# Treatment Question



## fyrfyter (Jul 3, 2011)

I have a 77y/o Female. We were called for weakness, difficulty breathing, abd pain. She has been feeling weak and has had the abd pain for approx. 1 week. She does not remember when her last bowel movement was and has been vomiting for the past couple of days. She also has COPD. Her lung sounds there was some wheezes present. Pt has not ate anything in the past couple of day either. Pt is 130 Sinus Tach.  Pt had labored breathing at 22x min. Pulse OX 83% via a NC at 4lpm. 12 lead was negative and a blood glucose was 90 mg/dL. PT was AO X3 for the whole transport. Also pt rated her pain a 10/10 very tender upon palpation. Her first pressure was 97/79. I have an approx. 7 Min transport time. I started a breathing treatment, IV (18GA). Upon my arrival to the ED her pressure had fallen to 74/42. I did not place her in a trendlenbug position due to her COPD. Her next pressure while in the ED was 62/44. The ER nurse decided to yell at me that her breathing was not an issue and I should of for went the treatment and placed in in trendlenburg position. My belief was that there is no clinical proof that the trendlenburg position was effective and I wanted to correct her breathing problem before she went in to respiratory arrest. Also her pressures didn't start dropping until we were already in the ED. I am just wondering what should or could I  of done different.


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## Shishkabob (Jul 3, 2011)

IV fluids for dehydration.


Giving a "breathing treatment" usually entails albuterol... a beta agonist.  That will increase the HR on someone who's already dehydrated.  Did you also do Atrovent?


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## NomadicMedic (Jul 3, 2011)

Fluid bolus.


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## fyrfyter (Jul 3, 2011)

We only have albuterol as an option. I did have the fluids going. I do understand the risk of the increased HR but I felt that I should try to fix her breathing problem. One thing I forgot to mention was that she had not had her breathing treatment for a day and she usually has a treatment 4x a day.
When I left the ER she the DR. suspected a AAA.


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## mycrofft (Jul 3, 2011)

*Did breath sounds merit spending the itme on a treatment?*

 With seven minutes and a crashing BP, you had to decide which was the most pressing, no pun intended. She live?

Receiving people who get excited tend to ventilate. Some nurses look upon med techs as mindless scut workers.  Talk to your boss about your decision. Keep track of people who consistently dump on you when the boss's second guess was you did OK, turn the name over to the boss with dates times sand notes. The fugedaboutit.


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## Smash (Jul 3, 2011)

Pain relief?


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## fast65 (Jul 3, 2011)

fyrfyter said:


> We only have albuterol as an option. I did have the fluids going. I do understand the risk of the increased HR but I felt that I should try to fix her breathing problem. One thing I forgot to mention was that she had not had her breathing treatment for a day and she usually has a treatment 4x a day.
> When I left the ER she the DR. suspected a AAA.



It sounds like you were at least attempting to treat both problems. You were giving her a breathing treatment and you had fluids running, nothing else you really could have done for the BP unless you wanted to try a dopamine drip, but with a 7 minute transport time that would be kind of unproductive. Did you tell the nurse that there has been no clinical proof that Trendelenburg works?


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## mike1390 (Jul 3, 2011)

ill second the fluid bouls her breathing might always be like that due to her COPD 84% is probably normal for her.


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## MSDeltaFlt (Jul 4, 2011)

Trendellenburg is BS.  That nurse suffered from Cerebrorectal Inversion Syndrome.  Don't sweat it.

SpO2% with a low BP will more than likely be inaccurate unless you still have 2+ radial pulses giving a perfect sawtooth waveform on the pleth. Otherwise the SAT is lying to you period.  So don't trust it.

About the abd pain, where was it?  Tender to palpation?  Rebound?  Pulsating mass?  Radiating to her back?  Bowel sounds?  Vomiting?  Vomiting bile?  Fever?

Low BP.  Did she have radial pulses?  Did you take a manual?  If pulsating mass, BP's in both arms (for signs of dissecting AAA)?

You started a line.  How fast?

Pedal pulses?

Fever?

BGL?

Don't think You have enough information to discern whether or not you could have done more or less.

Not brow beating you by no means.  Just armchair quarterbacking to give you a different perspective.


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## MrBrown (Jul 4, 2011)

Could be any one of four billion things wrong with her.

Unless she had markedly increased work of breathing or was showing signs of being hypoxic Brown might not give her salbutamol.

Brown would put in a drip and give her a litre of fluid.

Brown would probably also have given her some methoxyflurane


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## usafmedic45 (Jul 4, 2011)

> ill second the fluid bouls her breathing might always be like that due to her COPD 84% is probably normal for her.



You know that hypoxic drive and all the related beliefs are a myth right?


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## mike1390 (Jul 4, 2011)

please debunk said myth


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## MrBrown (Jul 4, 2011)

usafmedic45 said:


> You know that hypoxic drive and all the related beliefs are a myth right?



Yes, but many COPD patients have SPO2 is the low seventies or high eighties no?


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## CAOX3 (Jul 4, 2011)

I would withheld the albuterol also, god knows how her muscle will react with the bump in activity, do you have CPAP?

And with the drop in systolic after fluid administration and the severe abdominal pain leads me to believe shes bleeding somewhere, did you witness any dip in her mentation.

Yup she is sick, and her best shot, is to maintain the pressure if you can maybe lay off the fluids see if her pressure bounces and address the respiratory problem if its feasible and bring her to the hospital.  

Sometimes are best efforts end up at the bottom of the toilet, not every complaint is within reach, sometimes you just have to hold the mess together until you reach the ER, you did that 

The nurse is a nitwit., don't sweat it.


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## EMSrush (Jul 4, 2011)

mike1390 said:


> please debunk said myth



I'd like to hear more too.


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## jwk (Jul 4, 2011)

fyrfyter said:


> I have a 77y/o Female. We were called for weakness, difficulty breathing, abd pain. She has been feeling weak and has had the *abd pain for approx. 1 week*. She *does not remember when her last bowel movement was and has been vomiting for the past couple of days.* She also has COPD. Her lung sounds there was some wheezes present. Pt has not ate anything in the past couple of day either. Pt is 130 Sinus Tach.  Pt had labored breathing at 22x min. Pulse OX 83% via a NC at 4lpm. 12 lead was negative and a blood glucose was 90 mg/dL. PT was AO X3 for the whole transport. Also pt rated her pain a 10/10 very tender upon palpation. Her first pressure was 97/79. I have an approx. *7 Min transport time*. I started a breathing treatment, IV (18GA). Upon my arrival to the ED her pressure had fallen to 74/42. I did not place her in a trendlenbug position due to her COPD. Her next pressure while in the ED was 62/44. The ER nurse decided to yell at me that her breathing was not an issue and I should of for went the treatment and placed in in trendlenburg position. My belief was that there is no clinical proof that the trendlenburg position was effective and I wanted to correct her breathing problem before she went in to respiratory arrest. Also her pressures didn't start dropping until we were already in the ED. I am just wondering what should or could I  of done different.



Screw the ER nurse.  A zillion things are in the differential - bowel obstruction high on my list, not treatable in the field.  IV and transport.


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## jwk (Jul 4, 2011)

MSDeltaFlt said:


> SpO2% with a low BP will more than likely be inaccurate unless you still have 2+ radial pulses giving a perfect sawtooth waveform on the pleth. Otherwise the SAT is lying to you period.  So don't trust it.



Really?  Come to my OR and I'll totally dispel that myth for you.  

If you don't have a pulse ox waveform, your readings are questionable at best (I try and tell this to my recovery room nurses all the time when they scream that the SaO2 is 70 and the patient's lips are pink and they're conversing with me and smiling.)

If you DO have a pulse ox waveform, ignore the number at your own risk.  It doesn't have to be a "perfect sawtooth" pattern to get a reading.  As the pressure gets lower, the waveform may decrease in amplitude or look like more of a "damped out" tracing, just like an arterial pressure waveform.


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## Smash (Jul 4, 2011)

jwk said:


> Screw the ER nurse.  A zillion things are in the differential - bowel obstruction high on my list, not treatable in the field.  IV and transport.



Pain relief?  Anyone? (well done Brown though  )


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## MrBrown (Jul 4, 2011)

Smash said:


> Pain relief?  Anyone? (well done Brown though  )



Thanks mate, Brown remembers something from the Clinical Procedures about "pain" being an indication for "pain relief" hmm ....

Brown LOL'd at "12 lead was negative" oh no .... you mean he put on the dots and nothing printed? That's not good! Good on this bloke for even doing a 12 lead, but they are useful for things other than STEMI mate


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## jwk (Jul 4, 2011)

Smash said:


> Pain relief?  Anyone? (well done Brown though  )



What are you treating?


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## mike1390 (Jul 4, 2011)

What do you carry for pain relief that you can use with that BP?


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## MrBrown (Jul 4, 2011)

mike1390 said:


> What do you carry for pain relief that you can use with that BP?



Morphine is not contraindicated in hypotensive patients, however a reduced dose is prudent.

What is stopping you from ensuring a good running drip and starting with say 1mg as an initial dose and going up in 0.5mg increments provided no significant decrease in blood pressure develops?

Or would you rather leave Nana in pain?

