In fact, of all the drugs carried by medics, narcotics are one of the easiest to fix if you mess up. Hate to see a medic thats afraid to give narcotics ever work a complex cardiac arrest.


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## 46Young (Oct 12, 2010)

jjesusfreak01 said:


> I don't get that. In a worst case scenario if you overdose a patient you can just titrate with naloxone, right? In fact, of all the drugs carried by medics, narcotics are one of the easiest to fix if you mess up. Hate to see a medic thats afraid to give narcotics ever work a complex cardiac arrest.



It's true. I've had fights with partners that didn't want to crack open the box. They think that they're going to hit a bump and spray everything all over the bus, or slightly over dose the pt, get sued, and do 10 years in prison or something.


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## Aidey (Oct 12, 2010)

46Young said:


> I prefer fent as well. We have the choice.



Oh no no no no, don't misunderstand me. I do not in any way shape or form prefer to give fent. But since it is all I have that dosing method is how I prefer to give it.


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## Aidey (Oct 12, 2010)

Veneficus said:


> Yea, I keep hearing that, but I don't know if I really believe it.
> 
> 
> 
> ...



You need us, because we give you the good stuff! 

lol, sorry. I understand what you are saying, I'm just not sure demonstrating usefulness by advertising that we give pain meds is the best way to go about things.


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## rhan101277 (Oct 12, 2010)

I can give up to 3mg per dose.  No fentanyl where I work. 10mg max dosage over time.

In hindsight since I did not feel uncomfortable with giving it due to her history, I could have called med control.

That way if something did happen, it wouldn't all be on my shoulders.

If her heart rate was not so low and she wasn't on blood thinners and multitudes of other drugs I would have given it.

Yeah I could have bolused her, but its possible that if things were to go wrong, then her coronary artery perfusion would be affected, coupled with ST depression.

I guess its easy for me to backseat quarterback my own call.

-First, Do No Harm


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## Veneficus (Oct 12, 2010)

Aidey said:


> You need us, because we give you the good stuff!
> 
> lol, sorry. I understand what you are saying, I'm just not sure demonstrating usefulness by advertising that we give pain meds is the best way to go about things.



I much prefer "help reduce pain and suffering." It has worked for practicioners of medicine for 1000+ years. It is also far more accurate than "saving lives."


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## Aidey (Oct 12, 2010)

Like I said, I don't disagree. I'm just in an odd humor today, which has led me to imagine ad slogans like "you call, we haul, with some fentanyl".


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## Handsome Robb (Oct 22, 2010)

Is ILS a choice? Nitronox would be indicated for pain relief, as long as it wasn't contraindicated, which in this scenario none are present...It would provide the pt some relief and keep the ALS provider from having to get involved. I might be way wrong too though.


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## LonghornMedic (Oct 22, 2010)

NVRob said:


> Is ILS a choice? Nitronox would be indicated for pain relief, as long as it wasn't contraindicated, which in this scenario none are present...It would provide the pt some relief and keep the ALS provider from having to get involved. I might be way wrong too though.



Problem with that is there are only a few EMS systems that let EMT-I's administer Nitronox. For that matter, there aren't that many systems that let Paramedics do it either.


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## usalsfyre (Oct 22, 2010)

*Nitronox....*

...is an accountability nightmare. I think that's why you rarely see it in the US. Imagine a non-controlled, non-schedule drug, which gives a decent high, wears of quickly, is tough to track use of and doesn't show up on standard drug screens. I give you nitrous!

Seriously, the one system I carried it in we had to weigh the bottles daily to make sure it didn't "leak" into providers. Considering we were a fire-based EMS who had to through a heavy duty background/polygraph I really doubt it would have been a problem, but admin still didn't trust us. Entonox may be less of a pain (I imagine you could have a single pressure gauge), but is not approved for US use because it's premixed. Add in the fact I'm not sure the Nitronox blenders (which are heavy and awkward themselves) are available anymore and you have a great drug that got a raw deal in the US due to the system being awkward to use and bosses not trusting their employees.


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## Handsome Robb (Oct 22, 2010)

Thanks for clearing that up. Theoretically, if it were within protocol would it be a viable option? They keep teaching us to manage pain and thats our only drug that allows us to do that. Teaching for NREMT rather than real life I guess?


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## akflightmedic (Oct 22, 2010)

usalsfyre said:


> ...is an accountability nightmare. I think that's why you rarely see it in the US. Imagine a non-controlled, non-schedule drug, which gives a decent high, wears of quickly, is tough to track use of and doesn't show up on standard drug screens. I give you nitrous!
> 
> Seriously, the one system I carried it in we had to weigh the bottles daily to make sure it didn't "leak" into providers. Considering we were a fire-based EMS who had to through a heavy duty background/polygraph I really doubt it would have been a problem, but admin still didn't trust us. Entonox may be less of a pain (I imagine you could have a single pressure gauge), but is not approved for US use because it's premixed. Add in the fact I'm not sure the Nitronox blenders (which are heavy and awkward themselves) are available anymore and you have a great drug that got a raw deal in the US due to the system being awkward to use and bosses not trusting their employees.



In my system, the bottle was sealed in a heavy duty plastic bag. You literally had to work hard to tear the plastic or cut it to get to the bottle.

Once it was opened and used on a patient, you notified supervisor and they either brought out a new one already sealed or we went by main station and picked up one and sealed it. The tank which was used was then drained to empty and witnessed, just like any other type of narc administration procedure.

They do have small compact blenders, was very light and had a nice little case with shoulder strap.


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## swissmedic (Oct 27, 2010)

If you have an open fracture or any acute pain it is ALS call.
In my opinon are any other fractures also an ALS call but without light and sirens....
Matt


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## Dutch-EMT (Oct 27, 2010)

swissmedic said:


> If you have an open fracture or any acute pain it is ALS call.
> In my opinon are any other fractures also an ALS call but without light and sirens....
> Matt



Thinking about this subject about ALS or not ALS...
Isn't it stupid that there are differences in BLS, ILS or ALS calls?
Why not draw a line like this:
Interclinical transport, discharge transports: BLS ambulances
All 911 calls: ALS ambulances


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## emt_irl (Oct 27, 2010)

if it was a simple fx with no major complications or moi, im going to say bls, keep als for more important calls.

emt's here can give entanox for pain relief and paracetamol.


