# [Separated] Give drugs to drug seekers



## DrankTheKoolaid (Dec 18, 2011)

usalsfyre said:


> "2mgs of morphine is enough"



Amazing how much of a struggle it has been to get people to treat pain at my service, thankfully all but 1 or 2 have come around.  "But they looked fine"
or "I could live with that pain" or "He got better while enroute" is the typical excuse while still noting 8/7/6 - 10 pain in the VS .......

But in time they will leave the darkside and join the force!  Or find employment elsewhere...  whichever comes first.


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## DesertMedic66 (Dec 18, 2011)

Patient rates pain at a 10 out of 10 but yet are still smiling and no issues moving. Then you follow that with the wonderful 10ml preload of the "pain medication" saline. Their pain magically drops to a 1 or 2.


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## usalsfyre (Dec 18, 2011)

^^^Horribly unethical...

I've never understood WHY people care about giving meds to drug seekers. Your withholding them makes no difference at the end of the day.


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## Remeber343 (Dec 18, 2011)

usalsfyre said:


> ^^^Horribly unethical...
> 
> I've never understood WHY people care about giving meds to drug seekers. Your withholding them makes no difference at the end of the day.



I was discussing this the other day actually.  Who are we to judge someone's pain level. We can't see it, we have to go off of what they tell us. We can observe their behavior. For example "10/10 chest pain" but the pt is laying there, legs cross, arms behind head relaxing. But who are we to say no he isn't in pain, he's just seeking meds. 

On the other hand, I kind of think that drug seekers should get the 10ml NS. Just to show the ER that the pt is full of crap and is just using the system. But as I said before,who are we to judge.


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## Sasha (Dec 18, 2011)

Remeber343 said:


> I was discussing this the other day actually.  Who are we to judge someone's pain level. We can't see it, we have to go off of what they tell us. We can observe their behavior. For example "10/10 chest pain" but the pt is laying there, legs cross, arms behind head relaxing. But who are we to say no he isn't in pain, he's just seeking meds.
> 
> On the other hand, I kind of think that drug seekers should get the 10ml NS. Just to show the ER that the pt is full of crap and is just using the system. But as I said before,who are we to judge.



How does it affect you? Give them drugs. I would rather give drugs to ten drug seekers than withhold from someone truly in pain.

Don't ever lie to your patient about what you are giving them. 

Sent from LuLu using Tapatalk


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## Remeber343 (Dec 18, 2011)

Who said anything about lying?


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## Remeber343 (Dec 18, 2011)

And if you read what I said, who are we to judge.


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## DesertMedic66 (Dec 18, 2011)

usalsfyre said:


> ^^^Horribly unethical...
> 
> I've never understood WHY people care about giving meds to drug seekers. Your withholding them makes no difference at the end of the day.



How is it unethical? I never said that we withheld the pain meds. After the 10ml flush their pain goes away so there is no need for pain medication. If they want pain medication then they are going to get pain meds. If they say they are in pain they are more then likely going to get pain meds (up to the medics).


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## DrankTheKoolaid (Dec 18, 2011)

*re*

Back in the days of working as an ER tech I once asked the head of the ED MD group why he gave obvious drug seekers medications. 

His answer that has stuck to this day and always will was *"I would rather give 9 drug seekers drugs they didn't need, then withhold pain drugs from someone who truly needed them"*.  

Who are we to be real judges of pain?  Cant rely on VS, as someone with chronic pain may actually decrease there BP and HR instead of the opposite that we expect.  And don't even get me started on nationalities and the way they express their pain...  that's a whole can of worms there.


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## Sasha (Dec 18, 2011)

Remeber343 said:


> And if you read what I said, who are we to judge.



And then you said they should give them the saline to prove what a liar they are.

It's lying to mislead a patient into believing that you are giving them pain meds when you aren't. 

Sent from LuLu using Tapatalk


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## Remeber343 (Dec 18, 2011)

And who said its lying. You can tell them. They aren't going to know why the difference is. What I'd like to happen and what I do are two different things.


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## usalsfyre (Dec 18, 2011)

firefite said:


> How is it unethical? I never said that we withheld the pain meds. After the 10ml flush their pain goes away so there is no need for pain medication. If they want pain medication then they are going to get pain meds. If they say they are in pain they are more then likely going to get pain meds (up to the medics).



Your administering a placebo in place of real medication. Look up the Tuskegee Syphilis experiment to see the slope this can lead down.


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## DesertMedic66 (Dec 18, 2011)

usalsfyre said:


> Your administering a placebo in place of real medication. Look up the Tuskegee Syphilis experiment to see the slope this can lead down.



I say it's 10ml of saline. That's all I say. If it makes their pain go away then that's all them. I don't tell the patient it's any sort of pain med.


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## Shishkabob (Dec 18, 2011)

While I'm an outspoken proponent of anagesia and am happy to be called "Candyman" by the amount of Fentanyl I give out... let's be honest here.


10/10 (or more) pain will manifest itself in some outward way.  If someone says they're 10/10 (or my pet peave, 11+/10) and there is no other possible way to show (even as little as a small facial grimace) aside from them just saying "10", I'm going to doubt they understood my directions, or failed kindergarten math.   10 is the wrost you've ever been in, EVER.  I've yet to see someone in true 10/10 pain that weren't on the verge of crying/screaming out,  if not already there.  I don't care how much 'tolerance' for pain you have, 10/10 will do SOMETHING to you.

If you say 12/10 abd pain, cramping, and you jump up and walk to me with a smile on your face... yeah, I'm calling a spade a spade.  I won't ever doubt someone is in pain... doesn't mean I can question the number they give me to myself.  




But just because I don't believe them, I never said a word about withholding.  ($10 says someone is going to ignore that last tidbit and jump in with a "It's not your job to believe" or some crap of that nature)


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## the_negro_puppy (Dec 18, 2011)

usalsfyre said:


> ^^^Horribly unethical...
> 
> I've never understood WHY people care about giving meds to drug seekers. Your withholding them makes no difference at the end of the day.





Sasha said:


> How does it affect you? Give them drugs. I would rather give drugs to ten drug seekers than withhold from someone truly in pain.
> 
> Don't ever lie to your patient about what you are giving them.
> 
> Sent from LuLu using Tapatalk



I never withold pain meds, but I can't help but think that if drug seekers weren't given opioid analgesia by EMS and ED staff, then they would stop calling 911?

There has to be a way of stopping the repeating cycle. Why would anyone in my state try to buy drugs on the street / commit crimes to pay for them, when they can call 000 (911) get an ambulance straight away, lie to receive opioids, lie to the hospital and not get charged a single penny.


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## Shishkabob (Dec 18, 2011)

At some point, the hospitals, and potentially the EMS agency, will put the patient on a no-treat list.  (If the hospitals and agency are progressive enough)



I know of several patients in my service area who some hospitals refuse to see, and several more who have no choice in which hospital they get taken to.  If they don't want to go to the one they're being taken to, they get refused by the agency.


I also knew of one patient at my last agency who I ran on constantly who a big hospital absolutely refused to see the patient any longer.


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## BandageBrigade (Dec 18, 2011)

They may refuse to give pain medication or any non lifesaving treatment, but they cannot refuse to examine a patient.


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## medicsb (Dec 18, 2011)

Comparing the administration of saline to the Tuskegee experiment is a bit hyperbolic... sayin'.

But, what should be pointed out (if it already has, then I apologize) is that one is NOT necessarily "proving" that someone if "faking" (or whatever) by administering saline/placebo for pain.  It raises the potential that they are a placebo responder, as are many people here (statistically speaking).  Something like 1/3 of people will respond to placebo for treatment of pain.  It does not mean that they were not experiencing pain.  

Anyhow I don't think it is wrong to withhold IV narcotic analgesia if your H&P tells you it may be inappropriate.  If someone tells me 10/10 and is able to hold a conversation, laugh, etc., then I do not think that they are experiencing the worst pain ever (not saying that I don't think they are experiencing some degree of pain).  The problem with EMS analgesia is that it is "all or nothing".  Many pain complaints could be managed just fine with PO narcs, NSAID, an ice pack, or, god forbid, placing them in a position of comfort. I've had patients rate their pain 5 or 6 and obviously in distress due to pain, and I've treated them.  And conversely I've had a few tell me 9,086,987/10, who, if I had no way of getting a number from them, I would assign a "wong-baker" faces score of 1 or 2,  and yes, in the prehospital setting, I triaged some of them to BLS.  So, put me in the group that uses the pain rating as just one component of the H&P that is integrated with any other findings to determine a treatment disposition.  Just because they say 10, or anything else, doesn't mean they NEED (or do not need) IV analgesia.


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## adamjh3 (Dec 18, 2011)

Linuss said:


> While I'm an outspoken proponent of anagesia and am happy to be called "Candyman" by the amount of Fentanyl I give out... let's be honest here.
> 
> 
> 10/10 (or more) pain will manifest itself in some outward way.  If someone says they're 10/10 (or my pet peave, 11+/10) and there is no other possible way to show (even as little as a small facial grimace) aside from them just saying "10", I'm going to doubt they understood my directions, or failed kindergarten math.   10 is the wrost you've ever been in, EVER.  I've yet to see someone in true 10/10 pain that weren't on the verge of crying/screaming out,  if not already there.  I don't care how much 'tolerance' for pain you have, 10/10 will do SOMETHING to you.
> ...



