# Pain Control



## Shishkabob

Guess what?  If you don't care about even attempting to help most of your patients pain, you are not a good provider, you never will be, and anyone who says you are is sadly mistaken.  



The Paramedic who relieves me constantly calls me out for my aggressiveness of pain control (ex- 250mcg Fent and some Ativan for a tib/fib last week) and boasts that she has given pain control MAYBE 3 times in the past year, and that I have the "New medic med push syndrome" where I just want to push a med (though she's never been on a call with me).  Maybe she's just angry that she has to go to the pharmacy to refill the narcs...



Just can't get through to some people. We have aggressive pain control guidelines for a reason...


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## Epi-do

Eh....she'll get over it.

I tend to get razzed from time to time about letting the fentanyl flow more freely than a lot of the other medics I work with as well.


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## LucidResq

Kinda baffles me... I mean, after getting people to a doctor, I would hope making them feel better would be goal #2. 

For some reason it reminds me of how I've had certain dentists hesitate to give me nitrous. The stuff will wear off before I get out of your chair, it reduces anxiety and pain for me, and I'm paying for it. But Mr. Dentist (or ER doc in the EMS equivalent) will happily leave me a script for Vicodin with my discharge paperwork that I could theoretically go home and take 20 of and sell the rest? That's what I don't understand. Granted, it's not the medic writing the script, and I've heard of dentists/doctors that are less friendly with the carry-out opiods, but honestly, I've yet to meet one. 

Am I the only one that's noticed this phenomenon? I'll tell you when I ended up in the ED a few months ago for severe abd pain, I only got IV Zofran and fluids while curled up on the bed wincing in pain, but left with an RX for Vicodin to fill at Walgreen's.


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## Shishkabob

I make it a habit to give my final bit of Fent (50mcg or so) just as we pull in to the ER bay so they have SOMETHING while waiting.


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## rhan101277

Initially after my first administration of morphine, I will ask the patient if they would like more pain medicine.  I will usually give 2-4mg of morphine and then see how it goes, if they are sedated, zonked out or what not then I don't give anymore or even ask.  If they are still AAOx3 and they are still hurting but not to the point where I can tell, I will ask would you like more pain medication.  Most people say no thanks, that helped alot.  I have only given morphine three times since I have been cleared paramedic, which was since January.

I to believe in pain management, after all they are paying for an ambulance ride. Why not give them the care that you can?


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## Veneficus

I think Linuss is exactly right on this one.

I have noticed in my travels that managing pain seems to be a problem in the US.

For some reason, despite the managment of pain being one of the oldest functions of medicine, US providers seem to be taught to fear the use of analgesia and there is a cultural bias against those who would make use of it.

Narcs and benzos together, there is hope for at least one excellent provider. Now if only the rest of the country would catch on.


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## Bieber

I'm always baffled at how many of my colleagues seem to emphasize (proudly) how they're not "candy stores" and that "you have to be in a lot of pain for me to give you anything".  There's not a lot of evidence suggesting what we do is all that valuable, but pain control is certainly one of those areas where we in EMS CAN and DO make a valuable difference.

Unfortunately, I'm sad to say that my protocols are rather limiting when it comes to pain control.  Chest pain, abdominal pain, and isolated injuries.  Absolutely no pain control for polytrauma, and benzos are for seizures and sedation for cardioversion (which, unless it's V-tach, we need to get an order for).  Hopefully things will change soon, but it's a rather conservative medical community around here (which I find somewhat ironic considering here in Kansas we're one of the few states that requires a degree to become a paramedic).



LucidResq said:


> Kinda baffles me... I mean, after getting people to a doctor, I would hope making them feel better would be goal #2.


Not to get off topic, but this comment stuck out to me and I'd like to ask you: is the goal really to get patients to a doctor (period), or to provide patients with the most appropriate medical care (whatever form it may take)?


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## cruiseforever

Had a co-worker that thought pt's having pain from kidney stones were just a bunch of cry babies.  He ended up getting them twice.  Since that time he has changed his tune and now treats pain with a vegence.  There has to  be a God.


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## Aidey

Veneficus said:


> I think Linuss is exactly right on this one.
> 
> I have noticed in my travels that managing pain seems to be a problem in the US.
> 
> For some reason, despite the management of pain being one of the oldest functions of medicine, US providers seem to be taught to fear the use of analgesia and there is a cultural bias against those who would make use of it.
> 
> Narcs and benzos together, there is hope for at least one excellent provider. Now if only the rest of the country would catch on.



Narcs and benzos together?!?! THAT IS CONSCIOUS SEDATION!!!!! YOU CAN'T DO THAT !!!11!

At least that is the attitude around these parts with my fellow paramedics. Thank goodness the ER MDs don't seem to agree. I called for orders one time for a teen with a shattered femur so I could get versed to add to the fent I had already given her. The MD told me to have at it, keep an eye on her breathing and not to exceed *10mg.* 

I've tried explaining the difference between a conscious sedation dose and an anti-anxiety/muscle relaxant dose, but I haven't gotten anywhere. 

As I've mentioned before, my personal problem with pain control is lack of options. I've got fent and that its it.


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## usalsfyre

There's a massive cultural bias against pain management in EMS. Providers who appropriately manage pain are seen as "weak" and "gullible". Like Linuss says, there's some who see it as a badge of honor NOT to give out narcotics. You gave to "prove" your pain to these people. There also the folks that will say an ambulance "isn't a damn taxi". The only place I haven't consistently encountered a large percentage of these medics is in CCT.

I've been on the other end. I've experienced a painful injury, and received no pain management from EMS or the ED. This transpired after I was an EMS provider, and had seen the pain management light. It sucks and is providing $hity medical care. If your not managing your patients pain appropriately to the extent allowed under your protocols, guess what, YOU suck as a medic.

What pisses me off about medics in my own service who do this is I was one of the guys jumping up and down screaming in the clinical services office about the homeopathic doses of morphine we used to have written in our protocols. To me, consistent failure to manage pain should be treated the same as any other consistent clinical failure. Remediation, discipline and termination.


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## usalsfyre

Aidey said:


> Narcs and benzos together?!?! THAT IS CONSCIOUS SEDATION!!!!! YOU CAN'T DO THAT !!!11!



LOL, I actually told him the same thing (with the same sarcasm)about another issue off-line earlier today .

We can't technically do narcs and benzos together for straight pain control without an online order. Which can be a pain to get depending on the doc and dispatch. However, benzos are rather liberally dosed for agitation in our guidelines. To me, anyone who can't sit still, is screaming, ect due to pain is agitated. Walla, narcs and benzos together...


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## Shishkabob

Heh, like I told you before usal, I like doing the "Hey, they're screaming, they obviously aren't happy, therefore they're agitated!" route... but I still called in my Ativan on the tib/fib guy JUST to cover my bases, and the doc I spoke with (Dr Cameron... still have to meet the guy) said "Sounds reasonable to me, go ahead"


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## Aidey

usalsfyre said:


> ....I was one of the guys jumping up and down screaming in the clinical services office about the* homeopathic doses of morphine* we used to have written in our protocols....



I am so stealing that. 


We technically can't either, and depending on the case I justify it the same way you do. I am more apt to call for orders if it is a fringe case (like my teenager who was about 90lbs). If it was up to me we would have dosing protocols for benzos to use as a "muscle relaxant". 



On a side note, there was a case recently where a 115lb female with 25% 2nd degree burns was given.....wait for it....wait for it.....65mcg of fentanyl during a ~20 minute transport.


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## usalsfyre

Linuss said:


> Heh, like I told you before usal, I like doing the "Hey, they're screaming, they obviously aren't happy, therefore they're agitated!" route... but I still called in my Ativan on the tib/fib guy JUST to cover my bases, and the doc I spoke with (Dr Cameron... still have to meet the guy) said "Sounds reasonable to me, go ahead"



I understand completely why you called. I probably should on some occasions too. I'm just too much of a h34r: medic sometimes. What's the fun in coming to work if you can't be subversive .


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## Icenine

Epi-do said:


> Eh....she'll get over it.
> 
> I tend to get razzed from time to time about letting the fentanyl flow more freely than a lot of the other medics I work with as well.



Keeps it from sitting in the truck expiring...


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## Veneficus

Aidey said:


> Narcs and benzos together?!?! THAT IS CONSCIOUS SEDATION!!!!! YOU CAN'T DO THAT !!!11!
> 
> At least that is the attitude around these parts with my fellow paramedics. Thank goodness the ER MDs don't seem to agree. I called for orders one time for a teen with a shattered femur so I could get versed to add to the fent I had already given her. The MD told me to have at it, keep an eye on her breathing and not to exceed *10mg.*
> 
> I've tried explaining the difference between a conscious sedation dose and an anti-anxiety/muscle relaxant dose, but I haven't gotten anywhere.
> 
> As I've mentioned before, my personal problem with pain control is lack of options. I've got fent and that its it.



When you use opioids and benzos together you use less overall than you would using just one. 

People need anesthesia teaching pain control, they are the only ones who get it right.


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## usalsfyre

Aidey said:


> I am so stealing that.


To be fair, I stole it too (from either Rogue Medic or Kelly Grayson's blog).