Brown recalls one old Nana who was crook, like critical problem crook, hypotensive at 90/60, septal infarct on 12 lead, in extreme pain ... you know what happened? Nana got started out 0.5mg of morphine and another 0.5mg and she was much more comfy and her BP was no worse for wear.


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## mike1390 (Jul 4, 2011)

Maybe it's not where your from but out here you need a systolic of atleast 100. And since her Second BP was 72/(who cares that is too low anyways) and she is fluid depleted anyways not to mention that MS has vasodilatory effects I would never even think of giving this to her. But you cowboys out In NZ are doin it different. She has a fluid problem fix that first. Not to mention do I really wanna slow down her labored breathing w/ wheezes? Come on I know you guys might play MDs on TV but let's get back to the basics....low BP fix it.
But Im just a CA medic what do I know right?


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## MrBrown (Jul 4, 2011)

mike1390 said:


> And since her Second BP was 72/(who cares that is too low anyways) and she is fluid depleted anyways not to mention that MS has vasodilatory effects I would never even think of giving this to her.



The initial BP was 97/79 that is entirely an appropriate BP for a small dose of morphine, it's not an appropriate BP for GTN 



mike1390 said:


> But you cowboys out In NZ are doin it different. She has a fluid problem fix that first.



No, we are not cowboys left to practice wild and untamed rogue medicine in the street and Nana's living room.  

What fluid problem does Nana have? Is it intravascular? Free fluid in the abdomen? ECF expansion? 

Low blood pressure does not always mean hypovolaemia!  



mike1390 said:


> Not to mention do I really wanna slow down her labored breathing w/ wheezes?



A respiratory rate of 22/min is not really laboured although Brown conceeds somebody with a very long expiratory phase (such as a wheezy asthmatic) might also be considered laboured breathing.

If morphine and other opiod analgesics have such a negative respiratory effect then maybe they should not be given to anybody?

Do you know how many patients Brown has seen firsthand, heard about second or thirdhand that have suffered any sort of respiratory problems from having morphine administered? None.



mike1390 said:


> But Im just a CA medic what do I know right?



At the end of the day, you said it not Brown ....


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## usalsfyre (Jul 4, 2011)

mike1390 said:


> Maybe it's not where your from but out here you need a systolic of atleast 100. And since her Second BP was 72/(who cares that is too low anyways) and she is fluid depleted anyways not to mention that MS has vasodilatory effects I would never even think of giving this to her. But you cowboys out In NZ are doin it different. She has a fluid problem fix that first. Not to mention do I really wanna slow down her labored breathing w/ wheezes? Come on I know you guys might play MDs on TV but let's get back to the basics....low BP fix it.
> But Im just a CA medic what do I know right?



Yeah...no.

What you refer to is a LOCAL PROTOCOL restriction on the administration of morphine. It is by no means an absolute contraindication. When we carried morphine on the truck here we had no B/P "floor" for administration, the word was use with caution. Morphine has "unreliable" vasodilatory effects, it's a side effect caused by histamine release, diphenhydramine as a pretreatment MAY be effective in preventing this anyway. None of this is being a "cowboy", it's understanding the medications you carry and they're end effect beyond "treating pain".

Further, while the "pump, pipe, fluid" model of shock is easy to understand it's a bit simplistic for treating shock at the paramedic level. Based on the falling (not "already low and staying there") B/P I strongly suspect acute whole blood loss i.e. acute hemorrhage. This is not a "fluid problem" you can fix without blood products and possibly surgery. "Fixing" her low B/P will likely kill her. Crystaloids for hemorrhage you can't control do NOTHING good. "Fluid" in the hospital setting vs the EMS setting may mean different things.

Finally I've found the respiratory depression component of opiates to be vastly overplayed by EM, especially in patients with any significant catecholamine drive.

I would hesitate on pain relief in this patient, but because these patients are often VERY catecholamine dependent. JWK might have better thoughts on this subject.


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## usalsfyre (Jul 4, 2011)

mike1390 said:


> What do you carry for pain relief that you can use with that BP?



BTW, one of the reasons Fentanyl has become so popular is hemodynamic stability. 

Plus they've got access to Ketamine down there.


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## the_negro_puppy (Jul 4, 2011)

mike1390 said:


> Maybe it's not where your from but out here you need a systolic of atleast 100. And since her Second BP was 72/(who cares that is too low anyways) and she is *fluid depleted* anyways not to mention that MS has vasodilatory effects I would never even think of giving this to her. But you* cowboys out In NZ* are doin it different. She has a *fluid problem* fix that first. Not to mention do I really wanna slow down her labored breathing w/ wheezes? Come on I know you guys might play MDs on TV but let's get back to the basics....low BP fix it.
> But Im just a CA medic what do I know right?



Define "fluid problem"


Cowboys in NZ


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## mike1390 (Jul 4, 2011)

Ok so this is my second time typing this cause the long version was reloaded by my ipad before I sent it so it got erased any who. Short hand version, labored breathing was stated by the OP so lets take his word for it, a BP of 97/79 and a second BP of 74/42 and falling isn't concerning to you? I could see pain management if I was a hospice nurse for this pt. As the OP stated she was a ST @ 130 so not really a pump problem. Could we do anything for a bleed? nope. Can I do something to help with her falling BP? sure can, is it the best solution? nope but its better than nothing in the pre-hospital setting. Im not gunna sit around and play Doogie Howser on this pt, its a Fluid challenge,O2, and diesel. The argument here is would MS really benefit this pt? Plain and simple no, would it do more harm then good? guess well never know. There are to many factors we dont know about this pt, and there are a handful of ways this call could have been run. You've got your way I have mine in the end this pt needs one thing... a Doctor. So i guess we could agree to disagree.


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## mike1390 (Jul 4, 2011)

Im still waiting to hear back on why the hypoxic drive is a myth. Anybody?


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## usalsfyre (Jul 4, 2011)

mike1390 said:


> nope but its better than nothing in the pre-hospital setting.


Wrong. NOTHING is the perfect thing to do. Why do you feel the need to treat B/P? As long as their conscious, withhold fluid.



mike1390 said:


> Im not gunna sit around and play Doogie Howser on this pt, its a Fluid challenge,O2, and diesel.


See previous why a fluid challenge is a bad idea. O2, ehhh, okay. Transport is appropriate.



mike1390 said:


> The argument here is would MS really benefit this pt? Plain and simple no,


:blink:Huh? Treating pain isn't beneficial?


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## MrBrown (Jul 4, 2011)

Come on mate, this lady is obviously in pain so how is pain relief not indicated? Gosh Americans seem so scared of giving anybody analgesia :unsure:

It sounds like this lady might have had an abdo bleed but she might have one of eleventybillion other things wrong with her.  Hypotension is highly nonspecific.


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## MrBrown (Jul 4, 2011)

usalsfyre said:


> See previous why a fluid challenge is a bad idea. O2, ehhh, okay. Transport is appropriate.



Brown might give her a small fluid bolus .... maybe 250cc to see if we can get her BP up a wee bit.

Now, obviously if her tummy is pulsating so bad even blind Brown can see it or she has no distal pluses and screaming about her tearing back pain Brown would think it a bad idea.


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## usalsfyre (Jul 4, 2011)

mike1390 said:


> Im still waiting to hear back on why the hypoxic drive is a myth. Anybody?



Summary article, I prefer to quote original sources but don't have the time tonight


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## usalsfyre (Jul 4, 2011)

MrBrown said:


> Brown might give her a small fluid bolus .... maybe 250cc to see if we can get her BP up a wee bit.
> 
> Now, obviously if her tummy is pulsating so bad even blind Brown can see it or she has no distal pluses and screaming about her tearing back pain Brown would think it a bad idea.


The plummeting pressure with abd pain says "hemorrhage" to me. A SMALL challenge I might agree with...but I without seeing the patient I can't say.

Like I said before I'm even a little dubious on analgesia, simply because strong sympathetic drive is the only thing keeping these folks alive. The anesthetic technique often described for the patient in severe hemorrhagic shock is "succinylcholine and an apology". However this has nothing to do with B/P or the specific properties of any opiate.


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## MrBrown (Jul 4, 2011)

If this lady was Super Crook™ i.e. pale, no radial pulse, unrecordable blood pressure, falling level of consciousness then Brown would give a small fluid bolus only and take her to the hospital with much of the fastness.

Other than that, it sounds like the patient was in pain and had some signs and symptoms which lead us to believe she has a possible intra-abdominal bleed.

Sure, she is probably going to die in surgery and make the anaesthetist fill out lots of paperwork ... but in the meantime, Brown does not think it is contraindicated to give her a tiny dose of analgesia if she is in severe pain. even if it some methoxyflurane or 0.5mg-1mg of morphine.


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## usalsfyre (Jul 4, 2011)

MrBrown said:


> If this lady was Super Crook i.e. pale, no radial pulse, unrecordable blood pressure, falling level of consciousness then Brown would give a small fluid bolus only and take her to the hospital with much of the fastness.
> 
> Other than that, it sounds like the patient was in pain and had some signs and symptoms which lead us to believe she has a possible intra-abdominal bleed.
> 
> Sure, she is probably going to die in surgery and make the anaesthetist fill out lots of paperwork ... but in the meantime, Brown does not think it is contraindicated to give her a tiny dose of analgesia if she is in severe pain. even if it some methoxyflurane or 0.5mg-1mg of morphine.