Going off of this, how do y'all document the pain scale? I don't really like using the 1-10 scale as that is very subjective and is often not accurate at all. 

With the kids I see at my stand by job I generally don't even ask for a scale and document it as I see it and how they react to my assessment. Palpate an injury and they scream: "severe pain." They wince with a little groan: "moderate." They say "it hurts" but show no outward signs of discomfort? "Mild/minor"


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## medicsb (Dec 18, 2011)

adamjh3 said:


> Going off of this, how do y'all document the pain scale? I don't really like using the 1-10 scale as that is very subjective and is often not accurate at all.
> 
> With the kids I see at my stand by job I generally don't even ask for a scale and document it as I see it and how they react to my assessment. Palpate an injury and they scream: "severe pain." They wince with a little groan: "moderate." They say "it hurts" but show no outward signs of discomfort? "Mild/minor"



I will document the the patient's rating and then document a Wong-Baker faces scale (applicable for all ages) and qualify it with a description of the patient at the time of assessment and their vital signs.


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## usalsfyre (Dec 18, 2011)

My understanding is Wong-Baker is not really designed to be used in the conversant patient. 

While I agree a dearth of pain management options (PO NSAIDS or narcotics being chief among the missing options) is a problem, I ask again, why exactly do we care if we get "tricked"?


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## bigbaldguy (Dec 18, 2011)

Picked up a guy from a job site once. His hand had gotten caught between two steel i beams that were being rolled. Crushed hand, partial amputation of 4 fingers significant de glove of what was left. We ask the guy what his pain is 1 to 10 he says "not too bad maybe a 5". Huh? Screw that, medic already has the Fent ready so he administers it. After the fent kicks in the guy visibly relaxes. Was the guy just a steel core stoic Mofo or was it just shock, who cares either way the guy felt better after the Fent, and that's what it's all about right? When I see a medic refuse to give meds to someone who says they have 10/10 I think about that guy and the kind of pain he was probably in.  If I were to withhold pain meds from one person who was in as much pain as that guy was because they might be a drug seeker and it turned out I was wrong? I've done some horrible things but I think that would go right at the top of the list.


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## bigbaldguy (Dec 18, 2011)

the_negro_puppy said:


> I never withold pain meds, but I can't help but think that if drug seekers weren't given opioid analgesia by EMS and ED staff, then they would stop calling 911?
> 
> There has to be a way of stopping the repeating cycle. Why would anyone in my state try to buy drugs on the street / commit crimes to pay for them, when they can call 000 (911) get an ambulance straight away, lie to receive opioids, lie to the hospital and not get charged a single penny.



So you're saying it's better that people commit crimes rather than call 911 cuz then they don't have to pay...for....huh? I'm confused.


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## medicsb (Dec 18, 2011)

usalsfyre said:


> My understanding is Wong-Baker is not really designed to be used in the conversant patient.
> 
> While I agree a dearth of pain management options (PO NSAIDS or narcotics being chief among the missing options) is a problem, I ask again, why exactly do we care if we get "tricked"?



Technically, you're supposed to instruct the pt. to pick a face that corresponds to their level of pain, but many use it for patient who are nonverbal.  I admit, I don't use it exactly as it is supposed to, but it can provide insight for QA as the local health system Wong-baker faces has some descriptions associated with the face/# in terms of grimacing, distraction, etc. Anyhow, this is not about being tricked.  It's about providing an appropriate level of care based on a proper H&P.  Not everyone reporting pain needs IV analgesia.


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## usalsfyre (Dec 18, 2011)

medicsb said:


> Anyhow, this is not about being tricked.  It's about providing an appropriate level of care based on a proper H&P.  Not everyone reporting pain needs IV analgesia.


So in the absence of other options you'd rather withhold analgesics rather than go for overkill?

I've been on the other end of that decision (sort of). It sucks.


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## bigbaldguy (Dec 18, 2011)

I find it fascinating that in nearly every area of American life we tend to go for a "more is better" philosophy with two major exeptions, sex Ed and pain/anxiety management.


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## usalsfyre (Dec 18, 2011)

Moral majority baby. Sex is bad and pain management makes addicts.

You can add mental health services availability to your list as well.


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## bigbaldguy (Dec 18, 2011)

usalsfyre said:


> Moral majority baby. Sex is bad and pain management makes addicts.
> 
> You can add mental health services availability to your list as well.



Crazy people have the devil in em man, why would you want to provide services and housing to people with Satan in em


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## SteveTP (Dec 18, 2011)

usalsfyre said:


> ^^^Horribly unethical...
> 
> I've never understood WHY people care about giving meds to drug seekers. Your withholding them makes no difference at the end of the day.



I disagree, psychosomatic pain and drug addiction both require treatment, and that treatment is not simply to narc them up.  Ultimately the question that must be answered is: Is the educational foundation present to allow providers to make decisions with regards to differential diagnosis of pain via saline placebo?  That is a question which I cannot answer.  I really wouldn't care that a patient pulled the wool over my eyes, I would care if a patient did not recieve proper treatment for their condition.  Narcotics for drug addiction is not proper treatment.  

The problem with the Tuskegee Study (assuming my recollection of he subject matter is correct) is that there was no potential benefit (to the subject) from witholding information about syphilus status.  whereas there is the potential for benefit (to the subject) from temporarily witholding narcotic analgesia.  Using a placebo to form a diagnosis may or may not be unethical depending on the situation, whereas witholding treatment for a treatable condition (without consent), "just so we can see what happens" is never ethical.


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## Handsome Robb (Dec 18, 2011)

adamjh3 said:


> Going off of this, how do y'all document the pain scale? I don't really like using the 1-10 scale as that is very subjective and is often not accurate at all.



"PT states 10/10 pain when asked to rate their pain on a 10 scale" Then include your findings of your assessment of the area the PT is complaining of pain in. 

I agree that we have no right withholding pain meds, but use your head and your assessment alongside what the PT tells you to determine when they are appropriate though.


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## 18G (Dec 18, 2011)

firefite said:


> How is it unethical? I never said that we withheld the pain meds. After the 10ml flush their pain goes away so there is no need for pain medication. If they want pain medication then they are going to get pain meds. If they say they are in pain they are more then likely going to get pain meds (up to the medics).




This is way out of line and no EMS provider has the right to administer saline for pain. This goes against the standard of care and practically every position out there for pain management. There is no way (unless you have prior knowledge of patients history) of determining in a brief field contact that a patient is only drug seeking. Sure, we may have suspicions but it is not up to us or in our scope of practice to make that determination. 

If you truly believe that the patient is BS'ing than you can be passive in your denial by talking more, taking longer to do your assessment, vitals, etc. But again, a patient's pain rating is completely subjective. What the patient feels may not be the same as you would feel. As mentioned, it is a bad practice to try and decide what someone else is feeling. 

Who really cares if a patient gets a dose of fentanyl or morphine? If you start to see this patient over and over than yes, you just identified a problem. But first time encounters shouldn't be judged. 

I am a great proponent of analgesia and get so tired of out dated attitudes and opinions on using opiates.


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## usalsfyre (Dec 18, 2011)

SteveTP said:


> whereas there is the potential for benefit (to the subject) from temporarily witholding narcotic analgesia


Wanna clue me in on what that is?

Substance abuse is a huge issue. But it's not within EM's (the hospital too) scope to diagnose or treat it, and your withholding pain meds is not going to give them a lifestyle changing moment.


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## bigbaldguy (Dec 18, 2011)

Isn't a symptom of sudden opiate cessation severe cramps and generalized severe pain? Pain's pain right? I have no idea how bad it hurts coming off heroin, but from the couple of cases I've seen I'm guessing it's pretty rough. Sure you could argue that they caused the pain by becoming an addict but you could argue that a guy who broke his leg falling off a horse should have known better than to get on. The pain in either case is real and at least in my opinion should be treated no differently.

Anybody notice what I did there with the heroin/horse thing?


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## DesertMedic66 (Dec 18, 2011)

18G said:


> This is way out of line and no EMS provider has the right to administer saline for pain. This goes against the standard of care and practically every position out there for pain management. There is no way (unless you have prior knowledge of patients history) of determining in a brief field contact that a patient is only drug seeking. Sure, we may have suspicions but it is not up to us or in our scope of practice to make that determination.
> 
> If you truly believe that the patient is BS'ing than you can be passive in your denial by talking more, taking longer to do your assessment, vitals, etc. But again, a patient's pain rating is completely subjective. What the patient feels may not be the same as you would feel. As mentioned, it is a bad practice to try and decide what someone else is feeling.
> 
> ...



I think you misread what I wrote. The 10ml of Saline is NOT used in anyway as a pain medication. It is used as a flush (what a 10ml preload of saline is for...). The patient is just told if at all that it is saline (nothing more, nothing less). Ive had a couple of patients get instant pain relieve with the saline flush. If they say their pain when away with the flush then why would you give pain medications to a patient who no longer has any pain?

Once again so everyone understands what I am saying: the 10ml saline preload is used as a saline flush, nothing more and nothing less. It is NOT used as any kind of pain medication.


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## the_negro_puppy (Dec 18, 2011)

bigbaldguy said:


> So you're saying it's better that people commit crimes rather than call 911 cuz then they don't have to pay...for....huh? I'm confused.