Aidey said:


> On a side note, there was a case recently where a 115lb female with 25% 2nd degree burns was given.....wait for it....wait for it.....65mcg of fentanyl during a ~20 minute transport.


I don't know why this crap goes on. Let me burn THAT medic over 25% of his body and see how satisfied he is with 65mcgs of fentanyl...


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## Aidey

Veneficus said:


> When you use opioids and benzos together you use less overall than you would using just one.
> 
> People need anesthesia teaching pain control, they are the only ones who get it right.



I know. I was just a little surprised that the MD authorized up to 10mg of Versed in a 90lb patient when he knew I was mixing it with fentanyl. I think I ended up using 1mg of versed and 150mcg of fent? It was a while ago, so I can't remember exactly. I do know that when I dropped her off I had managed to hit the sweet spot, where her pain was significantly reduced, and she wasn't overly sedated.


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## usalsfyre

Veneficus said:


> People need anesthesia teaching pain control, they are the only ones who get it right.


AbsoFreakingLoutely!

 But there's too many medics out there that think the only people who can teach EMS are medics, or maybe an EM physician (who preferably used to be a medic) because "we do it in the streets" .


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## Shishkabob

Aidey said:


> I know. I was just a little surprised that the MD authorized up to 10mg of Versed in a 90lb patient when he knew I was mixing it with fentanyl. I think I ended up using 1mg of versed and 150mcg of fent? It was a while ago, so I can't remember exactly. I do know that when I dropped her off I had managed to hit the sweet spot, where her pain was significantly reduced, and she wasn't overly sedated.



Oh yes, the sweet spot.  I got my tib/fib guy to that zone to where it only caused pain/discomfort when we moved him.  Just so happened that it took 250mcg/fent and 0.5mg Ativan.    The receiving doc was shocked at the 250 at first, till I reminded him that it was nearly an hour transport.

I typically aim to cut the pain in half at least... 10 to a 5, etc etc.  



usalsfyre said:


> I understand completely why you called. I probably should on some occasions too. I'm just too much of a h34r: medic sometimes. What's the fun in coming to work if you can't be subversive .



I told you earlier how I was h34r: like today... your evil habits are rubbing off on an impressionable newbie!


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## MrBrown

The chair of our Clinical Management Group is both a consultant anaesthetist and a consultant intensivest.  Brown has two uncles who are consultant anaesthetists and a very good friend who is a HEMS Doctor (anaesthetist) and Browns side interest is anaesthesia.  It is therefore fair to say we have one or two analgesia options in our bag of tricks and that Brown is not afraid to use them ...

We have methoxyflurane, morphine on its own, morphine+midazolam and ketamine.  Some areas have entonox still but Brown hears its being withdrawn.

Methoxyflurane is good for basic stuff, busted arm, nungered shoulder, kidney stones etc while you get a bit of history and a drip going if narcotics are needed.  It's also a good tool for our volunteer Technicians.

Morphine is good stuff, we have unlimited morphine here so it's up to the Ambulance Officer to decide how much the patient should get.  

One thing nobody in the US seems to understand is that you can give different amounts of morphine to different people for different presentations.  Everything Brown has seen generally says 2-4mg (both standing order and in educational material).  Somebody who is screaming in pain from an angulated open femur is not going to be touched by 2mg of morphine and needs you know, a decent dose.

Examples of loading doses of morphine given here:

- Motorcyclist hit by a car who is agitated with several fractured ribs: 2.5mg
- Guy who fell out of tree with an open humerus fracture:  5mg
- Lady with kidney stones who had never had morphine before:  2mg
- Young bloke with bilateral coles fractures:  10mg
- Teenager who fell off fence and screaming in pain:  5mg 
- Sick infarct with crushing chest pain:  1mg 

We usually start off with a dose of between 2mg and 10mg depending upon presentation and cardiovascular state then go up in 2.5mg or 5mg increments, if pain is not sufficiently controlled by the time we've given somebody over 10-15mg its time to ring up Intensive Care for some ketamine.  Repeat dosing of morphine is inappropriate if it is not relieving pain and its time to try something different.  

Morphine+midazolam was introduced in 2001 here and works bloody wonderfully but it's largely fallen out of fashion now that we have ketamine.  Example Brown has seen is some bloke with two femurs absolutely shattered to bits trapped in a car wreck, zonked him out nicely with some midaz and off to hospital he went.

Ketamine has been around since 2007 and it is the best thing Brown has ever seen, its just the most awesome thing since sliced bread.  

If you do not adequately control your patients pain you are a clinically inferior provider who should not be allowed to touch patients.


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## 8jimi8

Linuss said:


> Guess what?  If you don't care about even attempting to help most of your patients pain, you are not a good provider, you never will be, and anyone who says you are is sadly mistaken.
> 
> 
> 
> The Paramedic who relieves me constantly calls me out for my aggressiveness of pain control (ex- 250mcg Fent and some Ativan for a tib/fib last week) and boasts that she has given pain control MAYBE 3 times in the past year, and that I have the "New medic med push syndrome" where I just want to push a med (though she's never been on a call with me).  Maybe she's just angry that she has to go to the pharmacy to refill the narcs...
> 
> 
> 
> Just can't get through to some people. We have aggressive pain control guidelines for a reason...



Not questioning your judgement just curious. Because that dose seems pretty huge to me.  (Granted when i have people on fentanyl, its a continuous infusion.)

was there any change in level of consciousness with that amount of fentanyl?


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## usalsfyre

Linuss said:


> I told you earlier how I was h34r: like today... your evil habits are rubbing off on an impressionable newbie!


(Imperial music in the background, best Darth Vader voice)

Feel the power of the Dark Side...soon you too will be asking for ketamine in our formulary....


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## Shishkabob

8jimi8 said:


> Not questioning your judgement just curious. Because that dose seems pretty huge to me.  (Granted when i have people on fentanyl, its a continuous infusion.)
> 
> was there any change in level of consciousness with that amount of fentanyl?



I had him for over an hour from first contact to transfer of care.  The 250 of Fent was throughout the whole time I was with him, and the final 50 was within 5 minutes of pulling in to the hospital.  

Even with the 0.5mg of Ativan, there was no change in consciousness, just the usual "deep thinking mode" that patients go in to when they get Benzoes.  Not as bad as a big dose of Ketamine, he was fully awake and conversing, but he took a bit longer to respond to questions.




usalsfyre said:


> Feel the power of the Dark Side...soon you too will be asking for ketamine in our formulary....



You and I need to get in talks about getting Nitronox... I think that should fix some of the apprehension that some medics have.


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## Aidey

8jimi8 said:


> Not questioning your judgement just curious. Because that dose seems pretty huge to me.  (Granted when i have people on fentanyl, its a continuous infusion.)
> 
> was there any change in level of consciousness with that amount of fentanyl?



I've given doses like that a couple of times, generally in long transports. I gave one pt 275mcg. 300lbs, dislocated shoulder, 3-4 broken ribs, hour and 20 min transport down hill for the first 1/2. Aside from being more relaxed and calm there was no significant change in LOC.


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## Aidey

Linuss said:


> You and I need to get in talks about getting Nitronox... I think that should fix some of the apprehension that some medics have.



I used to have it, and I loved it. It was awesome, and has few contraindications. No needles, self dosed, no over sedation, good pain relief, need I go on? 

The biggest thing I have heard against it are control issues. I think that could easily be remedied with a regulator that has a counter on it that counts each discharge.


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## Shishkabob

I had Nitronox at the agency I did my Paramedic school internship at and LOVED it for all the reasons you mentioned.  


Just, from what I've been told, it's not extensively used because of the high costs associated with it since the FDA wont allow a pre-mixed version, and you need the Nitrogen bottle and the O2 bottle.


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## Aidey

We had an adapter that plugged into the O2 port on the wall. Same as our Whisperflow CPAP units have now.


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## 8jimi8

Linuss said:


> I had him for over an hour from first contact to transfer of care.  The 250 of Fent was throughout the whole time I was with him, and the final 50 was within 5 minutes of pulling in to the hospital.
> 
> Even with the 0.5mg of Ativan, there was no change in consciousness, just the usual "deep thinking mode" that patients go in to when they get Benzoes.  Not as bad as a big dose of Ketamine, he was fully awake and conversing, but he took a bit longer to respond to questions.
> 
> 
> 
> 
> You and I need to get in talks about getting Nitronox... I think that should fix some of the apprehension that some medics have.



Oh. when I first read it, I read it as a 250mcg bolus.  If you were dosing out aliquots, there doesn't even need to be discussion.  The only other question is why didn't you use dilaudid?  Do y'all have hydromorphone?  

Aidey,

I am fully on board /c 1mcg/kg/hr.   Often when I'm on the unit and see patients /c 8-10 mg/hr of versed on like ... 25mcg of fent.... i immediately change it to 1mcg/kg/hr of fentanyl and let that versed work its way out.  It usually works out to a sweet spot of 75-90% of fentanyl /kg/hr and 1 - 2 mg/hr of versed.  

I just don't understand why people set our patients up on such bad sedation packages.

We had a guy on 10mg of versed /s analgesia!  I talked to the intensivist and asked him why the patient wasn't on fentanyl and he said... "NO ONE STARTED FENTANYL!!??!!"