Probably not...I just get a little nutless when the pressure dips south of 70 systolic .


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## MrBrown (Jul 5, 2011)

usalsfyre said:


> Probably not...I just get a little nutless when the pressure dips south of 70 systolic .



As does Brown, but if Brown picked this lady up with a pressure of 97 systolic and she was in severe pain then Brown would be fine with a very small dose of morphine.  If her pressure was 70 then no, obviously not.


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## usalsfyre (Jul 5, 2011)

MrBrown said:


> As does Brown, but if Brown picked this lady up with a pressure of 97 systolic and she was in severe pain then Brown would be fine with a very small dose of morphine.  If her pressure was 70 then no, obviously not.


True, I've gotten too used to Q5 minute NIBPs from the LP12. My thought process went "it trended from 97 to 72 systolic...holy blood loss Batman!" Then I went back and read that was initial vs drop-off pressure. Stupid on me, carry on...


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## usafmedic45 (Jul 5, 2011)

> Im still waiting to hear back on why the hypoxic drive is a myth. Anybody?



Sorry....life got in the way of my following up with your question. 



mike1390 said:


> please debunk said myth



Basically the idea of "that's where COPDers live" is an outdated idea that stemmed from poor interpretation of limited data analyzed through the lens of less scientific knowledge of physiology than we have today.  Jeff Whitnack (a very smart RT and a man I consider myself lucky to call a friend) has an entire Powerpoint about this.  Basically, the rise in CO2 that was the origin of the "you depress ventilation if you give O2 to COPDers" stems from three things:
1. The Haldane effect (RBCs not carrying O2 can carry CO2 instead and when you start giving O2, it pushes that CO2 into the plasma where it is detected by the ABG or ETCO2 (indirectly in the latter case))
2. Release of the V/q mismatch seen in hypoxia (basically you suddenly start perfusing sections of lung that were previously not being ventilated and up comes the CO2; you actually can see the same thing happen if you have a ventilated patient with a PE who is given thrombolytics)
3. For the last factor, I can't do any better than to quote Jeff directly: "A small amount of the CO2 retainers whom are in acute failure, and whom have their PaCO2 increased further from the two mechanisms listed above, will then reduce their minute ventilation further by about 15-20%.  Usually the PaO2 will have been about 40 on room air, the PaCO2 70.  Given 100% O2 the PaO2 rises well above the 170 range whereby all hypoxic drive is obliterated, and the PaCO2 rises to 90 or more.  But is this a result of a central drive deficiency?  Or of central wisdom?  When the PaO2 is 40 the patient can’t let their PaCO2 go up to 90.  If they did the PaO2 would plummet to about 20 and rapid death would ensue (per the alveolar air equation).  But when the hypoxic drive “gun to the head” is removed, the patient then titrates their respiratory effort such that the ventilatory effort and work is proportioned out for the long haul.  It is not a drive deficiency.  We may view this as patient permissive hypercapnea, may apply non-invasive ventilation, may simply realize that hypoxemia kills and hypercapnea does not, or may intubate them.   Or hypoxemia may be used as a respiratory stimulant.  But if this is the tactic chosen, it should be viewed as akin to giving epinephrine to an already compromised myocardium in order to maintain adequate perfusion pressure.  Just as if we were to see this same patient arrive in stable condition for a clinic condition later we wouldn’t insist they needed an epi drip to maintain a sufficient cardiac output, so too should we not insist that a CO2 retainer not in crisis needs hypoxemia in order to stimulate adequate respiratory drive."  SOURCE: http://home.pacbell.net/whitnack/The_Death_of_the_Hypoxic_Drive_Theory.htm

There is also a list of references on that website and if anyone is interested, I can see if Jeff will allow me to repost the full powerpoint that goes with that presentation.  



> Yes, but many COPD patients have SPO2 is the low seventies or high eighties no?



If inadequately treated yes, but to simply let someone ride with a low sat out of fear of the oxygen boogie man (who doesn't exist) is an incredibly stupid thing to do.  The vast majority of COPDers with adequate therapy and rehabilitation can and do achieve and maintain saturations >90.  If someone has a sat that low and is not getting treated for it, then whomever is responsible for their medical care has dropped the ball and is endangering that patient.


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## mycrofft (Jul 5, 2011)

*To addit to USAF:*

How many patients over the years have we seen in nursing homes wearing oxygen deliverers, or transported with oxygen running, or even resuscitated inluding oxygen, and they weren't dead? How many actually reported and appeared relieved and improved?

And how many times have we seen *someone** announce "That guy's got COPD, fergoshsakes get that O2 off", it is DC'ed, and the pt starts to decompensate? Nice to have some scientific muscle behind decades of observation, excellent.

_* New EMT, in the ambulance, after leaving the originating facility where the pt was on O2, in most cases._ :sad:

PPS:  I thought I had posted a reply that sometimes nurses, especially when they are tired or stressed, will try to bully techs, and yes some are still working where someone still does Trendellenberg. As a retired RN and former EMT, I just wanted to reveal that earth shattering news flash.


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## mycrofft (Jul 5, 2011)

*Note to Brown on American Analgesia*

I wonder if it is a historic relic. Many times battlefield casualties (the roots of our EMS lore and science) seen first by medics had enough morphine on board to bother the anesthesiologists of the day at the MASH or whatever. Furthermore, some casualties undoubtably arrived obtunded and without adequate documentation to assist triage . This may have led to our reliance on biting on a piece of rawhide or whatever.
Even then, it is arguable that analgesia either helped combat shock, or at least comforted someone _*in extremis.*_


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## usafmedic45 (Jul 5, 2011)

mycrofft said:


> I wonder if it is a historic relic. Many times battlefield casualties (the roots of our EMS lore and science) seen first by medics had enough morphine on board to bother the anesthesiologists of the day at the MASH or whatever. Furthermore, some casualties undoubtably arrived obtunded and without adequate documentation to assist triage . This may have led to our reliance on biting on a piece of rawhide or whatever.
> Even then, it is arguable that analgesia either helped combat shock, or at least comforted someone _*in extremis.*_



Actually, if you look at the data from WWII (the last major conflict where your standard company aidman was told to dose people willy nilly with morphine) there was a significant rate of overdose among wounded casualties.  That's one of the primary reasons it fell out of favor.


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## usafmedic45 (Jul 5, 2011)

> And how many times have we seen *someone** announce "That guy's got COPD, fergoshsakes get that O2 off", it is DC'ed, and the pt starts to decompensate? Nice to have some scientific muscle behind decades of observation, excellent.
> 
> _* New EMT, in the ambulance, after leaving the originating facility where the pt was on O2, in most cases._ :sad:[/FONT]



Quite a few times.  Usually right before I resort to (choose one or more):
1.  Suspending them
2.  Firing them
3.  Letting our medical director know so he can decide whether to go after their credentials.


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## mycrofft (Jul 5, 2011)

*WII morphine syrettes (I digress)*

Individual aid kits sometimes included a morphine syrette.
Just found this wild website, "WW2 US Medical Reserach Centre":
http://www.med-dept.com/morphine.php

Brown, we may have found your culprit. Morphine syrettes took 20 to 30 minutes (!!!) to take full effect, longer if the injection was placed in poorly circulating skin.


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## usalsfyre (Jul 5, 2011)

> containing ordinarily ½ Grain of  Morphine Tartrate



1/2 grain, if I'm doing my calculations right, seemingly comes out to 30mgs and some change. The majority of paramedics I know would be messing their drawers with that level of dosing .


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## MrBrown (Jul 5, 2011)

It would appear 1/2 grain is 0.032g or ... 32mg 

You know IV anaesthesia fell out of fashion for a while too after the high mortality rate experienced by Trippler Army Hospital during the Pearl Harbour attacks too, why? Because the physiology of shock and need for adequate oxygenation (and hmm, a bit less IV thiopental?) was poorly understood.

And then we got over it ....


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## usafmedic45 (Jul 5, 2011)

> You know IV anaesthesia fell out of fashion for a while too after the high mortality rate experienced by Trippler Army Hospital during the Pearl Harbour attacks too, why? Because the physiology of shock and need for adequate oxygenation (and hmm, a bit less IV thiopental?) was poorly understood.



More likely it was the lack of blood transfusion capability than anything else.  Even the ability to store plasma was very new and literally 99.99% of the nation's supply was on a plane bound for Pearl the day of the attack. 

There are several good references freely available on the internet from the US Army Medical Corps that discusses the issues pertaining to pre-, intra- and post-operative resuscitation during WWII.  Most of them pin the blame on the failure to recognize that it's not just volume but circulating red cell volumes that you have to replace in a trauma patient (in addition to stopping any further blood loss).  Gee...this all sounds vaguely familiar....


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## J. Burdett (Jul 5, 2011)

Sounds like a handful!

My initial treatment probably would've consisted of Xopenex via neb at 6lpm, 18g IV w/ 250ml bolus, and Trendelenburg positioning if the pt would tolerate it.

I've witnessed Trendelenburg increase BP many, many times. It's not a myth in my book. What was the pt's position upon arrival and what position did you transport her in? If she was supine and you transported in semi-fowlers the drop in BP would be expected given the suspected hypovolemia.