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## swissmedic (Oct 27, 2010)

Dutch-EMT said:


> Thinking about this subject about ALS or not ALS...
> Isn't it stupid that there are differences in BLS, ILS or ALS calls?
> Why not draw a line like this:
> Interclinical transport, discharge transports: BLS ambulances
> All 911 calls: ALS ambulances



Dear Dutch-EMT
I think your way is the best !
BLS Units for any clinical transports
ALS Units for any emergency calls, so there is notany dead time for the patients.
Here in Switzerland we have only ALS Units and in some counties the have also emergency doctor units too. 
Matt


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## MrBrown (Oct 27, 2010)

I agree, most of our vehicles are ILS or ALS

ILS is capable of cardioversion, 12 leads, morphine, adrenaline, GTN, salbutamol, naloxone, IV fluids etc whereas ALS can do RSI, atropine, ketamine etc etc .... 

The American ALS vs BLS is hillariously ridicolous from an international standpoint


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## DrParasite (Jun 11, 2020)

Since we have some new people here, would anyone like to contribute their opinion to this thread (and vote in the poll)?


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## RedBlanketRunner (Jun 11, 2020)

Female in her 70's fell getting out of a vehicle in the parking lots of the hospital. ER nurse came on scene and took charge. Woman lying on her side, left forearm extended laterally behind her back. Nurse relocated the arm to the front. An artery was lacerated and one of the major nerves partially severed. Humerus head had broken off.
BLS or ALS, at least have the sense to immobilize in place, not play ortho doc.


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## medichopeful (Jun 11, 2020)

DrParasite said:


> Since we have some new people here, would anyone like to contribute their opinion to this thread (and vote in the poll)?



Sure, I’ll contribute. 

All broken bones are ALS for me, unless they refuse pain meds. If they refuse meds, I may still ride it in because they might change their mind. 

If I got requested by a BLS crew for a broken bone, or pain meds/comfort meds in general, I would have absolutely zero issue with it, and would actually commend them for doing that.


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## DesertMedic66 (Jun 11, 2020)

medichopeful said:


> Sure, I’ll contribute.
> 
> All broken bones are ALS for me, unless they refuse pain meds. If they refuse meds, I may still ride it in because they might change their mind.
> 
> If I got requested by a BLS crew for a broken bone, or pain meds/comfort meds in general, I would have absolutely zero issue with it, and would actually commend them for doing that.


This. All day and everyday. Pain medications are one of the things that can actually help a patient feel much better. If they refuse pain meds or are not having any pain from the fracture then I am OK with them going BLS.


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## E tank (Jun 11, 2020)

RedBlanketRunner said:


> Female in her 70's fell getting out of a vehicle in the parking lots of the hospital. ER nurse came on scene and took charge. Woman lying on her side, left forearm extended laterally behind her back. Nurse relocated the arm to the front. An artery was lacerated and one of the major nerves partially severed. Humerus head had broken off.
> BLS or ALS, at least have the sense to immobilize in place, not play ortho doc.



What if the hand was pulseless as presented?


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## Phillyrube (Jun 11, 2020)

eveningsky339 said:


> The pain management aspect aside, splinting is a technique that every EMT has in his or her bag of tricks.



Only if the splint has velcro.  I dont think they teach real splinting anymore...


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## CCCSD (Jun 11, 2020)

I do.


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## Ensihoitaja (Jun 12, 2020)

Our EMTs can give 100 mcg of IV fentanyl, so unless someone's in a lot of pain or there's something weird going on there's no reason to make it ALS.


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## DesertMedic66 (Jun 12, 2020)

Ensihoitaja said:


> Our EMTs can give 100 mcg of IV fentanyl, so unless someone's in a lot of pain or there's something weird going on there's no reason to make it ALS.


In that case BLS is more than appropriate. Our EMTs aren’t even trusted with oral glucose


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## Peak (Jun 12, 2020)

DrParasite said:


> Since we have some new people here, would anyone like to contribute their opinion to this thread (and vote in the poll)?



A simple fracture can go be driven in POV like the majority that present to clinic or the ED.


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## Peak (Jun 12, 2020)

Ensihoitaja said:


> Our EMTs can give 100 mcg of IV fentanyl, so unless someone's in a lot of pain or there's something weird going on there's no reason to make it ALS.



To be transparent the majority of the busses are double medic, and there aren’t any BLS only crews except for the detox can, correct?


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## DragonClaw (Jun 12, 2020)

Extreme situation aside. 

If I broke my arm I'd just drive myself to the hospital.  Or I'd drive the pt (assuming I'm off duty)

If I was on duty I'd give them an informed option. They're stable and it hurts but you won't like this bill.  If you can't grit the pain, call an uber or a friend.

I broke my ankle and had I not been at the hospital already(and on duty) I'd have driven myself probably.


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## FiremanMike (Jun 12, 2020)

Ensihoitaja said:


> Our EMTs can give 100 mcg of IV fentanyl, so unless someone's in a lot of pain or there's something weird going on there's no reason to make it ALS.



Is this in America?  Who starts the IV?


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## hometownmedic5 (Jun 12, 2020)

Any of you medics out there who think patients only deserve analgesia if you have bones sticking out or 90% burns etc can pick your favorite cheek and pucker up. I have nothing but loathing and disdain for each and every one of you. Try a little humanity on for size. Administering narcotic analgesia isn't launching the space shuttle. It's ten minutes of extra paperwork. Boo Hoo. What kind of sick thrill do you people get sitting there watching someone writhe around in pain, often fighting some sort of anxiety causing restrictions and general stress?