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## Shishkabob

No hydromorphone... Fentanyl is our only opiod.  We then have Ativan and Versed as our Benzos.


Our Fentanyl dosages used to be 1-2mcg/kg with no true limit (3mcg/kg for RSI).  However, apparently some medics walked in to ERs multiple times with patients totally snowed on Fent, so now we're 1mcg/kg Fent, can be repeated another time for a total of 2mcg/kg Fent... for acute pain for patients between the ages of 10-70.  Everything else they'd prefer if we called.


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## 8jimi8

At least you've got 1mcg/kg.  That is a healthy dose that should cut anything in half.

Repeat dosing should handle the long transports.  If you need more, you need versed!

Nice work Linuss, I'm proud of you.

Just remember... As Bob Marley said... "who feels it, knows it"


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## usalsfyre

8jimi8 said:


> At least you've got 1mcg/kg.  That is a healthy dose that should cut anything in half.
> 
> Repeat dosing should handle the long transports.  If you need more, you need versed!
> 
> Nice work Linuss, I'm proud of you.
> 
> Just remember... As Bob Marley said... "who feels it, knows it"



The problem before was we had too many medics who thought 2mcgs/kg was a good starting point for a fast push. On 4ft9 100kg patients. 

To give you an idea of most of these medics inexperience with opioids, our previous morphine dose  was 0.04mg/kg...


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## Icenine

The protocols for medics here don't allow for versed.  They have been finalizing a rewrite of our protocols for about the last 2 years and I'm told they allow for much better pain control.  Until a few years ago the only ALS agencies in the county shared a zip code with both of our hospitals.  Now there are more than a few with 40+ min transport times.

Morphine 2-5 mg every 5 min (unlimited)

If allergic or unresponsive to Morphine, 50 mcg Fentanyl w/ 1 additional 50 mcg dose in 5 mins.

Tordol 30 mg 1 time

4mg Zofran 1 time


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## the_negro_puppy

At my level we have only methoxyflurane (inhlaer), paracetamol and morphine.


Makes it interesting when you have a pt thats in moderate pain, has had paracetamol within 4 hours, cant have methoxyflurane (hx liver cancer with recent jaundice/bilary stent) and is hypotensive +tachy (? sepsis). 

Our protocols state that hypotension = 2.5mg increments and Intensive Care Paramedic backup must be requested if giving. When you are 15 minutes from hospital, and waiting for ICP backup will probably take 10-15 mins (road speed) its frustrating when you have to leave the pt in pain til they get to hospital.

It would be good to have another option, with Ketamine only an ICP drug for bad fracture pain management


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## medicRob

Nothing pisses me off more than the providers who play the "Who is a drug seeker" game. In the patient bill of rights, one of their rights is the right to not be in pain. 

Also, as a wise medic said:

 2 mg of morphine + Severe Pain = Severe Pain.


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## MrBrown

medicRob said:


> Also, as a wise medic said:
> 
> 2 mg of morphine + Severe Pain = Severe Pain.



Anybody who gives 2.5mg of morf so somebody in severe pain should be relegated to driving 



			
				the_negro_puppy said:
			
		

> Our protocols state that hypotension = 2.5mg increments and Intensive Care Paramedic backup must be requested if giving. When you are 15 minutes from hospital, and waiting for ICP backup will probably take 10-15 mins (road speed) its frustrating when you have to leave the pt in pain til they get to hospital.
> 
> It would be good to have another option, with Ketamine only an ICP drug for bad fracture pain management



Do you have a copy of the QAS procedures somewhere? 

Paramedic here (~QAS ACP) have methoxyflurane, paracetamol and morphine too.  We can give 1.5g to somebody who has had paracetamol four hours ago and don't have to ring up for Intensive Care if we are giving morph to somebody who is hypotensive.

Brown would be judicious about morphine in hypotension, if you think they are septic they should be getting a litre of fluid anyway.


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## the_negro_puppy

MrBrown said:


> Anybody who gives 2.5mg of morf so somebody in severe pain should be relegated to driving
> 
> 
> 
> Do you have a copy of the QAS procedures somewhere?
> 
> Paramedic here (~QAS ACP) have methoxyflurane, paracetamol and morphine too.  We can give 1.5g to somebody who has had paracetamol four hours ago and don't have to ring up for Intensive Care if we are giving morph to somebody who is hypotensive.
> 
> Brown would be judicious about morphine in hypotension, if you think they are septic they should be getting a litre of fluid anyway.



The first thing I did once loaded was run a bag of fluids (got about 500ml before arrival)


Also the 2.5mg increment is for hypotension with systolic BP < 90 mmhg. This patient was 75/48 o/a mainting in different positions. 500ml of fluid = 82/53 roughly o/a hospital.

Ive attached a copy of QAS DTPs for your perusal


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## cruiseforever

One thing nobody in the US seems to understand is that you can give different amounts of morphine to different people for different presentations.  


How can one make that statement?   When I first started in EMS it was a big deal to give 5-10 mg of Morphine Sulfate.  But now we have grown and earned the trust and respect of our Medical Control.   Some areas in the US are very progressive in dealing with pain control.  I wish people would stop coloring everything with one stroke of the brush.


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## 18G

Pain management is something I take seriously as a Paramedic and feel like my system has pretty decent standing orders for pain management with both morphine and Fentanyl available. We can also use nitrous oxide but I don't know of any EMS Department that carries it. 

We just had our pain management protocol revamped and now have standing orders for pain management in patients with acute onset back pain and acute thoracic / rib pain after trauma. Before it was just for suspected isolated extremity fractures unless of course we consulted for orders. 

Here is a link that gives some good perspective on attitudes surrounding pain management in EMS and Emergency Medicine and why there is still hesitation to treat pain aggressively. 

http://www.emsworld.com/print/EMS-World/Taking-EMS-Into-Tomorrow--Part-6/1$4214


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## MrBrown

cruiseforever said:


> How can one make that statement?   When I first started in EMS it was a big deal to give 5-10 mg of Morphine Sulfate.  But now we have grown and earned the trust and respect of our Medical Control.   Some areas in the US are very progressive in dealing with pain control.  I wish people would stop coloring everything with one stroke of the brush.



Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?

Brown has seen one area (Wake County) has entonox and it's a Paramedic (ALS) level skill for frig sake, back in 1975 our one week trained Elementary Ambulance Aid Officers could give entonox.


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## medic417

MrBrown said:


> Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?
> 
> Brown has seen one area (Wake County) has entonox and it's a Paramedic (ALS) level skill for frig sake, back in 1975 our one week trained Elementary Ambulance Aid Officers could give entonox.



I can administer Morphine (carry 50mg minimum ), Fentanyl ( carry 500mcg minimum ) , Ketamine, Versed, Toradol, Nubain, and many more on standing orders to get patient relief, no maximimum.  If they hurt we treat.


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## reaper

Hit them with a D cylinder. They won't hurt any more! Saves money!


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## usafmedic45

The service I was a supervisor with had nitrous as the BLS measure for pain control.  The state wasn't happy about it, but to quote our medical director "You're not the one with a medical license so I think you can figure out what part of my anatomy to stimulate your gag reflex upon.  Good day sir."  

(...and you wonder where I get the attitude from?)


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## Shishkabob

MrBrown said:


> Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?



Errr.. mine and usalfyres agency.


We have 1250mcg of Fent on our truck, and no true maximum, just a "consider calling for consultation for something more effective"


Also have Ativan and Versed for "agitation" (our call who's agitated)


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## usafmedic45

Veneficus said:


> People need anesthesia teaching pain control, they are the only ones who get it right.



...or some oncologists.  One of the best pain control folks I've ever met was an oncologist I worked with in the Air Force.  She's the one who taught me not to be afraid of narcotics and introduced me to the marvels of ketamine for otherwise intractable pain.


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## Shishkabob

Or a burn ward doctor...




Narcs don't scare me, we have Narcan.   Amiodarone and Lidocaine in a conscious patient?  Yeah, that scares me.


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## usafmedic45

To quote a slide from the presentation I do on palliative care:  "You can save someone's life but leave them in pain and they will curse your name for the rest of their days.  You can be powerless to save someone but ease their pain and they will sing your praises for eternity as will their family."


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## cruiseforever

MrBrown said:


> Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?
> 
> Brown has seen one area (Wake County) has entonox and it's a Paramedic (ALS) level skill for frig sake, back in 1975 our one week trained Elementary Ambulance Aid Officers could give entonox.



The service I work for is one.  THe only limit we have on Morphine is 10 mg in a cardiac pt.  When we hit 10 mg med control wants to know.  Other wise 60 would be our limit because that is what we carry for Morphine.  We can use Ketamine, Dilaudid, Versed.  Used to carry Nitrous.  It was a cost issue that led to that being pulled.

I am new to this site.  But from what I have read, I think you are seeing Medics that are frustrated by systems that are holding them back.  And they are more vocal due to their frustrations


----------



## jjesusfreak01

MrBrown said:


> Can you show me any area which has more than 10mg of morphine or equivalent on standing order, or has standing order morphine+midazolam, or has ketamine or any sort of combination analgesia?
> 
> Brown has seen one area (Wake County) has entonox and it's a Paramedic (ALS) level skill for frig sake, back in 1975 our one week trained Elementary Ambulance Aid Officers could give entonox.