Also, I would have to say MS would be a poor choice for this pt due to it's histamine release which could exacerbate her hypotension and bronchospasm, depression of the vasomotor center in the medulla could also exacerbate her hypotension, and stimulation of the CTZ could exacerbate her vomiting. No bueno. 

That's just me though!     





fyrfyter said:


> I have a 77y/o Female. We were called for weakness, difficulty breathing, abd pain. She has been feeling weak and has had the abd pain for approx. 1 week. She does not remember when her last bowel movement was and has been vomiting for the past couple of days. She also has COPD. Her lung sounds there was some wheezes present. Pt has not ate anything in the past couple of day either. Pt is 130 Sinus Tach.  Pt had labored breathing at 22x min. Pulse OX 83% via a NC at 4lpm. 12 lead was negative and a blood glucose was 90 mg/dL. PT was AO X3 for the whole transport. Also pt rated her pain a 10/10 very tender upon palpation. Her first pressure was 97/79. I have an approx. 7 Min transport time. I started a breathing treatment, IV (18GA). Upon my arrival to the ED her pressure had fallen to 74/42. I did not place her in a trendlenbug position due to her COPD. Her next pressure while in the ED was 62/44. The ER nurse decided to yell at me that her breathing was not an issue and I should of for went the treatment and placed in in trendlenburg position. My belief was that there is no clinical proof that the trendlenburg position was effective and I wanted to correct her breathing problem before she went in to respiratory arrest. Also her pressures didn't start dropping until we were already in the ED. I am just wondering what should or could I  of done different.


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## systemet (Jul 5, 2011)

jwk said:


> What are you treating?



I recognise and respect that you're a physician, and I think I understand the point that you're making -- but given that it's essentially impossible to rule out life-threatening causes of abdominal hemorrhage in the prehospital environment, wouldn't it be more humane to administer a dose of fentanyl here?

If this is an aortic aneurysm, is it likely that the fentanyl is going to be the push on the see-saw that results in clinical misadventure?  (This is an honest question, I'm happy to be corrected here if I'm in error).

And if we're seeing a bowel obstruction (which doesn't seem to be clear here), is a small amount of narcotic with a short t1/2 going to push a medical case towards surgical management?  And if so, is this risk worth leaving the patient in acute pain? 

I accept that once the patient decompensates pain management is less of a priority, but with an initial pressure of 97/systolic, it seems like fentanyl, or a small dose of morphine might be reasonable.  Or not?

With respect.


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## MrBrown (Jul 5, 2011)

systemet said:


> I accept that once the patient decompensates pain management is less of a priority, but with an initial pressure of 97/systolic, it seems like fentanyl, or a small dose of morphine might be reasonable.  Or not?.



Brown does not think it is unreasonable, perhaps what is unreasonable is the mentality of ambo's who feel uneasy about such situations because they push the bounds of their limited education and critical thinking so shy away from such decisions.

Again, this is not being a renegade cowboy free to practice wanton rogue medicine ... it is about critically analysing the situation before you and responding appropriately based upon proportional clinical risk vs benefit.

Lets put this another way:  Do you give Nana who has a history of two infarcts adrenaline for her life threatening asthma or not?


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## RocketMedic (Jul 5, 2011)

With a 7-minute transport time, I personally would not manage her pain. Pressure dropping that much over a 7-minute transport, nonspecific abdominal pain, advanced age, COPD, near-certain polypharmacy, and a lack of food x 4 days, to me, is a great sign of a life-threatening abdominal problem, probably a bleed. I have no objections to running a small fluid challenge, but for such a short transport, I wouldn't go for the narcs.

If transport time was longer AND I had a positive response from Trendelenberg and the fluid challenge AND I felt that her respirations were adequate, THEN I would probably give fentanyl if available. Morphine if not, in small doses- say 1mg initial with 0.5mg for effect.


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## MrBrown (Jul 5, 2011)

Rocketmedic40 said:


> With a 7-minute transport time, I personally would not manage her pain.



Would you manage pain for somebody with a shattered femur or rupturing ovarian cysts? What about somebody who has burn pain or somebody who has appendicitis?

What little faith Brown has in American Paramedics is not going to get bigger any time soon.


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## RocketMedic (Jul 5, 2011)

Brown, considering that in all of those cases, you have posed patients with relatively clear-cut complaints. The OP involved an elderly woman with nonspecific abdominal pain, COPD, unknown pharmacy, and unknown other history WITH A SHORT TRANSPORT TIME! This patient was not in a critical life-threatening amount of pain, but her V/S were enough to alarm not just a paramedic, but the receiving team and the MD as well. This patient is not the one we want to start depressing with narcotics. 

What faith I have in New Zealand's EMS is not shaken, but I'd recommend you refrain from insults. I'm sure there's a lot that we could pick apart about NZ as well.


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## RocketMedic (Jul 5, 2011)

MrBrown said:


> Would you manage pain for somebody with a shattered femur or rupturing ovarian cysts? What about somebody who has burn pain or somebody who has appendicitis?
> 
> What little faith Brown has in American Paramedics is not going to get bigger any time soon.



Yes, by splinting and then chemically, as needed, absent contraindications.
Ruptured ovarian cysts- depends, but probably (absent any contraindications).
Burns- That's pretty obvious.
Appendicitis- Yes.


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## STXmedic (Jul 5, 2011)

Transport time and time to treatment are completely different. 
7min transport time + 2min park, call out, unload, and get in the ER + 3min for you to get a room assignment + 5min until a nurse comes in for report + 10min until the doctor finally shows up and orders anything + another 10min for the nurse to get the Rx, chat with employees on the way back, and finally administer the pain management = the patient unnecessarily being in pain for far too long. 
If you have pain management as an option, transport times should not be one of the issues considered when deciding on whether or not to use them! I've given fentanyl to a patient when we were <2 blocks from the hospital. There is no need for a patient to suffer longer if we can alleviate that suffering.


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## CANMAN (Jul 5, 2011)

Rocketmedic40 said:


> Brown, considering that in all of those cases, you have posed patients with relatively clear-cut complaints. The OP involved an elderly woman with nonspecific abdominal pain, COPD, unknown pharmacy, and unknown other history WITH A SHORT TRANSPORT TIME! This patient was not in a critical life-threatening amount of pain, but her V/S were enough to alarm not just a paramedic, but the receiving team and the MD as well. This patient is not the one we want to start depressing with narcotics.
> 
> What faith I have in New Zealand's EMS is not shaken, but I'd recommend you refrain from insults. I'm sure there's a lot that we could pick apart about NZ as well.



I am sorry but I gotta back up RocketMedic here as well. If my transport time was 7 minutes long then I am sorry but pain management is certainly not the top thing on my list in this case. Not to mention the fact her pressure dropped upon present to the ED and not giving narcs saved the extra explaination to an already PITA RN about you gave her XXX mg of Morphine and now her pressure is in the crapper. 

If some people on this forum can break out the narcs,  draw up, and administer morphine, fentanyl, etc in a matter of a couple blocks then you are certainly a better medic then I. It takes a solid 2 minutes for me to access safe, open second seal, remove med, draw up med, check med, then give med.... I get the whole " no one should have to suffer from pain " trip but honestly NO ONE dies from pain either.... Think about how many people with abdominal pain present to the ED themselves and sit in the waiting room at large hospital for hours, I know in my area, inner city, it isn't unheard of to wait 8 hours.


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## Smash (Jul 5, 2011)

jwk said:


> What are you treating?



10/10 abdominal pain...


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## usalsfyre (Jul 5, 2011)

CANMAN13 said:


> I am sorry but I gotta back up RocketMedic here as well. If my transport time was 7 minutes long then I am sorry but pain management is certainly not the top thing on my list in this case.


As I stated before I've got some reservations about opiates in this case...but transport time is not (nor should it ever be) one of the factors.



CANMAN13 said:


> Not to mention the fact her pressure dropped upon present to the ED and not giving narcs saved the extra explaination to an already PITA RN about you gave her XXX mg of Morphine and now her pressure is in the crapper.


This is what's known as "losing patient focus". Not having to explain something that's needed to the receiving staff is one of the poorest excuses I've ever heard. I've been known to tell receiving nurses (and for that matter physicans) who got crappy the number where they could reach my medical director. He's never gotten a call to my knowledge.



CANMAN13 said:


> If some people on this forum can break out the narcs,  draw up, and administer morphine, fentanyl, etc in a matter of a couple blocks then you are certainly a better medic then I. It takes a solid 2 minutes for me to access safe, open second seal, remove med, draw up med, check med, then give med....


I'll bet I can acomplish this in around a minute, and I've pushed narcs as we were backing in the ED bay before.



CANMAN13 said:


> I get the whole " no one should have to suffer from pain " trip but honestly NO ONE dies from pain either....


I was waiting for this. In the words of Rogue Medic...prove it.



CANMAN13 said:


> Think about how many people with abdominal pain present to the ED themselves and sit in the waiting room at large hospital for hours, I know in my area, inner city, it isn't unheard of to wait 8 hours.


Different situation. None of those folks are waiting 8 hours to get triaged.