I guess i'm more saying that our system is set up to be abused easily without any repercussions. We have state laws existing to punish people who abuse EMS but its nearly impossible to officially determine tnat someone does not need an ambulance (even for a basic assessment)


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## bigbaldguy (Dec 18, 2011)

the_negro_puppy said:


> I guess i'm more saying that our system is set up to be abused easily without any repercussions. We have state laws existing to punish people who abuse EMS but its nearly impossible to officially determine tnat someone does not need an ambulance (even for a basic assessment)



I got yah I just couldn't resist digging yah a little. It's a catch 22, addicts can either break the law to get their narcs or break the law to get their narcs. Pick your evil I suppose.


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## 18G (Dec 18, 2011)

firefite said:


> I think you misread what I wrote. The 10ml of Saline is NOT used in anyway as a pain medication. It is used as a flush (what a 10ml preload of saline is for...). The patient is just told if at all that it is saline (nothing more, nothing less). Ive had a couple of patients get instant pain relieve with the saline flush. If they say their pain when away with the flush then why would you give pain medications to a patient who no longer has any pain?
> 
> Once again so everyone understands what I am saying: the 10ml saline preload is used as a saline flush, nothing more and nothing less. It is NOT used as any kind of pain medication.



I understand perfectly what you are saying and I do not agree with it. I'm not into the practice of "tricking" my patients or lying to them by an act of omission.

Your injecting a fluid into a patient that is not indicated and providing care on a false pretense which isn't cool. Yes, it is only NSS and isn't going to hurt them but the principle in practice is the issue. Are you documenting in your PCR that the patient was having pain and you treated them with 10mL of NSS? 

If the patient is having pain, get them pain medication. If it is beyond your scope than call for ALS or the patient waits until they get to the hospital.


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## SteveTP (Dec 18, 2011)

usalsfyre said:


> Wanna clue me in on what that is?
> 
> Substance abuse is a huge issue. But it's not within EM's (the hospital too) scope to diagnose or treat it, and your withholding pain meds is not going to give them a lifestyle changing moment.



I think we probably approached the issue from different angles, while I looked at it from a hypothetical angle, you looked at it in the more practical sense, directly applicable to EMS presently.  I probably would have been better off using multi-quote for clarity. 

My point was that if educational standards and mission changed (notwithstanding potential personal freedom issues), It would be possible to withold analgesia ethically.  While Tuskegee is unethical no matter what, witholding analgesia can  be ethical as a form of diagnosis (more for psychosomatic illness). 

I absolutely agree with you that substance abuse intervention is not within our scope, and that presently witholding analgesia is unethical (witholding narcotics, in my view is ethical, as long as a suitable non-narcotic form of pain relief is available) .  While it would be great if we could treat substance abuse, it really isnt all that practical, and not giving them morphine really wont turn them into productive members of society.  What we should do,for now at least, is encourage them to seek treatment and attempt to connect them to the most effective pathways for treatment, anything less is failing to provide the highest level of care to a patient


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## DesertMedic66 (Dec 18, 2011)

18G said:


> I understand perfectly what you are saying and I do not agree with it. I'm not into the practice of "tricking" my patients or lying to them by an act of omission.
> 
> Your injecting a fluid into a patient that is not indicated and providing care on a false pretense which isn't cool. Yes, it is only NSS and isn't going to hurt them but the principle in practice is the issue.
> 
> If the patient is having pain, get them pain medication. If it is beyond your scope than call for ALS or the patient waits until they get to the hospital.



No your still not understanding me. The patient is not tricked in any way. The patient is not lied to. The medic will get a saline lock on scene. Then they will use the flush to flush out the line. NS flush is called for that. After it is flushed they will connect the IV tubing so they can inject the pain medication into the tubing thru the port.

As soon as the flush is done we connect the tubing. We don't give the flush and then wait. The NS flush is used as only a flush to clear the cath and then the line is connected. In no way is it used as a pain medication.


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## Sasha (Dec 18, 2011)

I don't understand people's drug seeker radar.

Do you think by with holding the medication you are going to cure them of their habit?

All you're doing is starting them through the whole withdrawal roller coaster which causes pain.

Pain that you should be treating.

And please keep in mind, drug seekers CAN feel pain.


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## silver (Dec 18, 2011)

I think this conversation is pointless. Prudence should be used on a case by case situation to best assure a positive outcome. Principle based ethics has its limitations, and this is specifically true in medicine, because of its complexity. By saying everyone should or shouldn't get pain relievers is a slippery slope (if you believe the slippery slope argument is valid at all).


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## Sublime (Dec 18, 2011)

Sasha said:


> Do you think by with holding the medication you are going to cure them of their habit?



Do you think by giving them pain medicine you're curing them of their habit? Or are you supporting it?



Sasha said:


> All you're doing is starting them through the whole withdrawal roller coaster which causes pain.



And all you're doing is starting the cycle over again. They will come down and call 911 again when they need more paid meds, because they know you'll give it to them.



Sasha said:


> Pain that you should be treating.
> 
> And please keep in mind, drug seekers CAN feel pain.



I don't believe this is the proper treatment for these people. Do you honestly believe that? Do you give an alcoholic withdrawal patient more booze because he is in withdrawals? This is the worst logic I've ever heard. How about suggesting a proper treatment facility where they can get real help if they want it.



Maybe my view is different than many on those on this site because I live in an area where there is A LOT of drug users, but I am very surprised to see people advocating giving pain medicine to drug seekers. I work in a county hospital where we get A LOT of these people, and on the box you get those call pretty regularly too in this area. I literally have watched a guy walk down a set of stairs from his apartment carrying his backpack, get in the ambulance and sit on the stretcher (all the while in no pain), and then immediately once he sits down start having severe 10/10 abdominal pain that he can't stand, and starts flailing around like he's dying.

Fortunately we have the ability to look up these people's previous ambulance rides and many of them get marked as drug seekers. I don't think a lot of people on here understand the insane amount of abuse on 911 and the hospitals in some areas by drug seeking individuals. I have literally seen a homeless patient in the hospital here who claimed 10/10 chest pain that was relieved by nothing but Dilaudid. He went through every test (CE's, Cath lab, ect.) and all came back negative. Trust me he never appeared to be in any pain others than stating "My pain is 10/10, I need Dilaudid". After days of nothing coming back on him he was D/C'd and he refused to leave so he was arrested. We get people like this often. 

If every paramedic here had the attitude of "Well if he says he has pain, I must give him pain meds", and every abuser got narcs, the system would be a nightmare.


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## 18G (Dec 19, 2011)

Sublime said:


> Do you think by giving them pain medicine you're curing them of their habit? Or are you supporting it?
> 
> 
> 
> ...



This isn't what we are saying. We don't freely hand out pain meds to all that ask with no indication. It is best practice and of expert opinion to treat pain based on the patients description and complaint. We don't treat pain based on our own perception of what the patient is feeling. 

Yes, there are overt signs of drug seeking behavior of which we can pick up on when its very clear. But outside of the very obvious I don't recommend playing judge.


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## Medic419 (Dec 19, 2011)

I don't believe this is the proper treatment for these people. Do you honestly believe that? Do you give an alcoholic withdrawal patient more booze because he is in withdrawals? This is the worst logic I've ever heard. How about suggesting a proper treatment facility where they can get real help if they want it.



Maybe my view is different than many on those on this site because I live in an area where there is A LOT of drug users, but I am very surprised to see people advocating giving pain medicine to drug seekers. I work in a county hospital where we get A LOT of these people, and on the box you get those call pretty regularly too in this area. I literally have watched a guy walk down a set of stairs from his apartment carrying his backpack, get in the ambulance and sit on the stretcher (all the while in no pain), and then immediately once he sits down start having severe 10/10 abdominal pain that he can't stand, and starts flailing around like he's dying.

Fortunately we have the ability to look up these people's previous ambulance rides and many of them get marked as drug seekers. I don't think a lot of people on here understand the insane amount of abuse on 911 and the hospitals in some areas by drug seeking individuals. I have literally seen a homeless patient in the hospital here who claimed 10/10 chest pain that was relieved by nothing but Dilaudid. He went through every test (CE's, Cath lab, ect.) and all came back negative. Trust me he never appeared to be in any pain others than stating "My pain is 10/10, I need Dilaudid". After days of nothing coming back on him he was D/C'd and he refused to leave so he was arrested. We get people like this often. 

I see this frequently see this issue both  in Pre-hospital and in the Emergency Room. My issue is typically not an issue of giving the narc's but the behavior of the PT while they are waiting.


If every paramedic here had the attitude of "Well if he says he has pain, I must give him pain meds", and every abuser got narcs, the system would be a nightmare.

I agree here as well.


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## usalsfyre (Dec 19, 2011)

Do y'all really think your withholding narcotics makes a hill of beans?

Is it your job to be "system defender"?


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## usalsfyre (Dec 19, 2011)

18G said:


> Yes, there are overt signs of drug seeking behavior of which we can pick up on when its very clear. But outside of the very obvious I don't recommend playing judge.


Very, very good advice.

We have a frequent patient who causes a painful orthopedic insult to himself, likely to obtain narcotics. Are you not going to treat him?


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## Melclin (Dec 19, 2011)

I don't see what the big fuss is all about.

When they're *clearly* drug seeking (which is reasonably rare in my limited experience), then I'll say, "Oi, Frank you've called us seven times this week mate, and I keep telling you, I don't have any pain killers for you". And if they say, "Oh hey, hey bro! Give us some morphine, eh", I'll tell them I don't hand out drugs of dependence to New Zealanders.