FFS, do your job. I'm not saying every patient with "10/10" atraumatic back pain off and on for forever gets dosed every time they call. This isn't that. Just about any patient not waving a bright red "I'm drug seeking" flag is going to get the benefit of the doubt from me. Of course, I'm a paramedic who spun their motorcycle into the interstate at just under the speed of light and laid their incredulously while the medic made up a lie about why he didn't want to medicate me. No joke. I asked, he said "well..", looked at his watch, and then out the window to estimate time to destination. I worked with a medic a number of years ago who, in complete seriousness told me there was no situation he could conceive in which he'd administer narcotics. None.


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## Peak (Jun 12, 2020)

hometownmedic5 said:


> Any of you medics out there who think patients only deserve analgesia if you have bones sticking out or 90% burns etc can pick your favorite cheek and pucker up. I have nothing but loathing and disdain for each and every one of you. Try a little humanity on for size. Administering narcotic analgesia isn't launching the space shuttle. It's ten minutes of extra paperwork. Boo Hoo. What kind of sick thrill do you people get sitting there watching someone writhe around in pain, often fighting some sort of anxiety causing restrictions and general stress?
> 
> FFS, do your job. I'm not saying every patient with "10/10" atraumatic back pain off and on for forever gets dosed every time they call. This isn't that. Just about any patient not waving a bright red "I'm drug seeking" flag is going to get the benefit of the doubt from me. Of course, I'm a paramedic who spun their motorcycle into the interstate at just under the speed of light and laid their incredulously while the medic made up a lie about why he didn't want to medicate me. No joke. I asked, he said "well..", looked at his watch, and then out the window to estimate time to destination. I worked with a medic a number of years ago who, in complete seriousness told me there was no situation he could conceive in which he'd administer narcotics. None.



I beg to differ. A simple, union, fracture with intact CMS does not warrant intervention beyond a splint and non-opioid pain management. There are is a lot of literature that shows non-opioid pain management to be just as effective.

I think that there is an important distinction between withholding opioids versus treating with the correct analgesic therapy (which is often not an opioid).


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## FiremanMike (Jun 12, 2020)

hometownmedic5 said:


> Any of you medics out there who think patients only deserve analgesia if you have bones sticking out or 90% burns etc can pick your favorite cheek and pucker up. I have nothing but loathing and disdain for each and every one of you. Try a little humanity on for size. Administering narcotic analgesia isn't launching the space shuttle. It's ten minutes of extra paperwork. Boo Hoo. What kind of sick thrill do you people get sitting there watching someone writhe around in pain, often fighting some sort of anxiety causing restrictions and general stress?
> 
> FFS, do your job. I'm not saying every patient with "10/10" atraumatic back pain off and on for forever gets dosed every time they call. This isn't that. Just about any patient not waving a bright red "I'm drug seeking" flag is going to get the benefit of the doubt from me. Of course, I'm a paramedic who spun their motorcycle into the interstate at just under the speed of light and laid their incredulously while the medic made up a lie about why he didn't want to medicate me. No joke. I asked, he said "well..", looked at his watch, and then out the window to estimate time to destination. I worked with a medic a number of years ago who, in complete seriousness told me there was no situation he could conceive in which he'd administer narcotics. None.



While there are certainly medics who are generally lazy about giving narcs because they are lazy, there are also those of us knee deep in the opiate crisis who are evaluating each case individually to decide if it's worth the risk of introducing the patient to the joys of opium intoxication.

Have I given opiates to fractures?  Yes.. Do I give opiates to all fractures?  No..  If that means you loathe and disdain me, I'm ok with it.

Pain should have never been made a vital sign.


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## DrParasite (Jun 12, 2020)

hometownmedic5 said:


> I'm not saying every patient with "10/10" atraumatic back pain off and on for forever gets dosed every time they call.


 as someone who has had 10/10 atraumatic back pain off and on forever, I can say when it's hurting, and I can't move, I would love some pain meds.  





hometownmedic5 said:


> Of course, I'm a paramedic who spun their motorcycle into the interstate at just under the speed of light and laid their incredulously while the medic made up a lie about why he didn't want to medicate me. No joke. I asked, he said "well..", looked at his watch, and then out the window to estimate time to destination.


and you filed a formal complaint with his agency, and demanded corrective action be taken against this medic, because he was not acting in the best interests of his patient, nor was he following the current standard of care... right?  if you didn't, then you seem to be a keyboard commando, who is more than willing to judge and complain about people online, but when an actual wrong occurs, you don't do a thing to actually rectify the situation.





hometownmedic5 said:


> I worked with a medic a number of years ago who, in complete seriousness told me there was no situation he could conceive in which he'd administer narcotics. None.


If I had been in your position, I would have driven back to the station, and told my manager that I refuse to work with someone who clearly has no business being on an ambulance.  That person should be stripped of their certification and terminated.  I am not saying that all pain should be treated by narcotics (in fact, I think quite the opposite), but to refuse to give narcs under any circumstances?  Nope, I'm not working with a provider like that.

And i think everyone should read from page 1 to the current one, to see that many of the opinions are identical to what is being said now.

oh, and @Phillyrube, we teach every student how to splint in my EMT class.  I am usually the evaluator, and all of my students know that I don't care how pretty it is, as long as it actually immobilizes the injury.


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## Aprz (Jun 12, 2020)

I'll frequently give Morphine even if I don't suspect fracture. It's easy to do and pain is pain. Who cares about 5-10 mg Morphine as long as I didn't use it on myself or steal, right?

I'll sometimes give the call to an EMT if the patient insist on not having any pain management. If it looks bad to me and the transport isn't just down the street, I'll retain the call just in case.

We carry intravenous Tylenol/Ofirmev for patients who Morphine is contraindicated in, an alternative if they don't want Morphine, orif their pain isn't severe. Works well.


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## mgr22 (Jun 12, 2020)

Aprz said:


> I'll frequently give Morphine even if I don't suspect fracture. It's easy to do and pain is pain. Who cares about 5-10 mg Morphine as long as I didn't use it on myself or steal, right?