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## Melclin (Jul 5, 2011)

*Too many things I wanna say.*

I wish I'd have thrown my hat into the ring earlier.



mike1390 said:


> Maybe it's not where your from but out here you need a systolic of atleast 100. And since her Second BP was 72/(who cares that is too low anyways) and she is fluid depleted anyways not to mention that MS has vasodilatory effects I would never even think of giving this to her. But you cowboys out In NZ are doin it different. She has a fluid problem fix that first. Not to mention do I really wanna slow down her labored breathing w/ wheezes? Come on I know you guys might play MDs on TV but let's get back to the basics....low BP fix it.
> But Im just a CA medic what do I know right?



Not that I think it applies to this case, but I've found that mildly hypotensive pts often come good with a bit of morphine rather than the other way around. 

Hell, we put 45mg of morphine into a bloke the other night and it didn't touch his blood pressure.

I'm having a bit of trouble picturing this pt, but if her COPD is really hitting her hard, I'd be more concerned about morphine and that. But it would just mean I went gently.

Still, my partner says I could come across a runny nose and I'd still have a line in, a litre of fluid up and 10 of morph in by the time we got to the truck  



MrBrown said:


> The initial BP was 97/79 that is entirely an appropriate BP for a small dose of morphine, it's not an appropriate BP for GTN
> 
> 
> A respiratory rate of 22/min is not really laboured although Brown conceeds somebody with a very long expiratory phase (such as a wheezy asthmatic) might also be considered laboured breathing.
> ...



I had this condundrum the other day, male mid 30's I think, super serious asthma hx, sounded like he'd fractured a rib earlier in the night and then his asthma kicked into gear. The current attack wasn't too bad, but it also wasn't responsive to salbutamol, atrovent and prednisolone. 10/10 chest pain. So I'm thinking gently gently with the morph. Gave him 5mg in the end (ended up sticking the penthrane through the hole in the neb mask which worked a treat incidentally). Didn't touch his resps. I was talking to a CSO about it later and he reckoned as long as I stuck with small increments and kept a good eye on it, I should have just kept going until his pain was under control. 

He wasn't worried about the resp depression at all and he's one smart cookie.  



mike1390 said:


> Ok so this is my second time typing this cause the long version was reloaded by my ipad before I sent it so it got erased any who. Short hand version, labored breathing was stated by the OP so lets take his word for it, a BP of 97/79 and a second BP of 74/42 and falling isn't concerning to you? I could see pain management if I was a hospice nurse for this pt. As the OP stated she was a ST @ 130 so not really a pump problem. Could we do anything for a bleed? nope. Can I do something to help with her falling BP? sure can, is it the best solution? nope but its better than nothing in the pre-hospital setting. Im not gunna sit around and play Doogie Howser on this pt, its a Fluid challenge,O2, and diesel. The argument here is would MS really benefit this pt? Plain and simple no, would it do more harm then good? guess well never know. There are to many factors we dont know about this pt, and there are a handful of ways this call could have been run. You've got your way I have mine in the end this pt needs one thing... a Doctor. So i guess we could agree to disagree.



Why does a sinus tach at 130 not mean a "pump problem" to you? Pain relief is important in many ways aside from it being humane. If we didn't use analgesics we'd just about never open the drug bag, its a big part of our job. 

I can say with complete confidence that we are better at pain management in ambulance than most hospitals. If a pts pain wasn't managed well in hospital, I wouldn't take that to mean it didn't need to be managed. 



usalsfyre said:


> The plummeting pressure with abd pain says "hemorrhage" to me. A SMALL challenge I might agree with...but I without seeing the patient I can't say.
> 
> Like I said before I'm even a little dubious on analgesia, simply because strong sympathetic drive is the only thing keeping these folks alive. The anesthetic technique often described for the patient in severe hemorrhagic shock is "succinylcholine and an apology". However this has nothing to do with B/P or the specific properties of any opiate.



This doesn't scream haemorrhage to me, at least initially. It sounds more like one of the many poorly cared for oldies who are miscellaneous crook and a bit dry. I'm having a hard time picturing this pt from the narrative and the second pressure is certainly cause for concern.

Sux and an apology is considered to be inhumane by a lot of people round these parts. Even very sick pts with generally still get some level of sedation/analgesia for intubation.



Rocketmedic40 said:


> Yes, by splinting and then chemically, as needed, absent contraindications.
> Ruptured ovarian cysts- depends, but probably (absent any contraindications).
> Burns- That's pretty obvious.
> Appendicitis- Yes.



You'd splint a femur before any analgesia? :unsure:


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## CANMAN (Jul 5, 2011)

Well somehow my six paragraph defense post didn't post and in turn got deleted and I don't have the energy or care to really type it all again. I just find this forum amusing in the fact that certain people like to dissect peoples entire post. In the OP 83% sats and a borderline pressure without knowing a baseline doesn't scream "get the narcs to me", I am sorry. If you wanna spend 10 minutes on scene to get history, vitals, O2 on board, 3 lead, line, 12 lead, consult, etc and then take you 7 minutes to give meds then great. Me personally I like to work on the way, if anyone on here can do all the above in 7 minutes and give pain meds then great. Time does play a role in certain interventions and if I don't have some basic stuff done then I am not jumping to give pain meds. I am not cold hearted or unsympathetic. If you can draw up, and administer pain meds in under a minute congrats I am excited for you and you deserve a merit badge.

You can ask 20 medics, RN's, or MD's about the same situation, call, patient, whatever and you will most likely get a good amount of different answers. Every provider does some stuff different. On this forum we all come from different backgrounds, skill levels, knowledge base, experience, states, protocols, stengths, weaknesses, you get my drift. Does this mean our patient's are getting a lesser quality of care because we are different. In my short time on the forum there is alot of good info and experienced people on here, but there are also ALOT of egos. Anyone can keyboard quaterback a situation


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## usalsfyre (Jul 5, 2011)

Melclin said:


> This doesn't scream haemorrhage to me, at least initially. It sounds more like one of the many poorly cared for oldies who are miscellaneous crook and a bit dry. I'm having a hard time picturing this pt from the narrative and the second pressure is certainly cause for concern.


Yeah, when I went back and looked I realized there was more of a time differential than I thought when I initially read the scenario.  



Melclin said:


> Sux and an apology is considered to be inhumane by a lot of people round these parts. Even very sick pts with generally still get some level of sedation/analgesia for intubation.


They get SOMETHING for sedation analgesia, but at almost homeopathic doses (0.5-1mcg/kg of fent for intubation I read somewhere...yikes)


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## Melclin (Jul 5, 2011)

CANMAN13 said:


> I am sorry but I gotta back up RocketMedic here as well. If my transport time was 7 minutes long then I am sorry but pain management is certainly not the top thing on my list in this case. .





usalsfyre said:


> As I stated before I've got some reservations about opiates in this case...but transport time is not (nor should it ever be) one of the factors.
> 
> ....
> 
> I'll bet I can acomplish this in around a minute, and I've pushed narcs as we were backing in the ED bay before.



I don't understand this "7 mins transport time isn't much argument". I get that a you'd wanna boogie for a serious abdo bleed, but this pt doesn't scream severe bleed to me. Aside from the hx, the pulse pressure is pretty decent. wonder what her temp was. I'm not having a go at you, but why is this a do everything on the way kind of case? Initially the pt doesn't present as being massively time critical. You've had your time to do all the initial assessment before the pressure drops. Surely 7 mins is then plenty to draw up a drug. 

Besides, the transport time is 7 mins but the time to analgesia is much much more than that. I regularly give morphine in the ambulance bay to set the pt up for the move to a hospital bed or the long wait for a doc to pull their thumb out of their arse and write up a Tylenol or something equally inappropriate. I sometimes give drugs on stretcher while waiting for a bed. Does it absolutely have to have been done before you role in the door? How do things work in the states? Do triage nurses administer pain relief at all? Do pt's have to be seen by a doctor before analgesia is written up?


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## usalsfyre (Jul 5, 2011)

CANMAN13 said:


> I just find this forum amusing in the fact that certain people like to dissect peoples entire post.


If you put it out there, then it's fair game. Don't whine when you don't like the replies. A very god way to learn is being picked apart, and it's what your medical director and clinical department are going to do.



CANMAN13 said:


> In the OP 83% sats and a borderline pressure without knowing a baseline doesn't scream "get the narcs to me",


I'll just say an SpO2 sans waveform is about as useful as ETCO2 sans waveform.



CANMAN13 said:


> I am sorry. If you wanna spend 10 minutes on scene to get history, vitals, O2 on board, 3 lead, line, 12 lead, consult,


Unless your taking every patient to a trauma/cardiac/stroke center that never goes on divert a lot of the stuff you mention is pretty vital to direct traffic. 



CANMAN13 said:


> etc and then take you 7 minutes to give meds then great.


On most calls a vial of fentanyl and a vial of versed live in my shirt pocket so there's not any delay in having the meds available. 



CANMAN13 said:


> Me personally I like to work on the way, if anyone on here can do all the above in 7 minutes and give pain meds then great. Time does play a role in certain interventions and if I don't have some basic stuff done then I am not jumping to give pain meds. I am not cold hearted or unsympathetic.


Not cold hearted or lacking empathy, but it's more important to work quickly and keep your routine than relieve pain? Patient focus folks, patient focus...



CANMAN13 said:


> If you can draw up, and administer pain meds in under a minute congrats I am excited for you and you deserve a merit badge.


IN it's really not that hard...