We have Versed (5mg max), Morphine (20mg max, except for burn patients), and Fentanyl (200mcg max) here in Wake County. Although NOX is in the protocols, I haven't ever seen it on a truck.

These are all standing orders...


----------



## Melbourne MICA

*Cruel and unusual punishment.....*

The philosophy on MICA here re analgesia is; if  the patient still needs it they keep getting it and we have virtually no limit beyond common sense and the patients vitals ( and reasonable interpretation of guidelines. 

I think the context of situations where you are providing narcotic or other IV analgesia does matter though. Multi-trauma patients come to mind - this is where the midaz/narcotic combination is risky. Whilst I have never seen Morph/Fentanyl trash the pts BP when they have genuine severe pain, Midaz will certainly do it. Not a good idea when you want to RSI or have other perfusion sensitive situations.

MM


----------



## MrBrown

Melbourne MICA said:


> The philosophy on MICA here re analgesia is; if  the patient still needs it they keep getting it and we have virtually no limit beyond common sense and the patients vitals ( and reasonable interpretation of guidelines.
> 
> I think the context of situations where you are providing narcotic or other IV analgesia does matter though. Multi-trauma patients come to mind - this is where the midaz/narcotic combination is risky. Whilst I have never seen Morph/Fentanyl trash the pts BP when they have genuine severe pain, Midaz will certainly do it. Not a good idea when you want to RSI or have other perfusion sensitive situations.
> 
> MM



That is why we have ketamine now, provides profound analgesia and amnesia (in large enough doses for amnestic properties) with a very low haemodynamic risk.

Is partic good for shocked patients


----------



## Veneficus

Linuss said:


> Narcs don't scare me, we have Narcan.   Amiodarone and Lidocaine in a conscious patient?  Yeah, that scares me.



If I could just offer some perspective that night save yor patients a lot of grief?

If you induce the side effects of narcotics, it is much more humane to control ventilation and BP support than it is to acutely reverse them with narcan. 

The patient was in enough pain for you to do something about it in your clinical judgement. If you acutely reverse it you will eleiminate all analgesia and then alternatives which usually are not always available in the ED must be used.

That basically means that you put your patient in irretractable pain until the narcan wears off. Once somebody "OD's" on medically administered narcs, every person after will be hesitant to give them any for quite a while.


----------



## Shishkabob

I knew that already, vene, and am just fine supporting ventilation on a narcotic overdose. 


My point was, of necessary I could reverse a narcotic.    I cant reverse an anti-arrythmic.


----------



## Smash

MrBrown said:


> That is why we have ketamine now, provides profound analgesia and amnesia (in large enough doses for amnestic properties) with a very low haemodynamic risk.
> 
> Is partic good for shocked patients



Ketamine is indeed the nuts of the duck


----------



## MrBrown

Smash said:


> Ketamine is indeed the nuts of the duck



Brown thought there was much kerfuffel about ketamine over your way? 

Queensland only have it for fracture management (although this is where its very useful) we have it for "severe pain unresponsive to morphine" which is not defined but is mostly pacing, burns, fractures and suchlike as well as RSI.

Brown seems to remember something about MAS wanting another eleventybillion dollars for having it.


----------



## Smash

MrBrown said:


> Brown thought there was much kerfuffel about ketamine over your way?
> 
> Queensland only have it for fracture management (although this is where its very useful) we have it for "severe pain unresponsive to morphine" which is not defined but is mostly pacing, burns, fractures and suchlike as well as RSI.
> 
> Brown seems to remember something about MAS wanting another eleventybillion dollars for having it.



No kerfuffle, it's just that only the whirlybird types have it, not everyone else.  There is currently kerfuffle over research and what it is worth to the community, and what we should be getting in return.  The RSI study got a few backs up as it showed a very significant reduction in cost to the community, improved outcomes for the patients and was a significant advance in work-practice for the road MICA, but the service (govt) said that it was not worth anything to anyone and would not increase our pay as a result.
All we want is to be recognised for the value we provide.  And maybe to not be the worst paid ambos in the country!

EDIT:  Sorry, there may be some kerfuffle from higher up the chain, I have heard second, third, fourth hand that they are worried about the potential for abuse of ketamine   Doesn't stop them giving us all rubber stoppered 300mcg/ml fentanyl vials though!


----------



## MrBrown

You could always go work in WA or NT ....... no?


----------



## johnrsemt

I thought the comment by someone on this thread about his goal to cut pain from 10 to 5 was interesting:  why?  Why not make the pain go away?

  My old area Medical Directors attitude was if the pain is a stubbed toe, and over 3/10 it had better be 0/10 when they get to the ED.

   One of my old supervisors used to go to Med Director about me, almost quarterly because of my pain management:  at one point the MD told me that I was giving out more pain meds than the next three medics combined at my company.  He challenged me to increase my usage til I was giving more than ALL of the other medics at the company.   I came close a few times,  I think the MD was trying to get the manager to have a CVA.


----------



## Shishkabob

johnrsemt said:


> I thought the comment by someone on this thread about his goal to cut pain from 10 to 5 was interesting:  why?  Why not make the pain go away?



I said I make it a goal to cut in ATLEAST half, ie 10 to a 5, 8 to a 4, etc.  If more, fantastic, but I'm not one to go "I gave you 100mcg of Fent, I don't care if it's still an 8"


But I'm also not going to completely snow my patient if they are comfortable.


----------



## usalsfyre

I agree, my goal is to get a patient to a "comfortable" level. Zero is ideal, but other factors come into play.


----------



## mc400

Excellent post. I agree 100% with pain management and being aggressive with it. I remember being an EMT and treating a guy with multiple but not critical gunshot wounds and the medics on scene were concerned with shock and all kinds of other stuff because the guy was sweaty, rapid HR etc. Flight medic walked up asked him how bad his pain was and gave him 100mcgs of Fent and a couple mg's of a benzo and 2 minutes later told the medic see Pain is a :censored::censored::censored::censored::censored:, makes an patient with otherwise no life threats feel like they are dying. Ever since that day I am an advocate for pain control and anxiety relief. I really like the Idea of a Chest pain protocol including Ativan along with the MONA. Just works so damn good.


----------



## 8jimi8

mc400 said:


> Excellent post. I agree 100% with pain management and being aggressive with it. I remember being an EMT and treating a guy with multiple but not critical gunshot wounds and the medics on scene were concerned with shock and all kinds of other stuff because the guy was sweaty, rapid HR etc. Flight medic walked up asked him how bad his pain was and gave him 100mcgs of Fent and a couple mg's of a benzo and 2 minutes later told the medic see Pain is a :censored::censored::censored::censored::censored:, makes an patient with otherwise no life threats feel like they are dying. Ever since that day I am an advocate for pain control and anxiety relief. I really like the Idea of a Chest pain protocol including Ativan along with the MONA. Just works so damn good.



I wish people would stop quoting MONA.  It is not appropriate for all chest pain.


----------



## EMTinNEPA

I would rather be duped by a thousand seekers than not give pain medication to one person who needed it.


----------



## rhan101277

mc400 said:


> Excellent post. I agree 100% with pain management and being aggressive with it. I remember being an EMT and treating a guy with multiple but not critical gunshot wounds and the medics on scene were concerned with shock and all kinds of other stuff because the guy was sweaty, rapid HR etc. Flight medic walked up asked him how bad his pain was and gave him 100mcgs of Fent and a couple mg's of a benzo and 2 minutes later told the medic see Pain is a :censored::censored::censored::censored::censored:, makes an patient with otherwise no life threats feel like they are dying. Ever since that day I am an advocate for pain control and anxiety relief. I really like the Idea of a Chest pain protocol including Ativan along with the MONA. Just works so damn good.



I would have to consult with med control on this because we only have toradol and morphine.  We are getting fent soon and maybe we can do the same.

I would hate to give morphine and be incorrect.  If they are in a shocky state you can go ahead and check them on out with some morphine if you are not careful.  I am all for pain med.  Sometimes I will get the doc on the phone just to cover myself though.


----------



## BandageBrigade

I never truly appreciated how lucky I am to work in the system i do until I started to read this forum. At my service, our pain protocols (read: pain, not agitation or anxiety. Even though they are just as liberal) consists of: morphine, fent, Diluadid, ketorlac, ativan and versed. All on standing orders with no real limits except in special circumstances. I cant remember having to ever call for an order on any type of call.


----------



## johnrsemt

Sorry Linuss;  mis read your post the first time around


----------



## lightsandsirens5

Smash said:


> Ketamine is indeed the nuts of the duck



Ah ha ha! I have not heard that one! I like that.


----------



## Crunch

man, my system sucks as far as pain management goes. We have to call for orders for ANY pain management. We carry morphine and toradol, but toradols only intended to be used for kidney stones (at 15 mg with online orders). Cardioversion is a standing order, however any sedation to go along with it requires a phone call.  There are medics at my service that brag about not breaking the narc box for years. 