Otherwise, if they say they've got pain, they've got pain. Its not my morphine and they're addicted whether or not I give it to them so I may as well make sure I never withhold from someone who is actually in pain. 

Its a no brainer in my opinion.


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## bigbaldguy (Dec 19, 2011)

Sublime said:


> Do you think by giving them pain medicine you're curing them of their habit? Or are you supporting it?
> 
> 
> 
> ...



Wow you work somewhere people have a lot of drug problems? Wow I guess the rest of us just work in some bizarre part of the world where drug addiction is a non issue. 

We don't give a patient in severe alcohol detox alcohol we give them benzos, lots and lots if benzos, at least that's the accepted treatment. Just like we don't give someone in severe heroin withdrawal heroin, we give them morphine for the pain and methadone to manage their other symptoms.

So the hospital allowed a homeless guy to stay in the hospital for days, receive every expensive test they could run on him probably ran up a 50000 dollar hospital bill and then got sent to jail where he will cost the state another 50000 thousand and this was all to avoid giving him a 300 dollar shot of dilaudid? Wow I guess the hospital really showed him.


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## 18G (Dec 19, 2011)

Medic419 said:


> Do you give an alcoholic withdrawal patient more booze because he is in withdrawals?



Actually, I have seen first hand where doctors prescribe alcohol to patients admitted in the hospital. And yes, the nurse hands the patient a can of beer or dispenses the prescribed amount of liqueur. This is to prevent withdrawal.

Pain and nausea are two of the worst feelings human beings can experience! Why are we so bent on neglecting effective treatment of these two conditions when it can be done cheaply, safely, quickly, effectively, and yield great results and improvement in the patient!!!!!!

I don't understand the whole taboo surrounding narcotics within healthcare circles. I really don't.


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## Sasha (Dec 19, 2011)

And a patient should only addiction  their drugs under care of a doctor to monitor and treat their condition accordingly. Withdrawals can kill. 

You're not a doctor so stop trying to fix their addiction. 

Sent from LuLu using Tapatalk


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## systemet (Dec 19, 2011)

Medic419 said:


> Maybe my view is different than many on those on this site because I live in an area where there is A LOT of drug users, but I am very surprised to see people advocating giving pain medicine to drug seekers.



I don't think anyone is advocating intentionally giving analgesics to drug seekers.  I think what is being advocated is that it is impossible to distinguish drug-seekers with a 0% false-positive rate, and that it's better to bias towards treating pain to avoid accidentally labelling a patient in acute pain as a drug seeker.  This will follow them around through the healthcare system, and may result in their symptoms not being treated appropriately in the ER, or even worse, them being undertriaged as a malingerer while there's serious underlying pathology going on.

This is being presented as an acceptable risk of giving narcotic analgesia.  Some people will try and trick you, and some of them will do a very good job of it.  I think we have all probably given morphine (or fentanyl or demerol or....) to someone, and then had a nagging doubt afterwards as to whether they were genuine.  It's being suggested that it's best not to make these sort of decisions, because if we do, we're going to eventually withhold pain medication from someone in need.

And let's look at this realistically here.  How much morphine / whatever are we realistically giving?  If someone is an injection heroin user, and I give them 5mg MS IV, it is barely barely going to touch them.  I mean, think about that dose -- is that even remotely appropriate for a cancer patient with chronic pain?  I've got orders of 30mg morphine IVP as a single dose for these patients.  

We are not getting these people high and euphoric.  At the best (or worst), we're taking the edge off their withdrawal.  And I'll freely admit that people will call us for that.  I'm sure we've all done the abdo pain at the rehab clinic.  There's no doubt these people are abusing the system, but all we're doing is providing a very temporary relief -- they're hoping for a script for something they can crush and inject at the ER.  We're not the main source of anyone's narcotics.


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## Shishkabob (Dec 19, 2011)

This is why Nitronox needs to be on every ambulance.  I love that stuff.


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## 18G (Dec 19, 2011)

Linuss said:


> This is why Nitronox needs to be on every ambulance.  I love that stuff.



Never used it but always read and heard great things about it.


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## BF2BC EMT (Dec 19, 2011)

firefite said:


> I think you misread what I wrote. The 10ml of Saline is NOT used in anyway as a pain medication. It is used as a flush (what a 10ml preload of saline is for...). The patient is just told if at all that it is saline (nothing more, nothing less). Ive had a couple of patients get instant pain relieve with the saline flush. If they say their pain when away with the flush then why would you give pain medications to a patient who no longer has any pain?
> 
> Once again so everyone understands what I am saying: the 10ml saline preload is used as a saline flush, nothing more and nothing less. It is NOT used as any kind of pain medication.



How is this documented? 

How is it communicated to hospital staff?

It's bad practice to put anything in anyone that's A&O and not tell them what it is, even if only a flush. One day it will come back to bite whoever may or may not be telling the pt what is going on. Pt says they were given pain medicine by the medic and feel a little bit better yet none of the tests they had done are showing opioids? Sounds like a diversion investigation although not true.


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## 18G (Dec 19, 2011)

BF2BC EMT said:


> How is this documented?
> 
> How is it communicated to hospital staff?
> 
> It's bad practice to put anything in anyone that's A&O and not tell them what it is, even if only a flush. One day it will come back to bite whoever may or may not be telling the pt what is going on. Pt says they were given pain medicine by the medic and feel a little bit better yet none of the tests they had done are showing opioids? Sounds like a diversion investigation although not true.



Very good point!


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## DesertMedic66 (Dec 19, 2011)

BF2BC EMT said:


> How is this documented?
> 
> How is it communicated to hospital staff?
> 
> It's bad practice to put anything in anyone that's A&O and not tell them what it is, even if only a flush. One day it will come back to bite whoever may or may not be telling the pt what is going on. Pt says they were given pain medicine by the medic and feel a little bit better yet none of the tests they had done are showing opioids? Sounds like a diversion investigation although not true.



"a saline lock was attached to the cath. The cath was then flushed with a 10ml preload of saline. After the cath was flushed the IV tubing was connected and the patient stated 'my pain is alot better now', even tho no pain medication was given." 

Patient may state whatever he/she wants. But the medic states only the flush was given and not any pain medication. 

I hate how my posts got separated from the other thread and placed in this one. My posts have nothing to do with giving drug seekers pain medications. If they are in pain then give them the medication.


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## exodus (Dec 19, 2011)

Sublime said:


> Do you think by giving them pain medicine you're curing them of their habit? Or are you supporting it?



IIRC, I remember reading somewhere back where severe chronic alcoholics who were admitted to the ICU for withdrawal symptoms would actually get an IV alcohol drip.

Source: http://www.surgicalcriticalcare.net/Guidelines/alcohol_2009.pdf  (Page 5 pp1)


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## 18G (Dec 19, 2011)

firefite said:


> "a saline lock was attached to the cath. The cath was then flushed with a 10ml preload of saline. After the cath was flushed the IV tubing was connected and the patient stated 'my pain is alot better now', even tho no pain medication was given."
> 
> Patient may state whatever he/she wants. But the medic states only the flush was given and not any pain medication.
> 
> I hate how my posts got separated from the other thread and placed in this one. My posts have nothing to do with giving drug seekers pain medications. If they are in pain then give them the medication.



This isn't the practice you were coming across with initially.


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## Veneficus (Dec 19, 2011)

I find the FLACC scale the most objective measure.


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## 18G (Dec 19, 2011)

Veneficus said:


> I find the FLACC scale the most objective measure.



Isn't the FLACC scale more for infants and children?


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## medicdan (Dec 19, 2011)

Veneficus said:


> I find the FLACC scale the most objective measure.



Can the scale be generalized for adults? I thought we were talking about adults seeking narcotics (legitimately or not). Are there any verifiable quantifiable measures of pain for adults- if we're not trusting Wong-Baker and changes to VS?


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## Veneficus (Dec 19, 2011)

18G said:


> Isn't the FLACC scale more for infants and children?



A large amount of the evidence is from children, but it is easily adaptable to adults.

Look at the posts here, if you saw somebody in visible distress, you are basically using the FLACC scale whether you realize it or not.

Distracting injury, facial grimace, preoccupation with pain, etc.

If you use 1-10 scale it is subjective to the patient. (I admit I probably over medicate, but relieving pain has been fundamental to medicine since its inception.)

If you use simply clinical signs or opinion, you are using your subjective findings instead of the patients subjective findings.

Faces, FLACC, etc, were designed for children you could not ask. But nothing stops adapting these scales for at least some level of objectivity.


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## DesertMedic66 (Dec 19, 2011)

18G said:


> This isn't the practice you were coming across with initially.



That is the practice that I have been trying to say the whole time lol.


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## the_negro_puppy (Dec 19, 2011)

Sasha said:


> I don't understand people's drug seeker radar.
> 
> Do you think by with holding the medication you are going to cure them of their habit?
> 
> ...



By withholding we are not try to cure them of their habit, we are removing the incentive for them to abuse EMS. Why should we hand out narcs like candy if the Emergency Departments at hospital don't?


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## 18G (Dec 20, 2011)

the_negro_puppy said:


> Why should we hand out narcs like candy if the Emergency Departments at hospital don't?



We don't hand em out like candy. 

Don't use a hospital as the perfect example. They are sometimes guilty of denying effective pain and nausea relief. In fact, I prefer to medicate onboard my unit because who knows how long it will be until they get relief in the ED. Especially if the patient get's a nurse or doc who doesn't look at pain and nausea relief as anything important.