CANMAN13 said:


> You can ask 20 medics, RN's, or MD's about the same situation, call, patient, whatever and you will most likely get a good amount of different answers. Every provider does some stuff different. On this forum we all come from different backgrounds, skill levels, knowledge base, experience, states, protocols, stengths, weaknesses, you get my drift.


Very true.



CANMAN13 said:


> Does this mean our patient's are getting a lesser quality of care because we are different.


Quite honestly? Yes. Some patients get crappier care because of the provider or system. This happens at all levels.



CANMAN13 said:


> In my short time on the forum there is alot of good info and experienced people on here, but there are also ALOT of egos. Anyone can keyboard quaterback a situation


Very true, however a lot if those egos are earned, mine included. I'm willing to take my lumps though when deserved.


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## Melclin (Jul 5, 2011)

usalsfyre said:


> On most calls a vial of fentanyl and a vial of versed live in my shirt pocket so there's not any delay in having the meds available.



Whats wrong with your drug bag?


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## usalsfyre (Jul 5, 2011)

Melclin said:


> Whats wrong with your drug bag?


Unfortunately the DEA requires me to walk around to the side door, unlock the #?*+@^! safe and put the vials in my pocket on every call, and then return them to the #?*+@^! safe when we get to the ED. It's really a pain in the arse.


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## Melclin (Jul 5, 2011)

usalsfyre said:


> Unfortunately the DEA requires me to walk around to the side door, unlock the #?*+@^! safe and put the vials in my pocket on every call, and then return them to the #?*+@^! safe when we get to the ED. It's really a pain in the arse.



Oh right... I was just taking the piss. So you don't actually have a bag that you take into all your jobs that has all your drugs in it?


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## usalsfyre (Jul 5, 2011)

Melclin said:


> Oh right... I was just taking the piss. So you don't actually have a bag that you take into all your jobs that has all your drugs in it?



Drugs are in the airway bag along with around 35-40 pounds of other stuff depending on the model of portable suction. Maybe one day we will convince them to buy the Thomas packs instead of an Iron Duck bag.


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## CANMAN (Jul 5, 2011)

For some reason I cannot quote when replying....Anyway your missing my point or misinterpreting what I am saying. Getting vitals, and all the stuff I listed in previous post that you quoted is the meat and potatoes, I wasn't trying to say its not. I was saying that if a provider does all that stuff sitting on scene, then transports its easy to do anything in seven minutes, but myself I like to do things in transit and don't sit on scene all day like some (call dependent). Also like I said before, different systems can change how you do things. In Baltimore we don't just run around with narcs in our pocket for "faster administration times." By the time I access a safe, and another lock, all to prevent the addicts from breaking into the unit and stealing the narcs I am sure you can have your pocket vial drawn up. Your not comparing apples to apples and thus the point I was trying to make about you having no idea how other systems function and how that can impact things. 

You can toot your own horn all you want. I haven't gotten to where I am by bring a slack ***, un-educated, closed minded provider. I have had the opportunity to work with some really bright people and great clinicians, in some really prestigious institutions but have never come across anyone who says "I have earned my ego." Well I am glad you think that highly of yourself and its good you do because to the majority your most likely viewed as a pompous ***. Like I said different places, different systems. That attitude would get you no where fast in my department.


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## usalsfyre (Jul 5, 2011)

CANMAN13 said:


> For some reason I cannot quote when replying....Anyway your missing my point or misinterpreting what I am saying. Getting vitals, and all the stuff I listed in previous post that you quoted is the meat and potatoes, I wasn't trying to say its not. I was saying that if a provider does all that stuff sitting on scene, then transports its easy to do anything in seven minutes, but myself I like to do things in transit and don't sit on scene all day like some (call dependent).


I see what your saying, different strokes for different folks. I usually do things like assessments, IVs and meds while my partners hooking up the monitor, getting the 12 lead and figuring out how to remove the patient.



CANMAN13 said:


> You can toot your own horn all you want. I haven't gotten to where I am by bring a slack ***, un-educated, closed minded provider.


Never said you were. In fact you've put forth some extremely good info on other threads. I just think you've lost patient focus from what you posted here. But I've never seen you actually work, so u have no idea.



CANMAN13 said:


> I have had the opportunity to work with some really bright people and great clinicians, in some really prestigious institutions but have never come across anyone who says "I have earned my ego."


Everyone who is good at what they do has some ego investment. Every. Single. Person. If you don't believe your a good clinician, it's highly unlikely you are one. That said, there's people in this forum and that I know in real life that run circles around me. A few of them are not as loud and obnoxious as I can be. But they all have egos.



CANMAN13 said:


> Well I am glad you think that highly of yourself and its good you do because to the majority your most likely viewed as a pompous ***.


Maybe...but guess who their glad to see when they call for a backup truck on a critical patient. I have learned not everyone will like me. I can live with that. I've got friends and a family who do.



CANMAN13 said:


> Like I said different places, different systems. That attitude would get you no where fast in my department.


One of the problems with the Internet  is it's sometimes easier to be an @ss. I'm probably guilty of this. However, any department or service that thinks "years of service" or "seniority" at that particular place make you better is not the place for me. A person should stand on his own merits.


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## MrBrown (Jul 6, 2011)

CANMAN13 said:


> I am sorry but I gotta back up RocketMedic here as well. If my transport time was 7 minutes long then I am sorry but pain management is certainly not the top thing on my list in this case ... honestly NO ONE dies from pain either.... Think about how many people with abdominal pain present to the ED themselves and sit in the waiting room at large hospital for hours, I know in my area, inner city, it isn't unheard of to wait 8 hours.



Come on bro that's pretty crap.  Pain management is one of the most important things an Ambulance Officer does, if not arguably the most important because we know the most important sure aint going to cardiac arrests and dangling out of helicopters ... 

It is not unheard of to wait 6 or 8 hours here at the emergency department but not if you are in 10/10 pain you'd probably get seen in under 30 minutes



Melclin said:


> Hell, we put 45mg of morphine into a bloke the other night and it didn't touch his blood pressure.



We put 20mg into Nana and it didn't touch hers either



Melclin said:


> Sux and an apology is considered to be inhumane by a lot of people round these parts. Even very sick pts with generally still get some level of sedation/analgesia for intubation.



Brown thinks what usalsfyre is referring to is the "cascade anaesthesia technique" which Brown has read about in an anaesthesia textbook as being a legitimate medical thingamadongle 



CANMAN13 said:


> If you wanna spend 10 minutes on scene to get history, vitals, O2 on board, 3 lead, line, 12 lead, consult, etc and then take you 7 minutes to give meds then great. Me personally I like to work on the way, if anyone on here can do all the above in 7 minutes and give pain meds then great.



Gosh what is it with you Americans and this over zealous attitude that you have to rush in, throw the patient on some form of extracation device and race them to the hospital?

Here it is very common to spend 20 minutes at a job inside the house dealing with the patient, Brown has spent almost an hour at a job where Nana broke her leg before making sure she had enough morph and ketamine to where she was not in significant pain before we moved her.  We do most of our assessment and treatment at the scene unless the patient is very unwell



CANMAN13 said:


> Also like I said before, different systems can change how you do things. In Baltimore we don't just run around with narcs in our pocket for "faster administration times." By the time I access a safe, and another lock, all to prevent the addicts from breaking into the unit and stealing the narcs I am sure you can have your pocket vial drawn up. Your not comparing apples to apples and thus the point I was trying to make about you having no idea how other systems function and how that can impact things.



And yet this has absolutely no bearing on anything whatsoever, doesn't matter to Brown where the morphine is, doesn't change Brown's decision to give it or not.


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## usalsfyre (Jul 6, 2011)

CANMAN13 said:


> In Baltimore we don't just run around with narcs in our pocket for "faster administration times." By the time I access a safe, and another lock, all to prevent the addicts from breaking into the unit and stealing the narcs I am sure you can have your pocket vial drawn up.


Somehow I missed this....

Why is it inner city providers think they have the market sewn up on crazy addicts? 

My drugs are stored in a safe. As I stated earlier, I pull drugs on every call, just like I take equipment in. Otherwise I can't treat pain, do a neuroprotective RSI, treat status seizures or sedate an agitated patient. The narcs are as much a part of my equipment as the cardiac monitor. There's systems where the medics carry the narcs on their person, yet these locales don't seem to have medics getting shot over their drugs.

I've worked in and with many different systems in two different states, I'm aware there's operational differences.


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## RocketMedic (Jul 6, 2011)

I don't think that we want to find how this patient reacts to morphine unless we have to.
And yes, I'd splint a fracture before I give narcs. A decrease in pain is an indicator to good positioning, and I'd rather stabilize a fracture before medication. I know Brown thinks I'm wrong, but I know I'm right.


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## STXmedic (Jul 6, 2011)

Rocketmedic said:


> And yes, I'd splint a fracture before I give narcs. A decrease in pain is an indicator to good positioning, and I'd rather stabilize a fracture before medication. I know Brown thinks I'm wrong, but I know I'm right.



Many more people than Brown will think you are wrong. That's cruel, heartless, and bad medicine. Have you ever seen traction at a hospital? That patient is HEAVILY sedated before they do anything!


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## usafmedic45 (Jul 6, 2011)

> I don't think that we want to find how this patient reacts to morphine unless we have to.



Wait until you experience severe orthopedic or visceral pain and then see how you feel about that.