It goes all the way up the chain here too, the other day we were enroute to an acutely dislocated shoulder, and were canceled off for a BLS unit, which if I'm not mistaken requires supervision approval to send a BLS unit to a trauma. I'm sure it was a painful ride for that gentleman.

We can not medicate for abdominal pain even with online medical control, its really the only protocols of ours that can't be overridden with a phone call to the doc.

The reasoning behind our handcuffs is the idea that since were in urban ems service, were only 10-15 minutes from a hospital 95% of the time. It's frustrating when people, especially those in ems, fail to recognize that there is a difference between "time to the ED" and "time to definitive care" or really any care here. While they may only be in the ambulance for 10 minutes, its not uncommon for a pt to sit on our stretcher in the middle of the ed for 25 or 30 minutes before they even get a bed, let alone see a doc. It gets even worse when you add in the fact that the MDs here are notoriously bad about denying orders to EMS.


----------



## HotelCo

Crunch said:


> man, my system sucks as far as pain management goes. We have to call for orders for ANY pain management. We carry morphine and toradol, but toradols only intended to be used for kidney stones (at 15 mg with online orders). Cardioversion is a standing order, however any sedation to go along with it requires a phone call.  There are medics at my service that brag about not breaking the narc box for years.
> 
> It goes all the way up the chain here too, the other day we were enroute to an acutely dislocated shoulder, and were canceled off for a BLS unit, which if I'm not mistaken requires supervision approval to send a BLS unit to a trauma. I'm sure it was a painful ride for that gentleman.
> 
> We can not medicate for abdominal pain even with online medical control, its really the only protocols of ours that can't be overridden with a phone call to the doc.
> 
> The reasoning behind our handcuffs is the idea that since were in urban ems service, were only 10-15 minutes from a hospital 95% of the time. It's frustrating when people, especially those in ems, fail to recognize that there is a difference between "time to the ED" and "time to definitive care" or really any care here. While they may only be in the ambulance for 10 minutes, its not uncommon for a pt to sit on our stretcher in the middle of the ed for 25 or 30 minutes before they even get a bed, let alone see a doc. It gets even worse when you add in the fact that the MDs here are notoriously bad about denying orders to EMS.



I work in Detroit, and you can get to a level 1 within 10 minutes from anywhere in the city, plus we have 4 more ERs within the city limits, and our protocols aren't that restrictive.


----------



## Crunch

The last orders I got were for 4 of morphine on a 80 kg male with a shoulder injury after being hit on a bike by a car, no other injuries, with a good bp. Pt stated it felt dislocated, no obvious deformity, but noticible muscle spasm. I was denied any benzo. 

But, due to all the psych pts we run our acute agitation protocol is standing 5 mg versed and 5 mg haldol with a repeat 5 and 5 if necessary, i might have to try using that one next time.


----------



## Veneficus

Crunch said:


> The last orders I got were for 4 of morphine on a 80 kg male with a shoulder injury after being hit on a bike by a car, no other injuries, with a good bp. Pt stated it felt dislocated, no obvious deformity, but noticible muscle spasm. I was denied any benzo.
> 
> But, due to all the psych pts we run our acute agitation protocol is standing 5 mg versed and 5 mg haldol with a repeat 5 and 5 if necessary, i might have to try using that one next time.



Maybe it is time to find a new medical director?


----------



## Melbourne MICA

*Ouch!!!*

I'd have to say I'm gobsmacked to read what I'm reading. Pain relief is and has been fundamental to medical practice for thousands of f*##%* years. ANd you have to get medical approval to use 4mg of Morphine for someone with a dislocated shoulder who will probably be well over the 25-30mg mark before he's midazed for the shoulder re-alignment?!!

What's the issue for Gods'sake? And why am I hearing stories about Paras "proud" they haven't opened up the narc box for years. Is there an epidemic of sadism running through the EMS system in the US. Conversely I am delighted to hear others here equally disgusted and that not all the jurisdictions are doing the same thing.

Why is it those running EMS in the US just don't get it. People talk and people find out about all this - and that includes us overseas. We talk about it and our docs and bosses talk about it. The end result is laughter. With all due respect to those doing their best, the enlightened and dedicated, present company included, inevitably you all get tarred with the same brush - and the reputation of your wonderful country suffers as well.

The day my superiors expect me to grovel to give analgesia to ease some poor patients suffering is the day I'll burn my epaulettes and piss on the front lawn of our headquarters.

MM


----------



## MrBrown

Melbourne MICA said:


> \
> The day my superiors expect me to grovel to give analgesia to ease some poor patients suffering is the day I'll burn my epaulettes and piss on the front lawn of our headquarters.
> 
> MM



Yes but we are trusted, look at even in the days when Frank was teaching MICA Stage 1 at the AOTC it took two years to become a qualified Ambulance Officer and MICA was another year ontop of that.  

Even our old Advanced Care Officer qualification too four to five years to obtain.

Look at how closely we work with our physician colleagues; the MAS Medical Standards Committee and our Clinical Management Group know we are competent because the population of Paramedics is much smaller and they have a greater influence upon education than in the US.  Victoria only has a handful of Universities that MAS accepts graduates from and a consolidation year ontop of over a thousand hours of University practicum.  Here in New Zealand we have two Paramedic Degrees and 1,250 hours of practical clinical exposure during the Degree.

We have a whole gaggle of Clinical Standards Officers and a robust program of continuing education/CCE and Paramedic led research is big.  None of this exists in the US, you get your patch and you are left to be with maybe a few classes here and there which teach you nothing new except things like how to manage septic shock with permissive hypotension! 

If Brown had spent all that money and time investing in becoming a Consultant Physician and knew that these "Paramedics" could have as little as 12 weeks training Brown would be rather restrictive too!

And yes, its very sad indeed, breaks Browns heart.


----------



## Melbourne MICA

*Reds under the bed*

You're right Brown but the cynical leftie in me smells profit motive in the US. Not across the board - I won't do a disservice to the many who work their hearts out to set up and run great EMS organisations, provide their EMT's with every opportunity to be great practitioners (rather than technicians) over there but it's hard not to think many of the privates at least are only interested in profits not staff training and education and God forbid - actually providing great service to patients.

MM

Late PS - I wonder if any of the present company think litigation issues are a big driver in decison making in these things, perhaps overly so?


----------



## Frozennoodle

MrBrown said:


> If Brown had spent all that money and time investing in becoming a Consultant Physician and knew that these "Paramedics" could have as little as 12 weeks training Brown would be rather restrictive too!
> 
> And yes, its very sad indeed, breaks Browns heart.



Kind of makes me proud that despite being the ***-end of the country, my Paramedic program is 18 months long with 700 hours of clinical and internship required.  I can't see how anyone can come out of a 12 week course with any kind of confidence that they aren't killing their patients when we spend an entire semester on pathology and pharmacology.


----------



## DrParasite

Frozennoodle said:


> Kind of makes me proud that despite being the ***-end of the country, my Paramedic program is 18 months long with 700 hours of clinical and internship required.  I can't see how anyone can come out of a 12 week course with any kind of confidence that they aren't killing their patients when we spend an entire semester on pathology and pharmacology.


Just for clarification: was your program 18 months long, 2 nights a week for 4 hours each night (plus 700 hours of clinical time), or was it 18 months long, monday to friday, from 9am to 6pm with an hour lunch, plus 700 hours of clinical time?  Just want to see how much time you actually spend in a classroom, instead of how long you were a student for.


----------



## Frozennoodle

DrParasite said:


> Just for clarification: was your program 18 months long, 2 nights a week for 4 hours each night (plus 700 hours of clinical time), or was it 18 months long, monday to friday, from 9am to 6pm with an hour lunch, plus 700 hours of clinical time?  Just want to see how much time you actually spend in a classroom, instead of how long you were a student for.



A bit of both.  8:30-4:00 2x a week.


----------



## Veneficus

Melbourne MICA said:


> The day my superiors expect me to grovel to give analgesia to ease some poor patients suffering is the day I'll burn my epaulettes and piss on the front lawn of our headquarters.
> 
> MM



You have such a way with words.


I think the major problem is that a large percentage of US providers at all levels are taught in school to fear giving analgesia.

Litigation being secondary.


----------



## systemet

Frozennoodle said:


> I can't see how anyone can come out of a 12 week course with any kind of confidence that they aren't killing their patients when we spend an entire semester on pathology and pharmacology.



I've got to ask -- are there really 12 week paramedic programs?  That's an exaggeration, right? There can't actually be anywhere in 2011 where they teach medic in 3 months?


----------



## DrParasite

systemet said:


> I've got to ask -- are there really 12 week paramedic programs?  That's an exaggeration, right? There can't actually be anywhere in 2011 where they teach medic in 3 months?


ask and you shall receive: http://tinyurl.com/6z8uyro


----------



## systemet

DrParasite said:


> ask and you shall receive: http://tinyurl.com/6z8uyro



Awesome!  I bet you've been waiting for a while to use that.


----------



## systemet

Ok.  Now I've well and truly derailed this thread, I have to say, I am *shocked* that there are 12-week medic programs.  Mine was 2 years, M-F 40 hours / week, with 1200 hours on the ambulance and 400 in hospital.  And, in my opinion, that was way, way, too short for the things I was able to do as a medic.