I'm guessing you don't mean this the way it sounds to me, which is that morphine is benign except for its analgesic properties. I agree pain shouldn't be ignored, but nausea and allergic reactions are two reasons I wouldn't give it casually.


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## Bullets (Jun 12, 2020)

Peak said:


> I think that there is an important distinction between withholding opioids versus treating with the correct analgesic therapy (which is often not an opioid).


This is why we are emphasising microdosing of ketamine as an alternative to opiates


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## RocketMedic (Jun 12, 2020)

Pain medication is humane, safe, and generally appropriate.


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## hometownmedic5 (Jun 12, 2020)

DrParasite said:


> as someone who has had 10/10 atraumatic back pain off and on forever, I can say when it's hurting, and I can't move, I would love some pain meds.  and you filed a formal complaint with his agency, and demanded corrective action be taken against this medic, because he was not acting in the best interests of his patient, nor was he following the current standard of care... right?  if you didn't, then you seem to be a keyboard commando, who is more than willing to judge and complain about people online, but when an actual wrong occurs, you don't do a thing to actually rectify the situation.If I had been in your position, I would have driven back to the station, and told my manager that I refuse to work with someone who clearly has no business being on an ambulance.  That person should be stripped of their certification and terminated.  I am not saying that all pain should be treated by narcotics (in fact, I think quite the opposite), but to refuse to give narcs under any circumstances?  Nope, I'm not working with a provider like that.
> 
> And i think everyone should read from page 1 to the current one, to see that many of the opinions are identical to what is being said now.
> 
> oh, and @Phillyrube, we teach every student how to splint in my EMT class.  I am usually the evaluator, and all of my students know that I don't care how pretty it is, as long as it actually immobilizes the injury.




Im not spending the time breaking all of that down.

"as someone who has had 10/10 atraumatic back pain off and on forever" -- Do you notice how I put " " around my 10/10. Those are quotes, where "air quotes" go when they land. I have three slipped disks and five Fxs that didn't heal right. I haven't not been in pain, to some degree, since I hit the pavement ten years ago. There's real pain and ******** pain. The distinction when presented textually is the presence, or absence, of quotes. 

and you filed a formal complaint with his agency... -- Yes, I did. It was not well-received, being that I was a remote former employee of his current employer and employed by a commercial competitor.

 if you didn't, then you seem to be a keyboard commando... -- So yeah, I guess you can eat a fat one right there bud.

if I had been in your position, I would have driven back to the station... -- Blah, blah, blah. Sure you would have. And I bet you'd still have done exactly that if you were a basic that had been hired by that company about a week ago and was down to the decision between rent and food. I'm sure you would have stormed right into the bosses office and like a biggun in the locker room just flat out said "Fire that guy who has worked here for twenty years because I think he's a hack(and all my internet friends think so too...). I chose to keep my job and let him carry his own water; so I bow at your altar of resoluteness. I Am Not Worthy. 

I don't quite recall which argument it was that lit the fire under your backside about me, but if you're going to spend the time busting my apple bag on every post, would you at the very least do me the courtesy of reading for comprehension and offering rebuttals that are more than hollow, self aggrandizing ethics hypothetical.

----

Since there seems to be a comprehension issue, I reread my post. I must be missing the part where I wrote that I give every patient 100 of fent before I get their name. I looked all over, but the part where I wrote a nine year old with a skinned knee will need to be intubated by the time I'm done medicating her.

Obviously there are patients that don't need or want narcotic analgesics. Those people aren't going to get them from me, and shouldn't from anybody else. The people I'm talking about, partly in subtext anybody with access to narcotics and sharp things should be able to follow without a Frommers guide, are the people that should get narcotics, maybe ask for them(and maybe they don't)  but don't get them because of a BS excuse. 

The point I'm trying to make is that some medics are very proud of the fact that their bar for narcs is so high they never reach it and I think it should be legal to take those people out back and kick them until they piss blood and BLS em to the hospital. We shouldnt run around dosing everybody we see, but I'm not hard to impress. If someone needs to see broken bones and scorched flesh to make a patient feel better, I'm fine with the fact we just aren't going to get along.


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## ffemt8978 (Jun 12, 2020)

Play nice or become the focus of my complete and undivided attention.


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## CCCSD (Jun 12, 2020)

See? If you’d just let all these calls be handled as the BLS they are, then you wouldn’t be fighting with each other about pain meds...
😆


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## FiremanMike (Jun 12, 2020)

CCCSD said:


> See? If you’d just let all these calls be handled as the BLS they are, then you wouldn’t be fighting with each other about pain meds...
> 😆



/end thread


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## Ensihoitaja (Jun 13, 2020)

Peak said:


> To be transparent the majority of the busses are double medic, and there aren’t any BLS only crews except for the detox can, correct?



That's correct. We're 95%+ double medic ambulances.


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## Ensihoitaja (Jun 13, 2020)

FiremanMike said:


> Is this in America?  Who starts the IV?


Denver specifically. Colorado has an IV-certification for EMTs that in addition to IVs, allows fentanyl, D10/D50, and Zofran.


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## Carlos Danger (Jun 13, 2020)

An isolated extremity fracture is BLS all day long.

As someone else pointed out, most of them arrive by POV anyway, and many of them a day or two after they happen.


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## ffemt8978 (Jun 13, 2020)

Carlos Danger said:


> An isolated extremity fracture is BLS all day long.
> 
> As someone else pointed out, most of them arrive by POV anyway, and many of them a day or two after they happen.


And usually because a family member insisted on them going to the ER instead of their PCP.


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## akflightmedic (Jun 13, 2020)

FiremanMike said:


> Pain should have never been made a vital sign.



Be sure to tell all your nursing instructors this philosophy and share widely while on clinical...it will bring you much success.


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## FiremanMike (Jun 13, 2020)

akflightmedic said:


> Be sure to tell all your nursing instructors this philosophy and share widely while on clinical...it will bring you much success.