> And yes, I'd splint a fracture before I give narcs. A decrease in pain is an indicator to good positioning,



So is the decrease in pain you get after a slight dose of narcotics and THEN again after splinting.  However, you honestly shouldn't be reducing most fractures in the field to begin with but let's stay on topic.



> I know Brown thinks I'm wrong,



Well, USAFMedic45 thinks you're a borderline sadist or at least, not very :censored::censored::censored::censored:ing considerate of your patients.



> but I know I'm right.



"...but I _think_ I'm right."

Fixed that for you.


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## RocketMedic (Jul 6, 2011)

No, I said stabilize. Stabilization and traction are different things. Pain management is important, but skipping basic steps to push narcs is bad medicine. If you're medicating critical patients for pain before transport or assessment, you might be doing something wrong


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## Aidey (Jul 7, 2011)

Or you might actually be doing something right. 

I'm liberal with pain meds. Unless you snow someone giving them some pain meds right off is not going to eliminate your ability to assess them.


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## usafmedic45 (Jul 7, 2011)

> Pain management is important, but skipping basic steps to push narcs is bad medicine.



But assuring the patient is free of pain and not made to hurt more is too.  It's not skipping anything.  It simply is shuffling the order to place comfort over checklist medicine.



> If you're medicating critical patients for pain before transport or assessment, you might be doing something wrong



Who said anything about not assessing?  Who said anything about critical?  If the patient is critical, honest to G-d critical, I have bigger concerns than the extremity fractures and therefore formal splinting before transport or assessment isn't going to be a concern either.  When it's an isolated broken leg or arm, your priority is the alleviation of pain and further damage.  The best way to do that is to make the patient as free of pain as possible_ then _to apply the splint.  Welcome to the way that every MD I have ever worked under has told us how to do it.  You might think you know you're right, but if you aren't willing to listen to constructive criticism your opinion of your own skills does not matter a whole lot to anyone else.  The inability to strongly critique your approach things in way that isn't simply patting yourself on your back is very dangerous in a medical provider.


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## ffemt8978 (Jul 7, 2011)

Keep it polite


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## Melclin (Jul 7, 2011)

Rocketmedic said:


> And yes, I'd splint a fracture before I give narcs. A decrease in pain is an indicator to good positioning, and I'd rather stabilize a fracture before medication.



The same thing can be achieved with pain relief first. Its just that instead of agony turning into slightly less agony, its uncomfortable turning to less uncomfortable. 



> Pain management is important, but skipping basic steps to push narcs is bad medicine



It seems like a pretty common idea over your way, and I'll admit, it lingers here too, that morphine is some massive step in pt care and something to be avoided at all costs. Morphine isn't skipping a basic step, it IS a basic step. 

To me, splinting a serious fracture happens like this. Inhaled/intranasal analgesia, support in a position of comfort, morphine until still in pain but reasonably comfortable, in with more anaesthetic gas, splint, pt wakes with pain, morphine until pt is comfortable enough to snooze. I just can't fathom splinting a femur or humerus or something without any analgesia, that's just awful.


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## MrBrown (Jul 7, 2011)

Melclin said:


> I just can't fathom splinting a femur or humerus or something without any analgesia, that's just awful.



You are correct mate but what is more awful is these blokes with such notions like 2mg of morphine is an acceptable dose, nobody died from being in pain, get everybody to the hospital really quick, if you are close to the hospital don't bother with pain meds, morphine puts everybody into respiratory arrest ....

Brown is not trying to pick on specific people but the idea that such notions exist and are actively defended by our international colleagues is a bit frightening


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## usafmedic45 (Jul 7, 2011)

> Brown is not trying to pick on specific people but the idea that such notions exist and are actively defended by our international colleagues is a bit frightening



Welcome to the unfortunate idea that everyone's opinion matters even the dumbest idiot in room.  As Winston Churchill said, "The best argument against democracy is a five minute conversation with the average voter".


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## jwk (Jul 7, 2011)

usafmedic45 said:


> But assuring the patient is free of pain and not made to hurt more is too.  It's not skipping anything.  It simply is shuffling the order to place comfort over checklist medicine.



Shuffling the order is still checklist medicine.  Of course you're skipping something.  If you have no clue WHY you're treating pain, other than the fact that the patient has pain, then your priorities are off.


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## usafmedic45 (Jul 7, 2011)

> If you have no clue WHY you're treating pain, other than the fact that the patient has pain, then your priorities are off.



Seriously?  You've been around this forum long enough (more than a week) to know that analgesic administration just because we can is not what I am suggesting nor does it take more than a few seconds for anyone but a truly troglodytic moron who habitually drools uncontrollably (and we have more than a few of those in our ranks) to look at someone holding an arm or leg that is bent somewhere it's not supposed to bend and recognize the "clue" _why_ they need to have their pain managed.  The one thing that patients will remember above all other- regardless of everything we do for them- is whether we make them stop hurting.  Manipulating a fractured extremity without adequate analgesia is painful and unless you have significant extenuating circumstances (fire, shock, need to get to cover due to gunfire, etc) it should be delayed at most a couple of minutes to allow pain control to be initiated.  If nothing else, nitrous oxide is WONDERFUL for this.  Now if only we didn't have the problem of crews huffing it for their own amusement....


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## Melclin (Jul 7, 2011)

jwk said:


> Shuffling the order is still checklist medicine.  Of course you're skipping something.  If you have no clue WHY you're treating pain, other than the fact that the patient has pain, then your priorities are off.



We know WHY we're treating pain. The why is obvious. Its hurts. Not to mention the host of long and short term, physiological and psychological issues that go with pain. You mean no clue what the CAUSE of the pain is right?

I still don't agree with this at all. Treating pain is easy and fast and there is no guarantee we can figure out what the cause of the pain is. The same can be said of the ED. If they can't figure out whats causing a pt's pain, should they wait until admission for pain relief?


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## RocketMedic (Jul 8, 2011)

No, but by the same token, we need not make our reflexive reaction to deformities a morphine dose. I have nothing against pain management, but I've always learned that it's better to manage pain after an assessment and basic packaging have been completed, at least. Immediately reaching for narcotics before we assess a patient well is bad medicine.

On the topic of the original post, I feel that the conservative approach is the most appropriate. She's been in pain for four days and she's only now dropping her pressure, which to me means that she's decompensating for something. COPD and age contribute to my decision to withhold fluids and narcotics- if she's going to crash as a result of my pain management, I'd rather her crash a few minutes down the road @ the ER as opposed to at the beginning of my transport.


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## RocketMedic (Jul 8, 2011)

Melclin said:


> We know WHY we're treating pain. The why is obvious. Its hurts. Not to mention the host of long and short term, physiological and psychological issues that go with pain. You mean no clue what the CAUSE of the pain is right?
> 
> I still don't agree with this at all. Treating pain is easy and fast and there is no guarantee we can figure out what the cause of the pain is. The same can be said of the ED. If they can't figure out whats causing a pt's pain, should they wait until admission for pain relief?



I'm not arguing that it's not easy, but in some cases (the OP), I feel that the negatives of MS _especially in this case_ outweigh the benefits to the patient (less pain). Absent the BP drop, I would have considered the morphine, but with a 20-point systolic drop in only a few minutes, I would be very, very worried for the possibility of a bleed or other hemorrhagic problem.

Pain should be chemically managed in some cases. In others, I really think that we have other top-priority concerns.


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## NomadicMedic (Jul 8, 2011)

I think this is one of those subjects that is a no win. You're either a "package then pain manage" or a "pain manage, then package" medic. 

In cases where a patient is in obvious traumatic distress, an open distal tib/fib fx I recently saw comes to mind, I chose to start my pain management sooner than later. I'll start a line and get morphine on board before I try to package that injury. 

I know I'm still a newbie baby medic, but it's important to keep in mind that patients don't remember what you did, they remember how you made them feel. 

Obviously this is off in a tangent from the original post, but everyone is harping on the 7 minute transport. 7 minutes is a long time when you're in agony. I think I'd spend an extra minute or three on scene to make my patient comfortable before the ride to the ED. But, that's just how I practice. 



Sent from my iPhone using Tapatalk.


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## Handsome Robb (Jul 8, 2011)

n7lxi said:


> it's important to keep in mind that patients don't remember what you did, they remember how you made them feel.



This.

There is no one size fits all protocol or guide to treating a patient. If your afraid the vasodilation properties of morphine in a hemodynamically unstable patient such as the one in this scenario, use fentanyl as someone else has already said. 

I still am a student, but I don't understand why you couldn't use an analgesic that doesn't have an effect on BP to treat this patient. If it is unavailable then so be it, but if it is, help grandma out, a bumpy ride in the back of the box is only going to exacerbate her pain.


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## usalsfyre (Jul 8, 2011)

NVRob said:


> This.
> 
> There is no one size fits all protocol or guide to treating a patient. If your afraid the vasodilation properties of morphine in a hemodynamically unstable patient such as the one in this scenario, use fentanyl as someone else has already said.
> 
> I still am a student, but I don't understand why you couldn't use an analgesic that doesn't have an effect on BP to treat this patient. If it is unavailable then so be it, but if it is, help grandma out, a bumpy ride in the back of the box is only going to exacerbate her pain.



The reality is a lot of places only have homeopathic doses of morphine available for pain management.