----------



## Smash

DrParasite said:


> ask and you shall receive: http://tinyurl.com/6z8uyro



I just threw up in my mouth a little.  Click the second link that your (hilarious) link takes you to.  Watch the movie that plays.  Despair.


----------



## MrBrown

Brown is not sure if these ondansetron crackers work on cows 

You know all this time Brown thought Smash's avatar was of the female reproductive system, poor blind Brown


----------



## Sandog

MrBrown said:


> You know all this time Brown thought Smash's avatar was of the female reproductive system, poor blind Brown



Now that is heck a funny. ^_^  Now that you mention it, it does... hehe


----------



## Smash

Dammit, now I have to change it!


----------



## Smash

However, how scary is that video?  Lights, sirens, "I'm an adrenaline junkie" and crappy intubating technique in the first 30 seconds.  Just what we need more of!


----------



## MrBrown

Smash said:


> Dammit, now I have to change it!



No you don't!



Smash said:


> However, how scary is that video?  Lights, sirens, "I'm an adrenaline junkie" and crappy intubating technique in the first 30 seconds.  Just what we need more of!



Bro that video is revolting... giant whacker patches, that dude in the black jersey is horribly obese, incorrect terminology, that stretcher looks like its out of the eighties, chest palpation was horrible .... makes Brown want to vomit copiously


----------



## the_negro_puppy

MrBrown said:


> No you don't!
> 
> 
> 
> Bro that video is revolting... giant whacker patches, that dude in the black jersey is horribly obese, incorrect terminology, that stretcher looks like its out of the eighties, chest palpation was horrible .... makes Brown want to vomit copiously



lool I enjoyed the aviator sunnies and french kissing of the mannequins personally


----------



## MrBrown

the_negro_puppy said:


> lool I enjoyed the aviator sunnies and french kissing of the mannequins personally



Until that fat arsejockey can whip it out and show Brown his commercial pilots license and several thousand hours of jet type experience he is not qualified to wear aviator sunnies.

*Brown goes to look for Brown's aviator sunnies


----------



## paccookie

usalsfyre said:


> There's a massive cultural bias against pain management in EMS. Providers who appropriately manage pain are seen as "weak" and "gullible". Like Linuss says, there's some who see it as a badge of honor NOT to give out narcotics. You gave to "prove" your pain to these people. There also the folks that will say an ambulance "isn't a damn taxi". The only place I haven't consistently encountered a large percentage of these medics is in CCT.
> 
> I've been on the other end. I've experienced a painful injury, and received no pain management from EMS or the ED. This transpired after I was an EMS provider, and had seen the pain management light. It sucks and is providing $hity medical care. If your not managing your patients pain appropriately to the extent allowed under your protocols, guess what, YOU suck as a medic.
> 
> What pisses me off about medics in my own service who do this is I was one of the guys jumping up and down screaming in the clinical services office about the homeopathic doses of morphine we used to have written in our protocols. To me, consistent failure to manage pain should be treated the same as any other consistent clinical failure. Remediation, discipline and termination.



Completely agree.  It really makes me angry when medics refuse to treat pain.  I have personally been in the ER multiple times for kidney stones and you have no idea how crappy it is to have to "prove" your pain to get some relief.  It's ridiculous.  I also offer my patients more pain meds just before pulling into the ER.  You know they're going to be moved around and poked and prodded again and once they're inside, the rules are a little different regarding medications.  Orders must be written and sent to the pharmacy.  Procedures have to be followed, codes must be entered correctly, blah blah blah.  If I can help my pts by easing their physical pain a little, I will, every single time.


----------



## 18G

paccookie said:


> Completely agree.  It really makes me angry when medics refuse to treat pain.  I have personally been in the ER multiple times for kidney stones and you have no idea how crappy it is to have to "prove" your pain to get some relief.  It's ridiculous.  I also offer my patients more pain meds just before pulling into the ER.  You know they're going to be moved around and poked and prodded again and once they're inside, the rules are a little different regarding medications.  Orders must be written and sent to the pharmacy.  Procedures have to be followed, codes must be entered correctly, blah blah blah.  If I can help my pts by easing their physical pain a little, I will, every single time.



+1. That is my feeling too.


----------



## canisdoo

One of the greatest things we can provide is pain control.  People call 911 for pain. My chest hurts, my tummy hurts, my leg is cut off and it hurts, OMG that car hit that rebar  and impaled the driver...it must hurt, call 911.

Keep it up!! its nice to hear of other "candy man" out there....Hey does anybody have batteries for their "Painometer" ours is out. It Takes a picture of their face and it provides computations how much pain THEY ARE  IN.


----------



## NomadicMedic

I'm not only amazed at some providers that refuse to manage pain, but I'm blown away by some of the ridiculously tiny amounts of pain management meds you're allowed to work with before you have to get on the phone and beg for more from a doc.

I'm spoiled. At my primary service, our standing orders allow up to 40mg of Morphine and 500mcg of Fentanyl before calling for additional orders. Now, I'll admit I rarely need to use more than 10 of morphine to control pain, but for trauma with a long transport time, it's nice to know I've got the trust of my MPD and the leeway to *effectively* manage my patient's pain. If you're not on top of your patient's pain, you're not doing them any favors.

And like Linuss, I like to give a little bump of Morphine or Fent just as we pull into the ED, because I know the PT is going to sit in a room with no pain control for a while. And that ain't no fun.


----------



## zmedic

The problem is that a lot of people have flat orders for pain management, rather than weight based. For example a lot of people give morphine in 2-4mg boluses. But for pain control for things like trauma, the dose is .05-1mg/kg. So a trauma patient who is 100kg should be getting 5-10mg *per dose*. Think about that next time you see someone giving 2 of morphine for a tib/fib fracture on a normal sized male.


----------



## MrBrown

zmedic said:


> The problem is that a lot of people have flat orders for pain management, rather than weight based. For example a lot of people give morphine in 2-4mg boluses. But for pain control for things like trauma, the dose is .05-1mg/kg. So a trauma patient who is 100kg should be getting 5-10mg *per dose*. Think about that next time you see someone giving 2 of morphine for a tib/fib fracture on a normal sized male.



Tell Brown nobody actually gives 2mg for some bloke with a nungered tib/fib?

Something like that here, Brown cannot think of anybody who would give less than 5mg of morf, more like 10.  They would probably get some ketamine too.  Heck we gave the guy with kidney stones 7mg 

Good lord!


----------



## Veneficus

MrBrown said:


> Tell Brown nobody actually gives 2mg for some bloke with a nungered tib/fib?
> 
> Something like that here, Brown cannot think of anybody who would give less than 5mg of morf, more like 10.  They would probably get some ketamine too.  Heck we gave the guy with kidney stones 7mg
> 
> Good lord!



Outdated and ultraconservative protocols Brown, they are rampant.

In the US, pain medications are to be feared along with managing pain.


----------



## Mex EMT-I

From the land of fried beans and sombreros.

Here morphine is only used inside the hospital. It is a VERY controlled drug, along with other opiates (Thanks Mexican Druglords). So ambulance services are left with almost nothing.

To treat severe pain we got...... 

wait for it......

Ketorolac 60 mg.

Tell me how awful is that.

Recently we have been using Lysine clonixinate in 200 to 600 mg doses IVP. Its quite effective in moderate to severe pain.


----------



## marineman

My only option is morphine, protocols allow 2x5mg doses before I have to call. I have been begging for Fentanyl and Ketorolac for a while now and our medical director says until people start using what you have why would I give you more? 

I hate that so many people under treat pain. I'm sure I've been had by a drug seeker here or there but anyone that actually treats pain has been had. I blame both lazy/uncaring medics and the system for the undertreatment of pain. The control measures on Morphine are the biggest cited reason for not giving it, "She didn't seem that bad and then I have 10 extra pages of paperwork to fill out".


----------



## usalsfyre

marineman said:


> "She didn't seem that bad and then I have 10 extra pages of paperwork to fill out".



*[usalsfyre's head explodes]*

Yep, that quote is probably 50% of the problem. The other 50% is "He's a drug seeker and I don't want to reward his behavior/make him call more". Makes me want break the medic in question's arm and call him a seeker. As to this quote...





marineman said:


> our medical director says until people start using what you have why would I give you more?


 Isn't it his JOB to investigate why morphine isn't being used appropriately, educate/discipline those who aren't practicing good medicine, and change protocols/formulary as needed to ensure best practices?!? Sounds pretty lazy on his part. 

*[usalsfyre attempts to find all the pieces of his head and put them back together, Humpty Dumpty style]*


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## marineman

usalsfyre said:


> *[usalsfyre's head explodes]*
> 
> Yep, that quote is probably 50% of the problem. The other 50% is "He's a drug seeker and I don't want to reward his behavior/make him call more". Makes me want break the medic in question's arm and call him a seeker. As to this quote... Isn't it his JOB to investigate why morphine isn't being used appropriately, educate/discipline those who aren't practicing good medicine, and change protocols/formulary as needed to ensure best practices?!? Sounds pretty lazy on his part.
> 
> *[usalsfyre attempts to find all the pieces of his head and put them back together, Humpty Dumpty style]*



I agree with you 100% however our medical director is honestly as hands off as possible which is complete BS if you ask me but nobody asks me. I wish I could post our protocols for all to view how bad they are but the only place they are online is on our employee website and a login is required. The other day I compared our protocol book from 1997 to our newest one revised last month and only 2 protocols have changed. 