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## Shishkabob (Dec 25, 2011)

So, here's the question to those of you who say our job is not to decide who's in pain, but to treat it.


Where's the line, or is there even one, for you?  Does 1/10 pain get narcotics?  What about a papercut when someone demands transport?  Part of a chip being stuck between a tooth and gum for the better part of 9 hours?


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## WuLabsWuTecH (Dec 25, 2011)

18G said:


> I understand perfectly what you are saying and I do not agree with it. I'm not into the practice of "tricking" my patients or lying to them by an act of omission.
> 
> Your injecting a fluid into a patient that is not indicated and providing care on a false pretense which isn't cool. Yes, it is only NSS and isn't going to hurt them but the principle in practice is the issue. Are you documenting in your PCR that the patient was having pain and you treated them with 10mL of NSS?



I actually like the flush.  You do it anyway when starting a line with a lock, so you tell them you're giving them saline and then ask if it helps with the pain.  If it does, then you don't need to give them heavier stuff.  You can always give them more saline.  And yes, you do document it in the PCR.  It shows that the pain could be just psychological/anxiety induced, or that they are seeking drugs.  It's pertinent information.


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## bcemr (Dec 26, 2011)

Follow protocols. 10/10 pain? Treat with drugs.

God/Muhammed/Jesus/Their life- will judge them. That's not our moral or ethical job.

IMO.


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## STXmedic (Dec 26, 2011)

bcemr said:


> Follow protocols. 10/10 pain? Treat with drugs.
> 
> God/Muhammed/Jesus/Their life- will judge them. That's not our moral or ethical job.
> 
> IMO.



So does only 10/10 pain get analgesics? I'm with Linuss; where's the line drawn for pain management?  Obviously situational, but you need to use judgement. Personally, if they state they're in mild to moderate pain I will give them the option, informing them of pros and cons. If they're in obvious severe pain, it's pretty much a given that they're getting something unless they straight-up oppose (which doesn't often happen). If they are known drug seekers that show no real physical manifestations of pain, I'll be much more hesitant to offer anything.


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## DrParasite (Dec 26, 2011)

bcemr said:


> Follow protocols. 10/10 pain? Treat with drugs.


my back hurts, it's giving me 10/10 patient.  I'm going to travel to your system and call 911, since I want some pain meds.

so does my left toe, because I kicked a curb in 12 degree weather.

I hope i get a paramedic who will give me IV pain meds, since my pain is 10/10.


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## Remeber343 (Dec 26, 2011)

"My back hurts, 10/10, I need 2 mg dilaudid. That is the only thing that helps. Please, dilaudid".  Good times.


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## Melclin (Dec 26, 2011)

Linuss said:


> So, here's the question to those of you who say our job is not to decide who's in pain, but to treat it.
> 
> 
> Where's the line, or is there even one, for you?  Does 1/10 pain get narcotics?  What about a papercut when someone demands transport?  Part of a chip being stuck between a tooth and gum for the better part of 9 hours?



I'm president and founding member of the local 'give morphine to everyone' club. One of my preceptors said jokingly to me once after he refused pain relief to some idiot, that I would have tickled her feet (a reference to part of my neuro exam) and given her ten of morph but hell would have frozen over before I gave her oxygen ^_^


None the less, I have a line and everyone should. On the scale of no pain to agony, the first step for me is suggesting everyday OTC analgesia, regardless of if we're transporting. Then comes methoxyflurane. I realise this is not an option for most people on this board but it is a great bridge to more lasting analgesia and it is also great for people who don't require morphine or fent which are our only other two options currently, but are still in pain. The spontaneously resolving dislocations that will get a couple of acetaminophen/codeine preps and other such not so nasty kinds of pain are good examples of this. Also works a treat with kids.

Then after that its a case by case basis. Two questions I frequently ask are, "Could you sleep with this pain" and "do you want anything more (more than the methoxy or panadol) for the pain". I instruct them not to be stoic and I observe their outward signs of pain. How they handle going over bumps with things like ortho trauma also factor into it. The number scale really doesn't mean to much to me and I often don't even bother asking. Cardiac chest pain is the only kind of pain I routinely use it with. Otherwise I simply give pain relief until they say they're comfortable. Obviously these aren't methods to weed out drug seekers, but I don't really need to because its not too much of a problem here. This is how/why I don't give 20mg morphine to a paper cut but still consider myself aggressive with pain relief.


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## bcemr (Dec 26, 2011)

DrParasite said:


> I hope i get a paramedic who will give me IV pain meds, since my pain is 10/10.



I hope so too.


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## Shishkabob (Dec 26, 2011)

bcemr said:


> Follow protocols. 10/10 pain? Treat with drugs.



You'er an EMR, correct?  What sort of medications do you have for pain control?  Do you ever have to make the decision, BEYOND "Because protocols said so", as to who gets sufficient pain relief?


Guess what, my protocols state I am to use my clinical experience to make decisions, as not every patient fall within set protocols.  




> That's not our moral or ethical job.
> 
> IMO.


Says who?  My job is to treat my patient in the way I decide is best for the situation at hand.


Snowing someone simply because they grab a number out of thin air is not it.


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## EMSLaw (Dec 26, 2011)

DrParasite said:


> my back hurts, it's giving me 10/10 patient.  I'm going to travel to your system and call 911, since I want some pain meds.
> 
> so does my left toe, because I kicked a curb in 12 degree weather.
> 
> I hope i get a paramedic who will give me IV pain meds, since my pain is 10/10.



"On a scale of 1-10, where 10 is the worst pain you've ever felt in your life, how badly does it hurt?"  

"10"

"What's the worst pain you've ever felt?"

Sometimes, that's actually a useful question.  Also, sometimes I do wish our medics would be a bit more aggressive in their pain relief.  Then again, that requires them to open the narc bag, and fill out paperwork, and I suppose for some of them, that's just too much to ask.


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## DrankTheKoolaid (Dec 26, 2011)

*re*

Snowing someone and offering and administering analgesics for valid pain complaints is two totally different things.  It's unfortunate how many newer people I meet and talk to in EMS have a jaded view of pain management they most like obtained by working with medics who felt pain control wasnt a medics job.  Then again 5 - 10 minute eta's = glorified IV starters and not practicing paramedicine. 

Consider this the next time you have a patient with a valid pain complaint.  What would you do with a family member with the same complaint,  lets say your mother daughter or spouse.  Would you also withold analgesics?  What would you expect out of another medic treating your loved ones?

And for the answer for everthing types.  Would you consider analgesics any sooner with a real red~head or some other other ethnicity before you would on a caucasion


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## Shishkabob (Dec 26, 2011)

And we go back to my question, that you refused to answer...  Stubbed toe, 10/10.  Papercut, 10/10.  Piece of food stuck in gum, 10/10.  Do you give pain control to them to the point of getting rid of the pain to their satisfaction?  If not, you're a hypocrite.  If so, you're a cookbook medic.  So which is it?  Or will you relent and state that not everyone in pain, needs pain controlled by us in the field, and that it IS our job to decide who gets what?

Go back through my posts over the last 3 years.  I'm a huge advocate of analgesia, and love giving Fentanyl... but just because you say "Ow" and give me a number doesn't mean you're getting medicine from me.  The medicine has to match the complaint, and vice versa.  Most medics are too stingy, yes, but that doesn't mean we aren't to use our brains in the matter either.  I don't judge if someone is in pain, however, I do call in to question how much, and if I can't defend it, I'm not giving it.



Heck yes I'd treat my family with analgesics.  Guess what?  I'll also give my family $1,000 before I give some random person $1,000 when they say they are broke.


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## usalsfyre (Dec 26, 2011)

Corky said:


> lWould you consider analgesics any sooner with a real red~head or some other other ethnicity before you would on a caucasion


I have learned, through many years of working in different environments, malingering is an equal opportunity enterprise...

As others have said, some amount of judgement must be displayed. I'm just about as hard line as they come about pain management. Doesn't mean if I'm picking you up for the sixth time in two weeks for vague non-specific pain and we've hit a different ED each time I'm handing out narcs.


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## 46Young (Dec 26, 2011)

If you decide to (by being clinically negiligent) withhold pain meds in the field, the pt is just going to employ the "squeaky wheel" tactic and get the ED to get them high anyway. How many drunks, junkies or psych pts have you brought into the ED, nice and calm during txp, who flip out, scream bloody murder, and kick/punch everyone as soon as they're in triage? My record is four in one night. The pt knows that if they become violent, they'll be tied down and medicated, no matter what. I've seen it too many times.

I'd also hate to be the one who is wrong that one time about withholding pain meds, and then gets investigated for negligence, risking disciplinary action, being fired, or risk losing their card.


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## DrankTheKoolaid (Dec 26, 2011)

Linuss said:


> And we go back to my question, that you refused to answer...  Stubbed toe, 10/10.  Papercut, 10/10.  Piece of food stuck in gum, 10/10.  Do you give pain control to them to the point of getting rid of the pain to their satisfaction?  If not, you're a hypocrite.  If so, you're a cookbook medic.  So which is it?  Or will you relent and state that not everyone in pain, needs pain controlled by us in the field, and that it IS our job to decide who gets what?
> 
> Go back through my posts over the last 3 years.  I'm a huge advocate of analgesia, and love giving Fentanyl... but just because you say "Ow" and give me a number doesn't mean you're getting medicine from me.  The medicine has to match the complaint, and vice versa.  Most medics are too stingy, yes, but that doesn't mean we aren't to use our brains in the matter either.  I don't judge if someone is in pain, however, I do call in to question how much, and if I can't defend it, I'm not giving it.
> 
> ...