I oversimplified that thought process with that statement.. Pain should be assessed and treated appropriately, obviously..

I believe I stole that quote from Sam Quinones book "Dreamland".


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## RocketMedic (Jun 13, 2020)

If I break something I want to not feel it.


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## cruiseforever (Jun 13, 2020)

ffemt8978 said:


> And usually because a family member insisted on them going to the ER instead of their PCP.



In our area a PCP is going to send them to the ER.  Just as well avoid another stop.


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## DesertMedic66 (Jun 13, 2020)

cruiseforever said:


> In our area a PCP is going to send them to the ER.  Just as well avoid another stop.


Same here or at least send them to an urgent care. 

When I broke my leg, I would have loved some pain meds right away but the only way someone is going to call 911 for me is over my dead body.


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## hometownmedic5 (Jun 13, 2020)

RenegadeRiker said:


> If I break something I want to not feel it.



I’d be happy to help. Others here seem to be more the sit and watch you suffer for their own perverse enjoyment...


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## CCCSD (Jun 13, 2020)

I’ve broken plenty. Pain is managed at many levels by many people. Your comment makes it sound like we enjoy torturing our patients.


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## E tank (Jun 13, 2020)

CCCSD said:


> I’ve broken plenty. Pain is managed at many levels by many people. Your comment makes it sound like we enjoy torturing our patients.


That's the weird zeitgeist of our time...there is this weird witch hunt mentality where if someone perceives an adverse event or outcome, a nefarious motive is established... if something bad happens, someone did something bad....this is projected on actual bad things and completely legitimate actions....if a bias can be confirmed...all bets are off and it doesn't matter who gets hurt because an agenda has been advanced.

It's really nothing new as the med-mal industry is based on it....BLM, antifia, medical malpractice....it's all a page out of the same play book....


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## FiremanMike (Jun 13, 2020)

hometownmedic5 said:


> I’d be happy to help. Others here seem to be more the sit and watch you suffer for their own perverse enjoyment...


Dude drop the attitude for a minute.  I’ve seen numerous people trying to have actual discussions about their viewpoints and I’ve seen no one say they flat out wouldn’t give pain meds.


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## FiremanMike (Jun 13, 2020)

I would encourage everyone in this thread to read Dreamland.. It definitely makes you rethink your current pain management ethos.


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## mgr22 (Jun 13, 2020)

E tank said:


> That's the weird zeitgeist of our time...there is this weird witch hunt mentality where if someone perceives an adverse event or outcome, a nefarious motive is established... if something bad happens, someone did something bad....this is projected on actual bad things and completely legitimate actions....if a bias can be confirmed...all bets are off and it doesn't matter who gets hurt because an agenda has been advanced.
> 
> It's really nothing new as the med-mal industry is based on it....BLM, antifia, medical malpractice....it's all a page out of the same play book....



Yes, and there's another playbook that calls for sidestepping responsibility and blaming others.


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## MonkeyArrow (Jun 13, 2020)

FiremanMike said:


> Dude drop the attitude for a minute.  I’ve seen numerous people trying to have actual discussions about their viewpoints and I’ve seen no one say they flat out wouldn’t give pain meds.


Not (necessarily) taking a side here but doesn’t categorizing this as a BLS call effectively equal refusing to give pain meds?


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## FiremanMike (Jun 13, 2020)

MonkeyArrow said:


> Not (necessarily) taking a side here but doesn’t categorizing this as a BLS call effectively equal refusing to give pain meds?



Not necessarily, I think they’re two separate discussions.

Then again I work in an area without any BLS transport units, so that should be taken into account..  I’ve never “turfed” a run to the squad because it’s never been an option for me..


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## CCCSD (Jun 13, 2020)

Isn’t an Icepack pain control? Ibuprofen, etc?

I AM a fan of fentanyl lollies though...


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## akflightmedic (Jun 13, 2020)

Position of comfort. Splinting. Mindfulness. Square breathing.


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## Peak (Jun 13, 2020)

MonkeyArrow said:


> Not (necessarily) taking a side here but doesn’t categorizing this as a BLS call effectively equal refusing to give pain meds?





CCCSD said:


> Isn’t an Icepack pain control? Ibuprofen, etc?
> 
> I AM a fan of fentanyl lollies though...



The application of a splint is pain control. Ice packs, hot packs on chronic injuries, range of motion, distraction, minimizing stimulation, music, and so on can all decrease pain.

When we do look at meds there are a lot of very effective options that are non-opioid, granted to a more limited availability in EMS. Tylenol, NSAIDs, Robaxin, Flexeril, lidocaine patches, blocks, and so on. When we are able to use things like the on q ball we see better pain management and our narcotic use drops substantially. I’ve had hip fractures where we don’t have to give any narcotics once the patient gets a fascia iliaca block for sometimes well over a day.


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## E tank (Jun 13, 2020)

mgr22 said:


> Yes, and there's another playbook that calls for sidestepping responsibility and blaming others.



I'm missing something...we're agreeing, yeah?


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## Ensihoitaja (Jun 13, 2020)

FiremanMike said:


> I would encourage everyone in this thread to read Dreamland.. It definitely makes you rethink your current pain management ethos.



Seconded. It’s an absolutely fantastic and highly relevant book.


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## DrParasite (Jun 13, 2020)

MonkeyArrow said:


> Not (necessarily) taking a side here but doesn’t categorizing this as a BLS call effectively equal refusing to give pain meds?


As the OP on this, the answer is sometimes. 

If you have a BLS 911 crew, should they request an ALS unit to administer pain meds, and no other intervention?

if you are an ALS truck, are ALS pain meds appropriate to give for a broken arm?  Does it depend on how much pain the patient is in?  if the patient demands pain meds, does that mean a paramedic SHALL give the patient pain meds?  Even if they aren't clinically indicated?


CCCSD said:


> I AM a fan of fentanyl lollies though...