We are now doing "CCR" resuscitation of PNB's meaning we put a nonrebreather on and place an OPA before intubation rather than trying to bag them with an OPA. Other protocol is we have now adopted the hospitals code STEMI protocol and added Plavix. 

this ends the off topic rant, give more pain meds.


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## NomadicMedic

marineman said:


> this ends the off topic rant, give more pain meds.



Not more pain meds ... *appropriate* pain meds, in appropriate dosages for the patient. That's the key. 

Simply giving 2-4mg of Morphine to a patient with a traumatic injury doesn't do anything for anybody.

Being aware of the patient's discomfort and effectively managing that pain is what makes you a proficient caregiver that will be ultimately more respected by the other professionals you'll deal with. When I bring a trauma patient in to the ED and can clearly describe how I managed the patient's pain from 10/10 to zero (or as close as possible) through the judicious use of opiates and benzos, I'm routinely thanked by the docs for being aggressive with my pain management. 

If I'm ever pulled into farm equipment or take a high speed spill off a motorcycle, I just hope the paramedic that responds isn't afraid to open his narc box and deal out the stuff. We have the ability to manage pain. When we don't, it's unforgivable.


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## rhan101277

Administered 15mg of Toradol IVP for RLQ pain 10/10, w/ guarding, gramacing.  Pt had trouble urinating x3 days, no fever, no kidney stone hx, but I suspected kidney stones.  Had to call and get orders but it is better than nothing.  They don't want us bring in abdominal pain patients who are snowed, makes the doctors assessment more difficult.

It is also noteworthy that other medics won't even call for situations such as these, therefore no drug is given.

If it is like an obvious injury then I am captain pain management.


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## usalsfyre

rhan101277 said:


> They don't want us bring in abdominal pain patients who are snowed, makes the doctors assessment more difficult.


Simple solution, don't snow your patients. It's certainly possible to administer appropriate pain relief without snowing your patient under. If they still give you trouble (the whole "trained surgical hands" crap) show them any number of studies that state analgesia makes no difference in assessment accuracy.


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## Shishkabob

Or bring up the fact that every time I have ever been in a crap ton of pain, I could still describe what it felt like and exactly where it was even after the pain was gone.  Heck, I can still describe the two times I dislocated my kneecap... and those were 4 and 6 years ago.



If they still give you trouble, remind them that a drug exist called "Narcan".  They obviously don't care about pain control, so it won't matter that they can't give narcotics afterward.


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## Smash

rhan101277 said:


> They don't want us bring in abdominal pain patients who are snowed, makes the doctors assessment more difficult.



Noooooooooooo!!!!  **Smash's head explodes**

Less difficult!  It makes assessment less difficult!  And the patient happier!

Damn you Mr Cope!


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## rhan101277

Smash said:


> Noooooooooooo!!!!  **Smash's head explodes**
> 
> Less difficult!  It makes assessment less difficult!  And the patient happier!
> 
> Damn you Mr Cope!



Yeah this is just for abdominal pain, since you are never certain if it is a bleed or not.  Unless it is obvious.


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## NomadicMedic

rhan101277 said:


> Yeah this is just for abdominal pain, since you are never certain if it is a bleed or not.  Unless it is obvious.



Wait, I'm sorry... you can't treat abdominal pain at all? Even if the patient is hemodynamically stable? 

It's been shown in several papers (I'll post some cites in a few) that pre-hospital analgesia for abdominal pain facilitates the ED examination and reduces patient's anxiety.


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## usalsfyre

rhan101277 said:


> Yeah this is just for abdominal pain, since you are never certain if it is a bleed or not.  Unless it is obvious.



What does hemorrhage in the abdominal cavity have to do with withholding pain meds? Don't you think peritoneal irritation hurts?


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## Veneficus

rhan101277 said:


> They don't want us bring in abdominal pain patients who are snowed, makes the doctors assessment more difficult.



This is absolutely false.

I don't know who started saying this or when.

The earliest account of witholding pain medication for abdominal pain I can find is from a surgical practice dating back to the early 1900's.

The idea behind it was that because visceral pain is poorly localized, when the peritoneum which does have local stretch receptors becomes inflammed, then the origin of the insult could be deduced.

Unfortunately it wasn't very accurate.

Fortunately, our understaning of pathology and visceral pain mapping has gotten considerably better. 

As smash pointed out, controlling abdominal pain actually makes the physical exam easier and more accurate.

I have seen a US trauma surgeon withold pain meds on an abdominal GSW to determine the level of post surgical bleeding was increasing and not properly draining from the tube.

However, considering that the problem could easily be solved by serial ultrasound, I do not advocate repeating that "test."

In defense of the surgeon, because the use of ultrasound is dependant on user skill and not totally objective, its usage in the US is considerably less than in other places. Mostly out of fear of litigation, I am told. 

Like any skill, lack of usuage diminishes the skill even further.

The lack of use also equates to lack of training opportunities.

In my book, fear of litigation is not reason enough to leave a patient in pain.

As one of my best preceptors likes to say:

"You would never sue your friend, but would gladly sue your enemy."

I would think making the patient feel better by properly managing pain would make them less likely to sue than more. Even if there were complications to the treatment.

Some people sue no matter what, why worry about it?


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## rhan101277

I actually heard the RN say to the patient that they didn't want to give him to much morphine because the doc didn't know what he was treating.  Hypotension is a side effect of morphine admin.  You don't want to give it to abdominal pain that you determine might possibly be descending Aortic dissection.

But this case I had was kidney stones I thought, but field providers can be wrong.  We don't have all the fancy tests doctors have, nor do we have the education or experience.

Don't get me wrong, I am big on pain management.  A thorough assessment is required though.


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## Veneficus

rhan101277 said:


> I actually heard the RN say to the patient that they didn't want to give him to much morphine because the doc didn't know what he was treating.  Hypotension is a side effect of morphine admin.  You don't want to give it to abdominal pain that you determine might possibly be descending Aortic dissection.
> 
> But this case I had was kidney stones I thought, but field providers can be wrong.  We don't have all the fancy tests doctors have, nor do we have the education or experience.
> 
> Don't get me wrong, I am big on pain management.  A thorough assessment is required though.



You don't want to give it for billiary tree pathology either as the morphine causes contraction of the sphincter of oddi. 

But all of that just demonstrates the importance of physical exam and history skills. 

"What if" is poor medicine.


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## MrBrown

We are taught it is unethical to withhold pain medication, and it is!

*Brown calls the MAS Metro Clinician for advice on how to treat Humpty Dumpty syndrome


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## Veneficus

MrBrown said:


> We are taught it is unethical to withhold pain medication, and it is!
> 
> *Brown calls the MAS Metro Clinician for advice on how to treat Humpty Dumpty syndrome



Just to point out, if you give mophine to a patient suffering from the pathology i described, it actually increases pain. (not to mention can potentially cause a perforation)

However, you guys down there have considerably more options than US EMS when it comes to pain management.


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## rhan101277

Veneficus said:


> You don't want to give it for billiary tree pathology either as the morphine causes contraction of the sphincter of oddi.
> 
> But all of that just demonstrates the importance of physical exam and history skills.
> 
> "What if" is poor medicine.



How is "what if" poor medicine?  You have to leave all your options open and try to narrow down what it is w/ physical exam and hx taking.  You have to ask yourself what if it is this and I do this.  We can't make a 100% diagnosis in the field we aren't doctors.


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## Veneficus

rhan101277 said:


> How is "what if" poor medicine?  You have to leave all your options open and try to narrow down what it is w/ physical exam and hx taking.  You have to ask yourself what if it is this and I do this.  We can't make a 100% diagnosis in the field we aren't doctors.



Because if you worry about every "what if" you would end up doing nothing. 

Unless you are only worried about the "what if's" you know about. 

Nobody is asking you to diagnose 100% in the field. But from your own suspicion of renal stones, I don't think it is asking a lot to be able to narrow down the list of what might be wrong in the abdomen to the organ system involved.


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## jwk

Veneficus said:


> You don't want to give it for billiary tree pathology either as the morphine causes contraction of the sphincter of oddi.



We give narcotics for these patients all the time - sphincter of oddi contraction is not something that always happens when a patient is given narcotics, and is actually relatively rare.  I've seen it once in 30 years, and that patient's pain got better when we gave some Narcan.  If nothing else, if you give some narcotics and their belly pain gets worse, it's at least somewhat diagnostic, or at least helps your differential.


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## Veneficus

jwk said:


> We give narcotics for these patients all the time - sphincter of oddi contraction is not something that always happens when a patient is given narcotics, and is actually relatively rare.  I've seen it once in 30 years, and that patient's pain got better when we gave some Narcan.  If nothing else, if you give some narcotics and their belly pain gets worse, it's at least somewhat diagnostic, or at least helps your differential.



Could I ask you if you have some literature on this?