Re-read my post, i said VALID complaint.  I am totally for paramedics using their judgment if it is sound judgement and not a bias.

*usalsfyre*  I asked that question for a reason and obviously you didn't know it so I will just direct you to some light focused reading and you can find out for yourself why I asked the question regarding red-heads and other ethnicities.  

Sota Omoigui's Anesthesia Drugs Handbook - You can learn alot from reading what a world renowned expert has to say about pain control and various pain tolerances between ethnicities and even between Caucasian traits


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## epipusher (Dec 26, 2011)

I believe in the statement that it is not our place to be judging our patients. Some may respond by saying they are not judging, but using "clinical judgement". In my opinion, that is complete horse manure. Flame away.


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## usalsfyre (Dec 26, 2011)

Your talking about cultural differences in perception of pain I'm guessing? 

It's well established different cultures have different levels of pain tolerance and some may remain more stoic. While it's an interesting broad generalization, at the end of the day pain perception (and therefore analgesia) is still an individual sport.


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## usalsfyre (Dec 26, 2011)

epipusher said:


> I believe in the statement that it is not our place to be judging our patients. Some may respond by saying they are not judging, but using "clinical judgement". In my opinion, that is complete horse manure. Flame away.



Then a whole lot of chronic pain management specialists are full of equine puckey...

Like I said, I'm a fairly radical proponent of field analgesia. Even patients that I'm sure are seeking (the guy who's popped his hip out for the 8th time this month) get analgesia. If there's any doubt, give the meds, that morphine or fent isn't costing you anything.

That said...at some point there's a line. Treating conditions that are better taken care of with NSAIDs or APAP (the stubbed toe, minor headache, ect) with IV narcotics because we don't have another option is as inappropriate as withholding pain meds to an open fracture.


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## DrankTheKoolaid (Dec 26, 2011)

usalsfyre said:


> That said...at some point there's a line. Treating conditions that are better taken care of with NSAIDs or APAP (the stubbed toe, minor headache, ect) with IV narcotics because we don't have another option is as inappropriate as withholding pain meds to an open fracture.



This absolutely is our problem..  Would love to get some Toradol on the trucks!

But for those interested in pain management give Soto's book a read.  This goes way beyond generalizations and for the redhead it goes into cellular level why they react and feel pain differently.


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## triemal04 (Dec 26, 2011)

epipusher said:


> I believe in the statement that it is not our place to be judging our patients. Some may respond by saying they are not judging, but using "clinical judgement". In my opinion, that is complete horse manure. Flame away.


Fair enough, and I agree completely with you.  Of course, I hope that you aren't some sort of hypocrite, and whenever someone tells you that they are short of breath you use every single medicine that you have available for respiratory issues to treat them.  All of them.  For every respiratory issue.  After all, trying to determine what the cause of their complaint was and if they even have a valid complaint isn't using clincal judgement, it's judging someone.  And that's wrong.

Do you see how silly that is?

It's shocking how often this arguement comes up here, despite how few times I've had to argue about it in real life.  So, either I work with a truly elite group of paramedics (yeah...not completely true), nobody gives narcotics where I work (given how often the drug log get's updated that isn't the case) or most people have figured out something that is lacking here.

Saying that everyone who complains of pain will get treated for said pain indiscriminantly is no different than indiscriminently treating a complaint of SOB as above, or giving every single person complaining of chest pain nitro...:rofl:...  To decide if someone needs a narcotic is no different than deciding if someone needs albuterol or nitro or versed or magnesium or amiodarone or dopamine or epinephrine; it is our job to determine what treatement a patient needs based on our assessment and, yes, judgement of what is happening.  That does not mean judgement on a personal/socioeconomic level, but just focused on what the medical issue is.  Even a spineless protocol monkey can do that; they still have to decide which protocol they'll be blindly following.

If you aren't capable of doing that, then you should not be in a position where you have to make decisions about someone's care.  Period.  That's really what is always so disturbing about this thread when it repeats itself; people are argueing that you should mindlessly treat people without thinking...why does that sound like a bad idea?

If someone is blatantly drug seeking then no, they don't get narcotics.  If someone is in pain then they get treated until they aren't in pain anymore.  If you aren't sure because you actually assessed the patient and still can't tell if there really is a cause for their complaints...then they get narcotics, or whatever you may carry for pain relief.  See how simple that is?

Of course, at some point you'll be wrong if you do it like that, both in giving meds and withholding them.  Hopefully not very often, but it will happen.  But then...you'll also be wrong some of the times you give other medications, or choose not to give them.


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## epipusher (Dec 26, 2011)

You're comparing apples to oranges.


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## usalsfyre (Dec 26, 2011)

epipusher said:


> You're comparing apples to oranges.



Perhaps the same way your taking an overly dogmatic argument to the extreme?


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## epipusher (Dec 26, 2011)

usalsfyre said:


> Perhaps the same way your taking an overly dogmatic argument to the extreme?



Agreed. I do not see the problem in treating my patients with pain meds who complain of having said pain. Two major reasons: One being, if I deem them a bs, a frequent flier, or insert your own term, me not giving them pain meds on this particular run are not gonna keep them from calling again. Two, back to the whole being non-judgemental approach, who am I to say that this time their pain is not legit.


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## usalsfyre (Dec 26, 2011)

epipusher said:


> Agreed. I do not see the problem in treating my patients with pain meds who complain of having said pain. Two major reasons: One being, if I deem them a bs, a frequent flier, or insert your own term, me not giving them pain meds on this particular run are not gonna keep them from calling again. Two, back to the whole being non-judgemental approach, who am I to say that this time their pain is not legit.



What about the inappropriateness of 

1)chronic pain management by EM?

2)Treating relatively minor complaints with IV narcotics?


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## epipusher (Dec 26, 2011)

usalsfyre said:


> 2)Treating relatively minor complaints with IV narcotics?



Is this your opinion and dx of it being a relatively minor complaint? For me, if it is a minor complaint but the pain is rated by the pt of at least a 3/10, then I would be treating the pain relief.


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## triemal04 (Dec 26, 2011)

epipusher said:


> You're comparing apples to oranges.


Not really, no.

When someone presents to you with a complaint about their health, your job is to assess them, and then using your clinical judgement as you put it, treat them to the best of your abilities, based on your determination of what is wrong.  It doesn't matter if the complaint is "my head hurts" or "I can't breathe," to mindlessly start giving medicine is not appropriate.  It may be easier to assess one complaint than the other, and it may not be possible to be certain about one or the other, but it is still your job to make a decision based on your assessment and exam.

If your decision is to not bother because it's easier, then you shouldn't be making any decisions about how to treat someone.  And doing what you advocate is taking the easy way out, it's not a humane or nice decision, it's a cop out.  Sorry, but it is that simple.


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## triemal04 (Dec 26, 2011)

epipusher said:


> For me, if it is a minor complaint but the pain is rated by the pt of at least a 3/10, then I would be treating the pain relief.


So it's all just treating a number then?

Don't think, just do whatever the numbers say you should?  

Wow...


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## epipusher (Dec 26, 2011)

And if my assessment and exam reveals the patient is having pain, I am giving them pain medication. My original point is that I am performing this assessment, evaluation and exam and treatment regardless if they are a known drug seeker or a frequent flier.


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## usalsfyre (Dec 26, 2011)

epipusher said:


> Is this your opinion and dx of it being a relatively minor complaint? For me, if it is a minor complaint but the pain is rated by the pt of at least a 3/10, then I would be treating the pain relief.



Minor orthopedic injuries are, by definition, minor

Most dental complaints are minor.

Non-migrane, non-hemorrhagic, non-ischemic headaches are minor.

Muscoskeletal pain in a young adult related to a chest infection is minor.

Your not going to get push back from anywhere calling these complaints minor (and spare the "patient defines" rigamarole, if that were 100% true there'd be no triage). Each of these complaints is far more appropriately managed via non-narcotics or PO narcotics at the extreme end of things than via IV narcotics.

As I've stated, I'm a huge advocate of analgesia for professional and personal reasons. But, irresponsible use of opiates isn't the answer either.


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## epipusher (Dec 26, 2011)

triemal04 said:


> So it's all just treating a number then?
> 
> Don't think, just do whatever the numbers say you should?
> 
> Wow...



yes essentially, as our protocols state and our medical directors continually point out in audit and reviews of these particular runs. We of course, as do everyone, have to take into account LOC, allergies/sensitivities, consent, etc.


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## epipusher (Dec 26, 2011)

usal, i completely understand your post. I am just stating my reasoning for my way of treatment for those examples of patients you have listed.


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## usalsfyre (Dec 26, 2011)

epipusher said:


> usal, i completely understand your post. I am just stating my reasoning for my way of treatment for those examples of patients you have listed.



Sounds like you've got the same issue as the rest of us in US EMS, IV narcs or no analgesia at all. Makes me :wacko:.


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## triemal04 (Dec 26, 2011)

epipusher said:


> And if my assessment and exam reveals the patient is having pain, I am giving them pain medication. *My original point is that I am performing this assessment, evaluation and exam and treatment regardless if they are a known drug seeker or a frequent flier*.