I've heard of them... If we can give them to the BLS crews, does that mean they don't need to tie up an ALS unit, and still provide some pain management?


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## RocketMedic (Jun 14, 2020)

I’m super-glad I got fentanyl and ketamine when I ripped my finger open instead of square breathing.


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## mgr22 (Jun 14, 2020)

E tank said:


> I'm missing something...we're agreeing, yeah?



I am if you are


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## FiremanMike (Jun 14, 2020)

Peak said:


> The application of a splint is pain control. Ice packs, hot packs on chronic injuries, range of motion, distraction, minimizing stimulation, music, and so on can all decrease pain.
> 
> When we do look at meds there are a lot of very effective options that are non-opioid, granted to a more limited availability in EMS. Tylenol, NSAIDs, Robaxin, Flexeril, lidocaine patches, blocks, and so on. When we are able to use things like the on q ball we see better pain management and our narcotic use drops substantially. I’ve had hip fractures where we don’t have to give any narcotics once the patient gets a fascia iliaca block for sometimes well over a day.



We just added toradol to the protocol, hasn’t been used much yet, no data to share..


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## Carlos Danger (Jun 14, 2020)

RenegadeRiker said:


> If I break something I want to not feel it.


That's the attitude that a lot of people have, and it is actually a big problem. Physical pain is a normal part of the human experience and we should be able to deal with fair amount of it. The expectation of never having to tolerate any discomfort and catastrophizing about it and refusing to cope with it psychologically when it inevitably does happen is very self destructive - even if it doesn't ultimately lead to opioid addiction, which is of course the worst outcome and a shockingly likely one among patients who have the highest expectations for not experiencing pain. The medical community makes it worse by allowing patients to have unreasonable expectations and reinforcing the cognitive distortions that create further anxiety about pain and making it even more difficult for people to cope with.  Then they throw opioids and anxiety meds at the the problem and everyone wonders what went wrong. 



hometownmedic5 said:


> I’d be happy to help. Others here seem to be more the sit and watch you suffer for their own perverse enjoyment...


Yeah, you got me. All of us who see nuance and alternative management options where you aren't able to are just evil people. That follows logically, right?  



MonkeyArrow said:


> Not (necessarily) taking a side here but doesn’t categorizing this as a BLS call effectively equal refusing to give pain meds?



Not refusing anything. Just acknowledging that the management that these types of injuries doesn't typically IV opioids.


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## Carlos Danger (Jun 14, 2020)

CCCSD said:


> I AM a fan of fentanyl lollies though...


Aren't we all?


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## Phillyrube (Jun 14, 2020)

FiremanMike said:


> We just added toradol to the protocol, hasn’t been used much yet, no data to share..


I was amazed how many people came to the ED and they were all allergic to toradol.  The only thing that worked was that D drug.


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## FiremanMike (Jun 14, 2020)

Carlos Danger said:


> That's the attitude that a lot of people have, and it is actually a big problem. Physical pain is a normal part of the human experience and we should be able to deal with fair amount of it. The expectation of never having to tolerate any discomfort and catastrophizing about it and refusing to cope with it psychologically when it inevitably does happen is very self destructive - even if it doesn't ultimately lead to opioid addiction, which is of course the worst outcome and a shockingly likely one among patients who have the highest expectations for not experiencing pain. The medical community makes it worse by allowing patients to have unreasonable expectations and reinforcing the cognitive distortions that create further anxiety about pain and making it even more difficult for people to cope with.  Then they throw opioids and anxiety meds at the the problem and everyone wonders what went wrong.
> 
> 
> Yeah, you got me. All of us who see nuance and alternative management options where you aren't able to are just evil people. That follows logically, right?
> ...



I wish I could like this twice.


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## DesertMedic66 (Jun 14, 2020)

Carlos Danger said:


> That's the attitude that a lot of people have, and it is actually a big problem. Physical pain is a normal part of the human experience and we should be able to deal with fair amount of it. The expectation of never having to tolerate any discomfort and catastrophizing about it and refusing to cope with it psychologically when it inevitably does happen is very self destructive - even if it doesn't ultimately lead to opioid addiction, which is of course the worst outcome and a shockingly likely one among patients who have the highest expectations for not experiencing pain. The medical community makes it worse by allowing patients to have unreasonable expectations and reinforcing the cognitive distortions that create further anxiety about pain and making it even more difficult for people to cope with.  Then they throw opioids and anxiety meds at the the problem and everyone wonders what went wrong.
> 
> 
> Yeah, you got me. All of us who see nuance and alternative management options where you aren't able to are just evil people. That follows logically, right?
> ...


But to what extent is physical pain part of the normal experience? Should we no longer be giving pain medications at all because all pain is part of the human experience? Saying “hey man, I know you’re in a lot of pain because your leg was just amputated but you’re human and pain is good for you” doesn’t sit right by me. Patients experience pain differently and have different pain tolerances. A fractured arm on patient A may have no to minimal pain while on patient B it may be the most painful experience they have had. 

We all live with the daily aches and pains but, I’m fairly sure, no one is suggesting that we treat those with pain medications. Your post makes it seem as if you believe any provider who treats any form of pain is doing a disservice to their patient.


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## FiremanMike (Jun 14, 2020)

DesertMedic66 said:


> But to what extent is physical pain part of the normal experience? Should we no longer be giving pain medications at all because all pain is part of the human experience? Saying “hey man, I know you’re in a lot of pain because your leg was just amputated but you’re human and pain is good for you” doesn’t sit right by me. Patients experience pain differently and have different pain tolerances. A fractured arm on patient A may have no to minimal pain while on patient B it may be the most painful experience they have had.
> 
> We all live with the daily aches and pains but, I’m fairly sure, no one is suggesting that we treat those with pain medications. Your post makes it seem as if you believe any provider who treats any form of pain is doing a disservice to their patient.


We can all differentiate patients who can tolerate pain versus patients who aren’t.  We can usually tell those who are exaggerating their pain as well, but not always.