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## usalsfyre (Jul 8, 2011)

Rocketmedic40 said:


> No, but by the same token, we need not make our reflexive reaction to deformities a morphine dose. I have nothing against pain management, but I've always learned that it's better to manage pain after an assessment and basic packaging have been completed, at least. Immediately reaching for narcotics before we assess a patient well is bad medicine.


Who's saying pain management before assessment? However, pain management prior to manipulating a painful fracture (packaging) in the stable patient IS good medicine.

You won't find a reduction in the ED being done without conscious sedation. It's really not too much trouble to get something on board prior to moving things around.


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## systemet (Jul 8, 2011)

jwk said:


> Shuffling the order is still checklist medicine.  Of course you're skipping something.  If you have no clue WHY you're treating pain, other than the fact that the patient has pain, then your priorities are off.



I understand the point you're making here, and want to repeat that I respect your level of education and training.

But, if we consider the initial scenario, i.e. a patient with undifferentiated abdominal pain -- don't we have to accept at some point that we're not going necessarily going to be able to identify the underlying pathology in an ambulance?  

We have minimal (1-3 years) training, (generally) no diagnostic imaging, and often encounter patients who lack a previous pertinent diagnosis.  And we're dealing with people who (generally) are excited from just calling 911, and are often poor historians even after calming down a little in the ED.  

At some point, doesn't the ethical and appropriate action become recognising the limitations of our training and equipment, and trying to relieve the patient's discomfort?  An action which, in of itself, may aid in further physical examination or history?

I'm not suggesting we should be pushing morphine in unstable hypotensive patients -- just that I think it's generally appropriate to treat patients with undifferentiated abdominal pain with analgesia.


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## usafmedic45 (Jul 8, 2011)

> I feel that the negatives of MS especially in this case outweigh the benefits to the patient (less pain). Absent the BP drop, I would have considered the morphine, but with a 20-point systolic drop in only a few minutes, I would be very, very worried for the possibility of a bleed or other hemorrhagic problem.



Then you get it into your protocols to chase the morphine with 25 or 50mg of diphenhydramine which negates the BP drop which is largely due to the histamine release associated with morphine, in addition to potentiating the desired effects of the narcotic.  

....or you revert to using nitrous which does not have a pronounced hypotensive effect whatsoever.


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## jwk (Jul 8, 2011)

systemet said:


> I understand the point you're making here, and want to repeat that I respect your level of education and training.
> 
> But, if we consider the initial scenario, i.e. a patient with undifferentiated abdominal pain -- don't we have to accept at some point that we're not going necessarily going to be able to identify the underlying pathology in an ambulance?
> 
> ...



Believe me - I get everything that y'all are saying.  However...

I'm taking much of this in the context of the OP's case - abdominal pain of unknown etiology in a sick patient with a 7 minute transport time.  In this particular case there is little if anything to be gained by managing this patient in the field.  Regardless if it's my guess of bowel obstruction or whether it's a leaking aneurysm or SMA infarct - there just isn't much you can do outside the hospital.  Now, if I'm out in the country with an hour transport time, I might consider other options, including judicious use of MS for pain.  But with a short transport time and a far from certain diagnosis, I'm just not that hot on field management.  If you're doing all these things while transporting, that's fine - although my guess is the OP has done several things (12 lead, blood sugar, IV, etc.) all while at the patient's residence.  Again - for this particular case - O2, IV, transport would seem to be reasonable.  I'll even go for a little morphine.


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## jwk (Jul 8, 2011)

MrBrown said:


> even if it some methoxyflurane .



Ah, this of course caught my eye as I was reviewing this thread.  

Is there anywhere in the world this is used besides Australia?  Use of MOF in anesthesia was abandoned 20+ years ago, at least in the US, and it's probably been 25 years since I've used it personally.  I don't think it's even commercially available in the US in any form nowadays.


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## Trevor (Jul 10, 2011)

multiple studies have shown that people are more letigious if they are "unhappy". What almost always makes people unhappy???? Lack of pain management!!!! This is one reason JACHO is SO stuck on pain management... Now, Im not saying use this as a guide for treatment of patients, but i am saying think about it... If Im in pain, for the love of everything Holy, GIVE ME PAIN MEDS!!!!! I dont care whats causing the pain! This mentality of being afraid to or it being an "inconvience" to treat pain, has got to stop!
There's also been little research about whether or not EMS in general "is any good"... But one thing we can absolutely help with is pain management...
In this case, Grandma is going to sit in a room in the ED, probably (despite being hypotensive) wait a while for an ED doc to see her, hes gonna write for labs, UA, and depending on whats at the top of his DDX (and its hard to tell with the limited info) either a KUB/abd series or a CT... One thing he's not going to do is, Hes NOT GOING TO WAIT FOR RESULTS BEFORE HE TREATS THE PATIENT'S PAIN!!! 
If you dont have something in your box thats okay with Hypotension (Like Fentanyl) then perhaps you need to discuss your protocols with your Medical Director and ask what they want (i like the sound of MS with Benadryl {although have never tried it, as we dont have MS anymore})...Not treating people's pain is barbaric, and archaic...


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## systemet (Jul 10, 2011)

jwk said:


> Believe me - I get everything that y'all are saying.  However...
> 
> I'm taking much of this in the context of the OP's case - abdominal pain of unknown etiology in a sick patient with a 7 minute transport time.  In this particular case there is little if anything to be gained by managing this patient in the field.  Regardless if it's my guess of bowel obstruction or whether it's a leaking aneurysm or SMA infarct - there just isn't much you can do outside the hospital.  Now, if I'm out in the country with an hour transport time, I might consider other options, including judicious use of MS for pain.  But with a short transport time and a far from certain diagnosis, I'm just not that hot on field management.  If you're doing all these things while transporting, that's fine - although my guess is the OP has done several things (12 lead, blood sugar, IV, etc.) all while at the patient's residence.  Again - for this particular case - O2, IV, transport would seem to be  reasonable.  I'll even go for a little morphine.



Fair enough.

While this patient would get seen quickly as they became hypotensive following an initial stable presentation, most of the patients I've transported complaining of abdominal pain have had to wait substantial periods of time prior to being assessed by an MD.

This is probably a result of the particular health care system I worked in, previously.  We were expected to have provided analgesia, and would have been in trouble had we brought in a patient with severe pain that we hadn't tried to manage.  We also might have to wait in the triage area providing further pain control for hours, depending on the given day.

I think liability issues mean that this probably doesn't happen much in the US, where I think most of the posters are from.


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## Melclin (Jul 11, 2011)

jwk said:


> Ah, this of course caught my eye as I was reviewing this thread.
> 
> Is there anywhere in the world this is used besides Australia?  Use of MOF in anesthesia was abandoned 20+ years ago, at least in the US, and it's probably been 25 years since I've used it personally.  I don't think it's even commercially available in the US in any form nowadays.



Never heard of it being used anywhere else but Australia, NZ and a few of our satellite countries that we mentor in various ways. 

Its banned in America because people kept up and bloody dying. We no longer use it for anaesthesia for the same reason but its thought to be relatively safe in the smaller dose used for analgesia. Honestly, its the bees knees, especially for ortho trauma and procedural pain like applying a traction splint or moving a pt whose done his back in.

What I find interesting is that we use the same dose for everyone. For adults its fine, but you have to be careful with kids. I actually knocked a kid out cold once. I was a bee's **** away from ventilating him before he started to come good.  :unsure:


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## usafmedic45 (Jul 11, 2011)

> Its banned in America because people kept up and bloody dying



I believe it was actually related to an abnormally high incidence of kidney failure, if I recall correctly.


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## Cavity (Jul 11, 2011)

*agreed*



Rocketmedic40 said:


> With a 7-minute transport time, I personally would not manage her pain. Pressure dropping that much over a 7-minute transport, nonspecific abdominal pain, advanced age, COPD, near-certain polypharmacy, and a lack of food x 4 days, to me, is a great sign of a life-threatening abdominal problem, probably a bleed. I have no objections to running a small fluid challenge, but for such a short transport, I wouldn't go for the narcs.



I feel the same way. Where I am my transport time is pretty much the same. 5-7 minutes to two hospitals. I would manage the b/p and by the time I checked it for the third time we'd be at the hospital. Plus I feel like treating undiagnosed abdominal pain was always something I was taught not to do.


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## Melclin (Jul 11, 2011)

usafmedic45 said:


> I believe it was actually related to an abnormally high incidence of kidney failure, if I recall correctly.



Yep, breaking people's piss factories with fluoride ions and some other nasty gear. As such we don't give it to people who have knackered kidneys already.

I seem to remember some stuff in our lectures about straight up spontaneous deadness being a reported side affect as well.


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## Smash (Jul 11, 2011)

Cavity said:


> Plus I feel like treating undiagnosed abdominal pain was always something I was taught not to do.



:deadhorse:

:censored::censored::censored::censored: :censored::censored::


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## Melclin (Jul 13, 2011)

Smash said:


> :deadhorse:
> 
> :censored::censored::censored::censored: :censored::censored::



Unfortunately, I don't think the horse is dead yet.


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## MrBrown (Jul 13, 2011)

Melclin said:


> Unfortunately, I don't think the horse is dead yet.



What are you, a vet? 

Well Brown is, and it is very much alive ... *neigh

Brown feels that its best to put it down however


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