I absolutely agree with the bolded portion.  Not doing so is no different than blatantly handing out meds without thinking.  But you have to really do the first part of that sentence before you can get to the last part.

What I take issue with is what you said above.  "the pain is rated by the pt of at least a 3/10, then I would be treating the pain relief"  That's not thinking about what you are doing, that's following a cookbook.  That's not an assessment, that's a cop out.


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## epipusher (Dec 26, 2011)

Alot of times it is an absolute cop out. Not to sound corny, but I could change cop out to saying its a "keep out" of the Quality Assurance Chiefs office.


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## epipusher (Dec 26, 2011)

I've had similar discussions before where our fellow coworkers and I realized a lot of what we do is cya and a "cop out" to keep "under the radar" of our QA personnel


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## epipusher (Dec 26, 2011)

heading up to the bay rooms friends, thanks for the discussion. lets hope for a slow night.


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## usalsfyre (Dec 26, 2011)

Don't you love how we've swung from "2mgs of morphine for your femur sticking out" to "how much fentanyl do you want for your hangnail dear? I'll make sure I push it really fast in the closest IV port..."

We really need some balance on the whole issue.


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## triemal04 (Dec 26, 2011)

epipusher said:


> Alot of times it is an absolute cop out. Not to sound corny, but I could change cop out to saying its a "keep out" of the Quality Assurance Chiefs office.


Ok, I feel your pain on that one.  Not trying to sound like to much of an *** if that's the case, but still...come on...

This isn't one of those situations that can't be dealt with.  If you have someone who is truly drug seeking, be very clear when talking with the recieving doctors and nurses about what happened and why you didn't do anything, and very clearly document the same in your chart.  "patient complains of 10/10 head pain, is holding head, rolling on the floor and yelling initially.  During exam patient stops yelling/holding head and rolling on the floor and begins speaking normally, appears in no distress and holds an amicable conversation.  While distracted patient does not complain of pain or discomfort."

Overly dramatic, but you get the point, right?


usalsfyre said:


> We really need some balance on the whole issue.


It isn't balance that's needed.  People on both sides need to think before they do something, and think before they don't do something.


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## DrankTheKoolaid (Dec 27, 2011)

*re*



triemal04 said:


> Ok, I feel your pain on that one.  Not trying to sound like to much of an *** if that's the case, but still...come on...
> 
> This isn't one of those situations that can't be dealt with.  If you have someone who is truly drug seeking, be very clear when talking with the recieving doctors and nurses about what happened and why you didn't do anything, and very clearly document the same in your chart.  "patient complains of 10/10 head pain, is holding head, rolling on the floor and yelling initially.  During exam patient stops yelling/holding head and rolling on the floor and begins speaking normally, appears in no distress and holds an amicable conversation.  While distracted patient does not complain of pain or discomfort."
> 
> ...



Absolutely!  I am QA/QI and if people would write a narrative in a proper manner, it is very easy to justify both providing and not providing analgesia.  But when you document someone cant get comfortable on the gurney with a stated 7 - 8 pain with a 45 minute trip to the ED, c'mon on that's just bad medicine.  And then when I find out said patient had kidney stones etc etc on my follow up, there is a problem.   It's funny when I talk with paramedic students where I teach almost 95% of them come in with the attitude of not wanting to give "narc's" which has been beaten into them by other providers they have worked with.  And when asked why they would not give narcotics in a particular situation the most common answer is "Well I can live with that pain".  

I do believe it relates back to our lack of pain control options as field providers.  But unfortunately as long as the majority of EMS  read :            (Encouraging Minimum Standards) (swiped that one from someone else here) state medical directors would be hard pressed to offer other alternatives.  If a "provider" cant bother him/herself with a little out of the box education on pain control why would they expect them to further their education on the many many side effects and contraindications of other non narcotic analgesics and synergistic medications we could actually be using.


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## Remeber343 (Dec 27, 2011)

Saying giving everyone with pain Narcs is exactly like saying everyone GCS less then 8 = intubate.


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## Squad51 (Dec 27, 2011)

firefite said:


> I say it's 10ml of saline. That's all I say. If it makes their pain go away then that's all them. I don't tell the patient it's any sort of pain med.



That's not saline, I like to call it "normalzaline"! WOAH! Sounds good huh?  LOL


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## usalsfyre (Dec 27, 2011)

Squad51 said:


> That's not saline, I like to call it "normalzaline"! WOAH! Sounds good huh?  LOL



Coming from a guy that works for a place that think nalbuphine is appropriate pain control crap like this doesn't surprise me .

One of the more miserable episodes of my life was due to the Green Machine's lack of pain management.


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## Squad51 (Dec 27, 2011)

usalsfyre said:


> Coming from a guy that works for a place that think nalbuphine is appropriate pain control crap like this doesn't surprise me .
> 
> One of the more miserable episodes of my life was due to the Green Machine's lack of pain management.



10mg Nubain + 10/10 pain= 10/10 pain.


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## Basermedic159 (Jan 30, 2012)

firefite said:


> Patient rates pain at a 10 out of 10 but yet are still smiling and no issues moving. Then you follow that with the wonderful 10ml preload of the "pain medication" saline. Their pain magically drops to a 1 or 2.



Unethically and illeagal. that is considered a placebo and anytime a pt is given any type of placebo the pt must be made aware that they may or may not be getting the actual medication.


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## DesertMedic66 (Jan 30, 2012)

Basermedic159 said:


> Unethically and illeagal. that is considered a placebo and anytime a pt is given any type of placebo the pt must be made aware that they may or may not be getting the actual medication.



If you care to read all my posts then you will find out that there is nothing unethical or illegal about it. The patient is told it is saline. The patient is not told any about it being a pain medication, because it's not any kind of medication. 

The saline is used as a flush to flush out an IV. After the IV is flushed the patient feels pain relief. They see someone push something into an IV and they feel better right away.


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## Basermedic159 (Jan 30, 2012)

the_negro_puppy said:


> I never withold pain meds, but I can't help but think that if drug seekers weren't given opioid analgesia by EMS and ED staff, then they would stop calling 911?
> 
> There has to be a way of stopping the repeating cycle. Why would anyone in my state try to buy drugs on the street / commit crimes to pay for them, when they can call 000 (911) get an ambulance straight away, lie to receive opioids, lie to the hospital and not get charged a single penny.



You cant prove anyone is a drug seeker anymore than you can prove they're in pain. You can NOT say well their pain is 8/10 but their bp is 120/80, so they must be a drug seeker. Thats ludacris!


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## Basermedic159 (Jan 30, 2012)

firefite said:


> If you care to read all my posts then you will find out that there is nothing unethical or illegal about it. The patient is told it is saline. The patient is not told any about it being a pain medication, because it's not any kind of medication.
> 
> The saline is used as a flush to flush out an IV. After the IV is flushed the patient feels pain relief. They see someone push something into an IV and they feel better right away.[/QUOTE
> 
> I understand this concept. I thought you where telling the pt it was pain medication. But it really bothers me on a moral and ethical level, that Pain is so under treated in the pre-hospital setting as well as the ED, because of the stigma surrounding pain, seekers, and Opiod analgesia. I have had migraines since I was 8 years old and had to visit the ED several times in my life for Migraine pain. I myself have been refused pain medications because "my vitals are normal." I can tell you I am NOT a drug seeker. That goes to show you that refusing pain meds to someone who you think is a seeker, infact may not always be a seeker. There should be something done to improve pain analgesia and efficacy in the pre-hospital setting as well as the ED.


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## Basermedic159 (Jan 30, 2012)

Plus refusing pain meds to a pt that may or may not be a seeker, will not put a dent in the prescription abuse problems in america. You have the calls where you absolultely know they are, but when in doubt give em the pain medication, and you might have actually helped someone who actually needed it.


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## the_negro_puppy (Jan 30, 2012)

Basermedic159 said:


> You cant prove anyone is a drug seeker anymore than you can prove they're in pain. You can NOT say well their pain is 8/10 but their bp is 120/80, so they must be a drug seeker. Thats ludacris!



 No-one is suggesting this, But, when I pick-up  a patient for the 10th time in a matter of weeks, with the same chief complaint of chronic pain and having been told at the last arrival at hospital that they are a drug seeking patient under a management plan I can safely assume they are not genuine. This is particularly relevant when they are sitting, talking freely appearing in no discomfort stating pain is 10/10 and requesting analgesia by name and dosage strength.

Giving large doses of analgesia to every patient because "you cant" disprove pain is just as bad as withholding it from genuine cases. Use your clinical judgement along with the patients circumstances, presentations and history.


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## the_negro_puppy (Jan 30, 2012)

Basermedic159 said:


> Plus refusing pain meds to a pt that may or may not be a seeker, will not put a dent in the prescription abuse problems in america. You have the calls where you absolultely know they are, but when in doubt give em the pain medication, and you might have actually helped someone who actually needed it.



Or you may be perpetuating abuse of the EMS and hospital system because its "too hard" to determine a patients pain level and which analgesia is appropriate.


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## Basermedic159 (Jan 30, 2012)

the_negro_puppy said:


> Or you may be perpetuating abuse of the EMS and hospital system because its "too hard" to determine a patients pain level and which analgesia is appropriate.