Patients who are tolerating their pain don’t need to be pumped full of opium just for the sake of giving opium.

I’ll speak for me, some patients need pain control because their pain is notably intolerable to them.

There seems to be a disconnect with some on this thread that it’s either all or nothing.  The truth is that it’s in the middle.


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## Carlos Danger (Jun 14, 2020)

DesertMedic66 said:


> But to what extent is physical pain part of the normal experience? Should we no longer be giving pain medications at all because all pain is part of the human experience? Saying “hey man, I know you’re in a lot of pain because your leg was just amputated but you’re human and pain is good for you” doesn’t sit right by me. Patients experience pain differently and have different pain tolerances. A fractured arm on patient A may have no to minimal pain while on patient B it may be the most painful experience they have had.
> 
> We all live with the daily aches and pains but, I’m fairly sure, no one is suggesting that we treat those with pain medications. Your post makes it seem as if you believe any provider who treats any form of pain is doing a disservice to their patient.


I'm curious as to what exactly about my post it was that you interpreted as meaning that I don't think traumatic amputations should receive pain medicine, or that providing any form of pain management is doing a disservice? That follows what I actually wrote about as well as the nonsensical claim made earlier in this thread that some of us would "sit and watch you suffer for their own perverse enjoyment" just because we think fractures can generally be adequately managed with BLS interventions.

My comment was less about acute pain management in general and more about the attitude of "I want to not feel it". No one likes pain. Pain has no utility aside from signaling us that something is wrong, and severe acute or chronic pain that goes untreated can become a pathology of its own which contributes to a myriad of problems.

However, experiencing pain at times is normal and to be expected, and being unwilling or unable to cope with that to any degree is a maladaptive behavior and should not be encouraged, which is exactly what we do when we treat any degree of pain as an emergency and use the patient's subjective report of comfort as a primary metric for the quality of the care that we provide. Rewarding maladaptive behaviors with highly addictive drugs has predictable consequences, and it is known that an unusual degree of anxiety over pain is in itself a predictor for chronic pain syndromes and medication dependency. 

Even though this is clearly more of an issue and consideration in other settings, I don't think that means EMS gets a free pass here. Do we want to at least try to be part of the solution to one of the most pressing problems in healthcare today ? Do we want a seat at the table? Do we want to be seen as clinicians? Then let's start acting like it and realizing that pain is very complex, psychology is a big part of the pain experience, and that pain management can and should and at least sometimes consist of more than just slamming doses of the same drugs that are closely related to a massive problem with chronic pain, record numbers of addictions, and that directly cause the deaths of more people these days than any other non-natural cause.  But, as long as we can't appreciate nuance and can't discuss complex issues like this without ascribing evil motives and putting words in each other's mouths, I don't have much hope for our ability to do that.

Just to be clear, because apparently these disclaimers are necessary here: I _*do*_ give opioids, I _*would*_ give pain medicine to someone whose leg was amputated, and I *do not* get perverse enjoyment from watching people suffer. Yes, it is possible for those things to be true while at the same time believing that pain is rarely an emergency and opioids should not always be seen as the be all / end all of pain management.


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## hometownmedic5 (Jun 14, 2020)

Yeah, you got me. All of us who see nuance and alternative management options where you aren't able to are just evil people. That follows logically, right? [/QUOTE]

There are states that have very, very limited options. Toradol is great. I've given tons of it, but we only got it here two years ago. ASA/APAP for pain, that was last year and we still only have oral, which is about as useful for acute pain as your square breathing malarkey(contextually). Fent was 6 or 8 years ago. Bottom line is it has only been within the last decade that our pain protocol filled in any of the gap between ice pack and morphine; and there are plenty of states behind mine, still living with chem packs and morphine. Your ED, fully stocked with every option and help, not endless help but help, is a poor frame of reference to being alone in the box with somebody whose been injured, bouncing and rocking around. Maybe it's hot out. Maybe it's really hot. Maybe it's cold. Maybe it's really cold. Maybe the driver is driving like a donkey and the ops radio won't shut up and the drivers side dually has a hung caliper that's squeaking like mad. Go ahead and offer me your ice pack and square breathing BS in that context.

I've acknowledged that snowing every patient into next Tuesday is wrong; and you've acknowledged that there are patients who require narcotic analgesia; so we've established that there is a middle ground between our positions. I have reached the limit of the aggregate loss of seconds while we ****er about where the line is, so I'm checking out.

If you(communal) give everybody you can a sedating dose of fentanyl just because you can or you're bored or annoyed, you should probably stop. 
If you don't give anybody narcotics because you're too lazy, you're a waste of oxygen and I hope you die and long and painful death without analgesia.
Where you draw your own line is your own water to carry. Regardless of your specific belief structure, there's a force of some kind that's keeping track and will be along eventually to square up your account.

Seacrest, Out!


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## Peak (Jun 14, 2020)

hometownmedic5 said:


> ASA/APAP for pain, that was last year and we still only have oral, which is about as useful for acute pain as your square breathing malarkey(contextually).







__





						No Significant Difference in Pain Relief for Opioids vs Non-Opioid Analgesics for Treating Arm or Leg Pain - For The Media - JAMA Network
					






					media.jamanetwork.com
				












						Can intravenous paracetamol reduce opioid use in preoperative hip fracture patients? - PubMed
					

Pain due to intra- and extracapsular hip fractures is usually treated with opioid medication. Paracetamol (acetaminophen in North America) has better bioavailability when given intravenously than orally and has been successfully used in the postoperative care of orthopedic patients. However, no...




					pubmed.ncbi.nlm.nih.gov
				












						Acetaminophen provides pain relief similar to narcotics after humerus fracture fixation
					

Orthopedics Today | SAN FRANCISCO — Acetaminophen is as effective as narcotic analgesics for control of postoperative pain among pediatric patients who undergo closed reduction and percutaneous pinning of displaced supracondylar humerus fractures fixation, according to the results of a recently...




					www.healio.com


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## Peak (Jun 14, 2020)

For those are going to argue that IV Tylenol is too expensive, the current average bulk price is $57 per 1 gram bottle, far cheaper than most people think and many other disposables we carry on the bus.