The most recent study I found was 2004, but that was out of China, so it is highly suspect. 

The latest reliable one I could find was from 2001 from a hepato-biliary journal, which basically upheld meperidine over mophine.

I am always interested in finding things that go against conventional practice. Please if you could help with this particular topic?


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## MrBrown

Sorry Brown was referring to morphine in biliary pain, we are taught (and Brown has no independent evidence to support or refute the sphincter contraction theory, to PubMed!) that it is not contraindicated and unethical to withhold it.

Brown was also referring to withholding pain medicines in general.


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## Veneficus

MrBrown said:


> Sorry Brown was referring to morphine in biliary pain, we are taught (and Brown has no independent evidence to support or refute the sphincter contraction theory, to PubMed!) that it is not contraindicated and unethical to withhold it.
> 
> Brown was also referring to withholding pain medicines in general.



We were specifically taught it was not to be used in biliary pain. Sometimes ad nauseum.

In fact it is specified in 2 of my texts. (but i have heard it constantly over the last year)

All of my pub med and google search this eveing on it turned up stuff that basically said it demonstratively caused contraction.

Here is the original pubmed study I found and the rest were listed from it.

http://www.ncbi.nlm.nih.gov/pubmed/11316181


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## Smash

rhan101277 said:


> How is "what if" poor medicine?  You have to leave all your options open and try to narrow down what it is w/ physical exam and hx taking.  You have to ask yourself what if it is this and I do this.  We can't make a 100% diagnosis in the field we aren't doctors.



If you can't form a good working diagnosis, you should probably fall back to treating symptoms. Like pain. 

What benefit does unrelieved pain provide?


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## johnrsemt

My question is how many doctors that are not sure what the Abd or Head pain is from; don't do Emergent CT's?   And how does taking pain away affect a CT?  In fact it makes them better because the patient is NOT squirming in pain, and screwing up the CT.


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## zmedic

Veneficus said:


> All of my pub med and google search this eveing on it turned up stuff that basically said it demonstratively caused contraction.
> 
> Here is the original pubmed study I found and the rest were listed from it.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/11316181



Did you read the abstract you cited? 

"Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis." 

So you can use morphine in this case. 

The take home for you pre-hospital people is that you should use narcotic pain control for patient's with abdominal pain. Even if you think they have pacreatitis.


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## usalsfyre

johnrsemt said:


> My question is how many doctors that are not sure what the Abd or Head pain is from; don't do Emergent CT's?   And how does taking pain away affect a CT?  In fact it makes them better because the patient is NOT squirming in pain, and screwing up the CT.


The problem is your typical physician knows why the patient is having abdominal pain well before the CT based on history and physical exam. They still order a CT due to medicolegal concerns, but usually could do without it. How many paramedics can say the same? For that matter, how many of you work with medics that can't locate the major abdominal organs?


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## Veneficus

zmedic said:


> Did you read the abstract you cited?
> 
> "Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis.".


 
Yes, I did read the abstract, including the service that performed it.

But biliary tree obstruction has multiple causes, not just acute pancreatitis. 

I also read a handful of others, and most of them refered to the context of ERCP where sphincter contraction was measured by manometry.

2 of them also listed medications, nalaxone and another one I don't remember off hand as it has been a busy day for me, that specifically relieve the effects of morphine, as was stated by an earlier poster.


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## Veneficus

johnrsemt said:


> My question is how many doctors that are not sure what the Abd or Head pain is from;



Hopefully only a few.

Ultrasound is also considerably cheaper. 




johnrsemt said:


> don't do Emergent CT's?



CTing every is a waste of resources. Especially money.




johnrsemt said:


> And how does taking pain away affect a CT?  In fact it makes them better because the patient is NOT squirming in pain, and screwing up the CT.



It doesn't but many physicians I have met around the world don't advocate simply imaging everyone for everything.

CT is also not failsafe. It has limitations.


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## rhan101277

We only use toradol for abdominal pain.  I am sure it is not as effective against pain as morphine.  It is labeled as a NSAID with non-opioid analgesic properties.  I have never tried to ask for morphine due to it not being in the protocol for abdominal pain.


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## usalsfyre

rhan101277 said:


> I have never tried to ask for morphine due to it not being in the protocol for abdominal pain.


Why?


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## marineman

Question for those of you carrying and using Toradol, do you have to verbally screen pregnancy first with females or can you just give it? In the hospital all but 1 doc make us wait until we have a neg preg test before we can give it. Granted in the field you don't have access to the tests but is a verbal screening mandatory?


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## Aidey

We used toradol when I worked in primary care, and we didn't do pregnancy tests first. I don't carry it now, but it is a pregnancy category C, which a number of medications are. I'm not seeing why toradol would be treated any differently.


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## marineman

I'm not sure what their big stink about it is either, hydromorphone is also pregnancy category C and they will give it all the time without a second thought.


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## rhan101277

Scenario:

GSW victim, small caliber, two wounds.

One would is located on the left leg, above knee, proximal to pelvis.  It is through and through, PMS intact.

Other wound is medial to right knee, only one penetrating hole noted, motor and sensory is intact, not pulse can be found.  Large hematoma is noted on the lateral aspect of knee.  You suspect popliteal artery has been nicked or damaged in some way.

Pt is AAOx3, GCS 15.

B/P 157/83; pulse 85; pt reports pain 20/10.

Under your protocols, can you give pain medication for this scenario with standing orders?


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## Akulahawk

rhan101277 said:


> Scenario:
> 
> GSW victim, small caliber, two wounds.
> 
> One would is located on the left leg, above knee, proximal to pelvis.  It is through and through, PMS intact.
> 
> Other wound is medial to right knee, only one penetrating hole noted, motor and sensory is intact, not pulse can be found.  Large hematoma is noted on the lateral aspect of knee.  You suspect popliteal artery has been nicked or damaged in some way.
> 
> Pt is AAOx3, GCS 15.
> 
> B/P 157/83; pulse 85; pt reports pain 20/10.
> 
> Under your protocols, can you give pain medication for this scenario with standing orders?


Sacramento County? In short: No. Now if the small caliber bullets were to have fractured the femur... then I could probably finagle the existing pain control in the "Trauma" protocol to do it... However, under standing orders as presented... I'd have to get a BHP order for the pain control.


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## NomadicMedic

rhan101277 said:


> Scenario:
> 
> GSW victim, small caliber, two wounds.
> 
> One would is located on the left leg, above knee, proximal to pelvis.  It is through and through, PMS intact.
> 
> Other wound is medial to right knee, only one penetrating hole noted, motor and sensory is intact, not pulse can be found.  Large hematoma is noted on the lateral aspect of knee.  You suspect popliteal artery has been nicked or damaged in some way.
> 
> Pt is AAOx3, GCS 15.
> 
> B/P 157/83; pulse 85; pt reports pain 20/10.
> 
> Under your protocols, can you give pain medication for this scenario with standing orders?



Yes. Up to 40mg of morphine or 500mcg of Fentanyl. And we do a LOT of GSWs over here. 

However, in the city I'm close to the trauma center and usually don't have time to get pain meds on board before we're pulling up to the doors...


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## rhan101277

n7lxi said:


> Yes. Up to 40mg of morphine or 500mcg of Fentanyl. And we do a LOT of GSWs over here.
> 
> However, in the city I'm close to the trauma center and usually don't have time to get pain meds on board before we're pulling up to the doors...



Yeah I called in for orders on this one.  It was a 25 minute drive.


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## MrBrown

What can we give? Unlimited morphine + ketamine


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## ah2388

we use fentanyl in 50-100mcg increments titrated to relief of pain..and morphine up to 20mg...


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## Blessed187

LucidResq said:


> Kinda baffles me... I mean, after getting people to a doctor, I would hope making them feel better would be goal #2.
> 
> For some reason it reminds me of how I've had certain dentists hesitate to give me nitrous. The stuff will wear off before I get out of your chair, it reduces anxiety and pain for me, and I'm paying for it. But Mr. Dentist (or ER doc in the EMS equivalent) will happily leave me a script for Vicodin with my discharge paperwork that I could theoretically go home and take 20 of and sell the rest? That's what I don't understand. Granted, it's not the medic writing the script, and I've heard of dentists/doctors that are less friendly with the carry-out opiods, but honestly, I've yet to meet one.
> 
> Am I the only one that's noticed this phenomenon? I'll tell you when I ended up in the ED a few months ago for severe abd pain, I only got IV Zofran and fluids while curled up on the bed wincing in pain, but left with an RX for Vicodin to fill at Walgreen's.





I'm truly suprised the doc didn't give at least 5mg morphine for your abd px! That's crazy! I was in the ED two weeks ago with a typical migrain that had gone on for over 24hrs. Line in 5mg morphine, he did an LP just to make sure it was not anything serious than a migrane then he ordered another 5 mgs and I declined. He can in and asked why. I said I would much rather have 10 IM than 5 IV. As we all know the half life is all of 15 min of decent pain mgt. He agreed with me and ordered it along with 25 10/325 to go home with!!! Not even 5/325! I couldn't belive it.  Even thou LP's cause REALLY bad head aches for up to two weeks afterwards. No wonder all the drug seekers are going into the ER every week!!!


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