No, thats not true. If you have a pt that is taking on the phone, laughing, no facial grimace, requesting narcotics by name and dosage than they are more than likely a seeker. Now if you pick up a Migraine or Lower Back pain pt. that presents with N&V, photophobia, facial grimace, trying to find a position of comfort. Why withold pain meds? Mabey it's because you have a "Paragod" complex and you are unsure of the appropriate type of analgesia.

I'm not saying snow the pt with 100mcgs of fentanyl or 10 of morphine for an OBVIOUS drug seeker, but their are criteria of which can be utilized to determine a drug seeker. I'd rather be fooled by a damn good actor than not treat someones pain because I'm unsure. You just have to think about the reason you're there...to help people when they need help. Not to judge them or try and save the world, one seeker at a time. If thats the reason you're in emergency medicine, maybe you should think about switching to addictionology at a mental health institute.


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## epipusher (Jan 30, 2012)

It seems to me our profession is filled wit a lot of burned out and judgmental medics. It's absolutely embarrassing.


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## systemet (Jan 30, 2012)

Basermedic159 said:


> Thats ludacris!



No, this is ludacris:







What you're describing, is clearly ludicrous.


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## johnrsemt (Jan 30, 2012)

Remember that when you are looking at vital signs that you don't know what the patients normal vital signs are:

  Case in point:  My Normal B/P is 80/50;  so if I am telling you (prehospital or Doctor) that I am in extreme pain, and my BP is 120/80  and you are thinking that I am a seeker:  My BP is actually more than 50% higher than normal.   So you can't go just by vitals.
  And as an earlier poster stated;  sometimes pain does NOT increase pulse or BP  especially if the patient is on meds for HTN


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## systemet (Jan 30, 2012)

johnrsemt said:


> And as an earlier poster stated;  sometimes pain does NOT increase pulse or BP  especially if the patient is on meds for HTN



Or if there's a component of vagal stimulation occurring simultaneously, e.g. distension of a hollow organ.


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## the_negro_puppy (Jan 30, 2012)

Basermedic159 said:


> *Now if you pick up a Migraine or Lower Back pain pt. that presents with N&V, photophobia, facial grimace, trying to find a position of comfort. Why withold pain meds? Mabey it's because you have a "Paragod" complex and you are unsure of the appropriate type of analgesia.*



I wouldn't withhold treatment. I would deem them to be genuinely in pain and treat appropriately.


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## Basermedic159 (Jan 31, 2012)

epipusher said:


> It seems to me our profession is filled wit a lot of burned out and judgmental medics. It's absolutely embarrassing.



You are exactly right! Those are the medics that are just working a few more years just to draw a pension. Which I cannot completely blame them for, but when someone calls 911 and we show up, how we react, our attitude and demeanor towards pt's makes a big impact on how the pt as well as the family view an entire EMS system. Burnt out medics should work on convalescent trucks (if the agency their with has convalescent and emergency) to finish out their years.


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## Tigger (Jan 31, 2012)

Basermedic159 said:


> You are exactly right! Those are the medics that are just working a few more years just to draw a pension. Which I cannot completely blame them for, but when someone calls 911 and we show up, how we react, our attitude and demeanor towards pt's makes a big impact on how the pt as well as the family view an entire EMS system. Burnt out medics should work on convalescent trucks (if the agency their with has convalescent and emergency) to finish out their years.



So convalescent patients deserve a lower quality of care than the patient who calls 911?


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## Tigger (Jan 31, 2012)

johnrsemt said:


> Remember that when you are looking at vital signs that you don't know what the patients normal vital signs are:
> 
> Case in point:  My Normal B/P is 80/50;  so if I am telling you (prehospital or Doctor) that I am in extreme pain, and my BP is 120/80  and you are thinking that I am a seeker:  My BP is actually more than 50% higher than normal.   So you can't go just by vitals.
> And as an earlier poster stated;  sometimes pain does NOT increase pulse or BP  especially if the patient is on meds for HTN



Yesterday I had the misfortune of ending up in the ED after hitting a tree skiing with my left lumbar back. Despite being the worst pain of my life my BP was significantly lower than usual (no bleeds though). Still got 100mcg of fent, Valium IV, toradol IV, 2x 5mg
Percocet po, and 8mg zofran to keep me together. I can take baby steps with a walker now. Barely.


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## paradoqs (Feb 1, 2012)

If  a pt tells you they are an addict in withdrawal and in 10/10  generalized pain fro[GVIDEO][/GVIDEO]m that withdrawal, can you give narcs for pain or would you be treating their withdrawal symptoms? My medic said that could put his license at stake and he would never do that. Just a hypothetical.


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## Basermedic159 (Feb 1, 2012)

Tigger said:


> So convalescent patients deserve a lower quality of care than the patient who calls 911?



How in the world did you come to the concusion in the above statement you made, that convalescent pt's deserve a lower quality of care?


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## Basermedic159 (Feb 1, 2012)

paradoqs said:


> If  a pt tells you they are an addict in withdrawal and in 10/10  generalized pain fro[GVIDEO][/GVIDEO]m that withdrawal, can you give narcs for pain or would you be treating their withdrawal symptoms? My medic said that could put his license at stake and he would never do that. Just a hypothetical.



I believe it depends on what complaint you were called for. Im assuming you mean opiate withdrawl...
If an addict is in withdrawl from opiates they are going to thave pain regardless. If you are being called because of the withdrawl itself then no, I would not give narcotics.

If an addict called for a legitimate pain issue I would treat the pain appropriately, even if that constituted administering narcotics.
In my opinion a drug addict deserves the exact same pain control as someone without an addiction.

I heard someone say before- "Even drug addicts get sick, infact they tend to get sick more than not"


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## ffemt8978 (Feb 1, 2012)

Basermedic159 said:


> How in the world did you come to the concusion in the above statement you made, that convalescent pt's deserve a lower quality of care?


From you own post...I highlighted the relevant part in case you forgot.


Basermedic159 said:


> You are exactly right! Those are the medics that are just working a few more years just to draw a pension. Which I cannot completely blame them for, but when someone calls 911 and we show up, how we react, our attitude and demeanor towards pt's makes a big impact on how the pt as well as the family view an entire EMS system. *Burnt out medics should work on convalescent trucks (if the agency their with has convalescent and emergency) to finish out their years.*


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## Basermedic159 (Feb 1, 2012)

ffemt8978 said:


> From you own post...I highlighted the relevant part in case you forgot.



How does a burnt out medic on a convalescent truck mean they are getting a lower quality of care? I don't understand what you mean by that?


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## Basermedic159 (Feb 1, 2012)

Let me add to this post by saying I in no way trying to be rude, offensive or otherwise unpleasant by my previous posts. I just have a different way of saying things, that might be misconstrued as me being arrogant, which is not the case.


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## ffemt8978 (Feb 1, 2012)

Basermedic159 said:


> How does a burnt out medic on a convalescent truck mean they are getting a lower quality of care? I don't understand what you mean by that?



I'm not saying that.  I'm saying that's what Tigger was probably referring to, in answer to a question you posted about a comment he made.


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## Tigger (Feb 1, 2012)

ffemt8978 said:


> From you own post...I highlighted the relevant part in case you forgot.



I think ffemt88979 pretty much covered it for me. I think it's pretty much assumed by everyone on this forum that a burnt-out medic is not going to provide the same level of quality care as someone who still enjoys their job. Every patient we transport deserves quality care, even if they are dialysis patients going in for their thrice weekly visits. The "convalescent truck" still transports patients right?

I don't think I was the only one that interpreted your commented in such a way.


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## Basermedic159 (Feb 1, 2012)

Tigger said:


> I think ffemt88979 pretty much covered it for me. I think it's pretty much assumed by everyone on this forum that a burnt-out medic is not going to provide the same level of quality care as someone who still enjoys their job. Every patient we transport deserves quality care, even if they are dialysis patients going in for their thrice weekly visits. The "convalescent truck" still transports patients right?
> 
> I don't think I was the only one that interpreted your commented in such a way.




Yes they still transport patients. I have seen that burnt out medics seem to rather be on a convalescent unit rather than a 24hr emergency truck. They know when they get off, they get a lunch break, where as on the emergency truck thats not the case. Not saying this is true for every burnt out medic but from the ones i've talked to, they would rather work convalescent.


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## Jon (Feb 2, 2012)

But is the paramedic CAPABLE of doing the job? If they don't want to care for sick people - they need to step back and do something else. If they still can and WANT to do the job, then whatever.


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## Basermedic159 (Feb 2, 2012)

Jon said:


> But is the paramedic CAPABLE of doing the job? If they don't want to care for sick people - they need to step back and do something else. If they still can and WANT to do the job, then whatever.



I see your point....


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## Squad51 (Feb 14, 2012)

One day the newbies will realize you get paid the same whether you run or you walk. There's a difference between being burned out and just being tired. Myself, I've been there having worked high volume EMS for the better part of two decades. It's great having that young enthusiasm. It sucks getting old. It gets harder to get up 3 or 4 times in the middle of the night for calls. I still work in a busy 911 system, but would gladly give it up for a steady 8-5 and 3 squares a day gig on a transfer truck. It doesn't mean I'm burned out though. I still give excellent patient care and don't take shortcuts, all the time with a smile on my face. I think being burned out is when you don't care anymore and it compromises patient care by taking shortcuts because you're lazy and have a bad attitude. I guess what I'm trying to say is don't assume every medic who wants a quiet little transfer truck is burned out. You'll be there one day too.


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