If cost is still a serious concern rectal works almost as well and is much cheaper. One gram of suppositories are about $1.50.

Comparatively fentanyl lollipops are about $20-260each depending on the dose and manufacturer. IV bulk dosing is in the realm of $2.50 per 100 MCG, but that does not account for the manpower used to account for the drug for the DEA requirements.


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## Ensihoitaja (Jun 14, 2020)

Ensihoitaja said:


> Seconded. It’s an absolutely fantastic and highly relevant book.


It's also a Kindle Daily Deal on Amazon today- get it for $1.99! https://smile.amazon.com/Dreamland-...?s=digital-text&ie=UTF8&qid=1592177473&sr=1-6


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## MackTheKnife (Jun 14, 2020)

akflightmedic said:


> Be sure to tell all your nursing instructors this philosophy and share widely while on clinical...it will bring you much success.


BTW, pain has been removed as the 5th vital sign.


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## RocketMedic (Jun 14, 2020)

I’m pretty sure shoving a Tylenol suppository into a rednecks bum for his broken leg or pancreatitis is going to get me punched.
I’m also pretty sure that people in acute pain typically want some help.


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## Peak (Jun 14, 2020)

RenegadeRiker said:


> I’m pretty sure shoving a Tylenol suppository into a rednecks bum for his broken leg or pancreatitis is going to get me punched.
> I’m also pretty sure that people in acute pain typically want some help.



Well you should be getting consent before any intervention.


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## RocketMedic (Jun 14, 2020)

Peak said:


> Well you should be getting consent before any intervention.


“Hey I know I can see the bone but I need you to spread the cheeks.”


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## E tank (Jun 14, 2020)

Carlos Danger said:


> That's the attitude that a lot of people have, and it is actually a big problem. Physical pain is a normal part of the human experience and we should be able to deal with fair amount of it. The expectation of never having to tolerate any discomfort and catastrophizing about it and refusing to cope with it psychologically when it inevitably does happen is very self destructive - even if it doesn't ultimately lead to opioid addiction, which is of course the worst outcome and a shockingly likely one among patients who have the highest expectations for not experiencing pain. The medical community makes it worse by allowing patients to have unreasonable expectations and reinforcing the cognitive distortions that create further anxiety about pain and making it even more difficult for people to cope with.  Then they throw opioids and anxiety meds at the the problem and everyone wonders what went wrong.


 
There is an entire medical sub-specialty that depends on "catastrophizing" pain for it's success with the complicity of OB doctors...it's labor analgesia. I've even had OB's request epidural catheter placement before induction of labor so that at the very first indication of discomfort, the epidural can be bolused with medication. Never had the heart to tell a mom that the pain of a teenager was far more intense than labor (and booze only makes it worse....)


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## Peak (Jun 14, 2020)

RenegadeRiker said:


> “Hey I know I can see the bone but I need you to spread the cheeks.”



If that is your level of professionalism then you should probably work on that.


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## Carlos Danger (Jun 15, 2020)

E tank said:


> There is an entire medical sub-specialty that depends on "catastrophizing" pain for it's success with the complicity of OB doctors...it's labor analgesia. I've even had OB's request epidural catheter placement before induction of labor so that at the very first indication of discomfort, the epidural can be bolused with medication. Never had the heart to tell a mom that the pain of a teenager was far more intense than labor (and booze only makes it worse....)


OB call is the bane of my existence.


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## Peak (Jun 15, 2020)

Carlos Danger said:


> OB call is the bane of my existence.


I thought all the moms love anesthesia since y’all give the epidurals.


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## Carlos Danger (Jun 15, 2020)

Peak said:


> I thought all the moms love anesthesia since y’all give the epidurals.


Oh they do love us. To death. It's not usually the moms who are the problem, though they certainly can be difficult. It's just that OB is a strange world where the rules and expectations are different. Anesthesia providers tend to love OB or hate it. I……do not love it.


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## DrParasite (Jun 15, 2020)

MackTheKnife said:


> BTW, pain has been removed as the 5th vital sign.


according to whom? I saw many who wanted it removed, and recommending it be removed, but who actually made that decision, and where is it documented?


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## RocketMedic (Jun 15, 2020)

Peak said:


> If that is your level of professionalism then you should probably work on that.



Well it’s not like I’m actively spitting my dip while I get the drugs...


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## Kevinf (Jun 18, 2020)

DesertMedic66 said:


> In that case BLS is more than appropriate. Our EMTs aren’t even trusted with oral glucose



I love our fractured EMS systems. For quite a while in PA, EMTs were trusted with oral glucose but not finger poke CBG. Even before that, there was a time where you could apply oxygen, but might not be able to check on SpO2.


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## RedBlanketRunner (Jun 23, 2020)

E tank said:


> What if the hand was pulseless as presented?


I think we all can hear a physicians review; "So you have a displaced FX. In the off chance that the artery was only constricted and not lacerated, which it was, you chose to return the arm to a neutral position?"


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## RocketMedic (Jun 23, 2020)

RedBlanketRunner said:


> I think we all can hear a physicians review; "So you have a displaced FX. In the off chance that the artery was only constricted and not lacerated, which it was, you chose to return the arm to a neutral position?"


As opposed to leaving it in a position with impingement? I know you’re not actually trained, certified or educated in emergency medicine or basic anatomy, but even a cursory Google search explains this concept quite well.


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## E tank (Jun 23, 2020)

RedBlanketRunner said:


> I think we all can hear a physicians review; "So you have a displaced FX. In the off chance that the artery was only constricted and not lacerated, which it was, you chose to return the arm to a neutral position?"


Don't know anything about some "physicians review"...but just for argument's sake...how many arteries are in an arm? And what role might collateral arterial flow play in the setting of an arterial injury? And what might someone do to optimize collateral flow in a pulseless limb?


----------

